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Symptom Evolution in Patients with Esophageal and Gastric Cancer Receiving Palliative Chemotherapy: A Population-Based Study

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Introduction

Palliative chemotherapy (PC) is associated with a modest survival benefit in patients with incurable esophageal and gastric cancer; however, changes in symptom profile during treatment are not well described. Understanding the trajectory of symptoms during treatment may lead to improved care and facilitate shared decision making. In this study, we address this knowledge gap among all patients receiving PC in the Canadian province of Ontario.

Methods

Patients diagnosed with incurable esophageal and gastric cancer who received PC from 2012 to 2017 were identified from the Ontario Cancer Registry. Patients with one or more recorded Edmonton Symptom Assessment System (ESAS) scores in the 12 months following cancer diagnosis were included. The ESAS includes scores from 0 to 10 in nine domains (anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and lack of well-being). Symptom severity is categorized as none–mild (≤ 3), moderate (4–6), or severe (7–10). We focused on potentially modifiable symptoms, i.e. nausea, pain, and anxiety/depression. Logistic regression was used to identify factors associated with moderate–severe ESAS scores in these domains. Among those patients with serial ESAS scores (at 8 ± 2 and 12 ± 2 weeks) receiving chemotherapy, we describe changes during treatment (decrease by ≥ 1 = improved; − 1 > 0 > 1 = unchanged; increase by ≥ 1 = deteriorated).

Results

The cohort included 1900 patients who received PC, of whom 79% (1497/1900) had one or more recorded ESAS scores. In multivariate analysis, younger patients were more likely to have moderate–severe scores in nausea (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.23–2.90 [p < 0.01] in patients aged 41–50 years compared with patients aged ≥ 71 years) and pain (OR 1.88, 95% CI 1.36–2.60 [p < 0.01] in patients aged 51–60 years compared with patients aged ≥ 71 years). Compared with males, females were more likely to report moderate–severe scores in anxiety/depression (OR 1.58, 95% CI 1.21–2.08 [p < 0.01]). At 8 ± 2 weeks from PC initiation, symptom scores were unchanged in 19–42% of patients, improved in 30–51% of patients, and deteriorated in 17–35% of patients. The greatest change in symptom burden was observed for appetite (51% improvement) and anxiety/depression (35% deterioration). Similar trends were observed at 12 ± 2 weeks.

Conclusions

In this large, population-based study, we observed that younger patients were more likely to report moderate–severe symptoms in pain and nausea, and females were more likely to report moderate–severe symptoms in anxiety/depression. Anxiety/depression symptoms become increasingly problematic for a substantial proportion of patients receiving PC. Supportive care efforts to mitigate these symptoms in routine practice are needed.

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References

  1. Wagner AD, Syn NL, Moehler M, Grothe W, Yong WP, Tai BC, et al. Chemotherapy for advanced gastric cancer. Cochrane Database Syst Rev. 2017;8:CD004064.

  2. Janmaat VT, Steyerberg EW, van der Gaast A, Mathijssen RH, Bruno MJ, Peppelenbosch MP, et al. Palliative chemotherapy and targeted therapies for esophageal and gastroesophageal junction cancer. Cochrane Database Syst Rev. 2017;11:CD004063.

  3. Grunfeld EA, Maher EJ, Browne S, Ward P, Young T, Vivat B, et al. Advanced breast cancer patients’ perceptions of decision making for palliative chemotherapy. J Clin Oncol. 2006;24(7):1090–8.

    Article  Google Scholar 

  4. Potgieter T, Maree JE. The palliative chemotherapy decision and experiences of South African patients and their families. Int J Palliat Nurs. 2018;24(6):272–80.

    Article  Google Scholar 

  5. Merchant SJ, Brogly SB, Booth CM, Goldie C, Nanji S, Patel SV, et al. Palliative care and symptom burden in the last year of life: a population-based study of patients with gastrointestinal cancer. Ann Surg Oncol. 2019;26(8):2336–45.

    Article  Google Scholar 

  6. Seow H, Barbera L, Sutradhar R, Howell D, Dudgeon D, Atzema C, et al. Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol. 2011;29(9):1151–8.

    Article  Google Scholar 

  7. Barbera L, Seow H, Howell D, Sutradhar R, Earle C, Liu Y, et al. Symptom burden and performance status in a population-based cohort of ambulatory cancer patients. Cancer 2010;116(24):5767–76.

    Article  Google Scholar 

  8. Bubis LD, Davis L, Mahar A, Barbera L, Li Q, Moody L, et al. Symptom burden in the first year after cancer diagnosis: an analysis of patient-reported outcomes. J Clin Oncol. 2018;36(11):1103–11.

    Article  CAS  Google Scholar 

  9. Wen FH, Chen JS, Chou WC, Hsieh CH, Chang WC, Shen WC, et al. Quality of life and psychological distress are differentially associated with distinct symptom-functional states in terminally ill cancer patients’ last year of life. Psychooncology 2018;27(9):2111–8.

    Article  Google Scholar 

  10. Wilson KG, Chochinov HM, Skirko MG, Allard P, Chary S, Gagnon PR, et al. Depression and anxiety disorders in palliative cancer care. J Pain Symptom Manag. 2007;33(2):118–29.

    Article  Google Scholar 

  11. Brooks GA, Abrams TA, Meyerhardt JA, Enzinger PC, Sommer K, Dalby CK, et al. Identification of potentially avoidable hospitalizations in patients with GI cancer. J Clin Oncol. 2014;32(6):496–503.

    Article  Google Scholar 

  12. Barbera L, Atzema C, Sutradhar R, Seow H, Howell D, Husain A, et al. Do patient-reported symptoms predict emergency department visits in cancer patients? A population-based analysis. Ann Emerg Med. 2013;61(4):427–37.

  13. Hui D, Bruera E. The edmonton symptom assessment system 25 years later: past, present, and future developments. J Pain Symptom Manag. 2017;53(3):630–43.

    Article  Google Scholar 

  14. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991;7(2):6–9.

    Article  CAS  Google Scholar 

  15. Chang VT, Hwang SS, Feuerman M. Validation of the edmonton symptom assessment scale. Cancer 2000;88(9):2164–71.

    Article  CAS  Google Scholar 

  16. Tran K, Zomer S, Chadder J, Earle C, Fung S, Liu J, et al. Measuring patient-reported outcomes to improve cancer care in Canada: an analysis of provincial survey data. Curr Oncol. 2018;25(2):176–9.

    Article  CAS  Google Scholar 

  17. Moro C, Brunelli C, Miccinesi G, Fallai M, Morino P, Piazza M, et al. Edmonton symptom assessment scale: Italian validation in two palliative care settings. Support Care Cancer. 2006;14(1):30–7.

    Article  Google Scholar 

  18. Shamieh O, Khamash O, Khraisat M, Jbouri O, Awni M, Al-Hawamdeh A, et al. Impact of outpatient palliative care (PC) on symptom burden in patients with advanced cancer at a tertiary cancer center in Jordan. Support Care Cancer. 2017;25(1):177–83.

    Article  Google Scholar 

  19. Deodhar JK, Noronha V, Muckaden MA, Atreya S, Joshi A, Tandon SP, et al. A study to assess the feasibility of introducing early palliative care in ambulatory patients with advanced lung cancer. Indian J Palliat Care. 2017;23(3):261–7.

    Article  Google Scholar 

  20. Pereira J, Green E, Molloy S, Dudgeon D, Howell D, Krzyzanowska MK, et al. Population-based standardized symptom screening: cancer care Ontario’s edmonton symptom assessment system and performance status initiatives. J Oncol Pract. 2014;10(3):212–4.

    Article  Google Scholar 

  21. Li KK, Harris K, Hadi S, Chow E. What should be the optimal cut points for mild, moderate, and severe pain? J Palliat Med. 2007;10(6):1338–46.

    Article  Google Scholar 

  22. Selby D, Cascella A, Gardiner K, Do R, Moravan V, Myers J, et al. A single set of numerical cutpoints to define moderate and severe symptoms for the edmonton symptom assessment system. J Pain Symptom Manag. 2010;39(2):241–9.

    Article  Google Scholar 

  23. Robles SC, Marrett LD, Clarke EA, Risch HA. An application of capture-recapture methods to the estimation of completeness of cancer registration. J Clin Epidemiol. 1988;41(5):495–501.

    Article  CAS  Google Scholar 

  24. Hui D, Shamieh O, Paiva CE, Perez-Cruz PE, Kwon JH, Muckaden MA, et al. Minimal clinically important differences in the edmonton symptom assessment scale in cancer patients: a prospective, multicenter study. Cancer 2015;121(17):3027–35.

    Article  Google Scholar 

  25. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370(9596):1453–7.

    Article  Google Scholar 

  26. Davis LE, Gupta V, Allen-Ayodabo C, Zhao H, Hallet J, Mahar AL, et al. Patient-reported symptoms following diagnosis in esophagus cancer patients treated with palliative intent. Dis Esophagus 2020;33(8):doz108.

  27. Bodoky G, Scheulen ME, Rivera F, Jassem J, Carrato A, Moiseyenko V, et al. Clinical benefit and health-related quality of life assessment in patients treated with cisplatin/S-1 versus cisplatin/5-FU: secondary end point results from the first-line advanced gastric cancer study (FLAGS). J Gastrointest Cancer 2015;46(2):109–17.

    Article  CAS  Google Scholar 

  28. Kripp M, Al-Batran SE, Rosowski J, Pauligk C, Homann N, Hartmann JT, et al. Quality of life of older adult patients receiving docetaxel-based chemotherapy triplets for esophagogastric adenocarcinoma: a randomized study of the Arbeitsgemeinschaft Internistische Onkologie (AIO). Gastric Cancer 2014;17(1):181–7.

    Article  CAS  Google Scholar 

  29. van Kleef JJ, Ter Veer E, van den Boorn HG, Schokker S, Ngai LL, Prins MJ, et al. Quality of life during palliative systemic therapy for oesophagogastric cancer: systematic review and meta-analysis. J Natl Cancer Inst. 2020;112(1):12–29.

    PubMed  Google Scholar 

  30. Woo A, Fu T, Popovic M, Chow E, Cella D, Wong CS, et al. Comparison of the EORTC STO-22 and the FACT-Ga quality of life questionnaires for patients with gastric cancer. Ann Palliat Med. 2016;5(1):13–21.

    PubMed  Google Scholar 

  31. Cancer Care Ontario. Patient-Reported Outcomes and Symptom Management Program, Strategic Framework 2016–2019 [cited 6 May 2020]. https://www.cancercareontario.ca/sites/ccocancercare/files/assets/CCOPatientOutcomesStratFrame.pdf. Accessed 6 May 2020.

  32. Weisman AD. Vulnerability and the psychological disturbances of cancer patients. Psychosomatics 1989;30(1):80–5.

    Article  CAS  Google Scholar 

  33. Carlson LE, Tamagawa R, Stephen J, Drysdale E, Zhong L, Speca M. Randomized-controlled trial of mindfulness-based cancer recovery versus supportive expressive group therapy among distressed breast cancer survivors (MINDSET): long-term follow-up results. Psychooncology 2016;25(7):750–9.

    Article  Google Scholar 

  34. Lengacher CA, Reich RR, Paterson CL, Ramesar S, Park JY, Alinat C, et al. Examination of broad symptom improvement resulting from mindfulness-based stress reduction in breast cancer survivors: a randomized controlled trial. J Clin Oncol. 2016;34(24):2827–34.

    Article  Google Scholar 

  35. Rodin G, Lo C, Rydall A, Shnall J, Malfitano C, Chiu A, et al. Managing cancer and living meaningfully (CALM): a randomized controlled trial of a psychological intervention for patients with advanced cancer. J Clin Oncol. 2018;36(23):2422–32.

    Article  Google Scholar 

  36. Cramer H, Lauche R, Klose P, Lange S, Langhorst J, Dobos GJ. Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Rev. 2017;1:CD010802.

  37. Bekhet AH, Abdallah AR, Ismail HM, Genena DM, Osman NA, El Khatib A, et al. Benefits of aerobic exercise for breast cancer survivors: a systematic review of randomized controlled trials. Asian Pac J Cancer Prev. 2019;20(11):3197–209.

    Article  Google Scholar 

  38. Nicholls SG, Langan SM, Benchimol EI. Routinely collected data: the importance of high-quality diagnostic coding to research. CMAJ. 2017;189(33):E1054–E5.

    Article  Google Scholar 

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Funding

This study was funded by the CTAQ Endowment Fund, Queen’s University, awarded to Dr. Shaila Merchant.

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Authors and Affiliations

  1. Department of Surgery, Queen’s University, Kingston, ON, Canada

    Shaila J. Merchant MSc, MHSc, MD

  2. Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, ON, Canada

    Shaila J. Merchant MSc, MHSc, MD, Weidong Kong MSc, Michael Brundage MSc, MD & Christopher M. Booth MD

  3. Division of General Surgery and Surgical Oncology, Kingston Health Sciences Centre, Kingston, ON, Canada

    Shaila J. Merchant MSc, MHSc, MD

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  1. Shaila J. Merchant MSc, MHSc, MD
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  2. Weidong Kong MSc
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  3. Michael Brundage MSc, MD
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  4. Christopher M. Booth MD
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Contributions

All authors contributed to (1) substantial contributions to the study conception and design, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; (3) final approval of the version to be published; and (4) agreement to be accountable for all aspects of this work.

Corresponding author

Correspondence to Shaila J. Merchant MSc, MHSc, MD.

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Disclosure

Shaila J. Merchant, Weidong Kong, Michael Brundage, and Christopher M. Booth have no conflicts of interest to declare.

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Merchant, S.J., Kong, W., Brundage, M. et al. Symptom Evolution in Patients with Esophageal and Gastric Cancer Receiving Palliative Chemotherapy: A Population-Based Study. Ann Surg Oncol 28, 79–87 (2021). https://doi.org/10.1245/s10434-020-09289-6

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  • DOI: https://doi.org/10.1245/s10434-020-09289-6

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