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13 Quality ofLife After Lung Cancer Surgery
QOL was signicantly better (difference > 10 points)
after bilobectomy /lobeetomy than after
pneumonectomy. However, differences were
statistically signicant only with regards to physical
function (at 3 months), social function (at 3 and 6
months), role function (at 3, 6, and 12 months),
global health (at 3 and 6 months), and pain (at 6
months).
Twenty-four months after surgery, the QOL of the
lobectomy group was comparable with that of a
healthy, age-matched population. However, not all
the QOL functional scales recovered to preoperative
levels by 12–24 months. Mean QOL was> 10 points
higher in the lobectomy group, a difference that is
generally regarded as clinically, albeit not
statistically, signicant.
QCQ-C30
Preoperative
75.5%, at
discharge
57.2%, at 3
months 95%, at
6 months 97.8%,
at 12 months
92.5%, at 24
months 72.9%
There were no statistically signicant differences in
Overall functional QOL scores were similar in the
three groups in the full cohort (P = 0.32), and among
the anatomical lung resection subgroup (P = 0.32).
Within the full cohort, this similarity continued when
the scores for each group were compared in the 5
functional domains.
The overall functional QOL LS dropped below 50in
a minority of patients (3 patients <70, 4 patients
aged 71–80, and 5 patients aged 80). The lowest
overall functional QOL LS was found in a patient
aged <70 (LS 11.14), and the next lowest in a patient
aged 70 to 79 (LS 13.33).
EORTC
QCQ-C30
95.2%
scores between the older and younger groups,
EORTC
QCQ-C30
201
QLQ-C30; p 0.019 for QLQ-LC13)
% predicted forced expiratory volume in the rst
second, was a strong determinant of the worst
quartile of physical function, role function, fatigue,
pain, and dyspnoea scores. The occurrence of
pulmonary complications was also associated with
physical function outcome for the worst quartile of
however older patients had poorer physical function,
more fatigue, greater dyspnoea, and less depression.
Age at the time of questionnaire completion was
inversely related to physical function score (p =
0.002) and was directly related to fatigue score (p =
0.006) and dyspnoea scores (p = 0.016 for
57%
the QOL, mood, and symptom
(continued)
Pre op, at
discharge, 3
months, 6 months,
Yes 24 months EORTC
Lobectomy group:
mean age 63.6 ± 9.9
years, 26.7% female,
18.3% stage III/IV
Germany Bilobectomy/
Bilobectomy/
Lobectomy vs.
Pneumonectomy for
NSCLC.Comparison
with age-matched
12 months, 24
months
Pneumonectomy
group: mean age
60.7 ± 9.2 years,
14.2% female,
57.1% stage III/IV
healthy population
159 patients:
Bilobectomy/
Lobectomy (n = 131),
Pneumonectomy (n =
28)
days
Median interval
time 314 days
No Range 7—852
median age 63 years,
54.5% female,
15.5% sublobar
resection
70–79 years group:
U.K. <70 years group:
QoL after NSCLC
resection in
Octogenarians
compared to younger
patients
106 patients:
median age 73 years,
64% female, 22%
sublobar resection
≥80 years group:
median age 82 years,
54.1% female,
45.8% sublobar
<70years (n = 33),
70–79 years (n = 25),
≥80years (n = 48)
Average 2.6 years
to 6.4 years
No Range 3 months
resection
mean age 61.6 ± 6.5
years, 44.9% female,
USA <70 years group:
Patients after Major
Lung Resection
post op
years, 50.9% female,
11.6% post op
complications
124 patients: <70
years (n = 69), ≥70
25.5% post op
≥70 years group:
mean age 75.8 ± 4.2
years (n = 55)
complications
Schulte etal.
2009
1998–2004
Prospective
cohort study
Asemota etal.
2022
2015–2018
Prospective
cohort study
Ferguson etal. QoL in Elderly
202
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HRQOL
instrument used
Follow-up
One month after VATS, patients’ overall health and
physical, role and social function had deteriorated by
a clinically meaningful amount (C 10 points, 19–36).
At 3 months post-surgery, overall health had
recovered to pre-surgery levels, but problems with
reduced physical, role and social function persisted
76.6%
VATS group:
and were still present 12 months post-surgery
75.6%,
Thoracotomy
group: 83.3%
functioning (p = 0.026), role functioning-emotional
(p = 0.004), mental health (p = 0.005), and energy (p
= 0.044) in patients with lung cancer who underwent
Main ndings related to HRQOL
QCQ-C30
completeness rate
At 12 months
surgery.
A remarkable and durable reduction in physical
functioning (p < 0.001), role functioning-physical (p
= 0.002), role functioning-emotional (p = 0.002),
social functioning (p < 0.001), mental impairment (p
< 0.001), and bodily pain (p < 0.001) persists.
Changes in overall functioning status were
signicant between the time before surgery and one
week following treatment, but not signicant
observed 6 months after treatment.
Overall, the intensity of symptoms increased
signicantly 1 week after treatment (p < 0.001) but 6
months after treatment symptoms signicantly
QCQ-C30
64.2%
T. Tsitsias and T. Athanasiou
decreased.
Both EQ-5D VAS and the EORTC GHS scores
showed a signicant decrease at 1M after surgery
and then a signicant increase at 1Y after surgery,
more than then pre-surgery levels.
In multivariate analysis, absence of Diabetes,
preoperative EORTC GHS score, preoperative
cognitive function score and preoperative symptom
score of pain were identied as signicant predictive
factors of QoL at 1Y.
EORTC
QCQ-C30
85.9%
Follow-up duration
Time points of
HRQOL
measurements
HRQOL
assessment
Country Patient characteristics Pre-op
Study intent and no.
of patients
Yes 12 months EORTC
U.K. VATS group: mean
VATS vs.
Pre op, 1 month, 3
months, 12
months
age 70.3 ± 8.8 years,
42.4% female, 0%
pneumonectomy
Thoracotomy group:
mean age 65.1 ± 8.8
years, 38.9% female,
38.9%
Thoracotomy for
NSCLC
110 patients: VATS (n
= 92), Thoracotomy
(n = 18)
Preop, 6 months 74.1%
Yes 6 months SF-36 Signicant impairment was noted in physical
Pneumonectomy
Mean age 62.0 ±
10.62 years, 41%
female, 56.7%
thoracotomy, 36.7%
USA
(multicentre)
QoL 6 months after
lung resection for
NSCLC
103 patients
sternotomy
Pre op, 1 week, 6
months
Yes 6 months EORTC
years, 27.7% female
Poland Mean age 62.4 ± 8.9
QoL after surgical
removal of lung
cancer
72 patients
Pre op, 1 month,
12 months
Yes 12 months EQ-5D
39.4% female, 90%
minimally invasive
Japan Median age 70 years,
Preoperative
predictors of
restoration of QoL
after lung cancer
resection
223 patients
Avery etal.
2020
2014–2015
Prospective
Author,
Table 13.1 (continued)
publication year,
study period, and
study type
cohort study
Handy etal.
2002
Prospective
cohort study
Szeliga etal.
2019
2014–2017
Prospective
cohort study
Ichimura etal.
2021
2015–2018
Prospective
cohort study
13 Quality ofLife After Lung Cancer Surgery
Although there was considerable improvement 1
month after surgery, the recurrence group remained
below preoperative levels for physical and role
functioning, and those having pneumonectomy had
substantially worse role and social functioning
scores, which persisted till the end of the follow-up.
For the no-recurrence group, there was substantial
improvement 1 month after surgery in overall QOL
and functioning, but most dimensions remained well
below the preoperative levels. There were no
additional signicant changes after 4 months in the
overall QOL and functioning scores in this group.
CI: 1.02–5.17 and pneumonectomy OR: 5.60, 95%
CI: 1.29–24.2), age older than 65 years (OR: 1.95,
95% CI: 1.02–3.71), and adjuvant therapy (OR: 2.23,
95% CI 1.01– 4.90) were signicantly associated
QCQ-C30
94.2%
with a worse physical aspect of QOL 6 months
postoperatively.
There were no signicant associations between any
of the patient variables and worse mental aspect of
QOL 6 months after surgery
There was a signicant difference between the lung
cancer and CABG patients in terms of physical
function, with a difference of 9.5 between the mean
values.
Patients who continued to smoke after lung cancer
SF-36
Hospital Anxiety
& Depression
scale(HAD)
84.8%
surgery had signicantly lower scores for mental
health (p = 0.003), vitality (p = 0.027) and mental
components summary (p = 0.003) than former
smokers who stopped smoking at the time of surgery
or before and those who had never smoked.
There was a signicant correlation between reduced
lung function (FEV1 <60% before surgery) and the
physical summary components score (p = 0.05).
Furthermore, patients who underwent
pneumonectomy had a signicantly lower score for
physical summary components (p = 0.002) and role
emotional (p = 0.02) than those who had undergone
lobectomy.
203
Pre op, 1 month, 4
months, 8 months,
12 months, 16
months, 20
Yes 24 months EORTC
years, 27% female,
13.8% stage III/IV
Australia Mean age 66.0 ± 9.0
QoL in the 2 years
after surgery for stage
I/II NSCLC
173 patients
Recurrence (n = 62),
No-recurrence (n =
111)
months, 24
months
Pre op, 6 months 85.5%
Yes 6 months SF-36 The extent of resection (lobectomy OR: 2.29, 95%
10.8 years, 49%
female, 5.2% VATS
Sweden Mean age 64.8 ±
Predictors of
Postoperative QoL
after Surgery for
NSCLC
213 patients
months
No Range 4–48
years, 49.1% female,
22%
pneumonectomy
Sweden Mean age 67 (47–85)
QoL following lung
cancer surgery,
comparison with
CABG group
112 patients (121
Mean follow up
22.5 months
CABG patients)
204
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HRQOL
instrument used
Follow-up
Lung cancer surgery had short term negative effects
on QOL, but these effects had disappeared by 6
months after surgery.
Low preoperative HRQOL results did not predict
poor surgical outcome dened by either death or
major complication, although they were associated
with a worse postoperative QOL (at 6 months).
Preoperative percentage predicted TLCO was also
Main ndings related to HRQOL
QCQ-C30
100% at
baseline, 85% at
completeness rate
1 month, 75% at
suggestive of a worse postoperative QOL at 6
3 & 6 months
Lung cancer survivors and general population
subjects did not exhibit signicantly different
multivariate adjusted mean scores and clinically
meaningful worse scores as 10-point than the general
population in most of the functioning and symptoms
except for dyspnoea and nancial problems on the
subscales of the EORTC QLQ-C30.
Compared with survivors receiving only lung
months.
QCQ-C30
40.3%
resection, survivors receiving both lung resection and
radiotherapy were clinically meaningfully worse and
had worse nancial problems. Cancer survivors
receiving lung resection, radiotherapy, and
chemotherapy showed clinically meaningful worse
score in terms of dyspnoea than survivors receiving
only lung resection
T. Tsitsias and T. Athanasiou
Follow-up duration
Time points of
HRQOL
measurements
HRQOL
assessment
Country Patient characteristics Pre-op
Study intent and no.
of patients
Yes 6 months EORTC
U.K. Mean age 69 ± 8
Effect of lung cancer
Pre op, 1 months,
3 months, 6
months
years, 40% female,
33%
pneumonectomy,
22% major
complication post op
surgery on QoL
110 patients
Median time since
diagnosis 4.1
years
No EORTC
>55 years 45.5%,
42.8% female
All patients had
thoracotomy
Korea (2
centres)
QoL in Disease-Free
Survivors of
Surgically treated
Lung Cancer
Compared with
General Population
830 propensity
matched- pairs of
patients
Win etal. 2005
2001–2003
Prospective
Author,
publication year,
Table 13.1 (continued)
study period, and
study type
cohort study
Yun etal. 2012
2001–2006
Prospective
cohort study
13 Quality ofLife After Lung Cancer Surgery
Fig. 13.2 Variables
identied to have a
negative effect on
HRQOL outcomes
Patient
Factors
205
Surgical
factors
Smoking after lung
resection
Age >65
Cardiac and
Respiratory
comorbidities
Adjuvant
Chemotherapy
Preoperative HR-
QOL scores
Reduced (<60%)
Forced Expiratory
Volume 1 second
(FEV1)
Thoracotomy
Pneumonectomy
Tumor >2cm
Diabetes Mellitus
Low Albumin
Levels
206
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T. Tsitsias and T. Athanasiou
Study Objectives, Designs
andPopulation
The 38 studies included comprised a total of
6144 participants (range 22–830). 31 studies
were prospective cohorts; 4 were randomized
controlled trials; and there were 3 retrospective
cohorts. 20 (52.6%) studies originated from
Europe, 10 (26.3%) from the USA, 7 (18.4%)
from Asia and 1 (2.6%) from Australia.
For ease of reading and improved clarity of
results, the studies were categorized into the following groups.
Studies Comparing HRQOL Results
asper Surgical Approach [Thoracotomy
vs. Video-Assisted Thoracoscopic
(VATS) Lung Resection vs. RoboticAssisted Thoracoscopic Surgery (RATS)]
Thirteen studies reported outcomes comparing
the surgical approach [7–19].
Nine of the studies reported outcomes comparing directly thoracotomy to video- assisted
thoracoscopic (VATS) lung resection [7, 10–17]
Bentixen et al. [17] in their RCT showed that
quality of life by EORTC QLC-C30 did not differ
signicantly between groups (p = 0.13).
Emotional function was signicantly between in
the VATS group than in the thoracotomy group
for the entire follow-up period (p = 0.041).
In seven retrospective studies VATS was compared directly to thoracotomy. Hopkins etal. [7]
showed that VATS group has a slightly higher
mean QOL compared to the thoracotomy group,
but not statistically signicant (p = 0.799).
Neither was a signicant difference between the
two groups for each of the QoL subscales: physical (p = 0.444), social (p = 0.455), functional (p =
0.747) emotional (p = 0.721); and pulmonary (p
= 0.741). Schwartz etal. [11] reported A signicant decrease in Physical component score (PCS)
among the thoracotomy group (−2.8; 95% CI:
−4.38, −1.23) while there was a statistically nonsignicant improvement in post-surgical PCS
among the VATS group. Mental Component
Score (MCS) was statistically signicantly
improved after thoracotomy (+1.; 95%CI 0.51,
3.62) but improvement was not statistically signicant after VATS.The method of resection had
a signicant impact on both role function-physical and role function-emotional subscales from
pre- to post-surgery favouring the VATS approach.
MCS was statistically signicantly improved
after thoracotomy (.1.5; 95% CI: 0.54, 3.62), but
the improvement was non-statistically signicant
after VATS (.2.7; 95% CI: 3.06, 8.41). The difference in MCS from baseline to follow-up was
not signicantly different between the two methods of resection in both the univariate and multivariate regression models adjusting for sex, age,
pack-years of smoking, ethnicity, and education.
In their prospective study, Rizk et al. [14]
reported similar adjusted PCS between the
groups throughout the course of follow-up,
whereas adjusted MCS scores were consistently
better in the thoracotomy group. For each pain
outcome investigated, adjusted pain scores were
likewise similar between groups during the postoperative period (days 2 to 4). No difference was
found between groups with respect to the risk of
having clinically signicant pain at each of the
outpatient postoperative evaluations (months 4,
8, and 12).
Zhao etal. [15] in their cohort of 217 patients
revealed statistical analysis of SF-36 with the
VATS group scoring higher on seven health
dimensions: Bodily pain (BP), Energy, General
Health (GH), Physical Functioning(PH), Mental
Health (MH), Social Functioning (SF), and rolephysical (RP), but only BP, EG, and RP had statistical signicance. Patients undergoing VATS
lobectomy were scoring higher in most of the
components on the 1 month and 6 months landmarks, and RP was statistically signicant
throughout the study period (1, 6, 12 months).
Hence the group suggests that functional recovery of VATS lobectomy is superior to open
approach.
Li etal. [12] and Aoki etal. [16] reported outcomes for a period of 36 months and both reported
a trend for VATS patients to score higher on the
QoL scores in the early post operative period (3
months). At 36 months after surgery, QOL scores
for six health dimensions (PF, SF, RP, RE, BP and
13 Quality ofLife After Lung Cancer Surgery
207
GH) were higher in the VATS group than in the
thoracotomy group, and the difference was signicant for two dimensions (RP and RE).
Three studies [8, 9, 18] compared the roboticassisted surgery (RATS) approach to thoracotomy. Lacroix etal. [8] did not report a signicant
difference in mean PCS and MCS scores between
the two groups at 2 and 6 months.
Marzorati et al. [9] in a large cohort of 176
patients reported that RATS group was associated with signicantly improved scores across all
the subscales and therefore representing a predictor for QoL post-surgery. Cerfolio etal. [18] in
the retrospective study reported a signicantly
higher average mental quality of life score 3
weeks postoperatively in the RATS group compared to the thoracotomy group (53.5 vs 40.3; P
< .001, respectively). A similar trend was
observed for physical quality of life score at 3
weeks (40.1 vs 34.1; P = .07, respectively); however, the latter difference did not achieve a statistical signicance. The 4-month postoperative
mental and physical quality of life scores did not
differ signicantly between the 2 groups.
Studies Comparing Uniportal vs.
Multi-Portal VATS Lobectomy
Two studies compared uniportal to multi-portal
(3 or more) VATS lung resection [20, 21] however both had a relatively short follow-up period
(1 and 2 months respectively). Dai et al. [20]
found that uniportal group at 6 days post-op had
signicantly lower severe pain (p = 0.02), fatigue
(p = 0.001), constipation, coughing, SOB and
disturbed sleep. However, the QoL scores were
not signicantly different between two groups at
6-days hospitalization (p = 0.622) or during the 4
weeks post discharge (p = 0.168). Xu etal. [21]
in their prospective series showed that the functional areas such as physical function, role function, emotional function and social function and
the overall health status of the uniportal group
were signicantly higher than those of three-portal group (p < 0.05). The fatigue and pain scores
in the uniportal group were signicantly lower
than those of the three-portal group (p < 0.05)
throughout the follow-up period (2 months).
Studies Comparing Surgical Lung
Resection Vs. Stereotactic Ablative
Radiotherapy (SABR)
Three studies directly compared stereotactic ablative radiotherapy (SABR) to lung resection [22–
24]. The ROSEL randomized controlled trial
included 22 patients and reported only global
health status to be signicantly worse on univariable cox proportional hazard modelling for surgical patients when compared to SABR (HR 0.19, p
= 0.038) [22]. Pompili et al. [23] in their series
SABR patients, who have started with worse baseline scores, maintained overall stability over 12
months across all functions and symptoms and
their QLQ-C30 Summary score remained stable
during all time points. VATS patients, who had
relatively good functioning and less symptoms at
baseline, reported clinically signicant deterioration at 6 weeks, the rst timepoint after the surgery. The composite measure of QLQ-C30
Summary score, showed clinically meaningful
deterioration at 6 weeks, with recovery afterwards,
without reaching baseline scores. They conclude
that although SABR patients functioning, lung
symptoms and fatigue were stable over time, their
severity levels remained worse than those of VATS
patients over the 12 months follow-up period.
Finally, Alberts et al. [24] in their prospective
cohort of 306 patients reported no signicant difference in emotional and cognitive scores between
surgery and SBRT throughout the rst 12 months
after diagnosis. After- treatment differences were
also insignicant except for role functioning and
dyspnoea where the SBRT group scored higher.
Studies Comparing HRQOL Results
asPer Extent ofResection (Sublobar,
Lobectomy, Sleeve, Bilobectomy,
Pneumonectomy)
Nine studies reviewed and compared HRQOL
outcomes as per the extent of lung resection [25–
32]. The RCT by Stamatis etal. [32] compared
lobectomy with segmentectomy and showed that
for the entire follow-up period the segmentectomy group showed a fast recovery, documented
from baseline to follow-up at 3 months for physical functioning and from baseline to follow-up
208
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T. Tsitsias and T. Athanasiou
at 6 weeks for global QoL and social functioning. Within the lobectomy group there was a statistically signicant decrease in physical (p <
0.001) and cognitive (p = 0.025) functioning
from baseline up to 12 months, in social functioning (p < 0.001) and in the global QoL (p <
0.001) up to 6 weeks post-surgery. There was no
difference between the baseline and the postoperative scores up to 12 months for symptoms
scales regarding nausea and vomiting, insomnia,
appetite loss, constipation and diarrhoea, as well
as in each group separately, including in comparison between the segmentectomy and lobectomy cohort. Fevrier etal. [27] also compared
lobectomy to sublobar resection (segmentectomy, wedge) and reported that PCS scores
decreased in the rst two postoperative months
for both groups, but the decrease was less severe
for sublobar than for the Lobectomy patients
[−0.18 vs.−2.30, P = 0.02]. The average PCS
score at 12 months was signicantly higher than
the average baseline PCS score for sublobar
patients (48.88 vs. 46.34, difference =+2.55 or
rounded to 3, P = 0.02) and for lobectomy
patients (48.79 vs. 46.01, difference =+2.78 or
rounded to 3, P = 0.048). Average MCS scores at
baseline for sublobar and lobectomy patients
were 52.50 vs. 53.89, P = 0.33. At 12 months, the
average MCS was not signicantly higher than
the average baseline MCS for sublobar patients
(53.89 vs. 52.54, difference = 1.35; rounded to 1,
P = 0.32) or for lobectomy patients (54.87 vs.
53.89, difference =+0.98; rounded to 1, P =
0.46). Overall, the average mental health score
for both sublobar and lobar patients was above
the general population average prior to surgery,
improved by one point at the end of the rst
operative year.
Five studies compared outcomes between
pneumonectomy and lesser resections [Balduyck
EJCTS 2009, Brunelli, Sartipy, Schulte, Balduyck
J Thorac Oncol 2008)]. Balduyck et al. [25]
reported signicant differences in evolution of
physical functioning (6MPO p = 0.045), role
functioning (3MPO p = 0.035), social functioning (6MPO p = 0.006, 12MPO p = 0.001) and
general pain (6MP, p = 0.037) in favour of lobectomy. The pneumonectomy group had a more
favourable evolution of postoperative coughing
(1MPO p = 0.049, 3 MPO p= 0.012, 12 MPO p
= 0.022). Brunelli etal. [26] in their prospective
analysis of 156 patients showed that in patients
who underwent pneumonectomy had a signicantly lower PCS (p = 0.04) but similar MCS (p
= 0.2) compared with patients who underwent
lobectomy at the end of 3 months follow-up
period. Sartipy etal. [28] analysed HRQOL outcomes after a 6-month period and reported that
physical functioning and the vitality subscale
scores were signicantly lower in the pneumonectomy group compared to the lobectomy
group. There was also a signicant difference in
the change of PCS between the lobectomy and
pneumonectomy group (17% vs 32%, p = 0.04).
but not in the rate of MCS change (6.5% vs 12%,
p = 0.72). Schulte etal. [33] included a cohort of
patients with 2-year follow-up period and
reported that QOL was signicantly better (difference> 10 points) after bilobectomy /lobectomy than after pneumonectomy. However,
differences were statistically signicant only
with regards to physical function (at 3 months),
social function (at 3 and 6 months), role function
(at 3, 6, and 12 months), global health (at 3 and 6
months), and pain (at 6 months). Three months
after surgery, a decreased QOL with regards to
role function (p < 0.001) was more apparent in
patients who underwent pneumonectomy than in
patients who underwent lobectomy. This difference was reduced by the following month; however, a statistically signicant difference between
the two groups remained until 12 months after
surgery (p = 0.01). Physical function was lowest
3 months after surgery, although signicant differences were observed between the two groups
(p = 0.004). Global health was lowest at the time
of discharge, with signicant differences
observed between the groups (p = 0.013).
Twenty-four months after surgery, the QOL of
the lobectomy group was comparable with that of
a healthy, age-matched population. Mean QOL
was> 10 points higher in the lobectomy group, a
difference that is generally regarded as clinically,
albeit not statistically, signicant. The group
from Belgium [29] compared sleeve bronchoplastic lobectomy to pneumonectomy and
13 Quality ofLife After Lung Cancer Surgery
209
observed that 1 month after sleeve resection
global QoL, symptom and pain scores approximated their baseline preoperative values. On the
contrary 12 months after pneumonectomy there
was a signicant impact in physical and role
functioning that did not return to their baseline
values. On comparison between the two groups
there were signicant differences in evolution of
physical functioning (1MPO p = 0.014, 3MPO p
0.008, 6MPO p = 0.004), role functioning (1MPO
p = 0.041), cognitive functioning (6MPO p =
0.005, 12MPO p = 0.013) and shoulder dysfunction (12MPO p= 0.049) in favour of sleeve
lobectomy. Finally, Fernando etal. [31] reported
outcomes of their ACOSOG Z4032 randomized
controlled trial comparing sublobar resection
with versus without brachytherapy. Median PCS,
MCS and Shortness of breath (SOBQ) did not
differ signicantly between the two arms
throughout the 2-years follow-up period. At 12
months, there was a signicantly greater proportion of patients with a 10-point decline in SOBQ
scores among those who had segmental resection
(40.5%) versus wedge resection (21.9%) (p =
0.03), and for patients who had a thoracotomy
(38.8%) versus a VATS resection (20.4%) (p=
0.03).
Studies Comparing QoL Results After
Lung Resection Among Dierent Age
Groups
Two studies [34, 35] compared HRQOL outcomes on different age groups subjected to lung
resection. Asemota etal. [34] reported outcomes
on three different age groups (<70, 70–79, >80)
and showed no difference in the overall functional QoL scores (p = 0.32) as well as all the
physical QoL subdomain (p = 0.72) between the
three groups. The ≥80 patients reported signicantly lower levels of worry, irritability, and
depression than either of the younger age groups
(p = 0.008). Their cognition and social QoL
scores remained high and equivalent to the <80
years groups (p = 0.017 and p = 0.57). Ferguson
etal. [35] reported outcomes on groups of <70
and >70 years old patients undergoing lung resection and reported similar QoL and mood between
the two groups. Older (>70 years) patients had
poorer physical function, more fatigue, greater
dyspnoea and less depression however not statistically signicant. The DASS-21 depression
score tended to improve with age (p = 0.064).
The percent predicted forced expiratory volume
in the rst second (FEV1%) was the only strong
determinant of the wort quartile of physical function, role function, fatigue, pain and dyspnoea
scores on multivariate analysis.
Studies Comparing HRQOL After
Lung Resection Against Control
Population or No Comparison atAll
Nine studies compared HRQOL outcomes after
lung resection with matched general population
or simply reported a prospective cohort [36–44]
Avery etal. [36] reported outcomes after VATS
lung resection and showed that overall health and
physical, role and social function had deteriorated by a clinically meaningful amount at 1
month after surgery. At 3- and 12-months postop
overall health levels had recovered, however
there was a reduction in the physical, role and
social function ranging from 10 to 14 points.
Handy et al. [37] in their report from 2002 on
patients undergoing lung resection via thoracotomy and sternotomy found that Signicant
impairment was noted in physical functioning (p
= 0.026), role functioning- emotional (p = 0.004),
mental health (p = 0.005), and energy (p = 0.044)
inpatients with lung cancer who underwent surgery. At 6-months follow-up a remarkable and
durable reduction in physical functioning (p <
0.001), role functioning- physical (p = 0.002),
role functioning– emotional (p = 0.002), social
functioning (p < 0.001), mental impairment (p <
0.001) and bodily pain (p < 0.001) persisted.
Szeliga et al. [38] did not report a signicant
change in the functional scale of EORTC QLQC30 between 1-week and 6-months follow up.
On the symptomatic scale of the EORTC QLQC30 there was a signicant increase of reported
feelings of discomfort i.e., nausea, vomiting,
fatigue, sleep disturbances, loss of appetite, constipation at 1-week after surgery (p < 0.001).
However, at 6-months after treatment, symptoms
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T. Tsitsias and T. Athanasiou
signicantly decreased. Ichimura etal. [39] analysed the trajectory of EQ-5D VAS and EORTC
GHS scores and showed a decrease at 1-month
but increase at 1-year follow-up, more than the
preoperative levels. On multivariate analysis
(factors with p < 0.05 were entered), the albumin
level, preoperative EQ-5D VAS score, preoperative pain/discomfort, and anxiety/depression
were identied as signicant predictive factors of
QOL.In a similar fashion, Moller etal. [41] performed a multivariate analysis and reported that
the extent of resection (lobectomy OR: 2.29, 95%
CI: 1.02–5.17 and pneumonectomy OR: 5.60,
95% CI: 1.29–24.2), age older than 65 years (OR:
1.95, 95% CI: 1.02–3.71), and adjuvant therapy
(OR: 2.23, 95% CI 1.01–4.90) were signicantly
associated with a worse physical aspect of QOL 6
months postoperatively. The mental aspect of
QOL at 6 months after surgery was not associated with any of the patient variables. An
Australian group [40] reviewed a cohort of 173
the NSCLC within 2 years from surgery. Both
groups (recurrence, no-recurrence) showed signicant deterioration (18.1 to 55.2 points) in all
domains except emotional functioning, where the
decline was smaller (5.3 to 6.4 points). After
1-month, overall QOL as well as physical and
cognitive functioning deteriorated signicantly
in the recurrence group. The no-recurrence group
showed substantial improvement 1 month after
surgery in overall QOL and functioning, but most
dimensions remained well below the preoperative levels and no additional signicant changes
occurred after 4 months.
Myrdal etal. [42] reported outcomes on 194
patients undergoing lung resection via posterolateral thoracotomy and identied that patients who
continued to smoke after lung cancer surgery had
signicantly lower scores for mental health (p =
0.003), vitality (p = 0.027) and mental components (p = 0.003) compared to formers smokers
who stopped smoking at the time of surgery or
before and never- smokers. There was a signicant correlation between reduced lung function
(FEV1 <60% before surgery) and the physical
summary components score (p = 0.05).
Pneumonectomy was also found to be associated
with signicantly lower score for physical components (p = 0.002) and role emotional (p =
0.02) than the group of patients who underwent
lobectomy. Win etal. [43] in 2005 showed that in
their prospective cohort global QoL deteriorated
signicantly at 1 month after surgery (repeated
measured ANOVA compared to baseline p =
0.001) but had returned to preoperative levels by
3 months (p = 0.93). The was a marginally signicant correlation between baseline percentage
predicted transfer factor (TLCO) and 6-month
global health status (r = 0.22, p = 0.05), and also
an association between preoperative HRQOL
scales– specically, physical and cognitive functioning, fatigue, pain, dyspnoea and dysphagiaand 6 month global health status. Finally, Yun
et al. [44] reported on results on 830 patients
propensity-matched with a control group from
general population. The lung cancer survivors
had a signicant difference in multivariateadjusted mean scores and clinically meaningful
worse scores as 10-point than the general population only in the dyspnoea and nancial problems
subscales of the EORTC QLQ-C30 and dyspnoea, coughing, and pain in chest wall on subscales of the EORTC QLQ-LC13 instruments.
The addition of radiotherapy to lung resection
was also associated with clinically meaningfully
worse status postoperatively and had worse nancial problems. The group of patients that received
lung resection, radiotherapy, and chemotherapy
showed clinically meaningfully worse score in
terms of dyspnoea than the group of patients that
received lung resection alone. On analysis of
covariance, lung cancer survivors with a respiratory or cardiologic comorbidity had a clinically
lower (>10 points) level of social functioning,
along with clinically higher level of symptoms
such as fatigue, dyspnoea and nancial problems
on the EORTC QLQ-C30 subscales
Health-Related Quality-of-Life
Measures Used
A total of 7 instruments were used. The generic
HRQOL instruments used were the European
Organization for Research and Treatment of
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