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138
N. E. James et al.
able 9.4
(continued)
T
HRQOL in LR
Author/Year
(Ref)
Chen
2004
Ueno
2002
Tanabe
2001
Study No.
PC 36 LC LR GQLI Pre, 2
R 123 Recurrent
Pathology Procedure QOL
of
pts
96 HCC QOL impaired in
LR Vs HAIC Deteriorated
HCC
instrument
Time points
analyzed
(months)
weeks, 5
weeks, 10
weeks,
4months,
6months,
9months,
12months,
18months,
24months
HRQOL Outcome
(P<0.05)
Reduced signicantly
2–10weeks after the
operation. QOL
recovered gradually.
At 4months
increased to the
preoperative level. In
the patients who
survived more than
9months, the GQLI
score was higher than
that before the
operation. Major
hepatectomy
(lobectomy and
combined
segmentectomy)
reduced the GQLI
score more evidently
than did minor
hepatectomy (simple
segmentectomy) in
2–5weeks after the
operation. The age
and preoperative liver
function of the
patients played an
important role in the
recovery of the
quality of life in the
early postoperative
stage. Tumor
recurrence showed a
continuous decrease
in QOL.
cases of aged
patients, treatment for
recurrence, and Type
2 change of the serum
cholinesterase level.
Postoperative
maintenance of
protein synthesis
including
cholinesterase is one
measure to preserve a
satisfactory QoL.
performance status in
the repeat LR was
lower than in the
HAIC.LR shows
favorable QOL in
recurrent HCC.
9 Patient-Reported Quality ofLife After Pancreatic andLiver Surgery
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139
HRQOL instrument and 2 studies used two
instruments. The Functional Assessment of
Cancer Therapy- Hepatobiliary (FACT-Hep)
contains ve dimensions: Physical Well Being
(PWB), Social Well Being (SWB), Functional
Well Being (FWB), Emotional Well Being
(EWB) and Additional Concerns about
HCC. Higher scores represent better levels of
HRQOL.
The European Organisation for Research and
Treatment of Cancer Quality of Life Questionnaire
Core-30 (QLQ – C30) is a cancer-specic
30-item questionnaire including ve functional
scales: Physical Function (PF), Role Function
(RF), Emotional Function (EF), Cognitive
Function (CF) and Social Function (SF), and a
global health and QOL scale. Higher scores represent better levels of HRQOL.The Short Form36 (SF-36) Health Survey measures eight
dimensions: Physical Function (PF), Role limitation due to Physical health (RP), Bodily Pain
(BP), General Health (GH), vitality (VT), Social
Function (SF), Role limitation due to Emotional
health (RE) and Mental Health (MH). The
domains can be summarised into a Physical
Component Summary (PCS) and Mental
Component Summary (MCS). Higher scores represent better levels of HRQOL.Only 17 (71%)
studies mention baseline assessment of
HRQOL.The timing of post-operative HRQOL
follow up ranged signicantly from 2weeks to
36months.
Discussion
Patient-Reported Global Quality
ofLife After Pancreatic Resection
All but one study [8] reported overall QOL as an
outcome post-surgery. In the rst 3months postoperatively, 13 studies showed a clinically relevant decrease in overall QOL.Six of these studies
reported overall QOL which reverted to baseline
values or showed improvement after 6months. In
the longer postoperative period (i.e. 12months or
greater), only one study demonstrated signicant
improvement in overall QOL at 24months [10].
Amongst studies which examined outcomes
between patients groups undergoing different
types of surgical resection, Seiler etal. demonstrated no signicant difference in global QOL
after PD compared with PPPD [13], both in the
immediate postoperative period and in the longer term. This is in concordance with Schniewind
etal.’s ndings, which showed no difference in
global QOL between patients with PPD and
PPPD at 3, 6, 12 and 24months postoperatively
[12]. However, PD with ELND was associated
with a greater deterioration in global QOL compared with regional lymphadenectomy throughout the same follow-up period [12]. Similarly,
Farnell et al. reported a greater decrease in
global QOL after PD with ELND compared
with PD alone, although this was not statistically signicant. Belyaev et al. showed that
global QOL was decreased at 3months postoperatively for all pancreatic cancer patients irrespective of surgical procedure, and was
signicantly lower in those who underwent a
PD or TP compared with those who underwent a
DP [8]. In addition, the authors highlighted that
patients who had curative surgery experienced a
signicantly larger decrease in global QOL than
those with palliative intent [8]. Fig.9.2 provides
a summary of poor predictors of QoL in pancreatic surgery.
Looking at ndings of studies with patients
not amenable to radical resection, Walter et al.
noted that patients with DLB had greater decrease
in global QOL than those with palliative PD in
the immediate postoperative period [16]. There
was, however, no signicant statistical difference
between the two groups, and global health status
of both groups returned to near normalisation at
3months post-surgery [16]. These ndings were
corroborated by Kostro and Śledziński, whose
study demonstrated that patients who had undergone palliative PD had more favourable evaluation of their global QOL compared to those who
had undergone DBP or laparotomies [23]. Two
studies demonstrated a more rapid return to baseline by 3months [14, 22]. Both were randomised
clinical trials aimed at assessing QOL after neoadjuvant chemotherapy and surgery for patients
with resectable pancreatic adenocarcinoma.
140
N. E. James et al.
Predictors of poor QOL in Pancreatic Surgery
Extent and type of surgery Reference
(8)
PD with ELND Vs regional LND or PD alone 12,20
Curative Vs Palliative resection 8
Newly diagnosed pancreatic insufficiency 8, 28
PD or TP Vs DP 8
Predictors of poor QOL in Liver Surgery
Short term Reference Long term Reference
Advanced Age (>65) 33 Recurrence and
29 -33
advanced pTNM
Major complications 42 Depression and anxiety 30, 36
Poor liver function tests 29 Type 2 change of serum
33
cholinesterase post-op
Pain & Fatigue 35
Major operation 29, 31
Fig. 9.2 Predictors of poor QOL in HPB surgery
W here mortality rates and benets such as
symptom relief are similar among different interventions, a scenario commonly seen in malignant
conditions, measuring QOL after intervention
may have a determinant role in deciding the best
therapeutic option for the patient. This systematic
review therefore assesses short- and long-term
QOL in HPB cancer patients after surgical resection to help weigh the benets against the risks of
surgery.
Pancreatic surgery is associated with an initial
decrease in overall QOL in the early postoperative period (i.e. ≤3months). There seems to be a
similar trend in physical and social functioning,
where both demonstrated a decrease in QOL
scores in the rst 3 months following surgery.
Based on available data, most studies showed an
initial increase in pain, fatigue and diarrhoea in
the short term post-surgery. Similar to the functional scales, most postoperative symptom scores
were comparable to baseline measurements by
3–6months after surgery. This implies that there
is an overall positive effect on mental health
observed in pancreatic cancer patients after sur-
gery, supported by four different studies [8, 12,
18, 24], which described no worsening of mental
component scores after surgery, despite experiencing side-effects of surgery. This may be attributed to the ‘response shift mechanism’, a
psychological adaptation resulting from a change
in internal standard owing to a life-threatening
disease, rst described by Breetvelt and Van Dam
[27].
Additionally, this review compares QOL
between various surgical techniques. The data
shows that there is no signicant difference in
overall QOL between the Whipple’s procedure
and PPPD in both the short and long term. There
also appears to be no signicant difference
between baseline and postoperative overall QOL
and physical functioning for patients undergoing
Whipple’s. Issues favouring preservation of the
pylorus are improved postoperative weight gain
and avoidance of postgastrectomy syndromes,
which are positively correlated with improvement in physical, psychological and social functioning, independent of the underlying disease.
These were the results of Seiler et al.’s ran-
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141
domised controlled trial, which provide convincing evidence that PPPD is as effective as the
Whipple’s procedure in the resection of pancreatic cancers [13].
Belyaev etal.’s study showed that in the early
postoperative period, QOL of pancreatic cancer
patients was inuenced more by the type and
extent of surgery, rather than by their diagnosis
[8]. In general, patients who had undergone curative resection reported worse physical functioning and overall QOL, but better emotional and
social functioning, and less pain than those with
palliative resection. Whilst palliative resection
may have a prophylactic effect and can avoid
potential complications associated with latestage pancreatic cancer such as bile duct or gastric outlet obstruction, it does not appear to have
a positive effect on the QOL of pancreatic cancer
patients. This is supported by Kostro and
Śledziński’s study [23]. Hence, indications for
palliative surgery should be carefully discussed
when presenting treatment options to patients
with widespread malignant pancreatic disease.
Belyaev etal. also demonstrated that DP and TP
was the best and worst tolerated procedures
respectively, despite a greater incidence of postoperative pancreatic stulae in the former group
[8]. This could be attributed to a greater degree of
perioperative endocrine and exocrine pancreatic
insufciency developed amongst TP patients,
which is supported by the ndings of a previous
study by Halloran et al., who found that newly
developed pancreatic insufciency is a relevant
prognostic factor which signicantly decreased
QOL [28].
Patient-Reported Global Quality
ofLife After Liver Resection (LR)
In general, most studies found an initial shortterm adverse effect of HRQOL in LR with longterm improvement and stabilisation in overall
QOL.Chen etal. demonstrated a 19% decrease
in QOL scores 2weeks after operation for liver
cancer (p<0.010) [29]. At 4months QOL had
returned to baseline and improvement continued
throughout the 12 months. At 9 months QOL
recovered to scores better than preoperatively.
Likewise, in a secondary analysis of two prospective studies for LR in cancer, Tohme etal. showed
reduced HRQOL from baseline at 4 months
which stabilized to baseline values at 8 and
12months [30]. Dasgupta etal. demonstrated a
non-signicant trend towards deterioration of
most functional scores and global health status at
6months after LR for cancer, with a subsequent
return to baseline level by 12months [31]. The
short-term deterioration in QOL, which subsequently recovers, is further demonstrated in studies comparing LR to non-surgical interventions.
Huang etal. reported outcomes on QOL after LR
as compared to RFA in the treatment of small
(<3cm) solitary HCC. Despite RFA having signicantly better HRQOL scores than LR throughout the 36 months, the gap between the two
interventions narrowed over time as QOL following surgery progressively recovered beyond baseline. The longitudinal pattern of results could be
explained by the direct consequences of surgery
in the early postoperative period. Incisional
trauma, post treatment morbidity, decreased liver
parenchyma and worse liver function are more
pronounced in the short term and recover over
time. It is possible to suppose that as liver function recovers so does QOL.
Disease Recurrence Advanced pTNM and disease recurrence were signicantly predictive of
QOL deterioration over time after LR [29–33].
On the contrary, Banz etal. reported that postoperative diagnosis and poor clinical prognosis
did not correlate with QOL [34]. Interestingly,
Bruns etal. showed that MCS scores were superior after LR for metastatic disease compared to
primary carcinoma and benign disease (p=0.032)
[35]. Anxiety and depression were shown to be
negative predictive factors of postoperative QOL
in LR.In a study of 410 patients undergoing LR
for HCC, Lee etal. demonstrated that comorbid
anxiety and depression (ADS) had a signicant
(p<0.001) negative effect on HRQOL [36]. The
negative impact in QOL between comorbid and
non-ADS increased from baseline and over time.
142
N. E. James et al.
Tohme etal. also reported depressive symptoms
(p<0.0001) to be associated with reduced QOL
at 8 months [30]. Ueno et al. demonstrated that
the maintenance of protein synthesis post LR was
the only independent variable positively correlated to post-treatment QOL.Older age (> or=65
years), recurrence, and change of serum cholinesterase level were associated with impaired QOL
[33]. On multivariable analysis, Huang et al.
found the presence of concomitant disease, cirrhosis and surgical resection were signicant risk
factors associated with a worse HRQOL score
after treatment [37]. Figure9.2 provides a summary of poor predictors of QoL in liver surgery.
Laparoscopic Resection All three studies comparing outcomes in laparoscopic Vs open LR
demonstrated satisfactory HRQOL in the laparoscopic approach. Whereas Benzing etal. found no
signicant differences between laparoscopic and
open groups [38], Guiliani and Fretland etal. proposed a benet in the method of laparoscopy [39,
40]. Each study addressed a different population
looking into LR in benign & malignant, benign
only and CRLM respectively. Guiliani etal. demonstrated a better QOL in the laparoscopic group
early after surgery and at 1year [39]. At 6months
there was a strong statistically signicant difference in the QOL in the laparoscopic group from
the open group. Physical Function was statistically signicant better at 1 and 12 months after
laparoscopic surgery (p < 0.05). Similarly,
Fretland etal. found that at 1month post-operatively, patients undergoing laparoscopy for CRLM
had less deterioration in physical domain scores
than the open group [40]. By 4months, scores in
the laparoscopic group had returned to pre-operative levels but patients in the open group still
reported reduced scores in 2 domains (RP and
GH). Patients in both groups reported increased
scores for MH at 1month [40].
Minor Versus Major Hepatectomy Toro et al.
found a signicant QOL benet after 24months
in patients undergoing LR with no difference
between minor and major hepatectomy [41].
Bruns etal. showed that the physical component
of HRQOL was improved after major hepatectomy compared to minor hepatectomy (p=0.005)
[35]. Chen et al. showed a greater decrease in
QOL at 2weeks after operation in patients who
underwent major hepatectomy as compared to
minor hepatectomy (p < 0.050) [29]. Likewise,
Miller et al. demonstrated that global, physical
and overall QOL were decreased at rst postoperative visit relative to baseline (p < 0.05) in
patients undergoing major LR for cancer [42].
Along with increased pain and fatigue, these
recovered at the 6-week visit and remained stable
over the 6months of the study. Dasqupta et al.
demonstrated that patients undergoing major
hepatectomy returned to their baseline quality of
life at 3months with a progressive and sustained
increase in physical, emotional, and global rating
scale at 6months despite an initial decline [31].
Despite signicantly decreased social function
score, Banz et al. demonstrated overall good
QOL in LR for malignant disease and the extent
of resection did not signicantly inuence the
overall QOL [33].
Study Limitations
The included studies exhibit some limitations,
which must be considered when interpreting the
ndings of this analysis. Firstly, there is signicant variation in patient population, primary surgical resection techniques, the presence of
neoadjuvant or adjuvant therapy, and lymphadenectomy or vascular resection during surgery.
The heterogeneity of QOL instruments used and
time points of QOL assessment postoperatively
also made pooling of data difcult. Therefore, a
quantitative meta-analysis could not be performed. Nevertheless, the qualitative analysis in
this study clearly demonstrated a decrease in
QOL in several domains in the early postoperative period of patients undergoing surgery
for HPB cancer.
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143
Three studies reported HRQOL outcomes in
LR in relation to supportive peri-operative interventions and demonstrated that enhanced care
delivery can improve QOL after LR by means of
alleviating anxiety and depressive mood. In a
RCT of 136 patients undergoing LR for HCC,
Wang J. et al. demonstrated that a comprehensive education and care programme (CEC)
including health education, psychological nursing, caring activity and telephone condolence
signicantly improved QOL postoperatively. At
12months the QLQ-C30 global health status and
functional score was higher in patients undergoing CEC as compared to the control group
(P< 0.05). Similarly, in a randomised study of
82 patients undergoing LR for LC, Ji etal. demonstrated that patients exposed to High Quality
Nursing had better HRQOL both physically and
mentally as opposed to the control group
(p < 0.05). In a non- randomised study of 70
patients, Wang et al. showed improved social
and family well-being after LR in patients
enrolled in a prehabilitation programme as compared to the control group (p<0.0001). All studies were limited by their small population
samples.
Additionally, almost 80% of patients included
in the studies on pancreatic cancer underwent a
Whipple’s procedure or PPPD. Although results
may not be fully representative for patients
undergoing distal or total pancreatectomy, ndings from the former two procedures can be used
to inform patients about the expected effects of
pancreatoduodenectomy for pancreatic malignant on QOL. This information is valuable for
counselling of patients in the pre- and
post- operative phases. However, it is important to
note that in the studies which included patients
undergoing neoadjuvant or adjuvant therapy, no
additional statistical testing was performed to
assess QOL after resection before adjuvant therapy, or to compare QOL before and after resec-
tion for cases where neoadjuvant therapy was
administered. This should be taken into consideration when interpreting the present results, as a
detriment in any of the QOL domains especially
the symptom scales could be spuriously attributed to surgery instead of chemo- or
radiotherapy.
Conclusion
Our study provides evidence that QOL is substantially affected by HPB surgery, and demonstrates the need for detailed discussion and
tailoring of surgical techniques and resources to
the individual patient, based on their baseline
functioning, pathological diagnosis, and staging
of disease. Although surgical treatment for liver
and pancreatic cancers has short-term negative
impact on QOL, it is not associated with irreversible impairment in QOL.The relatively long
plateau phase supports the argument for resections in carefully selected patients. There is also
potential for minimally invasive approaches in
the management of HPB malignancies as studies
have shown comparable perioperative and oncologic outcomes with traditional approaches.
However, its impact on overall QOL after surgery needs to be more clearly dened through
improved training opportunities and future prospective studies in this research area.
Nevertheless, the ndings of this study will contribute positively towards shared decision-making between patient and clinician, and are useful
to inform patient’s expectations. Reassurance
may be given to patients that most functional
impairments and symptoms experienced in the
immediate post- operative period are likely to
improve by 3months and return to baseline levels by 6months. Figure9.3 provides a summary
of the key conclusions of this chapter for the
clinician.
144
Key Conclusions for the clinician
1 Review of the literature shows that HRQOL is substantially affected by HPB surgery
2 Surgical treatment for pancreatic and liver cancer has short -term negative impact on QOL, however it is
not associated with irreversible impairment in QOL
3 Most functional deterioration and symptoms experienced in the immediate post -operative period are likely
to improve by 3 months and return to baseline by 6 months
4 Disease recurrence, advanced pTNM stage and comorbid anxiety and depression negatively correlate with
QOL after LR
5 Type and extent of surgery can correlate with HRQOL in pancreatic cancer patients
6 Palliative resection does not appear to have a positive effect on QOL in pancreatic cancer
7 Knowledge of HRQOL outcomes can be useful to tailor surgical technique to the individual patient, based
on their baseline functioning, pathology and staging of disease
N. E. James et al.
Fig. 9.3 Key conclusions for the clinician
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Quality ofLife inHead & Neck
Surgical Oncology andThyroid
Surgery
GeorgeGaras, KeshavGupta, andSameerMallick
10
Quality ofLife (QoL) Instruments
inHead & Neck andThyroid Cancer
Introduction
Quality of Life (QoL) is dened as a patient’s
individual perspective of the impact of their disease or treatment on their physical, psychological, social, somatic, and functional well-being
[1]. With continued advances in modern medicine, surgical outcomes in terms of tumour resection and overall mortality have markedly
improved. As a result, optimising QoL outcomes
has become increasingly important in recent
G. Garas (*)
Department of Surgery and Cancer, Imperial College
London, St. Mary’s Hospital, London, UK
Head & Neck Unit, Department of
Otorhinolaryngology and Head & Neck Surgery,
Queen Elizabeth Hospital Birmingham, University
Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
e-mail: g.garas@imperial.ac.uk
K. Gupta
Head & Neck Unit, Department of
Otorhinolaryngology and Head & Neck Surgery,
Queen Elizabeth Hospital Birmingham, University
Hospitals Birmingham NHS Foundation Trust,
Birmingham, UK
S. Mallick
Department Otorhinolaryngology and Head & Neck
Surgery, Queens Medical Centre, Nottingham
University Hospitals NHS Trust, Nottingham, UK
years in order to match favourable outcome measures from both a patient and surgeon
perspective.
Head and neck cancer is a broad term that generally encompasses tumours of the oral cavity,
pharynx, larynx, and salivary glands, among
numerous other organs. This group of malignancies is highly heterogenous with varied presentations and disease courses. Most can be managed
with either surgery, radiotherapy, chemotherapy,
or multimodality therapy. Thyroid cancer is also
commonly included in this disease spectrum.
Head and neck cancer patients typically suffer
a disproportionate QoL burden compared to
patients with primary neoplasms originating outside the head and neck. Head and neck cancer
patients characteristically struggle with signicant physical (e.g. pain, mucositis, xerostomia),
functional (e.g. dysphagia, dysphonia, dysgeusia) and psychosocial (e.g. depression, disgurement, social isolation, and stigmatisation) issues
that can be permanently debilitating [2]. Radical
surgery allowing for complete oncological resection and disease-free survival can often be offset
with a substantial detriment in QoL as a result of
poor functional status and deformity. Traditional
surgeon- and oncological-focussed outcomes
may therefore not be as important to patients as
the potential physical, functional, and psychosocial treatment side effects. Given that such factors are central to patients’ QoL, there is an
increasing onus to utilise validated QoL instru-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
T. Athanasiou et al. (eds.), Patient Reported Outcomes and Quality of Life in Surgery,
https://doi.org/10.1007/978-3-031-27597-5_10
147
148
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
G. Garas et al.
ments to better guide surgeons facilitating clinical decision making according to patient-centred
outcomes. QoL measurement tools also have an
overlap with Patient Reported Outcome Measures
(PROMs). PROMs are becoming increasingly
employed in clinical trials, reecting the
importance of patient-centred outcomes in
Evidence Based Medicine (EBM).
Quality ofLife (QoL) Instruments
The Scientic Advisory Committee of the
Medical Outcomes Trust (SAC-MOT) state that
high quality QoL tools should be valid, reliable,
and be able to detect change over time [3]. There
are a number of generic surgical QoL questionnaires such as the SF-36 and EQ-5D that focus on
non-disease specic QoL measures such as
mobility, pain, anxiety and discomfort [4, 5].
Measuring QoL outcomes in head and neck cancer can be challenging due to the varied nature of
primary tumour sites and thus associated symptomatology, disease course, treatment options,
and patient response to treatment. The use of
disease-specic head and neck QoL measurement tools is therefore required in order to more
accurately measure such outcomes. Over the last
few years, several validated tools have been
developed for this purpose. These are commonly
patient-administered questionnaires that can generally be subdivided into site-specic, treatmentspecic, and/or symptom-specic measurements
tools. Usually, more than one tool is required to
allow for a comprehensive evaluation. Each tool
has different qualities that can inuence its utilisation, such as the domains evaluated, available
translations, and scales used. Table 10.1 summarises the available QoL measurement tools in
head and neck surgical oncology and thyroid
surgery.
Discussion
It is well established that head and neck cancer
survivors have a relatively poor QoL [64, 65].
These patients, and those with thyroid cancer,
can have their QoL affected by the disease course,
patient factors such as marital status, family
income and the variety of available treatment
options [66]. Radical surgery, (chemo)radiotherapy, or multimodality therapy can all lead to poor
physical, functional, and psychosocial outcomes.
These can not only vary in terms of which patients
they affect, but the same side effect of the disease
or treatment modality can also have a drastically
different impact on different patients who can
perceive complications differently. Figure 10.1
summarises the predictors of poor QoL in these
differential patient populations (discussed below
separately in each section) plus those common to
all head and neck primary tumour sites (including thyroid). It is therefore imperative that
patients are counselled appropriately in a multidisciplinary setting so that personalised treatment
options can be offered tailored to the individual
patient. QoL measures are vital in informing such
discussions. They can also be useful in adapting
management strategies for patients with existing
disease to help tailor treatment to what is most
important to them at a specic time period.
Presently, there are a multitude of available
QoL measurement tools. However, there is no
clear consistency in terms of design and reporting. The choice of which tool to use can therefore
be somewhat ambiguous. Currently, the most
commonly utilised tools in head and neck oncology include EORTC QLQ H&N35 [8], FACT-HN
[10], and UWQOL for site-specic measures
[26], HNRT-Q for treatment-specic measures
[28], MDADI [42] for dysphagia measures and
VHI/VHI-10 for voice measures [55]. Despite
their longevity of use, they still do not comprehensively cover all areas that may be of interest to
specic patients and surgeons. The use of more
than one tool is therefore commonly employed to
help bridge this gap. However, with this comes
another issue related to domain overlap in commonly evaluated factors such as pain, physical
function, and social function. Interpretation of
results can therefore be difcult as one may be
unsure as to how much weighting to place on
each overlapping domain.
Future research should focus on robust comparisons between QoL measurement tools to
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