1. Assessment of quality of life of patients with gastric cancer after 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, PhD FMUP/ Serviço de Bioestatística e Informática Médica

2. Introduction 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

3. 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. Introduction

4. Introduction Rate of death is decreasing GASTRIC CANCER IN CANCER DEATH RATE (1973-92) http://plan1998.cancer.gov/PRGRES.html http://plan1998.cancer.gov/PRGRES.html (National Cancer Institute) Quality of life (QoL) is then particularly important in health care. [4] [4] Kaptein AA, Morita S, Sakamoto J. Quality of life in gastric cancer World J Gastroenterol 2005

5. 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. Introduction

6. 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. Aims

7. Methods 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.

8. Methods 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

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

10. Methods Articles search 1. Pubmed Key words   MESH (Medical Subject Headings) terms:. Quality of life. Gastrectomy. Stomach neoplasm   Limits of the research: Language: English Humans Publication Date: from 1950 to September 2005 Only items with abstracts

11. Methods : Query's Definition 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

12. Methods 2. Scopus Limits of the research: - year: until 2005; - areas: "health" e "life sciences"; - document type: "review" e "article" 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

13. Articles reached 173 + 189 = 362 362 - 102 (found in both searches) = 260 Pubmed 173 Scopus 189 102 71 87

14. Methods : Flow chart

15. Methods - Extracted 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

16. Results - Results - Description of questionnaires: validation Validated questionnaires Non-validated questionnaires

17. 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.

18. AuthorYearType of SurgeryInstruments Kahlke V.2004Total gastrectomyEORTC QLQ-C30 Hoksch B.2002 Total gastrectomy with Longmire's reconstruction without pouch EORTC QLQ-C30 / Food Consumption 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.1997 Total gastrectomy with Roux-en-Y and Longmire's reconstruction and subtotal gastrectomy with Billroth I and II Gastrointestinal QoL Index Spector NM.2002 Total gastrectomy with Roux-en-Y reconstruction and esophagogastrectomy Gastrointestinal QoL Index / Life After Gastroesophageal Surgery Results Description of questionnaires: main characteristics

19. Results Summary of QoL in validated questionaires QoL according to type of surgery and time after treatment * mean * (Preop. - preoperative values) Total GastrectomyDistal Gastrectomy Without pouchWith pouchWithout pylorus preservation Preop.6 months 12 months Preop.6 months 12 months Preop.6 months 12 months EORTC QLQ-C30 (0-100) Kahlke V., 2004 [20] 4853------- Hoksch B., 2002 [21] 664749555265--- Gastrointestinal QoL Índex (0-144) Jentschura D., 1997 [22] --105-----113 Spector NM., 2002 [23] -95 - ---- - - Kalmar K., 2001 [24] -96----- - -

20. 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. Conclusions

21. 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. Conclusions

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23. Website