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Long-term health-related quality of life following surgery for oesophageal cancer

Long-term health-related quality of life following surgery for oesophageal cancer Abstract Background The aim of the study was to assess health-related quality of life (HRQL) in patients with surgically cured oesophageal cancer. Methods A Swedish nationwide cohort of patients undergoing oesophagectomy for cancer between April 2001 and January 2004 was studied prospectively, and compared with a Swedish age- and sex-adjusted reference population. Validated European Organisation for Research and Treatment of Cancer quality of life questionnaires were used to assess HRQL at 6 months and 3 years after surgery. A mean score difference of 10 or more between groups was considered clinically relevant and tested further for statistical significance. Results Of 358 patients, 117 (32·7 per cent) survived for at least 3 years. Of these, 87 patients (74·4 per cent) responded to the questionnaires. Six months after surgery, most aspects of HRQL were substantially worse than in the reference population with no improvement at 3 years. Patients alive at 3 years reported significantly poorer role and social function, and significantly more problems with fatigue, diarrhoea, appetite loss, nausea and vomiting, than in the reference population. Conclusion HRQL in long-term survivors after oesophagectomy does not improve between 6 months and 3 years after surgery, and is worse than that in a comparable reference population. Introduction The effects of oesophagectomy on long-term health-related quality of life (HRQL) in patients cured surgically of oesophageal cancer deserve attention. Although surgery offers a chance of cure, it is associated with a substantial risk of tumour recurrence, typically occurring within 1 year, and more than 60 per cent of patients undergoing oesophagectomy die within 3 years1. Patients who survive for 3 years, however, may be considered cured, as late tumour recurrences are rare2. Oesophageal resection often entails high morbidity and a greatly reduced HRQL in the early postoperative years3,4. Population-based studies have shown that 6 months after surgery patients have a significantly poorer HRQL than a background population5. Little is known, however, about long-term HRQL in patients who are considered cured, with a long remaining life expectancy and a HRQL that is not affected by tumour recurrence. Specific symptoms, functions or problems related to oesophageal surgery may be transient or persistent. To address the hypothesis that HRQL improves gradually over time in patients with oesophageal cancer cured by surgery, a prospective population-based study of the postoperative development of HRQL among long-term survivors was undertaken, and their HRQL scores were compared with those of the background population. Methods A prospective, nationwide, population-based cohort study was carried out in Sweden between 2 April 2001 and 31 January 2007. All patients in Sweden with oesophageal cancer who had survived for at least 3 years after curative surgery (performed between 2 April 2001 and 31 January 2004) were eligible for inclusion in the study. Data were collected prospectively via the Swedish Oesophageal and Cardia Cancer Register, which included almost all eligible patients6. The means by which rapid case ascertainment and prospective data collection among surgically treated patients were achieved have been presented elsewhere5,7. Details of patient and tumour characteristics, surgical procedures and complications were collected from surgical, histopathological, endoscopic, radiological and intensive care unit records, and assessed using a standard protocol. Tumour location and stage were classified according to established definitions8,9. Mortality was determined by linkage to the complete Swedish Register of the Total Population. Informed consent was obtained from all patients before inclusion in the study, which was approved by the ethics committee of Karolinska University Hospital and the Karolinska Institute. Health-related quality of life measurements HRQL was assessed 6 months and 3 years after surgery by means of mailed self-administered questionnaires, developed and validated by the European Organisation for Research and Treatment of Cancer (EORTC). The EORTC Quality of Life Questionnaire (QLQ)-C30 version 3.010 was used to measure core aspects of HRQL, and site-specific issues were addressed by the oesophageal-specific module, QLQ-OES1811. The QLQ-C30 consisted of one global HRQL scale, five functional scales (physical, role, emotional, cognitive and social), three symptom scales (fatigue, nausea or vomiting, and pain) and six single items (sleeping disorders, appetite loss, dyspnoea, diarrhoea, constipation and financial problems). Each item had four response alternatives (1, not at all; 2, a little; 3, quite a bit; 4, very much), and the global quality of life scale had a seven-step scale ranging from very poor to excellent. The QLQ-OES18 included four symptom scales (dysphagia, eating difficulties, reflux and pain) and six single items (trouble swallowing saliva, choking, dry mouth, taste, cough and speech); response alternatives were as for the QLQ-C30. Statistical analysis All questionnaire responses were transformed linearly into scores on a 0–100 scale according to the EORTC scoring manual12. A high score on functional scales and the global HRQL scale represented a high level of function and better quality of life respectively, whereas a high score on symptom scales and items indicated increased symptoms. Mean scores with 95 per cent confidence intervals were calculated. To provide a surrogate baseline representing HRQL before the development of oesophageal cancer, a Swedish reference population for the QLQ-C30 was used13. This reference was matched with regard to age and all comparisons with this reference group were stratified by sex. No such reference population was available for the QLQ-OES18. Based on previous research14, a difference of at least 10 mean score points between time points or comparison groups was considered clinically relevant, and a difference of 5–10 was considered weak. When the mean scores differed by 10 points or more, a two-sample t test was used to examine statistical significance at the 0·050 level. Missing responses were handled according to the EORTC scoring manual12. All analyses were performed with the statistical software Stata® 9·2 (Stata Corporation, College Station, Texas, USA). Results During the study, 358 patients underwent potentially curative surgery for oesophageal cancer. Seventy-eight patients (21·8 per cent) died before the 6-month assessment and a further 163 (45·5 per cent) died within 3 years of oesophagectomy. The remaining 117 patients (32·7 per cent), who survived for at least 3 years after surgery, were eligible for inclusion in the questionnaire study. Of these, 93 (79·5 per cent) returned the 6-month questionnaires and 87 (74·4 per cent) the 3-year questionnaires. Reasons for non-participation at 6 months were administrative error (18 patients) or patient choice (six). Non-participation at 3 years was due to administrative error (20), patient choice (nine) and emigration (one). Only 78 of the 93 patients who responded at 6 months also completed the 3-year questionnaires and were eligible for analysis. Patient, tumour and treatment characteristics are shown in Table 1. Table 1 Patient and tumour characteristics for 87 patients with surgically cured oesophageal cancer . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) Values in parentheses are percentages. Open in new tab Table 1 Patient and tumour characteristics for 87 patients with surgically cured oesophageal cancer . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) Values in parentheses are percentages. Open in new tab There were no clinically relevant differences (score of 10 or more) in mean scores at 6 months and 3 years. In general, mean scores were similar between the two assessments (Table 2). For weak mean score differences (score 5–10), improvements in the general symptoms of fatigue, appetite loss, diarrhoea and financial difficulties were suggested, along with worsening of the oesophageal-specific symptoms of dysphagia, reflux and dryness of the mouth (Table 2). Between 6 months and 3 years after surgery, most patients remained at the same level of HRQL (mean score change within ± 10 points); the proportions of patients who improved or deteriorated were similar (Table 3). In terms of physical function, about half of the patients (50 per cent) stayed at the same level, and improvement or deterioration was seen in 30 and 18 per cent of patients respectively. Dysphagia improved in 29 per cent and deteriorated in 32 per cent. The greatest improvement was seen for fatigue (47 per cent) and oesophageal pain (45 per cent); 42 per cent of patients reported increased problems with reflux (Table 3). Table 2 Health-related quality of life scores in 87 patients with surgically cured oesophageal cancer . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) Values in parentheses are 95 per cent confidence intervals. * Weak mean score difference (5–10). Open in new tab Table 2 Health-related quality of life scores in 87 patients with surgically cured oesophageal cancer . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) Values in parentheses are 95 per cent confidence intervals. * Weak mean score difference (5–10). Open in new tab Table 3 Postoperative change in health-related quality of life between 6 months and 3 years in the 76 patients with oesophageal cancer who responded to both assessments . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) Values in parentheses are percentages. Owing to missing data total for each variable does not add up to 100 per cent. * Mean score deterioration of at least 10; † mean score change within ± 10; ‡ mean score improvement of at least 10 or within 10 points of maximum score. Open in new tab Table 3 Postoperative change in health-related quality of life between 6 months and 3 years in the 76 patients with oesophageal cancer who responded to both assessments . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) Values in parentheses are percentages. Owing to missing data total for each variable does not add up to 100 per cent. * Mean score deterioration of at least 10; † mean score change within ± 10; ‡ mean score improvement of at least 10 or within 10 points of maximum score. Open in new tab Compared with the overall results, stratification into sex and age groups (less than 60, 60–69, and 70 years or more), and separate analyses of patients with tumour stage 0–I or of those who had total gastrectomy alone for cardia cancer, did not reveal any clinically relevant differences (data not shown). When mean HRQL scores from the QLQ-C30 questionnaire at 3 years after oesophagectomy were compared with those in an age- and sex-matched random sample of the Swedish general population, both male and female cohort participants showed a clinically relevant and statistically poorer HRQL (Table 4). Scores were worse for role and social functions, fatigue, nausea and vomiting, appetite loss and diarrhoea in both sexes. Women in the cohort also reported a poorer global quality of life, and physical, emotional and cognitive function scores than the female reference population. Table 4 Health-related quality of life scores at 3 years in 87 patients with surgically cured oesophageal cancer compared with a reference Swedish population . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 Values in parentheses are 95 per cent confidence intervals. * Two-sample t test performed when mean scores differed by 10 points or more. Open in new tab Table 4 Health-related quality of life scores at 3 years in 87 patients with surgically cured oesophageal cancer compared with a reference Swedish population . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 Values in parentheses are 95 per cent confidence intervals. * Two-sample t test performed when mean scores differed by 10 points or more. Open in new tab Discussion In this population-based study of patients undergoing surgery for oesophageal cancer, HRQL was similar at 6 months and 3 years after surgery. HRQL for patients surviving for 3 years was also significantly poorer than that of the age- and sex-matched background population. The population-based and prospective design, in combination with a high participation frequency, serves to reduce the risk of selection bias and facilitates generalizability. Selection bias is probably not the explanation for the lack of improvement between 6 months and 3 years, as previous research has indicated that non-responders are more likely to have a poorer HRQL15. Moreover, there were no differences in clinical variables between patients who did and those who did not participate in the 3-year follow-up (data not shown). Other possible sources of selection bias are incomplete registration and non-participation; however, the number of registered patients showed good correspondence with the incidence and resection rate of oesophageal cancer in Sweden1, and the total participation rate was high. The risk of misclassification of HRQL was reduced by the use of questionnaires with documented good reliability and validity10,11. The lack of data for individual baseline HRQL is a disadvantage, but would not affect the main finding of the study—a lack of improvement between 6 months and 3 years after surgery. In addition, a large and randomly selected reference population, adjusted for age and sex, was used as a surrogate for individual baseline values. Such an approach may in fact be better than using preoperative HRQL as baseline, as patients' preoperative HRQL is likely to be affected substantially by the newly detected oesophageal cancer and impending major surgery. The use of HRQL reported by sex- and age-matched controls from the background population has been suggested by others to be a better alternative than individual preoperative HRQL data16. The 6-month time window was chosen carefully on the basis of previous research indicating that the acute postoperative phase will have subsided by 6 months4,17–19. The 3-year assessment was carried out at a time when the relative (disease specific) survival is similar to the survival of the background population in Sweden2. Finally, to minimize the risks arising from multiple testing, statistical analysis was performed only when differences between mean scores in the comparison groups were clinically relevant14. The finding of worsening of HRQL measures 6 months after oesophageal cancer surgery is in accordance with the available literature17,20–22. A smaller study has, however, provided conflicting results23. A novel finding is that this level of HRQL persists over time, and is lower than in the general population, notably among patients who have had curative surgery. Although HRQL usually deteriorates rapidly in patients with recurrent disease, patients with surgical cure of oesophageal cancer are thought to regain their baseline HRQL within 1–2 years of surgery3. In one UK study3, many aspects of HRQL had recovered to baseline levels by 3 years, but patients still had significantly poorer physical function, and more problems with diarrhoea, breathlessness and reflux than before surgery. Other studies have indicated quicker recovery after oesophageal cancer surgery, although methodological differences may explain these results20–22. There is no improvement in HRQL between 6 months and 3 years after surgery for oesophageal cancer, and patients report worse HRQL than an age- and sex-matched background population. This finding should help patients to be better informed, improve clinical decision making and follow-up, and facilitate the treatment of symptoms after surgery. Acknowledgements This study was funded by the Swedish Cancer Society. T.D. was supported by the Karolinska Institute, J.L. by the Swedish Research Council, and P.L. by the Swedish Cancer Society, Karolinska Institute and Karolinska University Hospital. References 1 Rouvelas I , Zeng W, Lindblad M, Viklund P, Ye W, Lagergren J. Survival after surgery for oesophageal cancer: a population-based study . Lancet Oncol 2005 ; 6 : 864 – 870 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Sundelof M , Ye W, Dickman PW, Lagergren J. Improved survival in both histologic types of oesophageal cancer in Sweden . Int J Cancer 2002 ; 99 : 751 – 754 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Lagergren P , Avery KN, Hughes R, Barham CP, Alderson D, Falk SJ et al. Health-related quality of life among patients cured by surgery for esophageal cancer . Cancer 2007 ; 110 : 686 – 693 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Blazeby JM , Sanford E, Falk SJ, Alderson D, Donovan JL. Health-related quality of life during neoadjuvant treatment and surgery for localized esophageal carcinoma . Cancer 2005 ; 103 : 1791 – 1799 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Viklund P , Lindblad M, Lu M, Ye W, Johansson J, Lagergren J. Risk factors for complications after esophageal cancer resection: a prospective population-based study in Sweden . Ann Surg 2006 ; 243 : 204 – 211 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Viklund P , Lindblad M, Lagergren J. Influence of surgery-related factors on quality of life after esophageal or cardia cancer resection . World J Surg 2005 ; 29 : 841 – 848 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Lagergren J , Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma . N Engl J Med 1999 ; 340 : 825 – 831 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Siewert JR , Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction . Br J Surg 1998 ; 85 : 1457 – 1459 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 9 Sobin LH , Wittekind C. International Union Against Cancer: TNM Classification of Malignant Tumours (6th edn). Wiley-Liss : New York , 2002 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 10 Aaronson NK , Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology . J Natl Cancer Inst 1993 ; 85 : 365 – 376 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Blazeby JM , Conroy T, Hammerlid E, Fayers P, Sezer O, Koller M et al. Clinical and psychometric validation of an EORTC questionnaire module, the EORTC QLQ-OES18, to assess quality of life in patients with oesophageal cancer . Eur J Cancer 2003 ; 39 : 1384 – 1394 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Fayers PM Aaronson N, Bjordal K, Groenvold M, Curran D, Bottomley A, on behalf of the EORTC Quality of Life Group . The EORTC QLQ-C30 Scoring Manual (3rd edn). European Organisation for Research and Treatment of Cancer : Brussels , 2001 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 13 Michelson H , Bolund C, Nilsson B, Brandberg Y. Health-related quality of life measured by the EORTC QLQ-C30—reference values from a large sample of Swedish population . Acta Oncol 2000 ; 39 : 477 – 484 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 14 Osoba D , Rodrigues G, Myles J, Zee B, Pater J. Interpreting the significance of changes in health-related quality-of-life scores . J Clin Oncol 1998 ; 16 : 139 – 144 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Blazeby JM , Nicklin J, Brookes ST, Winstone K, Alderson D. Feasibility of quality of life assessment in patients with upper gastrointestinal tract cancer . Br J Cancer 2003 ; 89 : 497 – 501 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Moraca RJ , Low DE. Outcomes and health-related quality of life after esophagectomy for high-grade dysplasia and intramucosal cancer . Arch Surg 2006 ; 141 : 545 – 549 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Blazeby JM , Farndon JR, Donovan J, Alderson D. A prospective longitudinal study examining the quality of life of patients with esophageal carcinoma . Cancer 2000 ; 88 : 1781 – 1787 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Zieren HU , Jacobi CA, Zieren J, Muller JM. Quality of life following resection of oesophageal carcinoma . Br J Surg 1996 ; 83 : 1772 – 1775 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Brooks JA , Kesler KA, Johnson CS, Ciaccia D, Brown JW. Prospective analysis of quality of life after surgical resection for esophageal cancer: preliminary results . J Surg Oncol 2002 ; 81 : 185 – 194 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Avery KN , Metcalfe C, Barham CP, Alderson D, Falk SJ, Blazeby JM. Quality of life during potentially curative treatment for locally advanced oesophageal cancer . Br J Surg 2007 ; 94 : 1369 – 1376 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Viklund P , Wengstrom Y, Rouvelas I, Lindblad M, Lagergren J. Quality of life and persisting symptoms after oesophageal cancer surgery . Eur J Cancer 2006 ; 42 : 1407 – 1414 . Google Scholar Crossref Search ADS PubMed WorldCat 22 de Boer AG , van Lanschot JJ, van Sandick JW, Hulscher JB, Stalmeier PF, de Haes JC et al. Quality of life after transhiatal compared with extended transthoracic resection for adenocarcinoma of the esophagus . J Clin Oncol 2004 ; 22 : 4202 – 4208 . Google Scholar Crossref Search ADS PubMed WorldCat 23 De Boer AG , Genovesi PI, Sprangers MA, Van Sandick JW, Obertop H, Van Lanschot JJ. Quality of life in long- term survivors after curative transhiatal oesophagectomy for oesophageal carcinoma . Br J Surg 2000 ; 87 : 1716 – 1721 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png British Journal of Surgery Oxford University Press

Long-term health-related quality of life following surgery for oesophageal cancer

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Publisher
Oxford University Press
Copyright
Copyright © 2022 BJS Society Ltd.
ISSN
0007-1323
eISSN
1365-2168
DOI
10.1002/bjs.6293
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See Article on Publisher Site

Abstract

Abstract Background The aim of the study was to assess health-related quality of life (HRQL) in patients with surgically cured oesophageal cancer. Methods A Swedish nationwide cohort of patients undergoing oesophagectomy for cancer between April 2001 and January 2004 was studied prospectively, and compared with a Swedish age- and sex-adjusted reference population. Validated European Organisation for Research and Treatment of Cancer quality of life questionnaires were used to assess HRQL at 6 months and 3 years after surgery. A mean score difference of 10 or more between groups was considered clinically relevant and tested further for statistical significance. Results Of 358 patients, 117 (32·7 per cent) survived for at least 3 years. Of these, 87 patients (74·4 per cent) responded to the questionnaires. Six months after surgery, most aspects of HRQL were substantially worse than in the reference population with no improvement at 3 years. Patients alive at 3 years reported significantly poorer role and social function, and significantly more problems with fatigue, diarrhoea, appetite loss, nausea and vomiting, than in the reference population. Conclusion HRQL in long-term survivors after oesophagectomy does not improve between 6 months and 3 years after surgery, and is worse than that in a comparable reference population. Introduction The effects of oesophagectomy on long-term health-related quality of life (HRQL) in patients cured surgically of oesophageal cancer deserve attention. Although surgery offers a chance of cure, it is associated with a substantial risk of tumour recurrence, typically occurring within 1 year, and more than 60 per cent of patients undergoing oesophagectomy die within 3 years1. Patients who survive for 3 years, however, may be considered cured, as late tumour recurrences are rare2. Oesophageal resection often entails high morbidity and a greatly reduced HRQL in the early postoperative years3,4. Population-based studies have shown that 6 months after surgery patients have a significantly poorer HRQL than a background population5. Little is known, however, about long-term HRQL in patients who are considered cured, with a long remaining life expectancy and a HRQL that is not affected by tumour recurrence. Specific symptoms, functions or problems related to oesophageal surgery may be transient or persistent. To address the hypothesis that HRQL improves gradually over time in patients with oesophageal cancer cured by surgery, a prospective population-based study of the postoperative development of HRQL among long-term survivors was undertaken, and their HRQL scores were compared with those of the background population. Methods A prospective, nationwide, population-based cohort study was carried out in Sweden between 2 April 2001 and 31 January 2007. All patients in Sweden with oesophageal cancer who had survived for at least 3 years after curative surgery (performed between 2 April 2001 and 31 January 2004) were eligible for inclusion in the study. Data were collected prospectively via the Swedish Oesophageal and Cardia Cancer Register, which included almost all eligible patients6. The means by which rapid case ascertainment and prospective data collection among surgically treated patients were achieved have been presented elsewhere5,7. Details of patient and tumour characteristics, surgical procedures and complications were collected from surgical, histopathological, endoscopic, radiological and intensive care unit records, and assessed using a standard protocol. Tumour location and stage were classified according to established definitions8,9. Mortality was determined by linkage to the complete Swedish Register of the Total Population. Informed consent was obtained from all patients before inclusion in the study, which was approved by the ethics committee of Karolinska University Hospital and the Karolinska Institute. Health-related quality of life measurements HRQL was assessed 6 months and 3 years after surgery by means of mailed self-administered questionnaires, developed and validated by the European Organisation for Research and Treatment of Cancer (EORTC). The EORTC Quality of Life Questionnaire (QLQ)-C30 version 3.010 was used to measure core aspects of HRQL, and site-specific issues were addressed by the oesophageal-specific module, QLQ-OES1811. The QLQ-C30 consisted of one global HRQL scale, five functional scales (physical, role, emotional, cognitive and social), three symptom scales (fatigue, nausea or vomiting, and pain) and six single items (sleeping disorders, appetite loss, dyspnoea, diarrhoea, constipation and financial problems). Each item had four response alternatives (1, not at all; 2, a little; 3, quite a bit; 4, very much), and the global quality of life scale had a seven-step scale ranging from very poor to excellent. The QLQ-OES18 included four symptom scales (dysphagia, eating difficulties, reflux and pain) and six single items (trouble swallowing saliva, choking, dry mouth, taste, cough and speech); response alternatives were as for the QLQ-C30. Statistical analysis All questionnaire responses were transformed linearly into scores on a 0–100 scale according to the EORTC scoring manual12. A high score on functional scales and the global HRQL scale represented a high level of function and better quality of life respectively, whereas a high score on symptom scales and items indicated increased symptoms. Mean scores with 95 per cent confidence intervals were calculated. To provide a surrogate baseline representing HRQL before the development of oesophageal cancer, a Swedish reference population for the QLQ-C30 was used13. This reference was matched with regard to age and all comparisons with this reference group were stratified by sex. No such reference population was available for the QLQ-OES18. Based on previous research14, a difference of at least 10 mean score points between time points or comparison groups was considered clinically relevant, and a difference of 5–10 was considered weak. When the mean scores differed by 10 points or more, a two-sample t test was used to examine statistical significance at the 0·050 level. Missing responses were handled according to the EORTC scoring manual12. All analyses were performed with the statistical software Stata® 9·2 (Stata Corporation, College Station, Texas, USA). Results During the study, 358 patients underwent potentially curative surgery for oesophageal cancer. Seventy-eight patients (21·8 per cent) died before the 6-month assessment and a further 163 (45·5 per cent) died within 3 years of oesophagectomy. The remaining 117 patients (32·7 per cent), who survived for at least 3 years after surgery, were eligible for inclusion in the questionnaire study. Of these, 93 (79·5 per cent) returned the 6-month questionnaires and 87 (74·4 per cent) the 3-year questionnaires. Reasons for non-participation at 6 months were administrative error (18 patients) or patient choice (six). Non-participation at 3 years was due to administrative error (20), patient choice (nine) and emigration (one). Only 78 of the 93 patients who responded at 6 months also completed the 3-year questionnaires and were eligible for analysis. Patient, tumour and treatment characteristics are shown in Table 1. Table 1 Patient and tumour characteristics for 87 patients with surgically cured oesophageal cancer . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) Values in parentheses are percentages. Open in new tab Table 1 Patient and tumour characteristics for 87 patients with surgically cured oesophageal cancer . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) . No. of patients . Sex  M 62 (71)  F 25 (29) Age (years)  < 60 27 (31)  60–69 28 (31)  70–84 32 (37) Co-morbidity  No 30 (34)  Yes 57 (66) Histological type of tumour  Adenocarcinoma and dysplasia 68 (78)  Squamous cell carcinoma 19 (22) Tumour location  Upper and middle oesophagus 12 (14)  Lower oesophagus 39 (45)  Cardia (Siewert II–III) 36 (41) Tumour stage  0–I 34 (39)  II 36 (41)  III 13 (15)  IV 3 (3)  Unknown 1 (1) Surgical approach  Transthoracic 68 (78)  Transhiatal (abdominal only) 19 (22) Substitute  Stomach 69 (79)  Jejunum 16 (18)  Colon 2 (2) Anastomosis  Stapled 56 (64)  Handsewn 31 (36) Complications  No 51 (59)  Yes 36 (41) Values in parentheses are percentages. Open in new tab There were no clinically relevant differences (score of 10 or more) in mean scores at 6 months and 3 years. In general, mean scores were similar between the two assessments (Table 2). For weak mean score differences (score 5–10), improvements in the general symptoms of fatigue, appetite loss, diarrhoea and financial difficulties were suggested, along with worsening of the oesophageal-specific symptoms of dysphagia, reflux and dryness of the mouth (Table 2). Between 6 months and 3 years after surgery, most patients remained at the same level of HRQL (mean score change within ± 10 points); the proportions of patients who improved or deteriorated were similar (Table 3). In terms of physical function, about half of the patients (50 per cent) stayed at the same level, and improvement or deterioration was seen in 30 and 18 per cent of patients respectively. Dysphagia improved in 29 per cent and deteriorated in 32 per cent. The greatest improvement was seen for fatigue (47 per cent) and oesophageal pain (45 per cent); 42 per cent of patients reported increased problems with reflux (Table 3). Table 2 Health-related quality of life scores in 87 patients with surgically cured oesophageal cancer . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) Values in parentheses are 95 per cent confidence intervals. * Weak mean score difference (5–10). Open in new tab Table 2 Health-related quality of life scores in 87 patients with surgically cured oesophageal cancer . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) . Mean score . . 6 months (n = 78) . 3 years (n = 87) . Global quality of life scale 66 (61, 71) 69 (64, 73) Functioning scales  Physical function 80 (75, 85) 81 (77, 85)  Role function 73 (67, 80) 74 (67, 80)  Emotional function 75 (69, 80) 77 (72, 82)  Cognitive function 82 (78, 87) 81 (77, 86)  Social function 76 (70, 82) 78 (72, 84) General symptom scales  Fatigue 40 (34, 47) 35 (29, 41)*  Nausea and vomiting 16 (11, 22) 15 (11, 19)  Pain 18 (12, 23) 16 (11, 21) General symptom items  Dyspnoea 25 (19, 31) 27 (21, 33)  Insomnia 22 (16, 28) 25 (18, 32)  Appetite loss 27 (20, 34) 18 (12, 25)*  Constipation 6 (2, 11) 10 (6, 15)  Diarrhoea 35 (28, 43) 29 (23, 35)*  Financial difficulties 15 (9, 21) 10 (5, 15)* Oesophageal-specific symptom scales  Dysphagia 16 (12, 21) 23 (16, 29)*  Eating difficulties 31 (25, 36) 28 (22, 33)  Reflux 29 (21, 36) 35 (28, 41)*  Oesophageal pain 23 (18, 28) 20 (15, 25) Oesophageal-specific items  Trouble swallowing saliva 11 (5, 17) 14 (9, 20)  Choking 18 (13, 24) 15 (10, 20)  Dry mouth 23 (16, 31) 32 (24, 39)*  Taste problems 17 (10, 24) 16 (11, 23)  Cough 24 (18, 31) 23 (17, 28)  Speech difficulties 10 (4, 15) 7 (3, 10) Values in parentheses are 95 per cent confidence intervals. * Weak mean score difference (5–10). Open in new tab Table 3 Postoperative change in health-related quality of life between 6 months and 3 years in the 76 patients with oesophageal cancer who responded to both assessments . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) Values in parentheses are percentages. Owing to missing data total for each variable does not add up to 100 per cent. * Mean score deterioration of at least 10; † mean score change within ± 10; ‡ mean score improvement of at least 10 or within 10 points of maximum score. Open in new tab Table 3 Postoperative change in health-related quality of life between 6 months and 3 years in the 76 patients with oesophageal cancer who responded to both assessments . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) . Worse* . Stable† . Improved‡ . Global quality of life scale 18 (24) 31 (41) 25 (33) Functioning scales  Physical function 14 (18) 38 (50) 23 (30)  Role function 19 (25) 26 (34) 28 (37)  Emotional function 13 (17) 35 (46) 25 (33)  Cognitive function 16 (21) 38 (50) 20 (26)  Social function 21 (28) 31 (41) 22 (29) General symptom scales  Fatigue 22 (29) 16 (21) 36 (47)  Nausea and vomiting 22 (29) 32 (42) 22 (29)  Pain 16 (21) 35 (46) 24 (32) General symptom items  Dyspnoea 16 (21) 46 (61) 12 (16)  Insomnia 22 (29) 30 (39) 22 (29)  Appetite loss 12 (16) 36 (47) 26 (34)  Constipation 11 (14) 55 (72) 6 (8)  Diarrhoea 14 (18) 34 (45) 25 (33)  Financial difficulties 8 (11) 52 (68) 14 (18) Oesophageal-specific symptom scales  Dysphagia 24 (32) 30 (39) 22 (29)  Eating difficulties 13 (17) 30 (39) 29 (38)  Reflux 32 (42) 16 (21) 25 (33)  Oesophageal pain 23 (30) 17 (22) 34 (45) Oesophageal-specific items  Trouble swallowing saliva 13 (17) 50 (66) 8 (11)  Choking 10 (13) 44 (58) 16 (21)  Dry mouth 18 (24) 39 (51) 14 (18)  Taste problems 10 (13) 45 (59) 15 (20)  Cough 14 (18) 42 (55) 17 (22)  Speech difficulties 5 (7) 58 (76) 10 (13) Values in parentheses are percentages. Owing to missing data total for each variable does not add up to 100 per cent. * Mean score deterioration of at least 10; † mean score change within ± 10; ‡ mean score improvement of at least 10 or within 10 points of maximum score. Open in new tab Compared with the overall results, stratification into sex and age groups (less than 60, 60–69, and 70 years or more), and separate analyses of patients with tumour stage 0–I or of those who had total gastrectomy alone for cardia cancer, did not reveal any clinically relevant differences (data not shown). When mean HRQL scores from the QLQ-C30 questionnaire at 3 years after oesophagectomy were compared with those in an age- and sex-matched random sample of the Swedish general population, both male and female cohort participants showed a clinically relevant and statistically poorer HRQL (Table 4). Scores were worse for role and social functions, fatigue, nausea and vomiting, appetite loss and diarrhoea in both sexes. Women in the cohort also reported a poorer global quality of life, and physical, emotional and cognitive function scores than the female reference population. Table 4 Health-related quality of life scores at 3 years in 87 patients with surgically cured oesophageal cancer compared with a reference Swedish population . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 Values in parentheses are 95 per cent confidence intervals. * Two-sample t test performed when mean scores differed by 10 points or more. Open in new tab Table 4 Health-related quality of life scores at 3 years in 87 patients with surgically cured oesophageal cancer compared with a reference Swedish population . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 . Mean score . Mean score . . Male study patients (n = 62) . Male reference 60–69 years (n = 278) . P* . Female study patients (n = 25) . Female reference 60–69 years (n = 271) . P* . Global quality of life scale 70 (64, 75) 77 64 (56, 73) 78 < 0·001 Functioning scales  Physical function 83 (78, 88) 88 77 (67, 85) 87 0·032  Role function 75 (67, 83) 87 0·003 71 (56, 85) 87 0·035  Emotional function 80 (74, 85) 86 70 (57, 82) 84 0·028  Cognitive function 82 (77, 87) 87 80 (70, 90) 90 0·056  Social function 77 (70, 84) 91 < 0·001 80 (68, 92) 92 0·015 General symptom scales  Fatigue 33 (26, 40) 20 < 0·001 39 (28, 51) 20 0·002  Nausea and vomiting 13 (8, 18) 2 < 0·001 21 (11, 32) 3 0·002  Pain 15 (9, 21) 18 21 (11, 31) 21 General symptom items  Dyspnoea 28 (21, 35) 19 25 (10, 40) 16  Insomnia 22 (14, 29) 17 32 (18, 49) 23  Appetite loss 15 (9, 21) 2 < 0·001 22 (8, 37) 4 0·015  Constipation 8 (4, 13) 4 16 (6, 26) 9  Diarrhoea 28 (20, 35) 5 < 0·001 31 (18, 44) 4 < 0·001  Financial difficulties 11 (5, 17) 5 9 (1, 19) 7 Values in parentheses are 95 per cent confidence intervals. * Two-sample t test performed when mean scores differed by 10 points or more. Open in new tab Discussion In this population-based study of patients undergoing surgery for oesophageal cancer, HRQL was similar at 6 months and 3 years after surgery. HRQL for patients surviving for 3 years was also significantly poorer than that of the age- and sex-matched background population. The population-based and prospective design, in combination with a high participation frequency, serves to reduce the risk of selection bias and facilitates generalizability. Selection bias is probably not the explanation for the lack of improvement between 6 months and 3 years, as previous research has indicated that non-responders are more likely to have a poorer HRQL15. Moreover, there were no differences in clinical variables between patients who did and those who did not participate in the 3-year follow-up (data not shown). Other possible sources of selection bias are incomplete registration and non-participation; however, the number of registered patients showed good correspondence with the incidence and resection rate of oesophageal cancer in Sweden1, and the total participation rate was high. The risk of misclassification of HRQL was reduced by the use of questionnaires with documented good reliability and validity10,11. The lack of data for individual baseline HRQL is a disadvantage, but would not affect the main finding of the study—a lack of improvement between 6 months and 3 years after surgery. In addition, a large and randomly selected reference population, adjusted for age and sex, was used as a surrogate for individual baseline values. Such an approach may in fact be better than using preoperative HRQL as baseline, as patients' preoperative HRQL is likely to be affected substantially by the newly detected oesophageal cancer and impending major surgery. The use of HRQL reported by sex- and age-matched controls from the background population has been suggested by others to be a better alternative than individual preoperative HRQL data16. The 6-month time window was chosen carefully on the basis of previous research indicating that the acute postoperative phase will have subsided by 6 months4,17–19. The 3-year assessment was carried out at a time when the relative (disease specific) survival is similar to the survival of the background population in Sweden2. Finally, to minimize the risks arising from multiple testing, statistical analysis was performed only when differences between mean scores in the comparison groups were clinically relevant14. The finding of worsening of HRQL measures 6 months after oesophageal cancer surgery is in accordance with the available literature17,20–22. A smaller study has, however, provided conflicting results23. A novel finding is that this level of HRQL persists over time, and is lower than in the general population, notably among patients who have had curative surgery. Although HRQL usually deteriorates rapidly in patients with recurrent disease, patients with surgical cure of oesophageal cancer are thought to regain their baseline HRQL within 1–2 years of surgery3. In one UK study3, many aspects of HRQL had recovered to baseline levels by 3 years, but patients still had significantly poorer physical function, and more problems with diarrhoea, breathlessness and reflux than before surgery. Other studies have indicated quicker recovery after oesophageal cancer surgery, although methodological differences may explain these results20–22. There is no improvement in HRQL between 6 months and 3 years after surgery for oesophageal cancer, and patients report worse HRQL than an age- and sex-matched background population. This finding should help patients to be better informed, improve clinical decision making and follow-up, and facilitate the treatment of symptoms after surgery. Acknowledgements This study was funded by the Swedish Cancer Society. T.D. was supported by the Karolinska Institute, J.L. by the Swedish Research Council, and P.L. by the Swedish Cancer Society, Karolinska Institute and Karolinska University Hospital. References 1 Rouvelas I , Zeng W, Lindblad M, Viklund P, Ye W, Lagergren J. Survival after surgery for oesophageal cancer: a population-based study . Lancet Oncol 2005 ; 6 : 864 – 870 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Sundelof M , Ye W, Dickman PW, Lagergren J. Improved survival in both histologic types of oesophageal cancer in Sweden . Int J Cancer 2002 ; 99 : 751 – 754 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Lagergren P , Avery KN, Hughes R, Barham CP, Alderson D, Falk SJ et al. 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Quality of life after transhiatal compared with extended transthoracic resection for adenocarcinoma of the esophagus . J Clin Oncol 2004 ; 22 : 4202 – 4208 . Google Scholar Crossref Search ADS PubMed WorldCat 23 De Boer AG , Genovesi PI, Sprangers MA, Van Sandick JW, Obertop H, Van Lanschot JJ. Quality of life in long- term survivors after curative transhiatal oesophagectomy for oesophageal carcinoma . Br J Surg 2000 ; 87 : 1716 – 1721 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Journal

British Journal of SurgeryOxford University Press

Published: Aug 8, 2008

Keywords: esophageal cancer; surgical procedures, operative; quality of life; surgery specialty; health-related quality of life; diarrhea; fatigue; desire for food; appetite or desire; cancer; esophagectomy; nausea and vomiting; organizations; survivors

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