Quality of Life After Esophagectomy

Abstract

Health–related quality of life (HRQL) is a multi-dimensional concept that includes physical, emotional, mental, and social functioning. HRQL focuses on the impact of a disease state, or its treatment, on an individual’s subjective reporting of their ability to live a meaningful and quality lifestyle under the constraints of the disease or its treatment. Historically, the exceedingly high mortality and morbidity associated with esophagectomy prohibited any meaningful consideration of post-operative HRQL. Current treatment modalities have improved both perioperative outcomes and long-term survival. However, there is still a significant negative impact of treatment on HRQL. The most commonly encountered long-term issues related to HRQL after esophagectomy include diminished physical function, gastrointestinal disturbances, alterations in body composition, and impaired psychosocial reintegration.

Appendix: Summary of Prospective Studies Assessing HRQL in Esophageal Cancer

Authors, year	n	Median length of follow-up (months)	Study design	Results
Scarpa [26] 2012	1282	12	Meta-analysis	– Global QOL markedly decreased following surgery (p = 0.04) – Global QOL increased through the first 6 postoperative months, but role and physical function never increased to baseline – On multivariate analysis, emotional function and dysphagia at diagnosis were directly associated to global QOL at diagnosis (p = 0.001 and p < 0.0001, respectively) – Patients experiencing any kind of postoperative complication had the same global QOL as those who did not, but had worse emotional function long term and worse physical function short term
Kauppila [22] 2017	2064	12	Meta-analysis	– Patients reported better global QOL, physical function, fatigue, and pain at 3 months following minimally-invasive versus open esophagectomy – This differences failed to be significant at 6 and 12 months follow-up
Van Heijl [51] 2009	199	3	Prospective RCT	– In the postoperative multivariate analysis, social functioning (p = 0.035), pain (p = 0.026), and activity level (p = 0.037) predicted survival, besides pathological T-stage (p < 0.001) and N-stage (p < 0.001)
De Boer [52] 2004	199	36	Prospective RCT	– Three months after the operation, patients in the transhiatal esophagectomy group (n = 96) reported fewer physical symptoms (P = 0.01) and better activity levels (P < 0.01) than patients in the transthoracic group (n = 103), but no differences were found at any other measurement point
Maas [24] 2015	115	12	Prospective RCT	– Overall HRQL was improved at 1 year for both minimally-invasive and open esophagectomy compared to preoperative and 6-week postoperative scores – Patients who underwent minimally-invasive esophagectomy had significantly improved physical activity (p = 0.003), global health (p = 0.004) and pain (p = 0.001) scores at 1-year follow-up compared to those who underwent open esophagectomy
Noordman [53] 2017	363	12	Prospective RCT	– HRQL declined during neoadjuvant chemoradiotherapy, but this effect was not apparent in postoperative HRQL compared to surgery-alone
Djarv [16] 2010	169	60	Prospective population based cohort	– Pre-treatment dyspnea was associated with shorter post-treatment survival – Better recovery of physical function, pain, and fatigue at 6 months post-treatment was associated with longer survival
Viklund [25] 2005	100	6	Prospective population based cohort	– Surgically related complications were main predictors of decreased QOL at 6 months (score of 54 from reference of 65) (p = 0.03)
Djarv [14] 2009	355	6	Prospective population based cohort	– Pre-treatment comorbidities, tumor stage III to IV, and tumor location in the middle and upper 1/3 of the esophagus were associated with poorer post-treatment HRQL – Patients with adenocarcinoma had better 6-month post-treatment HRQL than those with squamous cell carcinoma
Derogar [54] 2012	141	60	Prospective population based cohort	– Dyspnea (MD, 15; 95% CI, 6–23), fatigue (MD, 13; 95% CI, 5–20), and eating restrictions (MD, 10; 95% CI, 2–17) were clinically and statistically significantly deteriorated throughout the follow-up in patients with major postoperative complications compared with patients without major complications
Blazeby [20] 2005	103	22 (Chemoradiotherapy and surgery) 11 (Chemotherapy and surgery) 27 (Esophagectomy alone)	Prospective cohort	– Neoadjuvant therapy has a temporary negative effect on HRQL, most commonly related to treatment toxicity – Neoadjuvant therapy does not impair recovery of HRQL postoperatively
Zieren [55] 1996	149	12	Prospective cohort	– The most significant factors in reducing postoperative QOL was recurrence (p < 0.01) and anastomotic stricture (p < 0.05) – QOL decreased initially postoperatively, but was restored at 6 months in disease-free patients
McKernan [17] 2008	152	81	Prospective cohort	– On multivariate analysis, tumor stage (p < 0.001), operative treatment (p < 0.0001) and appetite loss (p < 0.0001) were independent predictors of cancer-specific survival
Parameswaran [23] 2010	62	12	Prospective cohort	– Patients had lower HRQL in the first 6 weeks following minimally invasive esophagectomy – HRQL scores returned to baseline at 6 months postoperatively and were maintained at 24 months
Healy [18] 2008	185	20	Prospective cohort	– Global QOL was associated with in-hospital mortality (p = 0.02) but not with major morbidity, cancer recurrence, or 1-year survival – On multivariate analysis, pre-treatment dyspnea predicted in-hospital mortality (p = 0.042) and pre-treatment fatigue was associated with reduce 1-year survival (p = 0.033)
Reynolds [21] 2006	202	12	Prospective cohort	– Neoadjuvant treatment reduced physical (p = 0.004) and role (p = 0.007) function prior to surgery while improving dyspnea (p = 0.043) – Esophagectomy negatively impacted HRQL scores at 3 months in both multimodal and surgery-alone groups, with improvement in scores at 6 months – At 12 months, global QOL was better in the multimodal group than in the surgery-alone group (P = 0.044)
Donohoe [56] 2011	132	70	Prospective cohort	– Global health status was significantly reduced at least 1 year after esophagectomy (mean ± SD score 48.4 ± 18.6) when compared to pre-treatment. The degree of subjective swallowing dysfunction was highly correlated with a poor QOL (Spearman’s ρ = 0.508, p < 0.01).
Egberts [57] 2008	105	24	Prospective cohort	– There was no statistically significant difference in any of the HRQL scales between patients with a cervical or a thoracic anastomosis.
Fujita [58] 1995	128	NR	Prospective cohort	– Three field lymphadenectomy resulted in similar HRQL to two field surgery

1. NR not reported