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

TLDR: 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.

Figures

Table 4. Adjusted relative health-related quality of life (HRQOL) scores and mean score difference (MD) with 95% confidence intervals (CI) from the EORTC QLQ-OES18 questionnaire in patients with and without predefined complications after esophageal cancer surgery at different time points from 6 months to 10 years. Values in bold are both clinically relevant and statistically significant.

Table 2. Postoperative complications occurring within 30 days of esophageal cancer surgery in the 616 patients in the cohort, and in the 92 patients responding to the 10 year follow-up questionnaires.

Table 1. Demographics and clinical characteristics of the 616 patients in the total cohort, and of the 92 patients surviving 10 years after esophageal cancer surgery with or without major postoperative complications.

Table 3. Adjusted relative health-related quality of life (HRQOL) scores and mean score difference (MD) with 95% confidence intervals (CI) from the EORTC QLQ-C30 questionnaire in patients with and without predefined complications after esophageal cancer surgery at different time points from 6 months to 10 years. Values in bold are both clinically relevant and statistically significant.

Full text

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

Frequently asked questions

Q1. What contributions have the authors mentioned in the paper "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" ?

Kauppila et al. this paper examined the impact of complications on HRQOL at 10 years after esophageal cancer surgery. 

Q2. What future works have the authors mentioned in the paper "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" ?

Future research may focus on the effect of specific complications on related HRQOL domains in more detail. Therefore, it is important to assess the association between Clavien-Dindo complication severity grading33 and HRQOL in future studies. 

Q3. What are the main reasons for the delay in the rehabilitation process?

Postoperative complications prolong the hospital stay and may delay the rehabilitation process, which are important for the patients’ recovery in general. 

Q4. How long after surgery did the study examine the effects of postoperative complications?

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. 

Q5. What is the potential limitation of the study?

Another potential limitation of the study is the change of patients’ perception of HRQOL over time by recalibration of their personal standards, reprioritization of their personal values, and reconceptualization of their quality of life. 

Q6. What are the main reasons for poor prognosis?

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. 

Q7. How many patients underwent esophageal cancer surgery?

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. 

Q8. How long after surgery is the impact of complications on the health-related quality of life?

To evaluate the impact of postoperative complications on health-related quality of life (HRQOL) up to 10 years after surgery for esophageal cancer. 

Q9. How long after surgery did the patients have esophageal cancer?

In this population-based prospective cohort study of patients undergoing open esophageal cancer surgery, postoperative complications were found to be independently associated with poor HRQOL as late as 10 years after surgery. 

Q10. How long after surgery did the study show that complications were associated with poor global quality of life?

12 Furthermore, an Italian study showed that postoperative complications were associated with poor global quality of life at 6-12 months.11 

Q11. What is the association between complications and poor health outcomes?

Severity of the complications might also be associated with poor HRQOL outcomes in the long-term due to greater inflammatory response and insult to tissue repair caused by for example single- or multi organ failure. 

Q12. How was the effect of the long follow-up and newly acquired comorbidities mitigate?

The long follow-up and the newly acquired comorbidities could potentially negatively affect the HRQOL of the patients and bias the results, but this effect was mitigated by adjustment for comorbidity status at the time of follow-up. 

Q13. What were the complications of the esophageal cancer surgery?

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. 

Q14. How long after surgery do patients with complications have worse quality of life?

The results of the present study show that patients with complications have poorer HRQOL and suffer from more symptoms than those without complications still as long as 10 years after surgery. 

Q15. How long after surgery is the occurrence of complications associated with poor HRQOL?

In conclusion, this prospective, population-based cohort study showed that occurrence of postoperative complications is associated with poor HRQOL outcomes up to 10 years after surgery.