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Journal ArticleDOI

Postoperative Complications and Health-related Quality of Life 10 Years After Esophageal Cancer Surgery.

01 Feb 2020-Annals of Surgery (Ann Surg)-Vol. 271, Iss: 2, pp 311-316

TL;DR: Postoperative complications are associated with considerably impaired HRQOL up to 10 years after esophageal cancer surgery, and 12 of the 25 scales and items were significantly worse in patients with postoperative complications 10 Years after surgery.
Abstract: Objective To evaluate the impact of postoperative complications on health-related quality of life (HRQOL) up to 10 years after surgery for esophageal cancer. Background The impact of postoperative complications on HRQOL past 5 years is unknown. Methods Some 616 patients undergoing open esophageal cancer surgery between April 2, 2001 and December 31, 2005 in Sweden were enrolled in this population-based, nationwide, and prospective cohort study. Exposure was the occurrence of predefined postoperative complications, and the outcome was HRQOL evaluated by validated European Organization for Research and Treatment of Cancer questionnaires at 6 months, 3, 5, and 10 years after surgery. Linear mixed models, adjusted for longitudinal HRQOL in the general population and confounders, provided mean score differences (MDs) with 95% confidence intervals (CIs) for each HRQOL item and scale in patients with or without postoperative complications. Results At 10 years, 104 (17%) patients were alive and 92 (88%) answered the HRQOL questionnaires. Of these, 37 (40%) had at least 1 predefined postoperative complication. Twelve of the 25 scales and items were significantly worse in patients with postoperative complications 10 years after surgery, for example, physical function (MD -15, 95% CI -24 to -7), fatigue (MD 16, 95% CI 5-26), pain (MD 18, 95% CI 7-30), dyspnea (MD 15, 95% CI 2-27), insomnia (MD 20, 95% CI 8-32), and eating problems (MD 14, 95% CI 3-24) compared to patients without complications. Conclusions Postoperative complications are associated with considerably impaired HRQOL up to 10 years after esophageal cancer surgery.

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Title: Postoperative complications and health-related quality of life 10 years after
esophageal cancer surgery.
Authors: Joonas H Kauppila,
1,2,3
MD, PhD, Asif Johar,
1
MSc, and Pernilla Lagergren,
1
RN,
PhD.
Affiliations:
1
Surgical Care Sciences, Department of Molecular Medicine and Surgery,
Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden;
2
Cancer
and Translational Medicine Research Unit, Medical Research Center Oulu, University of
Oulu, Oulu University Hospital, Oulu, Finland; and
3
Upper Gastrointestinal Surgery,
Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University
Hospital, 17176 Stockholm, Sweden.
Author correspondence and reprint requests to:
Joonas H Kauppila,
1
Surgical Care Sciences, Department of Molecular Medicine and Surgery,
Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden
Email: joonas.kauppila@ki.se,
Tel. +46 8-517 709 83, Fax: +46 8-517 762 80
Sources of support: This study was supported by the Swedish Research Council, Swedish
Cancer Society, the Cancer Research Foundations of Radiumhemmet, Sigrid Jusélius
Foundation, and Orion Research Foundation. The study sponsors had no role in the design
and conduct of the study; collection, management, analysis, and interpretation of the data;
preparation, review, or approval of the manuscript; or decision to submit the manuscript for
publication.
Running head: Postoperative complications and HRQOL

Mini-Abstract
Complications were analyzed in relation to 10-year HRQOL in a prospective nationwide
population-based Swedish cohort of 616 patients undergoing open esophageal cancer surgery,
HRQOL was impaired after complications on twelve of the 25 scales and items measured at
10-year follow-up, including physical function, fatigue, pain, dyspnea, insomnia and eating
problems.

3
Abstract
Objective: To evaluate the impact of postoperative complications on health-related quality of
life (HRQOL) up to 10 years after surgery for esophageal cancer.
Summary Background Data: The impact of postoperative complications on HRQOL past 5
years is unknown.
Methods: Some 616 patients undergoing open esophageal cancer surgery between April 2,
2001 and December 31, 2005 in Sweden were enrolled in this population-based, nationwide
and prospective cohort study. Exposure was the occurrence of predefined postoperative
complications, and the outcome was HRQOL evaluated by validated EORTC questionnaires
at 6 months, 3, 5 and 10 years after surgery. Linear mixed models, adjusted for longitudinal
HRQOL in the general population and confounders, provided mean score differences (MD)
with 95% confidence intervals (CI) for each HRQOL item and scale in patients with or
without postoperative complications.
Results: At 10 years, 104 (17%) patients were alive and 92 (88%) answered the HRQOL
questionnaires. Of these, 37 (40%) had at least one predefined postoperative complication.
Twelve of the 25 scales and items were significantly worse in patients with postoperative
complications 10 years after surgery, e.g., physical function (MD -15, 95% CI -24 to -7),
fatigue (MD 16, 95% CI 5 to 26), pain (MD 18, 95% CI 7 to 30), dyspnea (MD 15, 95% CI 2
to 27), insomnia (MD 20, 95% CI 8 to 32) and eating problems (MD 14, 95% CI 3 to 24)
compared to patients without complications.
Conclusions: Postoperative complications are associated with considerably impaired HRQOL
up to 10 years after esophageal cancer surgery.
Keywords: Esophagus; neoplasm; complications; quality of life; survivorship.

4
Introduction
Esophageal cancer, the 6
th
most common cause of cancer death globally, is characterized by
increasing incidence, demanding treatment and poor prognosis.
1, 2
The 5-year survival is
around 30-55% in patients eligible for curative treatment, and the risk of surgery-related
complications is over 40%.
3-5
The life of the patient after esophageal cancer surgery is
generally characterized by poor health-related quality of life (HRQOL).
6-8
Major
complications during treatment are known to cause deterioration of HRQOL in the short- but
also in the long term.
9-12
Moreover, complications and poor postoperative HRQOL are known
risk factors for poor prognosis.
13, 14
The impact of complications on 10-year HRQOL is thus
far not known.
We hypothesized that complications relate to poor recovery of HRQOL over time and poor
HRQOL also at 10 years after esophageal cancer surgery. The main aim of the study was to
examine the impact of complications on HRQOL at 10 years after surgery. The secondary aim
was to elucidate the HRQOL trajectory in relation to complications from 6 months to 10 years
postoperatively.

5
Methods
Study design
A nationwide Swedish, population-based, and prospective cohort study was conducted,
entitled the Swedish Esophageal and Cardia Cancer study (SECC).
8
SECC includes 616
patients, representing 90% of all patients operated with curative intent for oesophageal or
gastroesophageal junctional (GEJ) cancer in Sweden between April 2, 2001 and December
31, 2005. All patients in the cohort underwent open surgery, with majority operated by
transthoracic Ivor-Lewis esophagectomy. No minimally invasive surgeries were done during
the study period. Details about all study variables were prospectively assessed and reviewed
by the researchers according to a predefined study protocol to ensure uniformity, including
patient characteristics (age, sex), tumour characteristics (stage, histology), surgical treatment
and predefined complications occurring within 30 days of surgery. SECC is linked to the
Patient Registry and the Cancer Registry for information on co-morbidities. Moreover,
survival data was obtained from the 100% complete Swedish Registry of the Total
Population. The study was approved by the Regional Ethical Review Board in Stockholm,
Sweden. All participating patients gave informed consent.
Exposure
The main exposure of the study was complications occurring within 30 days of surgery
(yes/no). The complications were predefined by a group of experienced esophageal cancer
surgeons and researchers, and included: 1) major postoperative bleeding (exceeding 2000 ml
or requiring reoperation), 2) splenectomy (after failure of other methods of hemostasis), 3)
anastomotic insufficiency (clinically and radiologically verified), 4) necrosis of the substitute
(clinically significant ischemia with perforation or ulceration), 5) severe lymph leakage
(requiring drainage for more than 7 days or reoperation), 6) gastric perforation

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Abstract: BACKGROUND There are few data comparing health-related quality of life (HRQoL) after neoadjuvant chemotherapy alone (nCT) compared with neoadjuvant chemoradiotherapy (nCRT) in patients with oesophageal cancer. METHODS In the NeoRes trial, patients were assigned randomly in a 1 : 1 ratio to receive either cisplatin 100 mg/m2 on day 1 and an infusion of 750 mg per m2 5-fluorouracil over 24 h on days 1-5 in three 21-day cycles (nCT) or the same chemotherapy regimen, but with the addition of 40 Gy radiotherapy (nCRT). HRQoL data were collected at baseline, after neoadjuvant therapy and at 1, 3 and 5 years after surgery. The European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire QLQ-C30 and disease-specific modules were used. RESULTS Of 181 patients randomized, 165 were included in the analysis of HRQoL. In a direct comparison between the allocated treatments, odynophagia after completion of neoadjuvant therapy but before surgery (P = 0·047) and troublesome coughing at 3 years' follow-up (P = 0·011) were more pronounced in the nCRT arm. In the longitudinal analyses within each treatment arm, a large deterioration in HRQoL was noted at 1 year. Some recovery was seen in both arms over time but, after 3 and 5 years, patients in the nCRT arm reported more symptoms compared with baseline than patients in the nCT arm. CONCLUSION HRQoL after multimodal treatment for cancer of the oesophagus or gastro-oesophageal junction was impaired and more pronounced in patients who underwent nCRT, with only partial recovery over time.

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References
More filters

Journal ArticleDOI
TL;DR: The reliability and validity of the EORTC QLQ-C30 questionnaire were highly consistent across the three language-cultural groups studied: patients from English-speaking countries, Northern Europe, and Southern Europe.
Abstract: Background In 1986, the European Organization for Research and Treatment of Cancer (EORTC) initiated a research program to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials. Purpose We report here the results of an international field study of the practicality, reliability, and validity of the EORTC QLQ-C30, the current core questionnaire. The QLQ-C30 incorporates nine multi-item scales: five functional scales (physical, role, cognitive, emotional, and social); three symptom scales (fatigue, pain, and nausea and vomiting); and a global health and quality-of-life scale. Several single-item symptom measures are also included. Methods The questionnaire was administered before treatment and once during treatment to 305 patients with nonresectable lung cancer from centers in 13 countries. Clinical variables assessed included disease stage, weight loss, performance status, and treatment toxicity. Results The average time required to complete the questionnaire was approximately 11 minutes, and most patients required no assistance. The data supported the hypothesized scale structure of the questionnaire with the exception of role functioning (work and household activities), which was also the only multi-item scale that failed to meet the minimal standards for reliability (Cronbach's alpha coefficient > or = .70) either before or during treatment. Validity was shown by three findings. First, while all interscale correlations were statistically significant, the correlation was moderate, indicating that the scales were assessing distinct components of the quality-of-life construct. Second, most of the functional and symptom measures discriminated clearly between patients differing in clinical status as defined by the Eastern Cooperative Oncology Group performance status scale, weight loss, and treatment toxicity. Third, there were statistically significant changes, in the expected direction, in physical and role functioning, global quality of life, fatigue, and nausea and vomiting, for patients whose performance status had improved or worsened during treatment. The reliability and validity of the questionnaire were highly consistent across the three language-cultural groups studied: patients from English-speaking countries, Northern Europe, and Southern Europe. Conclusions These results support the EORTC QLQ-C30 as a reliable and valid measure of the quality of life of cancer patients in multicultural clinical research settings. Work is ongoing to examine the performance of the questionnaire among more heterogenous patient samples and in phase II and phase III clinical trials.

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"Postoperative Complications and Hea..." refers background in this paper

  • ...and pain), (10) wound infection (symptomatic collection of pus in the wound, requiring treatment), (11) wound rupture (clinically obvious dehiscence, requiring reoperation), (12) bowel obstruction (radiologically verified, demanding surgery), (13) sepsis (which caused clinical symptoms and positive bacterial culture in the blood), (14) pneumonia (which caused clinical symptoms and was radiologically verified), (15) liver insufficiency (progressive or permanent), (16) renal failure (in need of dialysis), (17) deep vein thrombosis (radiologically verified), (18) pulmonary embolism (radiologically verified), (19) myocardial infarction (verified with electrocardiogram or heart enzymes), (20) atrial fibrillation (newly diagnosed by ECG and needing treatment), (21) stroke (radiologically verified), (22) respiratory failure (in need of intubation or mechanical ventilation), and (23) pulmonary edema (newly diagnosed, radiologically verified, symptomatic, and needing treatment)....

    [...]


01 Jan 2006

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"Postoperative Complications and Hea..." refers background or methods in this paper

  • ...The complications were predefined by a group of experienced esophageal cancer surgeons and researchers, and included: (1) major postoperative bleeding (exceeding 2000 mL or requiring reoperation), (2) splenectomy (after failure of other methods of hemostasis), (3) anastomotic insufficiency (clinically and radiologically verified), (4) necrosis of the substitute (clinically significant ischemia with perforation or ulceration), (5) severe lymph leakage (requiring drainage for more than 7 days or reoperation), (6) gastric perforation (postoperatively identified leakage from the gastric tube), (7) esophagotracheal fistula (radiologically and clinically verified, requiring treatment), (8) empyema (radiologically or surgically verified collection of pus at least 3 cm in diameter with symptoms of fever, pain, or dyspnea), (9) intra-abdominal abscess (radiologically or surgically verified collec-...

    [...]

  • ...All analyses were adjusted for the following confounding factors: (1) reference HRQOL score for each scale and item at each time point; (2) age in years at each time point (continuous variable); (3) sex: male or female; (4) Charlson comorbidity index: 0, 1, and 2; (5) histology: squamous cell carcinoma or adenocarcinoma; (6) tumor stage: 0 to I or II to IV; and (7) annual surgeon volume: 0 to 6 per year or more than 6 per year....

    [...]


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TL;DR: This 5-year evaluation provides strong evidence that the classification of complications is valid and applicable worldwide in many fields of surgery, and subjective, inaccurate, or confusing terms such as “minor or major” should be removed from the surgical literature.
Abstract: Background and Aims:The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the co

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David Osoba1, George Rodrigues1, James Myles1, Benny Zee  +1 moreInstitutions (1)
TL;DR: The significance of changes in QLQ-C30 scores can be interpreted in terms of small, moderate, or large changes in quality of life as reported by patients in the SSQ.
Abstract: PURPOSETo determine the significance to patients of changes in health-related quality-of-life (HLQ) scores assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30).PATIENTS AND METHODSA subjective significance questionnaire (SSQ), which asks patients about perceived changes in physical, emotional, and social functioning and in global quality of life (global QL) and the QLQ-C30 were completed by patients who received chemotherapy for either breast cancer or small-cell lung cancer (SCLC). In the SSQ, patients rated their perception of change since the last time they completed the QLQ-C30 using a 7-category scale that ranged from "much worse" through "no change" to "much better." For each category of change in the SSQ, the corresponding differences were calculated in QLQ-C30 mean scores and effect sizes were determined.RESULTSFor patients who indicated "no change" in the SSQ, the mean change in scores in the corresponding QLQ-C30 domains was n...

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"Postoperative Complications and Hea..." refers background in this paper

  • ...Total number 317 (51) 299 (49) 55 (60) 37 (40) Age, median [IQR] 67 (60–73) 68 (60–74) 73 (68–80) 76 (69–81) Sex Male 259 (82) 238 (80) 40 (73) 33 (89) Female 58 (18) 61 (20) 15 (27) 10 (11) Histology Adenocarcinoma 248 (78) 218 (73) 43 (78) 29 (78) Squamous cell 68 (21) 81 (27) 12 (22) 8 (22) Missing 1 (0) 0 (0) Tumor stage I–II 154 (49) 138 (46) 46 (84) 32 (86) III–IV 159 (51) 156 (52) 9 (16) 5 (14) Missing 4 (1) 5 (2) 0 (0) 0 (0) Charlson comorbidity score 0 38 (12) 37 (12) 6 (11) 5 (14) 1 150 (47) 107 (36) 30 (55) 11 (30) 2 129 (41) 155 (52) 19 (35) 21 (57) Annual surgeon volume 0–6 150 (47) 115 (38) 23 (42) 16 (43) 7 167 (53) 184 (62) 32 (58) 21 (57)...

    [...]

  • ...and pain), (10) wound infection (symptomatic collection of pus in the wound, requiring treatment), (11) wound rupture (clinically obvious dehiscence, requiring reoperation), (12) bowel obstruction (radiologically verified, demanding surgery), (13) sepsis (which caused clinical symptoms and positive bacterial culture in the blood), (14) pneumonia (which caused clinical symptoms and was radiologically verified), (15) liver insufficiency (progressive or permanent), (16) renal failure (in need of dialysis), (17) deep vein thrombosis (radiologically verified), (18) pulmonary embolism (radiologically verified), (19) myocardial infarction (verified with electrocardiogram or heart enzymes), (20) atrial fibrillation (newly diagnosed by ECG and needing treatment), (21) stroke (radiologically verified), (22) respiratory failure (in need of intubation or mechanical ventilation), and (23) pulmonary edema (newly diagnosed, radiologically verified, symptomatic, and needing treatment)....

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Journal ArticleDOI
TL;DR: To estimate mortality, incidence, years lived with disability, years of life lost, and disability-adjusted life-years for 28 cancers in 188 countries by sex from 1990 to 2013, the general methodology of the Global Burden of Disease 2013 study was used.
Abstract: Importance Cancer is among the leading causes of death worldwide. Current estimates of cancer burden in individual countries and regions are necessary to inform local cancer control strategies. Objective To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 28 cancers in 188 countries by sex from 1990 to 2013. Evidence Review The general methodology of the Global Burden of Disease (GBD) 2013 study was used. Cancer registries were the source for cancer incidence data as well as mortality incidence (MI) ratios. Sources for cause of death data include vital registration system data, verbal autopsy studies, and other sources. The MI ratios were used to transform incidence data to mortality estimates and cause of death estimates to incidence estimates. Cancer prevalence was estimated using MI ratios as surrogates for survival data; YLDs were calculated by multiplying prevalence estimates with disability weights, which were derived from population-based surveys; YLLs were computed by multiplying the number of estimated cancer deaths at each age with a reference life expectancy; and DALYs were calculated as the sum of YLDs and YLLs. Findings In 2013 there were 14.9 million incident cancer cases, 8.2 million deaths, and 196.3 million DALYs. Prostate cancer was the leading cause for cancer incidence (1.4 million) for men and breast cancer for women (1.8 million). Tracheal, bronchus, and lung (TBL) cancer was the leading cause for cancer death in men and women, with 1.6 million deaths. For men, TBL cancer was the leading cause of DALYs (24.9 million). For women, breast cancer was the leading cause of DALYs (13.1 million). Age-standardized incidence rates (ASIRs) per 100 000 and age-standardized death rates (ASDRs) per 100 000 for both sexes in 2013 were higher in developing vs developed countries for stomach cancer (ASIR, 17 vs 14; ASDR, 15 vs 11), liver cancer (ASIR, 15 vs 7; ASDR, 16 vs 7), esophageal cancer (ASIR, 9 vs 4; ASDR, 9 vs 4), cervical cancer (ASIR, 8 vs 5; ASDR, 4 vs 2), lip and oral cavity cancer (ASIR, 7 vs 6; ASDR, 2 vs 2), and nasopharyngeal cancer (ASIR, 1.5 vs 0.4; ASDR, 1.2 vs 0.3). Between 1990 and 2013, ASIRs for all cancers combined (except nonmelanoma skin cancer and Kaposi sarcoma) increased by more than 10% in 113 countries and decreased by more than 10% in 12 of 188 countries. Conclusions and Relevance Cancer poses a major threat to public health worldwide, and incidence rates have increased in most countries since 1990. The trend is a particular threat to developing nations with health systems that are ill-equipped to deal with complex and expensive cancer treatments. The annual update on the Global Burden of Cancer will provide all stakeholders with timely estimates to guide policy efforts in cancer prevention, screening, treatment, and palliation.

2,072 citations