Assessment of quality of life of patients with gastric cancer after surgery: a systematic review a systematic review Ana Marques; Mylene Costa; Natália.

Assessment of quality of life of Assessment of quality of life of patients with gastric cancer after patients with gastric cancer after

surgery:surgery:

a systematic review a systematic review

Ana Marques; Mylene Costa; Natália Ferreira; Paula Campelo; Paula Moreira;

Paulo Leandro; Pedro Barbosa; Pedro Mendes [Class 17 – 1st year]

Supervisors: Claúdia Dias and Mário Ribeiro MD, PhDFMUP/ Serviço de Bioestatística e Informática Médica

IntroductionIntroduction

Meta-analysis, a final step in a systematic review:

“(…) statistical pooling of data across studies to generate summary estimates of effects .” [1]

“(…) the term “effect” refers to any measure of association between exposure and outcome” [1]

[1] Pai M, The National Medical Journal of India Vol.17 No.2,2004

Gastric cancer as:

•A malignant cell growth in the stomach;•Second leading cause of cancer deaths worldwide [2];

Surgery as the major way for treatment [3]:

• Distal gastrectomy without or with pylorus preservation;• Total gastrectomy without or with pouch;• Endoscopic mucosal resection or limited resections • Proximal gastrectomy

[2] Plummer M, Epidemiology of gastric cancer IARC Sci Publ. 2004;(157):311-26.[3] Roukos DH. Ann Surg Oncol. 1999 Jan-Feb;6(1):46-56. Review.

IntroductioIntroductionn

IntroductioIntroductionn

Rate of death is decreasing

GASTRIC CANCER IN CANCER DEATH RATE (1973-92)

http://plan1998.cancer.gov/PRGRES.html (National Cancer Institute)

Quality of life (QoL) is then particularly important in health care. Quality of life (QoL) is then particularly important in health care. [4][4]

[4] Kaptein AA, Morita S, Sakamoto J. Quality of life in gastric cancer World J Gastroenterol 2005

-60 -40 -20 0 20 40 60

Lung

prostate

lymphoma

liver

brain

colon and rectum

breast

pancreas

leucemia

stomach

ovary

uterus

Can

cer

loca

lizat

ion

Percent Change

Quality of life (QoL):

“The functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient.” [5]

“The degree to which a person enjoys the important possibilities of his or her life.” [6]

Instruments for studying QoL:

• Questionnaires• Interviews • Physical examination and laboratory tests

[5]Schipper H. Spilker B Philadelphia: Lippincott-Raven, 1996[6]Qualitty of life Research Unit, University of Toronto, www.gdrc.org/uem/qol-define.html.

IntroductionIntroduction

•Clarify reproducibility and validity of the instruments used to assess QoL in studies evaluating patients submitted to surgery for gastric adenocarcinoma.

•Summarize QoL in studies using validated questionnaires.

AimsAims

MethodsMethods

Type of study:

• Systematic review

Target population:

• Population with gastric cancer that have been submitted to a gastrectomy;

Inclusion criteria of the articles:

Include a population with gastric cancer that have been submitted to a gastrectomy;

Include post-surgery QoL evaluation; With abstracts.

MethodsMethods

Exclusion criteria of the articles:

Title: Refer to radiotherapy / chemotherapy exclusively

Abstract:• If there is only one case in study• Not refer to a post-operative instrument • Not approach QoL in a global view• If patients with gastric cancer were part of a large group of patients

with various other types of cancer

Full article: Not have access to article Not describe the patients studied Not refer QoL assessment Not have retrievable data

MethodMethodss

Quality of articles:

Consider a valid article if:- describe the patients studied;- refer the stage of disease;- refer the instrument used;- questionnaire is valid.

MethodMethodssArticles searchArticles search

1.1. PubmedPubmed• Key words

MESH (Medical Subject Headings) terms:

. Quality of life

. Gastrectomy

. Stomach neoplasm

Limits of the research:

Language: EnglishHumansPublication Date: from 1950 to September 2005Only items with abstracts

Methods : Methods : Query's Query's DefinitionDefinition

Pubmed

("Quality of Life" [MeSH] OR quality of life) AND ("Stomach Neoplasms" [MeSH]

OR stomach neoplasms OR gastric cancer OR stomach carcinoma) NOT

intestinal cancer AND ("Gastrectomy" [MeSH] OR gastrectomy OR gastric

surgery) NOT chemotherapy NOT radiotherapy

173 articles found

MethodsMethods

2. Scopus2. Scopus

Limits of the research:

- year: until 2005; - areas: "health" e "life sciences";

- document type: "review" e "article"

Query´s definition:Query´s definition:

TITLE-ABS-KEY("Quality of life") AND TITLE-ABS-KEY(("stomach neoplasms")

OR ("gastric cancer") OR ("stomach carcinoma")) AND NOT (intestinal cancer)

AND TITLE-ABS-KEY(("gastrectomy") OR ("gastric surgery")) AND NOT

(chemotherapy) AND NOT (radiotherapy)

189 articles found

Articles reachedArticles reached173 + 189 = 362173 + 189 = 362

362 - 102 (found in both searches) = 260362 - 102 (found in both searches) = 260

Pubmed173

Scopus189

10271 87

Methods : Methods : Flow chartFlow chart

Start

Pubmed search

Scopus search

Read titles and abstracts

No Yes

Apply exclusion criteria

Include articles not found at Pubmed

search

Excluded by 2 revisors?

76 Articles included

184 Articles excluded

Read full article

Apply exclusion criteria

Excluded by 2 revisors?

5 Articles included

71 Article excluded

NoYes

End

260 articlesreached

· Patients without gastric cancer or not gastrectomized (44,0 %)

· QoL after surgery wasn't evaluated (38,0 %)

· Refer to radio/chemotherapy (0,5 %)

· There is only one case in study (0,5 %)

· Do not use a instrument (questionnaire) (14,7 %)

· Do not approach QoL in a global view (0,5 %)

· Do not have abstract (1,6 %)

· Questionnaire is not validated (45,1%)

· Not refer QoL assessment (4,2%)

· Not have retrievable data (7,0%)

· Not have access to article (43,7%)

Methods - Methods - Extracted dataExtracted data

Extracted data:

- Geographical setting

- Characteristics of patients: - stage of disease at diagnosis

- Number of patients studied

- Questionnaires

- Type of surgery

- Timing of assessment of QoL

Results Results - - Description of questionnaires: validation

Validated questionnaires

Non-validated questionnaires

Results Results - - Description of questionnaires: validation

• Validity of the instruments used

• We found 40 different questionnaires.

• Only a minor part of them were validated (18%).

• There was a great a number of single time used questionnaires (19).

• In the 5 included articles were represented only 2 kinds of questionnaires: EORTC QLQ-C30 and Gastrointestinal QoL Index.

Questionnaires Validation

18%

82%

Validatedquestionnaires

Non-validatedquestionnaires

Author Year Type of Surgery Instruments

Kahlke V. 2004 Total gastrectomy EORTC QLQ-C30

Hoksch B. 2002Total gastrectomy with Longmire's

reconstruction without pouchEORTC QLQ-C30 / FoodConsumption Patterns

Kalmar K. 2001

Total gastrectomy with esophagojejunostomy and aboral pouch

reconstruction and Total gastrectomy with simple Roux-en-Y reconstruction

Gastrointestinal QoL Index

Jentschura D.

1997Total gastrectomy with Roux-en-Y and Longmire's reconstruction and subtotal

gastrectomy with Billroth I and IIGastrointestinal QoL Index

Spector NM. 2002Total gastrectomy with Roux-en-Y

reconstruction and esophagogastrectomy

Gastrointestinal QoL Index / Life After

Gastroesophageal Surgery

ResultsResultsDescription of questionnaires: main characteristics

ResultsResultsSummary of QoL in validated questionaires

QoL according to type of surgery and time after treatment * mean * (Preop. - preoperative values)

Total Gastrectomy Distal Gastrectomy

Without pouch With pouch Without pylorus preservation

Preop. 6 months12

monthsPreop. 6 months

12 months

Preop. 6 months12

months

EORTC QLQ-C30 (0-100)

Kahlke V., 2004 [20]

48 53 - - - - - - -

Hoksch B., 2002 [21]

66 47 49 55 52 65 - - -

Gastrointestinal QoL Índex (0-144)

Jentschura D., 1997 [22]

- - 105 - - - - - 113

Spector NM., 2002 [23]

- 95 - - - - - - -

Kalmar K., 2001 [24]

- 96 - - - - - - -

Clarify reproducibility and validity of the instruments used to assess QoL in studies evaluating patients submitted to surgery for gastric adenocarcinoma.

1.There is a great diversity of questionnaires used to assess QoL after surgery for gastric cancer;

2.Most studies use questionnaires that were not previously validated (82%).

3.The same questionnaire is used across different studies rarely.

ConclusionsConclusions

Summarize QoL in studies using validated questionnaires.

4.A summary pooled result for QoL after surgery for gastric adenocarcinoma was not possible to obtain.

5.Nevertheless, by observing the preoperative values, we can conjecture the existence of a slight decreasing of QoL after surgery followed by a more or less obvious recovery.

6.It is possible to see some benefit in the use of a pouch after total gastrectomy.

7.Further studies would be needed in order to give a more conclusive answer to the questions we raise, preferably using validated EORTC QLQ-C30 or Gastrointestinal QoL Index where the collected data could be fully used in further reviews.

ConclusionsConclusions

GGanttantt ChartChart

WebsiteWebsite