Quality of life after esophageal cancer surgery

Abstract

The principal aim of this research was to find ways to improve the quality of life of esophageal cancer patients after surgical treatment and to reduce persisting symptoms that often occur after that procedure. Since esophageal cancer surgery is extensive and carries a poor long-term prognosis, it is relevant to assess quality of life and complications as outcome measures.

In three of four studies, we used a nationwide, population-based, prospective design to evaluate the patients' quality of life and symptoms, and the relation between surgery-related factors and quality of life and complications. We used the Swedish Esophageal and Cardia Cancer Register, where most surgically treated esophageal cancer patients in Sweden are registered. Details about tumor characteristics and stage, surgical procedures, and complications were collected prospectively. Medical records and specific charts from surgical procedures, histopathology reports, and intensive care unit reports were continuously scrutinized. Six months after surgical treatment the patients received a self-administered written quality of life questionnaire, developed by the European Organisation for Research and Treatment of Cancer (EORTC), namely a core questionnaire, QLQ-C30, with an esophageal-specific module, QLQ-OES18.

In the fourth study we used a hospital-based design where all patients who had been in contact with the specialist nurse at the clinic received two study-specific questionnaires, for evaluation of the patients appraisal of given support and supportive care. Further, the medical records were reviewed to assess the reasons for contact with the specialist nurse.

Patients who undergo esophageal cancer resection still suffer greatly from a reduced quality of life and several general and esophageal-specific symptoms six months postoperatively. The global quality of life was considerably reduced compared with a general Swedish reference population. The most affected functions were role and social functioning, and the worst general symptoms were fatigue, appetite loss, diarrhea, and dyspnea, and among the esophageal-specific symptoms eating difficulties, reflux, and dysphagia were most frequently reported.

Among surgery-related factors, the occurrence of major complications importantly reduced the global quality of life, the physical functioning and the role functioning after the surgery. There was a statistically significant dose-response relation between number of complications and all these outcomes.

Almost every second operation (44%) entailed at least one severe complication within 30 days postoperatively. Esophageal resections conducted by low-volume surgeons (<5 operations per year) increased the risk of anastomotic leakage compared to those performed by surgeons with a higher volume (OR 7.9, 95% CI 2.1-29.0). Transthoracic esophageal surgery carried an increased risk of respiratory complications compared to a transhiatal (abdominal only) approach.

Support given by a specialist nurse was found to be important through the entire care pathway, particularly during the follow-up phase, as compared with that given by other health care professionals. Specialist nurse support was appraised by the patients as being both satisfactory and highly important, and the most frequent contact reason was nutritional problems.

In conclusion, patients who undergo esophageal cancer resection suffer greatly from reduced quality of life and several persistent symptoms six months postoperatively. The occurrence of surgery-related complications is a predictor of reduced quality of life, and esophageal cancer surgery conducted by low-volume surgeons carries an increased risk of anastomotic leakage. A specialist nurse who provides support to patients with esophageal cancer and coordinates the care pathway is a valuable resource.