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