ST. LOUIS — Little is known of the functional status and quality of life of long-term survivors after curative resection for esophageal carcinoma.
“Clearly, a better understanding of the functional outcome of life of long-term survivors is needed in this new era of health care,” Claude Deschamps, M.D., told attendees of a thoracic surgery meeting sponsored by Washington University.
Because the incidence of adenocarcinoma of the esophagus and gastroesophageal junction is increasing, “Endoscopic surveillance for Barrett's disease will very likely lead to earlier cancer detection and resection, and possibly improved long-term survival,” said Dr. Deschamps, professor of surgery at the Mayo Clinic College of Medicine in Rochester, Minn.
Esophagectomy is currently the standard of care in esophageal carcinoma, Dr. Deschamps said.
“Appropriate tools to measure outcome, however, are limited and development of such instruments will become increasingly important in the future if surgeons are to better plan preoperative counseling, surgical approach, and postoperative care.”
The patient's perspective on quality of life is crucial, he said. “We are in an era during which health care outcome will increasingly be evaluated from the patient's point of view.”
Dr. Deschamps cited J.D. Kirby, founder of the Oesophageal Patients Association, who suggested nine elements of a good quality of life after esophagectomy. These include the ability to eat adequately and enjoy it, to consume alcohol moderately as desired, to eat and drink socially, to have weight stability, to sleep comfortably in a normal position, to be free of pain, to earn one's living, to participate in sports or hobbies, and to have an unimpaired libido.
“Health outcome is better measured by using general health measures and traditional biomedical tools synchronously,” Dr. Deschamps said “We prefer to combine a questionnaire aimed at upper- and lower-digestive functions with a quality-of-life survey.”
“We recently reviewed our experience with function and quality of life after esophagectomy for high-grade dysplasia in Barrett's esophagus,” he said. From June 1991 through July 1997, 54 consecutive patients underwent esophageal resection for Barrett's esophagus with high-grade dysplasia (HGD) at the Mayo Clinic in Rochester.
Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended Ivor Lewis esophagogastrectomy in 8 (15%), and other in 2.
Follow-up data was obtained from the patient clinical records and a two-part mail survey that was sent to all 46 patients thought to be alive in August 1999.
” All 46 two-part written surveys were returned for a response of 100%. The follow-up was complete in all 54 patients. The median follow-up was 5.3 years.
“At last follow-up, 43 patients (80%) were alive and without evidence of recurrent disease. This included 13 of the 19 patients diagnosed with cancer. Overall 5-year “survival was 86%, which did not significantly differ from an expected survival of 87%.”
Dr. Deschamps reported long-term (greater than 2-year) functional outcome available for 48 patients.
Seven patients (13%) were entirely asymptomatic. Ten patients experienced no change in their weight. Thirty-one patients lost a median of 9 kg and seven patients gained a median of 2 kg. Thirty patients had no dysphagia. Mild, moderate and severe incidences of dysphagia were seen in 15, 1, and 2 patients, respectively. Reflux was present in 36 patients. The majority had minimal symptoms with medical management. Dumping was present in eight patients.
Forty-four patients (82%) completed the MOS SF-36 Health Status Questionnaire. “Only seven (13%) of our patients were truly symptom free 2 or more years after esophagectomy. Thirty-eight percent of patients had swallowing difficulties but in only 6% was this moderate to severe. Reflux was present in 68% of our patients. This, however, was well controlled with medication in the majority of patients,” Dr. Deschamps said.
“While the functional outcomes were acceptable but less than ideal, esophagectomy had no measurable negative impact on these patients' quality of life,” he said.