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Health-related quality of life in patients with oesophageal- and gastric cancer Lovisa Backemar, MD Surgical Care Sciences Department of Molecular Medicine and Surgery
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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 Lovisa Backemar2
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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 3
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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 Lovisa Backemar4
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Examples of PROs EORTC QLQ-C30 15 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 Lovisa Backemar5
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Scores 0-100 6
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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 Lovisa Backemar7 (Osoba et al. J Clin Oncol 1998)
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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 Lovisa Backemar8
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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) 9 Gastric cancer Age (older than 65) (Jakstaite et al. BMC Surg 2012) Lovisa Backemar
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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! 10Lovisa Backemar
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Neoadjuvant therapy vs surgery alone 11 (Blazeby et al Cancer 2005) Global QoLNausea/vomiting 21 patients - Surgery alone 34 patients - CRT + surgery 48 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 Lovisa Backemar
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Impact of neoadjuvant therapy on HRQOL over time cont. 12 (van Meerten et al. Int J Radiation Oncology Biol Phys 2008) Fatigue Global QoL 54 patients - CRT + surgery Similar trends for nausea, pain, dyspnoea and appetite loss Post-CRT = 1 week Lovisa Backemar
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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) Lovisa Backemar13
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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! Lovisa Backemar14
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3. Impact of surgery on HRQOL cont. Laparoscopy-assisted gastrectomy Better HRQOL 3 month after surgery compared to open Lovisa Backemar15 (Kim et al. Ann Surg 2008)
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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) Lovisa Backemar16
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4. Long-term impact of oesophageactomy on HRQOL cont. Baselin e score Higher score = better function * p 0.007 Preoperative score * * p 0.0008 * Preoperative score (Lagergren P et al. Cancer 2007) Lovisa Backemar17
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4. Long-term impact of oesophageactomy on HRQOL cont. Higher score = more symptoms * * p 0.0001 * 75 % of the patients (Lagergren P et al. Cancer 2007) Lovisa Backemar18
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Lovisa Backemar19 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)
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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) Lovisa Backemar (Derogar M et al. J Clin Oncol 2012) 20
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5. HRQOL among long-term survivors cont. Lovisa Backemar *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 functionDifficulty eating
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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 Lovisa Backemar22
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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 Lovisa Backemar (Djärv T et al, J Clin Oncol 2010, Blazeby JM et al. Gut 2001) 23
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6. HRQOL as a prognostic factor cont. Difference in survival - Physical function Difference in survival - Pain Number of years Stable or improvedDeteriorated (Djärv T et al J Clin Oncol 2010) Changes over time to 6 months after surgery cont. Lovisa Backemar24
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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 Lovisa Backemar (Djärv T et al EJC 2011) 25
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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 Lovisa Backemar26
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