quality of life after esophagectomy for cancer: an assessment using the questionnaire with the face...

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Surg Today (2002) 32:213–219 Quality of Life After Esophagectomy for Cancer: An Assessment Using the Questionnaire with the Face Scale Yoichi Tabira 1 , Masahiro Yasunaga 1 , Nobuhide Nagamoto 1 , Hisayuki Matsushita 1 , Yoshitaka Fukunaga 1 , Toshiko Ihara 2 , and Michio Kawasuji 1 1 Department of Surgery I and 2 Nutritional Management Department, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto 860-8556, Japan the elevation of survival rate. 1–3 An esophagectomy for esophageal cancer is one of the most invasive opera- tions and the morbidity and mortality of patients under- going this operation are 36% and 13%, respectively. 4 It is important to assess the quality of life (QOL) of these patients; however, there are few specific and unified QOL evaluation methods for a patient after an esophagectomy. 5 Because each researcher evaluates the QOL of patients using a different method and scale, whether or not the resection of esophagus for cancer gives a significant impact on the QOL level is still controversial. On the other hand, the face scale is an effective tool for the evaluation of patient’s mood. 6,7 A core question- naire including a linear scale and face scale is useful for evaluating the QOL of colon cancer patients in pallia- tive therapy 8 and lung cancer patients. 9 There has no report examining whether this questionnaire is useful for evaluating the QOL of patients with esophageal cancer. Moreover, it is not known whether the face scale is worthy as a global parameter of the QOL after an esophagectomy. The aims of this study were to assess the QOL of patients after undergoing a radical esophagectomy for thoracic esophageal cancer using a questionnaire in- cluding a linear scale and face scale, and to examine the usefulness of the face scale as a global parameter of QOL. Patients and Methods Four hundred patients underwent a curative esophagec- tomy (R0 resection in the TNM classification 10 ) for thoracic esophageal carcinoma from 1963 to 1999 at Kumamoto University Hospital. Of these patients, 71 patients who were alive without recurrence and re- turned the answer the questionnaire were enrolled in this study. The mean age was 70.5 (range 51–90) years Abstract Purpose. The face scale has not been used as a global param- eter of quality of life (QOL). The aims of this study were to assess the QOL of patients after esophagectomy for cancer and to examine whether a face scale is useful as a global parameter of QOL. Method. Seventy-one patients without postoperative recur- rence after curative esophagectomy answered the question- naire with the face scale and food intake. We calculated the QOL score (its full mark: 85) and examined the correlation between the QOL score and other parameters including the face scale. Result. The duration of the postoperative period ranged from 8 to 253 months (median 87 months). Gastric pullups at the left cervix were selected in 66 patients. The retrosternal route was performed in 55 patients. The mean QOL score was 64.2 (range 33–84). There was the significant positive correlation between QOL score and the face scale (P 0.0001). The quantity of meal intake decreased in 55 patients (77.55%) by more than 50% compared with their healthy state. About a half of the subjects still suffered from the swallowing problems and a decreased food intake. Conclusion. The face scale is correlative with the total QOL score after an esophagectomy and is useful as a global param- eter of the QOL. Key words Esophageal neoplasm · Esophagectomy · Quality of life · Face scale Introduction Recent progress in postoperative management has de- creased the incidence of postoperative complications, and advances in preoperative diagnoses has raised the ratio of early-staged esophageal cancer and resulted in Reprint requests to: Y. Tabira Received: April 16, 2001 / Accepted: September 11, 2001

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Page 1: Quality of Life After Esophagectomy for Cancer: An Assessment Using the Questionnaire with the Face Scale

Surg Today (2002) 32:213–219

Quality of Life After Esophagectomy for Cancer:An Assessment Using the Questionnaire with the Face Scale

Yoichi Tabira1, Masahiro Yasunaga

1, Nobuhide Nagamoto1, Hisayuki Matsushita

1, Yoshitaka Fukunaga1,

Toshiko Ihara2, and Michio Kawasuji

1

1 Department of Surgery I and 2 Nutritional Management Department, Kumamoto University School of Medicine, 1-1-1 Honjo,Kumamoto 860-8556, Japan

the elevation of survival rate.1–3 An esophagectomy foresophageal cancer is one of the most invasive opera-tions and the morbidity and mortality of patients under-going this operation are 36% and 13%, respectively.4 Itis important to assess the quality of life (QOL) of thesepatients; however, there are few specific and unifiedQOL evaluation methods for a patient after anesophagectomy.5 Because each researcher evaluates theQOL of patients using a different method and scale,whether or not the resection of esophagus for cancergives a significant impact on the QOL level is stillcontroversial.

On the other hand, the face scale is an effective toolfor the evaluation of patient’s mood.6,7 A core question-naire including a linear scale and face scale is useful forevaluating the QOL of colon cancer patients in pallia-tive therapy8 and lung cancer patients.9 There has noreport examining whether this questionnaire is usefulfor evaluating the QOL of patients with esophagealcancer. Moreover, it is not known whether the face scaleis worthy as a global parameter of the QOL after anesophagectomy.

The aims of this study were to assess the QOL ofpatients after undergoing a radical esophagectomy forthoracic esophageal cancer using a questionnaire in-cluding a linear scale and face scale, and to examine theusefulness of the face scale as a global parameter ofQOL.

Patients and Methods

Four hundred patients underwent a curative esophagec-tomy (R0 resection in the TNM classification10) forthoracic esophageal carcinoma from 1963 to 1999 atKumamoto University Hospital. Of these patients, 71patients who were alive without recurrence and re-turned the answer the questionnaire were enrolled inthis study. The mean age was 70.5 (range 51–90) years

AbstractPurpose. The face scale has not been used as a global param-eter of quality of life (QOL). The aims of this study were toassess the QOL of patients after esophagectomy for cancerand to examine whether a face scale is useful as a globalparameter of QOL.Method. Seventy-one patients without postoperative recur-rence after curative esophagectomy answered the question-naire with the face scale and food intake. We calculated theQOL score (its full mark: 85) and examined the correlationbetween the QOL score and other parameters including theface scale.Result. The duration of the postoperative period ranged from8 to 253 months (median 87 months). Gastric pullups at theleft cervix were selected in 66 patients. The retrosternal routewas performed in 55 patients. The mean QOL score was 64.2(range 33–84). There was the significant positive correlationbetween QOL score and the face scale (P � 0.0001). Thequantity of meal intake decreased in 55 patients (77.55%) bymore than 50% compared with their healthy state. About ahalf of the subjects still suffered from the swallowing problemsand a decreased food intake.Conclusion. The face scale is correlative with the total QOLscore after an esophagectomy and is useful as a global param-eter of the QOL.

Key words Esophageal neoplasm · Esophagectomy · Qualityof life · Face scale

Introduction

Recent progress in postoperative management has de-creased the incidence of postoperative complications,and advances in preoperative diagnoses has raised theratio of early-staged esophageal cancer and resulted in

Reprint requests to: Y. TabiraReceived: April 16, 2001 / Accepted: September 11, 2001

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214 Y. Tabira et al.: Quality of Life After Esophagectomy

old. There were 59 men and 12 women. The postopera-tive period of the subjects ranged from 8 to 253 months(median 87 months). The distribution of pathologicalTNM classification was the following: stage 0, 3; I, 35;IIA, 8; IIB, 12; III, 9; IVA, 0; IVB, 4. Of these patients,30 underwent an esophagectomy with three-field lym-phadenectomy, 35 patients underwent an esophagec-tomy with two-field lymphadenecomy, and the other6 patients underwent other type of esophagectomy.The meticulous systematic lymphadenectomy was per-formed as reported previously.11,12 The continuities ofthe alimentary tracts were recovered by the gastric pull-ups at the left necks in 66 patients, by the colon in threepatients, and by the small intestine in two patients. Theretrosternal route was selected as a reconstruction routein 54 patients, posterior mediastinal route in 7, subcuta-neous route in 6, and intrathoracic anastomoses werecarried out in 4.

We modified a core questionnaire for the QOL ofcolon cancer patients reported previously by Ishiharaet al.8 This modified questionnaire incorporates threefunctional multiscale items (basic aesthesia, activity,and mental condition) and five symptom multiscaleitems (quantity of meal intake, dysphagia, regurgita-tion, dumping syndrome, and hoarseness). In detail, thequestionnaire consists of 17 questions, which includethree questions about basic aesthesia, five questionsabout activity, seven questions about postoperativesymptoms including food intake, swallowing, andhoarseness, at last, two questions about a mental condi-tion (anxiety, relationship between family). This ques-tionnaire also includes the face scale to determine theglobal QOL and a table to mention the kind and dose offood and snack which a patient would take in 1 week(see Appendix). An answer column of these 17 ques-tions and the face scale is displayed with the linear scaleof five numbers (1, 2, 3, 4, 5). A higher number meansthe better condition in each question. We make thesubjects select the most appropriate number as an an-swer among five numbers of the linear scale. The ques-tionnaire was sent to each subject by mail. The patientwas requested to select one face best expressing theircurrent general condition among the five faces with dif-ferent facial expressions. We confirmed that no patientregularly used psychological medicine such as anti-depressant drugs or major tranquilizers.

We calculated the total score of 17 questions for eachsubject and defined it as the QOL score. A higher QOLscore indicates the higher QOL level. Moreover, wecalculated body mass index (BMI) using body length andbody weight derived from the questionnaire. The fullmark of this score was 85. Sixty-six of 71 patients (92.9%)replied to the table about kind and dose of oral intake.Referring to the table of this questionnaire, the regis-tered dietitian (T.I.) of our hospital calculated

the mean daily calorie intake of the subjects. The cor-relation between the QOL score and the face scale wasexamined using Kruskal-Wallis test. The correlationsbetween QOL score and other parameters were exam-ined using simple regression analyses. Statistical calcula-tions were performed using Statview (Abacus Concepts,Berkeley, CA, USA) software, Statistical significancewas defined as a two-sided P value of less than 0.05.

Results

The mean QOL score of the subjects was 64.2 (range33–84). The percentage of mean score in each categorywas 73.3% in a basic aesthesia category, 81.6% in acategory of activity, 72.9% in a category of postopera-tive symptoms, and 71.0% in a mental condition cat-egory, respectively (Table 1).

The mean calorie intake was 33.2 (range 13.4–55.0)kcal/kg per day. The mean BMI of the subjects was 18.7(range 13.3–55.0). Table 2 shows a positive correlationbetween calorie intake and QOL score. This correlationwas statistically significant (P � 0.007), and the correla-tion coefficient was 0.329.

The distribution of face scale was as follows: Scale 1:1; scale 2: 10; scale 3: 25; scale 4: 25; scale 5: 10. Themean QOL score in each face scale was 52.0 in scale 1,46.0 in scale 2, 59.8 in scale 3, 70.8 in scale 4, 78.3 in scale5, respectively. There was a significant difference in themean QOL score among these five faces (P � 0.0001,Kruskal-Wallis test) (Fig. 1). This shows that the patientwith a high QOL score tended to select the face corre-sponding with a big number in the face scale. There wasa significant correlation between QOL score and calorieintake (P � 0.007); however, there was no significantcorrelation between the QOL score and postoperativesurvival period (P � 0.61) (Table 2).

Table 3 shows the mean QOL score in the subgroups(type of operation, reconstruction route, and kind ofesophageal substitute). There was no statistical differ-ence among the mean QOL scores in each subgroup.

The quantity of meal intake at this study was “a quar-ter” compared with that of preoperative healthy state in12 patients (16.9%), “a half” in 43 patients (60.6%),

Table 1. Mean score in each category in the corequestionnaire

Category Mean score (%) Subtotal

Basic aesthesia 11.0 (73.3) 15Activity 20.5 (81.6) 25Mean intake /hoarseness 25.6 (72.9) 35Mental condition 17.1 (71.0) 10QOL score 64.2 (75.5) 85

QOL, quality of life

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215Y. Tabira et al.: Quality of Life After Esophagectomy

“three quarters” in 9 patients (12.7%), and “same” in 7patients (9.9%), respectively. The dosage of food which55 (77.5%) of 71 patients could take after an esopha-gectomy was less than half of the quantity that they hadtaken in their preoperative healthy state.

The number of patients who selected a number lessthan 3 regarding the questions about postoperativesymptoms was 35 (49.3%) regarding the question about

dysphagia, 33 (47.2%) regarding the question about re-gurgitation, 18 (25.4%) regarding the question aboutnight cough, 26 (36.6%) regarding the question aboutdiarrhea, 33 (47.2%) regarding the question about post-prandial abdominal full sensation, and 21 (29.6%) re-garding the question about hoarseness.

Discussion

The QOL score derived from this core questionnairereflected the level of QOL of patients after esophagec-tomy. The patient with a high QOL score tended toselect the face corresponding with a big number in theface scale. Furthermore, the face scale generally reflectsthe condition of basic aesthesia, the grade of postopera-tive symptoms, and mental stress against which thesepatients come up. These results indicate that a modifiedcore questionnaire including linear scales and face scaleis useful to assess the QOL of patients who have under-gone a radical esophagectomy for thoracic esophagealcancer, and the face scale correlated significantly withthe QOL score. This suggests that the face scale may beuseful for a global assessment of QOL.

A term QOL is often used, but its exact meaningremains controversial. When assessing the QOL, fourmajor areas or domain must be considered as follows:physical status, functional abilities, psychological statusand well-being, and economic status.13 In 1986, theEuropean Organization for Research and Treatment ofCancer (EORTC) initiated the QLQ-C30, which is thecore questionnaire incorporating nine multi-item scalesand is a reliable and valid measure of QOL of cancerpatients.14 The core questionnaire used in this study con-sisted of three functional items (basic aesthesia, activity,and psychological condition) and five symptom items,and may be a useful and valid method to assess theQOL after esophagectomy. It is important for the QOLto be evaluated from various standpoints; however, pre-vious researchers adopted the different methods as atool for the assessment of QOL. It is necessary to decideand unify the items for assessing the QOL.

There was no correlation between the QOL leveland the postoperative survival period. The QOL follow-ing resection of esophageal carcinoma had deteriorated

Table 2. Results of simple regression analyses between the QOL score and two param-eters (postoperative period, caloric intake)

Parameter n Slope Intercept Coefficient P

Postoperative period 71 0.014 63.051 0.061 0.61(months)

Calorie intake 66 0.012 46.855 0.329 0.007(kcal/kg/day)

Table 3. Types of operation and the QOL scores

Mean QOL score P

Operative procedure 0.69Three-field dissection 30 62.7Two-field dissection 35 65.4Others 6 65.0

Reconstruction route 0.52Antesternal 6 58.8Retrosternal 54 64.6Mediastinal 7 62.3Intrathoracic 4 70.5

Substitute 0.15Gastric pullup 66 64.4Colonic pullup 3 53.0Jejunum 2 75.0

Fig. 1. Correlation between the Face scale and QOL score(P � 0.0001, Kruskal-Wallis test)

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216 Y. Tabira et al.: Quality of Life After Esophagectomy

on discharge from hospital but improved within 6months of the operation in disease-free patients.15 TheQOL level after an esophagectomy gradually improvedas postoperative time passed in cases without postopera-tive recurrence of esophageal cancer.16 In the currentstudy, the postoperative period was more than 8 monthsand its mean was 83.0 months. These findings suggestthat the QOL of patients who underwent an esopha-gectomy had improved by at least 6 months after opera-tion in the patients without postoperative recurrence.

Although the number of patients in the individualsub-groups was not sufficient for a statistical analysis,there was no significant difference among the meanQOL scores in the subgroups (the type of operation, theroute of reconstruction, and the kind of esophageal sub-stitute). These results are consistent with those of pre-vious reports.17–19 The findings indicate that the type ofoperation and recovery of continuity of alimentary tractare not the main factor affecting the QOL level afteresophagectomy.

In this study, half of all patients who underwent anesophagectomy suffered from swallowing problems, re-gurgitation, and abdominal full sensation during or aftermeal. Moreover, the quantity of meal intake in 55 of 71patients (77.5%) had decreased by more than 50% in

comparison with the preoperative healthy state, and themean BMI of the subjects was 18, which was less than 22recommended as the Japanese standard advocated bythe Ministry of Health and Welfare. Other reports de-scribe that difficulty in swallowing, full sensation duringor after eating, and decrease in food intake continuemore than 5 or 10 years after an esophagectomy.17,19

These two impairments may be the main and retainedproblems affecting the QOL level of patients whounderwent esophagectomy. In the current study, thepatients with sufficient food intake acquired the highQOL score. On the other hand, regurgitation causesaspiration pneumonia, which sometimes results in a le-thal outcome in elderly patients.

In conclusion, the QOL of patients who underwent aradical esophagectomy stayed at a satisfactory level;however, swallowing problems, regurgitation, and a de-creased quantity of food intake were the main problemsaffecting the QOL. The face scale had a positive corre-lation with the global QOL level of patients who under-went an esophagectomy in this study. These resultsshow the face scale to be a useful global parameter ofthe QOL, and the evaluation system using the face scaleis therefore both a convenient and clinically usefulmethod.

Appendix

Name :

Age : Sex : 1. male 2. female

Body Height : cm Body Weight : kg

Please mark the number corresponding with your current condition in the following 18 questions.

1 How is your appetite now?very good very poor

5 4 3 2 1

2 How is your current mood?very good very bad

5 4 3 2 1

3 Can you sleep well?very well very badly

5 4 3 2 1

4 Can you go out by yourself?possible impossible

5 4 3 2 1

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217Y. Tabira et al.: Quality of Life After Esophagectomy

5 Can you enjoy a thirty-minute walk?possible impossible

5 4 3 2 1

6 Do you feel ill after a short walk?don’t feel ill do feel ill

5 4 3 2 1

7 Can you go upstairs and downstairs?possible impossible

5 4 3 2 1

8 Can you take a bath by yourself?possible impossible

5 4 3 2 1

9 How is the current quantity of meal intake?Please compare with the quantity at healthy state before suffering from disease of the esophagus.

same three-quarters a half a quarter none

5 4 3 2 1

0 Do you have difficulty in swallowing?never always

5 4 3 2 1

- Do you have regurgitation?(Does gastric juice or bile come up in the mouth?)

never always

5 4 3 2 1

= Do you cough while sleeping?never always

5 4 3 2 1

q Do you have diarrhea after meals?never always

5 4 3 2 1

w Do you feel an abdominal full sensation or pain at meals and after meals?never always

5 4 3 2 1

e Is your voice husky now?yes, feel

no “inconvenient”

5 4 3 2 1

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218 Y. Tabira et al.: Quality of Life After Esophagectomy

r Do you feel anxiety about your current symptoms?never frequently

5 4 3 2 1

t Do you think that your current condition is bothering your family?never frequently

5 4 3 2 1

y Please mark the number of the face corresponding to your current condition.

u Please list in detail the kind and quantity of meals and snacks which you will consume during the next week.

List of your meals and snacks. Name:_______________________

Date Breakfast Lunch Dinner Others

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219Y. Tabira et al.: Quality of Life After Esophagectomy

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