Health-related quality of life in patients with oesophageal- and gastric cancer Lovisa Backemar, MD Surgical Care Sciences Department of Molecular Medicine and Surgery
Jan 18, 2016
Health-related quality of life in patients with oesophageal- and gastric cancer
Lovisa Backemar, MD
Surgical Care Sciences
Department of Molecular Medicine and Surgery
Outline
Patient-reported outcomes (PROs) PRO research in oesophageal and gastric cancer
Predictors of poor HRQOL after surgery Neoadjuvant therapy Impact of surgery Long-term impact HRQOL among long-term survivors HRQOL as prognostic factor
Summery
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Lovisa Backemar
My whole life is ruined!
Mr X, everything is perfectly alright. The
cancer is gone!I have no appetite
I have no energy
I cannot sleep
© Pernilla Lagergren
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Why PROs?
Evaluate clinical treatment results Inform patients before and after treatment Clinical decision-making Form models of care and rehabilitation programs Prognostic factor
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Examples of PROs
EORTC QLQ-C3015 outcomes (global HRQL, functions; physical, role,
social, emotional, cognitive and symptoms EORTC QLQ-OG25
16 outcomes (oesophago-gastric symptoms) Hospital anxiety and depression scale (HADS)
Anxiety and depression evaluation Benefit finding scale
Positive aspects of the disease event
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Scores 0-100
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Clinical relevant difference in HRQOL
A level of change/difference noticeable for the patient 10% = moderate 20% = large
Statistical significance vs clinical significance
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(Osoba et al. J Clin Oncol 1998)
PRO research in oesophageal- and gastric cancer
1. Predictors of poor HRQOL after surgery
2. Neoadjuvant therapy
3. Impact of surgery
4. Long-term impact
5. HRQOL among long-term survivors
6. HRQOL as prognostic factor
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1. Predictors of poor HRQOL
Oesophageal cancer Comorbidities (yes) Histology (SCC) Tumour stage (III+IV) Tumour location (proximal) (Djärv et al. J Clin Oncol 2009)
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Gastric cancer Age (older than 65)
(Jakstaite et al. BMC Surg 2012)
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2. Neoadjuvant therapy
Negative impact during therapy Recovery before surgery No major influence postoperatively (Blazeby JM et al Cancer 2005, Reynolds JV et al. BJS 2006, van Meerten et al. Int J Radiation Oncology Biol Phys 2008,
Safiddine N et al J Thorac Cardiovasc Surg 2009, Scarpa et al J Gastrointest Surg 2013)
Increased risk of malnutrition (Martin L et al. Br J Surg 2008)
Lack of randomised clinical trials!
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Neoadjuvant therapy vs surgery alone
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(Blazeby et al Cancer 2005)
Global QoL Nausea/vomiting
21 patients - Surgery alone 34 patients - CRT + surgery48 patients - Chemotherapy + surgery
Similar trends for social, role and physical function
Similar trends for dyspnoea, diarrhoea, taste, cough, and dry mouth
High scores = better QoL / worse symptoms
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Impact of neoadjuvant therapy on HRQOL over time cont.
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(van Meerten et al. Int J Radiation Oncology Biol Phys 2008)
FatigueGlobal QoL
54 patients - CRT + surgery
Similar trends for nausea, pain, dyspnoea and appetite loss
Post-CRT = 1 week
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3. Impact of esopgagectomy on HRQOL
Negative impact Surgical procedure itself Postoperative complications
Short- and long-term Dyspnoea, fatigue, eating difficulties, sleeping problems, reflux
(Derogar et al J Clin Oncol 2012, Rutegård M et al. Br J Surg
2008)
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3. Impact of oesphagectomy on HRQOL cont.
Minimally invasive surgery oesophagectomy
Earlier recovery BUT:
Early tumours and HGD patients were included Generic instrument was used (SF 36)
(Luketich JD et al. Ann Surg 2003)
No differences BUT:
Retrospective study One center study
(Sundaram A et al Surg Endosc 2012)
Lack of randomised clinical trials with HRQL!
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3. Impact of surgery on HRQOL cont.
Laparoscopy-assisted gastrectomy
Better HRQOL 3 month after surgery compared to open
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(Kim et al. Ann Surg 2008)
4. Long-term impact of oesophageactomy on HRQOL
Much worse HRQOL than the general population at 6 months and 3 years postoperatively
No improvements between 6 months and 3 years post-operatively
(Djärv T et al. BJS 2008)
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4. Long-term impact of oesophageactomy on HRQOL cont.
020
4060
8010
0
0 1.5 3 6 9 12 18 24 36Time in months
Physical function in mean scores
Baseline score
Higher score = better function
* p 0.0070
2040
6080
100
0 1.5 3 6 9 12 18 24 36Time in months
Emotional function in mean scores
Preoperative score*
* p 0.0008
*
Preoperative score
(Lagergren P et al. Cancer 2007)
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4. Long-term impact of oesophageactomy on HRQOL cont.
020
4060
8010
0
0 1.5 3 6 9 12 18 24 36Time in months
Reflux in mean scores
Higher score = more symptoms
*
* p 0.0001
* 75 % of the patients
(Lagergren P et al. Cancer 2007)
020
4060
8010
0
0 1.5 3 6 9 12 18 24 36Time in months
Dysphagia in mean scores
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4. Long-term impact of gastrectomy on HRQOL
Only few small studies Problems sleeping, eating, distress.
But physical and social functioning, energy and vitality the same(TyrvainenT et al. J Surg Onc 2008)
Worse to 6 months -> stable Patients who die within 2 years
experience limited postoperative recovery
(Avery et al Eur J Cancer surg 2009)
5. HRQOL among long-term survivors
Patients who improve or are stable report HRQOL comparable to the background population for most measures at 5 years
Patients who deteriorate over time report clinically and statistically significant much worse for all functions (range -23 to -45) and symptoms (range 25 to 59)
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(Derogar M et al. J Clin Oncol 2012)
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5. HRQOL among long-term survivors cont.
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*Adjusted for age, sex and comorbidity. Based on 117 patients and 4910 background people
HRQOL 5 years after surgery compared to the background population
Physical function Difficulty eating
6. HRQOL as a prognostic factor
HRQOL before surgery Improved survival
Good physical function Good role function Good global quality of life
Increased mortality Fatigue Appetite loss Dyspnoea Pain
Blazeby JM et al, Gut 2001
Chau I et al JCO 2004
Blazeby JM et al, BJS 2005
McKernan M et al BJC 2008
Quinten C et al Lancet Oncol 2009
Djärv T et al J Clin Oncol 2010
van Heijl M et al Ann Surg Oncol 2010
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6. HRQOL as a prognostic factor cont.
Changes over time to 6 months after surgery Relation to longer survival time
Improvement in physical function Improvement in emotional function
Relation to higher risk of mortality Worsening in fatigue Worsening in pain
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(Djärv T et al, J Clin Oncol 2010, Blazeby JM et al. Gut 2001)
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6. HRQOL as a prognostic factor cont.
Difference in survival - Physical function Difference in survival - Pain
Number of years Number of years
Stable or improved Deteriorated Stable or improved Deteriorated
(Djärv T et al J Clin Oncol 2010)
Changes over time to 6 months after surgery cont.
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6. HRQOL as a prognostic factor cont.
Postoperative HRQOL Physical function, role function, global quality of life
50-60% increased risk Fatigue, pain, dyspnoea, appetite loss, dysphagia,
odynophagia 30-70% increased risk
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(Djärv T et al EJC 2011)
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Summary
Patients with oesophageal and gastric cancer have a reduced HRQOL in a short and long-term postoperative perspective
Comorbidity, histological type, tumour stage and tumour location predict HRQOL
Complications strongly predict poor HRQOL Most patients recover their HRQOL within 5 years after surgery A sub-group of long-term survivors strongly deteriorate in HRQOL HRQOL measurements may predict survival
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Thank you