Patient-reported outcomes following esophagectomy

Introduction

Patient-reported outcomes (PROs) are measures of long-term quality of life (QoL) and health from the patient or caregiver. They have been increasingly utilized and studied within the field of cardiothoracic surgery to help quantify patient symptoms and improve communication between the surgeon and their patients (1-3). Research efforts in cancer treatment primarily have focused on measurements of survival and major morbidity to establish the best therapy that provides the longest survival. This, however, does not consider the global well-being of the patient and how it affects their overall QoL (4).

There has been an adoption of minimally invasive techniques that have improved aspects of perioperative care, however, the data on long-term outcomes regarding the QoL following esophagectomy has been insufficient and conflicting. Not only does this apply to esophageal cancer but also benign esophageal disorders such as end-stage achalasia, where overall QoL may improve (5).

The morbidity surrounding esophagectomy largely lays within the significant lifestyle changes that can be permanent in some. The majority of studies, however, do not focus on these lasting lifestyle changes but highlight perioperative complications and this can exacerbate the issues surrounding patient experience (6-8). Approximately 60% of patients undergoing esophagectomy will experience some form of perioperative complication, including anastomotic leak, respiratory failure, and vocal cord paralysis (9-11). Understanding how these changes affect the QoL for patients is vital to attempting to improve surgical outcomes. The use of PROs can provide valuable information to measure preoperative and postoperative QoL following esophagectomy (12).

This manuscript will focus on gathering and utilizing PRO data, as well as reviewing the current literature regarding QoL research in those undergoing esophagectomy.

PRO measurements

PROs are a measure of QoL and health that is obtained from the patient or caregiver. These instruments provide a score that can be used to interpret overall well-being by the medical provider and followed longitudinally (3). It requires minimal burden and cost to the patient and is generally utilized before clinic visits. It has also been demonstrated to help quantify symptoms and improve communication between patients and their surgeons (1,13).

There are multiple different measurement systems utilized for esophageal cancer (14). An example of a measurement system is the Patient Reported Outcomes Measurement Information System (PROMIS). This is a PRO instrument developed and sponsored by the NIH which has been used for many different disease processes. This instrument has been normalized to the general United States population and makes results easy to interpret and compare (15). The PROMIS Short Forms can be used to assess different symptoms such as pain, dyspnea and physical function (16,17). These surveys taken over a series of visits both preoperatively and postoperatively can then be used to assess the overall QoL for the patient.

Several other metrics can be used to assess symptoms and overall QoL. An example of another type of instrument used in the assessment of PROs is the Functional Assessment of Cancer Therapy Scale-General (FACT-G) (18). This was developed in 1993 and looked at 28 different items. Seventeen items were then added to assess swallowing and eating alone to create the Functional Assessment of Cancer Therapy Scale-Esophageal (FACT-E) (19).

Other commonly used instruments within the thoracic literature also include the Modules and the Medical Outcomes Study Short Form 36 (SF-36) and the European Organization for Research and Treatment of Cancer (EORTC) (20,21). The EORTC measurement system is a refined list of 24 questions that assess dysphagia, eating, reflux, and pain. This has been utilized in many recent studies, as diagramed in Table 1. A brief description of the commonly used tools for PRO research in esophagectomy patients is listed in Table 2.

After a certain assessment tool is established, use of these tools can occur using electronic medical records. In a previously described study by Khullar and colleagues, surveys administered electronically using mobile devices and tablets in the clinic waiting areas allowed the achievement of a completion rate of over 90% in some patients (3). This study analyzed a total of 9,725 thoracic surgery office visits over 21 months with PRO data obtained in 6,899 visits from 3,551 patients. The overall completion rate was 65.7% with this method. This also demonstrated real-time availability of results within the electronic medical record creating significant clinical information regarding a patient’s health status and QoL (3).

Importance of PROs in esophagectomy

The subjective aspect of PRO research has led to more focus on objective measures such as long-term survival, mortality, and complication rates. Most research in esophageal surgery only investigates outcomes such as rates of anastomotic leak, long-term survival, and other significant postoperative complications. What is not well studied, however, is the significant lifestyle changes that these patients must then go through, especially considering those who experience a complication. Focus on only survival outcomes leads to an incomplete evaluation of treatment, as survival does not center on the complication rates that relate to the patient experience (4). These significant changes in QoL may be more important to the patient and their goals of care than a difference in their 5-year survival rates (4).

Counseling our patients regarding the potential complications is difficult without this particular data, especially given the limited and conflicting studies regarding the changes and differences in QoL following esophagectomy which will be described later in this manuscript. This is further evidenced by studies that demonstrate a difference in the patients’ and physicians’ assessments of treatment on postoperative QoL (13,50). Without this information, we continue to have a significant void in counseling patients following esophagectomy, particularly given the life-altering changes that a patient experiences (51).

Esophagectomy remains the mainstay of treatment for esophageal cancer. While there have been significant advances in technique, along with minimally invasive options, the physiologic changes with esophagectomy remain similar. The changes in lifestyle for patients are notably due to symptoms such as vomiting, dumping syndrome, regurgitation, and bile reflux (11). Not only this, but many also experience significant weight loss and fatigue. Given this, our discussions with our patients before the operation remain so important to improve the quality of patient-centered care.

For these reasons above, gathering of PROs should be a standard of practice as this remains the greatest concern to patients (2,4). Including PROs in studies that discuss treatment effectiveness and outcomes would be beneficial in addition to long-term survival. This has been further validated by the initiation of PRO measures into comparative effectiveness research (CER) and also the U.S. Food and Drug Administration (FDA) has recommended incorporating PRO measures in clinical trials to evaluate drugs and devices (52). The Society of Thoracic Surgeons (STS) has also recently created a task force to incorporate PRO measures into the STS National Database. The addition of PRO measures will assist with future research into outcomes research for all surgical patients including those undergoing esophagectomy (53).

Application of PROs following esophagectomy

There have been several studies that have examined QoL following esophagectomy. These, however, have been conflicting, with some studies demonstrating a persistent decrease in overall QoL and symptoms as long as 20 years after surgery versus others demonstrating patients reaching the general population after 3 years (42,47). There have been several reviews, as well, within the literature discussing the PROs following esophagectomy (54,55).

With the addition of the more recent literature, we can see that there is a general trend towards worsening QoL within the first year after esophagectomy. For example, in a recent study published by our group, we noted an overall decrease in QoL scores within the first 2 months following surgery. There were significant declines in physical function scores by 27.3% with an increase in dyspnea severity and pain interference by 24.5% and 17.1%, respectively (46). Another example of this particular trend in PROMIS scores was seen during a study by Heiden et al., which noted significant worsening in all fields within the first month after surgery and returned to baseline after 6 months (43).

Kauppila and associates had demonstrated long-lasting impairments and poor QoL over time following esophagectomy (33). This study used the EORTC QLQ-C30 questionnaire which may not have considered specific perioperative complications, such as anastomotic leak (33). Katz et al., however, evaluated those patients who developed complications following esophagectomy (47). They demonstrated no impact on the overall QoL except for those suffering from anastomotic leak and conduit necrosis (47).

Katz et al. obtained data using the FACT-E instrument and analyzed 480 patients undergoing esophagectomy (47). This study demonstrated an initial reduction in QoL metrics within the first 1-3 months postoperatively but over time this increased and surpassed baseline at 6 months with patients reaching the overall population at 3 years (47). They also noted no difference in outcomes when evaluating PRO scores between surgical approaches (47).

This is not the only study that demonstrates an overall improvement over time as seen by a prospective cohort study by Derogar et al. (11). They examined QoL scores from 6 months to 5 years following esophagectomy (11). This study utilized EORTC QLQ-C30 and EORTC QLQ-OES18 measurement systems and noted that most patients surviving at 5 years following esophagectomy had recovery of symptoms comparable to the general population (11).

Several systematic reviews have examined health-related QoL (HRQoL) studies for esophageal cancer patients, however many of these are difficult to interpret given the discordance of methodology and measurement systems. A systematic review by Jacobs et al. found 62 studies that noted that the EORTC was the most commonly used measurement system (56). The difficulty, however, was due to the poor methodology of many studies with only 26 articles meeting the criteria for evaluation (56).

A systematic review published in 2017 by Taioli and colleagues is yet another example demonstrating the difficulty of analyzing multiple PRO studies (57). They were able to gather 45 different studies to assess HRQoL outcomes in differing types of approaches for esophagectomy (57). Despite having multiple articles, they could only adequately compare 15 of these due to differing measurement systems used between studies.

Another limitation of many of these long-term prospective studies and systematic reviews looking at PROs is that there may be several patients that do not survive to completion of the collection of data points (46). Surveys may not be completed due to major illnesses requiring prolonged hospitalizations or mortality. This is evidenced not only in our previous study but also in a study by Courrech Staal et al. where out of 163 patients only 36 completed questionnaires (58).

Further studies regarding approach have also been evaluated. The previously mentioned systematic review by Taioli et al. evaluated the published literature to assess differences in QoL after open versus minimally invasive esophagectomy (57). This study evaluated 15 articles about PROs following esophagectomy (57). They noted improved QoL scores in some categories among those undergoing minimally invasive esophagectomy compared to open esophagectomy (57).

More recently, Sarkaria et al. evaluated the effect of robotic-assisted minimally invasive esophagectomy (RAMIE) on QoL metrics (59). This was a prospective trial of RAMIE in comparison to open esophagectomy measuring QoL using the FACT-E and Brief Pain Inventory (BPI) (59). They analyzed 170 patients who underwent esophagectomy via an open approach versus robotic-assisted (59). Total scores were lower at 1 month and returned to baseline at 4 months for both groups (59). Average pain scores were lower for RAMIE in comparison to open esophagectomy (59). A follow-up long-term study by the same group found improved patient-reported QoL, including esophageal symptoms, emotional well-being, and decreased pain, compared with open esophagectomy at 2 years (41).

Not only are there multiple studies regarding the approach, but also those that evaluate the QoL following neoadjuvant treatment. One of the earliest studies was performed by Blazeby et al., which performed an analysis of EORTC scores for patients treated with surgery or palliative chemoradiation (60). During this study, there were only 38 of the 89 patients who were alive at 6 months after treatment with a higher physical function score being associated with improved survival (60). This study is limited due to the number of patients that were alive to the end of the study time period and was during a time when neoadjuvant therapy was not commonly used in the early 1990s (60).

In an observational study by Avery et al., 132 patients undergoing chemoradiotherapy or chemoradiotherapy plus surgery were evaluated (61). They demonstrated an associated greater reduction in HRQoL in those undergoing surgery in comparison to chemotherapy (61). Contradictory to this, Best et al. performed a meta-analysis of 8 prospective, randomized trials comparing surgery to chemoradiotherapy with no difference found between the two arms in follow-up at 2 years (62). However, as some systematic reviews and meta-analyses will discuss, many trials are found to have low overall quality of evidence and are difficult to analyze between studies due to the instruments used (62).

Kidane et al. performed a systematic review of 4 studies using the FACT-E measurement system (63). Of the 129 patients receiving neoadjuvant chemoradiotherapy (nCRT), they found that higher baseline FACT-E scores were independently associated with better survival. However, only 43% of patients were alive at 6 months post-therapy (63). This review also had studies that were observing patients in the 1990s which did not have the same therapy regimen as modern days (63).

A more recent study by Noordman et al. in 2019 examined 96 total patients who underwent nCRT (64). Of these 96 patients, there was a negative impact in EORTC scores on all endpoints during the last cycle of chemoradiation and continued up to 2 weeks after. After completion of nCRT, QoL was decreased and then restored to baseline within 8 weeks (64). QoL scores were also evaluated from data obtained by the CROSS trial by the same group, which compared surgery versus nCRT followed by surgery and found no difference in QoL measurements between treatment groups even in the long-term analysis (34).

Another recent randomized control trial by Sunde and colleagues aimed to assess the short and long-term QoL in patients receiving chemotherapy (CT) versus chemoradiotherapy (CRT) (36). Patients were assigned to receive either cisplatin and 5-fluorouacial or the same chemotherapy regimen with the addition of 40 Gy radiotherapy (36). QoL data was collected using the EORTC questionnaire for 165 patients (36). Within each treatment arm, there was a significant deterioration in QoL scores at 1 year (36). There was some recovery seen in both arms over time but after 3 and 5 years patients in the CRT arm reported more symptoms than the CT arm (36). This analysis is also limited by a lack of responses in questionnaires which is an inherent issue for most PRO studies (36).

Conclusions

PROs research evaluating those undergoing esophagectomy has been increasingly recognized as an important adjunct to the comprehensive care of the patient. There are many advantages to the use of PRO in clinical practice and these are now acknowledged by multiple societies for future implementation within databases. Many studies have researched this topic, but they are difficult to compare given multiple different measurement systems with some being of low quality given the number of patients who survive to the end of the study. While PROs can be successfully integrated into the electronic medical records, a standardized approach to collection is needed which can be achieved using national databases. Overall, this will be vital to the relationship between surgeon and patient to give the best outcomes that are centered around the patient.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-487/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-487/coif). F.G.F. serves as an unpaid editorial board member of Journal of Thoracic Disease from May 2023 to April 2025. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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