Quality of Life in Patientswith Esophageal Cancer

Gail E. Darling, MD, FRCSC

KEYWORDS

� Esophageal cancer � Health-related quality of life � Dysphagia � Esophagectomy � EORTC QLQ-30� OES-18 � FACT-E � Palliation

KEY POINTS

� Patient perception of health-related quality of life (HRQOL) is the outcome of interest, not that of thehealth care professional, family, or caregiver.

� HRQOL is more than a list of symptoms, and although symptoms of the disease or treatment mayaffect HRQOL, other factors contribute and may be even more important.

� HRQOL assessed in longterm followup after esophagectomy is similar to the normal population.

� HRQOL assessed in early follow-up of patients treated with definitive chemoradiation may be betterthan in patients treated with surgery alone or chemoradiation followed by surgery, but survival maybe superior in patients whose treatment includes surgery.

� HRQOL recovers more quickly after minimally invasive surgery or transhiatal esophagectomy thanafter open esophagectomy.

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INTRODUCTION

Esophageal cancer has a significant effect onquality of life (QOL). Most patients present formedical attention because of dysphagia. Althoughdysphagia is just one symptom of esophagealcancer, it has a significant adverse effect onQOL, not just because of the physical problem ofdifficulty swallowing or the weight loss that mayresult, but because sharing a meal with friends orfamily is a social event, and inability to swallowcomfortably or regurgitation of food may lead towithdrawal from social situations and isolation.Sadness or depression may result irrespective ofthe cancer prognosis.

Evaluating outcomes of cancer therapy hasprimarily focused on effectiveness in terms of sur-vival, the side effects of treatment, and treatment-related mortality. It is only in the past decade orso that health-related quality of life (HRQOL) hasbeen recognized as an important outcome mea-sure of therapy for esophageal cancer, particularly

Division of Thoracic Surgery, Department of Surgery, ToUniversity of Toronto, 200 Elizabeth Street, 9N-955, ToroE-mail address: gail.darling@uhn.ca

Thorac Surg Clin 23 (2013) 569–575http://dx.doi.org/10.1016/j.thorsurg.2013.07.0111547-4127/13/$ – see front matter � 2013 Elsevier Inc. All

because of the low rate of cure in esophageal can-cer despite aggressive therapies. For many pa-tients, cure of their cancer may make toxicity oftreatment acceptable, but the investment of timeand the side effects of treatment may be lessacceptable if the cancer is not cured.

It is the patient’s perspective that is most impor-tant in assessing QOL, not the perception of thespouse, family, friend, or health care professional.Therefore, HRQOL questions must be answeredby the patient, and many HRQOL instruments areself-administered. HRQOL assessment evaluateshow the patient’s health state affects their QOL.Although symptoms may adversely impact QOL,HRQOL is not just a list of symptoms (either ofthe disease or its treatment), but also evaluatesvarious domains, including physical aspects offunction, social functioning, emotional well-being,and functional abilities. This article focuses onthe assessment of HRQOL in patients with esoph-ageal cancer after both curative- and palliative-intent therapy.

ronto General Hospital, University Health Network,nto, Ontario M5G 2C4, Canada

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HRQOL INSTRUMENTS

QOL instruments include generic and disease-specific instruments. The Medical OutcomesStudy 36 Item Short Form Health Survey (MOSSF-36) has been used to assess HRQOL acrossa broad range of diseases and conditions.1,2 Thisinstrument is useful in comparing HRQOL in a pop-ulation of patients with a specific disease relativeto the general population, or comparing HRQOLin patients with different health conditions. TheMOS SF-36 assesses 8 health domains (physicalfunction, role physical, pain, general health per-ception, energy/vitality, social functioning, roleemotional, and mental health) and provides 2 sum-mary measures of physical and mental well-being.Disease-specific HRQOL instruments are used

for specific disease states. In esophageal cancer,the most common instrument used is theEuropeanOrganization forResearchandTreatmentof Cancer (EORTC) QLQ (quality of lifequestionnaire)-30 with the esophageal cancerdisease-specific module OES (oesophageal)-18(previously the OES-24). Using a 4-point Likertscale, the EORTC QLQ-30 includes 5 functionalscales (physical function, emotional function, socialfunction, cognitive function, and role function) and3symptom scales (fatigue, nausea, and pain). Thereare 6 single-item questions (regarding dyspnea,insomnia, appetite, constipation, diarrhea, andfinancial worries), which are also evaluated using a4-point Likert scale. Global QOL is assessed by asingle question using a 7-point Likert scale. Theesophagealmodule (OES-18) includes 18 items ad-dressing areas such as dysphagia, swallowing,choking, eating, reflux, taste, abdominal pain, ody-nophagia, dry mouth, cough, and voice difficulties.TheOG (oesophageal-gastric)-25 is a similar instru-ment devised for esophagogastric tumors.3,4

The Functional Assessment of Cancer Therapy-General (FACT-G)may be used to evaluate HRQOLfor any cancer and consists of 28 questionscovering the domains of physical well-being, func-tional well-being, social well-being, and emotionalwell-being using a 5-point Likert scale. A majordifference between the FACT-G and the EORTCQLQ-30 is the assessment of global HRQOL,whichis evaluated by a single question in the EORTCQLQ-30, whereas the FACT-G uses a summationof the 4 subscales to generate a global QOL score.5

A disease-specific module is added for esopha-geal cancer, which consists of 17 items addressingareas such as eating, swallowing, enjoymentof food, voice, dry mouth, appetite, cough,choking, and pain, each evaluated using a 5-pointLikert scale to generate a summary score ofesophageal-specific concerns.6

In addition to these QOL instruments, severalother instruments have been used to evaluateHRQOL in esophageal cancer, including the Rot-terdam Symptom Checklist, Spitzer Quality ofLife Index, Profile of Mood States, GastrointestinalQuality of Life Index, and the University of Wash-ington Quality of Life Scale.7

HRQOL AFTER CURATIVE-INTENTTREATMENT FOR ESOPHAGEAL CANCERLong-term Effect of Esophagectomy onHRQOL

A systematic review of HRQOL assessed using theEORTC QLQ-30 or MOS SF-36 after esophagec-tomy found 21 studies, 5 of which used the MOSSF-36 and 16 used the EORTC QLQ-30; 14 of 16also used the OES-18. Five studies comparedpatients who underwent esophagectomy withhealthy subjects using the MOS SF-36 at follow-up intervals of 3 to 5 years. These studies foundthat with respect to pain and mental health, pa-tients who underwent esophagectomy had signifi-cantly better scores generally than the healthypopulation but significantly poorer HRQOL withrespect to physical function, vitality, and healthperception. Work, activities of daily living, andemotional and social function were similar to thehealthy population.8 However, these 5 studiesincluded patients with cancer and those withhigh-grade dysplasia, some resected with tran-shiatal esophagectomy and some with transtho-racic esophagectomy. Conceptually it seems thatthis heterogeneity of the patient population wouldlikely impact the HRQOL scores at least for phys-ical and functional domains.9,10 In a study of onlypatients with high-grade dysplasia, physical andemotional scores were similar or better thanthose for age-matched controls.11 Comparing5-year survivors after esophagectomy with age-and sex-matched nonpatient controls using theEORTC QLQ-30 and the OES-18, Derogar andLagergren12 reported that global HRQOL had sta-bilized or improved in 83% of patients by 6 monthspostoperatively, and these findings persisted to5 years postoperatively. Similarly, physical func-tion was stable or improved in 86% of patientsfrom 6 months to 5 years postoperatively, andscores were similar to those of the nonpatient pop-ulation. However, these authors found a subgroupof patients (14%) in whom HRQOL deterioratedover time even though their 6-month scores werenot significantly different from those of patientswhose HRQOL was stable or improved overtime. Patients in whom HRQOL deteriorated overtime had more symptoms and worse function inall domains. It seems unusual that this group

Fig. 1. Mean FACT-E scores in patients treated withchemoradiation and esophagectomy. Overall meanFACT-E scores decline during and after chemoradiationbut recover to baseline levels before surgery. Afteresophagectomy, overall mean FACT-E scores againdecline but, in patients who survive at least 12 monthspostesophagectomy, begin to recover by 1 monthpostoperatively and then continue to increase andare above baseline levels by 12 months postopera-tively. In contrast, patients who die of recurrent cancerwithin 12months of surgery havemore decline in over-all FACT-E scores postoperatively, which never recoverto baseline levels even at 3 months postoperatively,even before recurrence is suspected or evidentthrough clinical evaluation or imaging. Postsx, poste-sophagectomy; post neo, post neoadjuvant chemora-diation; presx, before surgery, approximately 6 to 8weeks after completion of neoadjuvant chemoradia-tion; pretx, before treatment/baseline. (From Safied-dine N, Xu W, Quadri SM, et al. Health relatedquality of life in esophageal cancer: effect of neoadju-vant chemoradiotherapy followed by surgical inter-vention. J Thorac Cardiovasc Surg 2009;137:39; withpermission.)

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would have such globally poor function and worsesymptoms at 5 years, even though their 6-monthscores were similar to those of the groups whoseHRQOL improved or was stable. This finding maybe from what is termed response shift, whereinthe patient’s perception of their QOL changesbecause of changes in their own values, priorities,or interpretation of QOL.

HRQOL as a Predictive Tool

Poor HRQOL scores at 6 months postoperatively(categorized as good vs poor function or minor/no symptoms vs symptomatic) were found tobe predictive of survival, with poor functionand symptoms predicting increased mortalityTable 1.13 Poor HRQOL scores before treatmentalso suggest worse survival.14

Safieddine and colleagues15 found that patientswho developed recurrence and died within12 months of surgery experienced decliningHRQOL postoperatively, which did not recoverby 3 months even before recurrent cancer hadbeen detected through imaging or clinical assess-ment, whereas patients who survived more than1 year postoperatively had overall HRQOL scoresthat improved postoperatively and continued toimprove beyond 3 months to 1 year after surgeryFig. 1. Blazeby and colleagues16 also found thatHRQOL continued to improve above baseline inpatients who survived more than 1 year. In partic-ular, Djarv and colleagues14 reported that recoveryof physical function postoperatively was associ-ated with improved survival.

Early Postoperative HRQOL

Surgery clearly has a negative impact on HRQOL inthe early postoperative period. Using the EORTC

Table 1HRQOL at 6 months predicts decreased survival

HRQOL DomainHazardRatio

95% ConfidenceInterval

Global HRQL 1.55 1.19–2.02

Physical function 1.56 1.23–1.99

Social function 1.52 1.19–1.94

Fatigue 1.65 1.30–2.11

Pain 1.45 1.22–1.87

Dyspnea 1.54 1.19–2.01

Appetite loss 1.69 1.32–2.14

Dysphagia 1.69 1.13–2.51

Esophageal pain 1.29 1.02–1.65

Data from Djarv T, Lagergren P. Six-month post-operativequality of life predicts long term survival after oesopha-geal cancer. Eur J Cancer 2011;47:530–5.

QLQ-30, essentially all aspects of HRQOL aresignificantly worse when measured at 6 weekspostoperatively. By 6 to 9 months, overall HRQOLand the domains of emotional, role functional, andsocial function recover to baseline.16,17 Brooksand colleagues18 reported similar results using theFACT-Esophageal (FACT-E). Safieddine andcolleagues15 reported somewhat different results.Total FACT-E scores, physical well-being, andfunctional well-being scores declined significantlyafter surgery, but emotional and social well-beingscores remained stable postoperatively throughouttrimodality (chemoradiation and surgery) treatment.Also, overall HRQOL recovered to baseline levelsby 3 months after surgery. Only physical well-being remained significantly below baseline levelsat 3 months.

Effect of Preoperative Chemoradiation onHRQOL After Esophagectomy

Some investigators have suggested that preoper-ative chemoradiation has a profound adverse ef-fect on HRQOL, with patients never recoveringtheir baseline HRQOL.8 However, studies using

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both the EORTC QLQ-30 and OES-18 and theFACT-E report that although HRQOL decreasessignificantly during chemoradiation, scoresrecover to baseline levels before and after surgeryFig. 2.15,17

When comparing HRQOL in patients treatedwith surgery alone versus those treated with che-moradiation followed by surgery, conflicting re-sults are reported. Blazeby and colleagues17

found no adverse impact on recovery of HRQOLpostoperatively in patients treated with preopera-tive chemotherapy or chemoradiation comparedwith those treated with surgery alone. Hurmuzluand colleagues,19 however, found that patientstreated with trimodality therapy had worse HRQOLthan those treated with surgery alone when as-sessed approximately 1 year postoperatively.Both groups used the EORTC QLQ-30 and OES-18; however, patients in the Norwegian study19

received high-dose radiation to 66 Gy withconcomitant cisplatin (100 mg/m2) and 5-fluoro-uracil (1000 mg/m2), whereas in the Britishstudy,17 patients were treated with a lower doseof both cisplatin (60 mg/m2) and 5-fluorouracil(300 mg/m2) and a total radiation dose of 45 Gy.This discrepancy illustrates one of the difficultiesin assessing the results of treatment for esopha-geal cancer: not only do surgical approaches differand have differing effects on HRQOL, but chemo-therapy and radiation therapy regimens differ.These differences may explain the contradictoryconclusions of the Norwegian and British studies,highlighting the importance of assessing HRQOLwhen evaluating different treatment regimens.Worse HRQOL would support using a less-toxic

Fig. 2. FACT-E scores in patients with esophageal cancer twell-being (EWB) and social well-being (SWB) are stable fative assessment. Physical well-being (PWB) and functionaradiation but recover by 12 to 14 weeks, which is juspreoperative values are not statistically significant. The eand swallowing (swal) subscales improve significantly frSafieddine N, Xu W, Quadri SM, et al. Health related qualchemoradiotherapy followed by surgical intervention. J T

regimen, unless significant improvement in sur-vival is seen.

Effect of Surgery Versus DefinitiveChemoradiation on HRQOL

Several nonrandomized studies have compareddefinitive chemoradiation versus surgery eitheralone or after neoadjuvant chemoradiation,7 re-porting worse HRQOL in patients undergoing sur-gery. One study found that the only independentpredictor of global HRQOL was esophageal pres-ervation.20 However, a randomized trial of surgeryalone compared with definitive chemoradiationfor operable squamous cell cancer of the esoph-agus reported no difference in HRQOL betweenthe groups in terms of overall HRQOL or func-tional or symptom subscales at any time point.No difference was seen in baseline scores be-tween the groups, and survival was similar. Inevaluating longitudinal scores, patients who un-derwent surgery experienced worsened physicalfunction up to 6 months postoperatively, whereasphysical function was at its worst 3 months afterchemoradiation.21

Effect of Surgical Technique on HRQOL

Confounding factors in evaluating HRQOL afteresophagectomy include variability in baselineHRQOL, the use of preoperative chemotherapyor chemoradiation, different surgical techniques,and postoperative complications. Comparingtranshiatal with transthoracic esophagectomy, deBoer and colleagues10 found that HRQOL wassimilar for both approaches, except that patients

reated with preoperative chemoradiation. Emotionalrom baseline through chemoradiotherapy to preoper-l well-being (FWB) decline significantly during chemo-t before surgery. Differences between baseline andsophageal cancer subscale (ECS) and the eating (eat)om baseline to preoperative assessment. (Data fromity of life in esophageal cancer: effect of neoadjuvanthorac Cardiovasc Surg 2009;137:36–42.)

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who had a transhiatal esophagectomy had fewersymptoms and were more active at 3 months aftersurgery. Not surprisingly, in comparing transhiatal,transthoracic, and minimally invasive esophagec-tomy at 1 year postoperatively, no differenceswere seen in global HRQOL of any of the functionalscales, single items, or symptoms scales of theEORTC QLQ-30 and OES-18.22 When HRQOLwas compared at 1 to 3 months after surgery,however, significant differences were seen be-tween open and minimally invasive esophagec-tomy in terms of role functioning and pain.23

Comparing patients undergoing a minimally inva-sive esophagectomy versus the normal populationusing the MOS SF-36, Luketich and colleagues24

reported no difference in terms of physical ormental scores or overall global QOL measured ata mean of 19 months (range, 1–68 months)postoperatively.

Esophagectomy alone or after chemoradiationleads to decreased HRQOL, which is at its lowestpoint approximately 6 weeks postoperatively.HRQOL gradually improves over time, returningto baseline levels by 3 to 6 months. Although over-all HRQOL returns to baseline, many patients stillhave significant symptoms at 3 to 6 months post-operatively, and these symptoms may persist formany months. Therefore, physical function orwell-being often remains below baseline even at9 to 12 months postoperatively.7,15

Complications after esophagectomy are com-mon, and major complications contribute to worseHRQOL in the long term as assessed by symptomscores, particularly with respect to dyspnea,fatigue, poor appetite, choking, reflux, and esoph-ageal pain. However, in terms of patient percep-tion of global QOL, no significant difference wasseen between those who experienced no compli-cations and those experiencing at least one majorcomplication, illustrating that symptoms do notnecessarily correlate with patient perception ofQOL.25

Using HRQOL to Evaluate Outcomes ofTreatment in Esophageal Cancer

Although the use of HRQOL as an outcome mea-sure of interest in esophageal cancer is an impor-tant advance in the management of patients withesophageal cancer, many confounding factorsclearly affect the results of these studies.Significantvariability exists among patients, stages of disease,surgical approaches, andchemotherapyor chemo-radiation regimens.This variabilitymayexplaincon-tradictory results in the published literature.

When HRQOL is compared before and aftertreatment, the effect of the treatment may be

assessed. A disease-specific measure is mostappropriate in this situation; however, the use ofpatient baseline data may be problematic,because HRQOL may be variable among patientsand is also affected by tumor factors. When com-paring patients with and without esophageal can-cer, a generic instrument such as the MOS SF-36is appropriate. But which instrument is mostappropriate in longitudinal studies? The answerdepends on the purpose of the study. In evaluatingrecovery after treatment, a disease-specific instru-ment may be appropriate, but if one wants toknow when the patient who has been treated foresophageal cancer recovers to the population“norm,” a generic instrument should be used. Animportant confounding factor may be that the pa-tient’s perception of their QOL may evolve overtime as their expectations, values, or prioritiesshift.25

In authors reporting HRQOL in the literature, atendency exists to report the global HRQOL. Inthe EORTC QLQ-30, this is the result of a singlequestion evaluated on a 7-item Likert scale,whereas in the FACT-G, the global HRQOL isderived from the sum of the 4 domains of physicalwell-being, functional well-being, emotional well-being, and social well-being. Which approach pro-vides a more valid reflection of the patient’sperception?

The use of global HRQOL may reduce the utilityof the HRQOL instruments. The use of the sub-scales may provide important information that isnot apparent from the global HRQOL assessment.As has been demonstrated in patients with esoph-ageal cancer postesophagectomy, physical func-tion and symptom scores remain abnormal morethan 6 months postoperatively, yet social, func-tional, and emotional well-being are at or abovebaseline.

HRQOL After Palliative Intent Treatment forEsophageal Cancer

Palliation of dysphagia is a primary goal of allesophageal cancer therapy. When curative intenttherapy is inappropriate, available treatmentoptions for palliation of dysphagia include esopha-geal stenting, external-beam radiation, bra-chytherapy, neodymium:yttrium-aluminum-garnetlaser; photodynamic therapy, thermoablative ther-apy, and chemotherapy. The ideal treatmentwould provide immediate and durable relief ofdysphagia without the need for reintervention.

The most common methods for palliation ofdysphagia are external-beam radiation, brachy-therapy, and self-expanding metals stents(SEMS). SEMS have largely replaced previous

Fig. 3. Comparison of SEMS andbrachytherapy in palliation of dys-phagia in esophageal cancer.Although SEMS provide almost imme-diate improvement in dysphagia, overtime dysphagia scores worsen. In pa-tients treated with brachytherapy,dysphagia scores improved moreslowly,but improvementwasmoredu-rable over time. Overall HRQOL scoresalso worsened over time in patientswith SEMS, but were maintained inthe brachytherapy group (data notshown). (From Homs MY, SteyerberEW, Eijkenboom WM, et al. Single-dose brachytherapy versus metalstent placement for the palliation ofdysphagia from oesophageal cancer:multicentre randomised trial. Lancet2004;364:1497–504; with permission.)

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stents because of their ease of insertion, reducedrate of perforation, and reduced mortality. SEMSmay be associated with reduced QOL in the first6 weeks after insertion because of pain associ-ated with insertion.26 However, 2 randomized tri-als of SEMS versus brachytherapy reported thatSEMS provided almost immediate relief ofdysphagia, whereas brachytherapy was associ-ated with more durable/stable relief of dysphagiaand overall improved QOL Fig. 3.27,28 Recurrentdysphagia and other delayed complications mayoccur in 30% to 45% of patients after SEMSplacement because of tumor overgrowth, hemor-rhage, stent migration, food bolus obstruction,and fistula formation. After brachytherapy, up to15% of patients may have persistent dysphagia.29

Durable improvement in dysphagia without theneed for reintervention and reduced complica-tions may account for the overall improved QOLin patients treated with brachytherapy comparedwith those treated with SEMS. Brachytherapymay be more appropriate for patients who mayhave more prolonged survival, whereas SEMSmay be more appropriate for those with verylimited survival.

SUMMARY

Assessment of HRQOL is an important outcomemeasure in evaluating treatment for esophagealcancer, whether for curative or palliative intent. Cli-nicians must realize that the patient’s perceptionof their QOL is the most important consideration,and that HRQOL is not simply a list of symptoms.Assessment of HRQOL in esophageal cancer inthe setting of curative-intent therapy is compli-cated by the variety of treatment approaches,

including different surgical techniques, varyingdoses of radiation, and differing chemotherapyregimens. Variability in patient factors even at thetime of baseline measurement may make compar-isons difficult, and shifts in patient responses overtime may confound the results of long-termstudies. Despite these challenges, performing aHRQOL assessment provides the patient, care-giver, and health care provider with important in-formation when comparing therapeutic options.

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