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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 5  |  Page : 661-668

Effects of clinical factors on quality of life following curative gastrectomy for gastric cancer


1 Department of General Surgery, Kartal Training and Research Hospital, Istanbul, Turkey
2 Department of General Surgery, Bahcesehir University VM Medical Park Hospital, Istanbul, Turkey

Date of Acceptance10-Jan-2019
Date of Web Publication15-May-2019

Correspondence Address:
Dr. M F Kundes
Kartal Egitim ve Arastirma Hastanesi, Genel Cerrahi Kliniği, Cevizli, Kartal, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_181_18

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   Abstract 


Aim: We aimed to assess the factors which may affect the quality of life (QoL) of the patients who underwent curative gastrectomy for gastric cancer. Subjects and Methods: Patients with gastric cancer, who underwent gastrectomy with curative intent at Department of Gastrointestinal Surgery, Kartal Training and Research Hospital from January 2013 to December 2015, were retrospectively reviewed. Gastrointestinal Quality of Life Index was utilized for this research. The clinical factors that might affect QoL after gastrectomy were selected. They were demographic data (age and gender), the American Society of Anesthesiologists classification, body mass index (BMI), operative variables (level and type of resection, type of dissection [D1, D2], type of reconstruction, and additional organ resections), postoperative appetite level, type of oncological treatment, and pathological stages. One hundred and eighteen patients were included in this study. Results: Eighty-seven (73.7%) of them were male and mean age was 59.4 ± 10.2 (36–74). Mean follow-up period was 25.7 ± 11.3 (6–42) months. According to multivariate analysis, advanced stage, neoadjuvant therapy, lower BMI, poor appetite, and shorter follow-up were independently associated with poorer cumulative scores. Conclusions: Advanced stage, application of neoadjuvant therapy, low BMI level, and poor postoperative appetite may deteriorate the postoperative QoL of the patients with gastric cancer.

Keywords: Gastrectomy, gastric cancer; quality of life


How to cite this article:
Kundes M F, Kement M, Yegen F, Alkan M, Kaya S, Kaptanoglu L. Effects of clinical factors on quality of life following curative gastrectomy for gastric cancer. Niger J Clin Pract 2019;22:661-8

How to cite this URL:
Kundes M F, Kement M, Yegen F, Alkan M, Kaya S, Kaptanoglu L. Effects of clinical factors on quality of life following curative gastrectomy for gastric cancer. Niger J Clin Pract [serial online] 2019 [cited 2019 Aug 25];22:661-8. Available from: http://www.njcponline.com/text.asp?2019/22/5/661/258265




   Introduction Top


Gastric cancer is the fourth most common cancer and second leading cause of cancer death worldwide.[1] It is especially prevalent in Eastern countries. Unfortunately, symptoms of gastric cancers are nonspecific and they are usually detectable in advanced stages. Although the extent of lymph node dissection remains a challenging debate, complete resection of the tumor with negative margins is the gold-standard treatment modality in the current practice. Overall survival rate of gastric cancer has been increasing due to the modern diagnostic tools, new treatment modalities, and mass screening programs.[1]

Health has been defined as a state of physical, mental, and social well-being by World Health Organization since 1948.[2] Each patient has the right to know the impact of the treatment on his or her quality of life (QoL).[3] Health-related QoL can be defined as the patients' multidimensional and subjective appraisal and satisfaction with their current level of functioning as compared to what they perceive to be ideal. Studies that investigate the health-related QoL of patients are gradually increasing.[4] Surgeons should be aware and ready to inform the patients about every single detail of possible consequences of the treatment. Although there is a mutual agreement of deterioration of QoL in gastric cancer patients, there are limited data in the literature, evaluating QoL after gastric cancer surgery. In our study, we aimed to assess the factors which may affect the QoL of the patients who underwent curative gastrectomy for stomach cancer.


   Subjects and Methods Top


Patients

Patients with gastric cancer, who underwent gastrectomy with curative intent at Department of Gastrointestinal Surgery, Kartal Training and Research Hospital from January 2013 to December 2015, were retrospectively reviewed. All study protocol and contact documents were approved by the Ethics Committee of our hospital. A formal written consent was obtained from all the patients.

Exclusion criteria

In our study, exclusion criteria included refusal to participate, the American Society of Anesthesiologists (ASA) classification score IV, physical or intellectual disability, R1 or R2 resection, local recurrence or metastatic disease during follow-up period, and follow-up of less than 6 months from the date of completion of oncological treatment if needed.

Quality-of-life assessment

QoL questionnaires were administrated to all patients in individual sessions by a physician (MFK). Gastrointestinal Quality of Life Index (GIQLI) was utilized for this research. GIQLI was developed by Eypasch and colleagues to measure health-related QoL in gastrointestinal diseases.[5] The questionnaire contains up to 36 items, scored on a 5-point Likert scale. According to this index, maximal score for healthy person was 144. Main symptoms, physical, psychological, medical, and social parameters were assessed.

Parameters

The clinical factors that might affect QoL after gastrectomy were selected. These were demographic data (age and gender), ASA scores, body mass index (BMI), operative variables (level and type of resection, extent of lymph node dissection [D1, D2], type of reconstruction, and additional organ resections), postoperative appetite level, oncological treatment modalities, and pathological stages.

Data collection and statistical analyses

Data were collected using paper/pencil instruments by MFK and entered into a computer by a statistical staff. All data were analyzed using SPSS 17.0 for Windows (SPSS Inc., Chicago, IL). Parameters were evaluated for predictive significance by independent t-tests for continuous variables or Chi-square tests for categorical variables. Multivariate analyses were used to evaluate the joint significance of those parameters and GIQLI scales that were shown to be predictive in univariate analyses. A difference was considered to be statistically significant if the P value was <0.05.


   Results Top


Patients

During the study period, a total of 151 patients with gastric cancer underwent gastrectomy with curative intent in our department. Thirty-three patients were excluded from the study for the following reasons: refusal to participate in seven patients, death from various causes in eight patients, missing during follow-up in nine patients, ASA IV in four patients, and local recurrence or metastatic disease during follow-up period in five patients. Eventually, 118 patients were included in this study. Eighty seven (73.7%) of them were male and mean age was 59.4 ± 10.2 (36–74) years. Mean follow-up period was 25.7 ± 11.3 (6–42) months. Details of demographic and clinical characteristics of the patients were demonstrated in [Table 1].
Table 1: Demographic and clinical characteristics of the patients

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GIQLI scales

Main symptoms

Using multivariate analysis, female gender, advanced age, omega reconstruction, splenectomy, and advanced stage were independently associated with poorer main symptoms scores [Table 2].
Table 2: GIQoL main symptoms

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Physical

Using multivariate analysis, advanced stage and neoadjuvant therapy were independently associated with poorer physical scores [Table 3].
Table 3: GIQoL physical

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Psychological

Using multivariate analysis, advanced stage, higher ASA score, neoadjuvant therapy, and bad appetite were independently associated with poorer psychological scores [Table 4].
Table 4: GIQoL psychological

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Social

Using multivariate analysis, advanced stage, neoadjuvant therapy, and lower BMI were independently associated with poorer social scores [Table 5].
Table 5: GIQoL social

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Illness dependent

Using multivariate analysis, total gastrectomy, higher ASA score, lower BMI, and advanced stage were independently associated with poorer illness-dependent scores [Table 6].
Table 6: GIQoL illness dependent

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General (Cumulative)

Using multivariate analysis, advanced stage, neoadjuvant therapy, lower BMI, bad appetite, and shorter follow-up were independently associated with poorer cumulative scores [Table 7].
Table 7: GIQoL general

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   Discussion Top


Gastrectomy is one of the most commonly performed surgical procedures in the world. Unfortunately, signs and symptoms of gastric cancer are usually nonspecific and result in delayed diagnosis. For this reason, QoL of these patients usually deteriorates prior to surgery. Complete resection of the tumor with negative margins is the gold-standard treatment modality for these patients. Additionally, lymph node dissection plays major role for curative treatment in gastric cancer. In our study, we enrolled all the patients who underwent curative gastrectomy and completed their medical oncological treatment. Impaired levels of QoL in our cases were similar to findings in the literature.[6],[7],[8]

Distal gastrectomy usually allows adequate resection in patients with tumors localized in the distal stomach. For patients with proximal tumors, resection with clear margins is achieved with total or proximal gastrectomy. In extensive tumors, subtotal or total gastrectomy may be needed to achieve clear margins. Even if these operative approaches seem to be oncologically equivalent for appropriate tumors,[9] the effect of each approach on QoL changes and should help to direct surgical practice. In our study, the QoL following total gastrectomy was similar in all scales to the QoL following distal gastrectomy. Our results were similar with well-designed recent prospective study by Karanicolas et al.;[10] they reported that the QoL following total gastrectomy was identical in all domains to the QoL following distal gastrectomy. They also reported that the patients who underwent proximal gastrectomy suffered from significantly more reflux, nausea/vomiting, and a worse overall QoL. They concluded that proximal gastrectomy might not be the optimal procedure for most patients with tumors localized to the proximal stomach.[10] In our study, no patient underwent proximal gastrectomy.

The extent of lymph node dissection remains controversial. D2 lymph node dissection is the standard treatment for curable patients in Eastern Asia. In the West, D2 lymph node dissection is a recommended but not required procedure.[11] In our study, the QoL following D2 dissection was similar in all scales to the QoL following D1 dissection. Wu et al. compared the patients with D1 to those with D3 in a prospective controlled study and showed no significant difference in QoL.[6] The results of our study support their findings.

BMI is a contributing factor affecting QoL in our study. We showed that poor postoperative appetite and BMI less than 18.5 impaired QoL. Qian et al. applied home enteral nutrition and investigated impacts of QoL on advanced gastric cancer survivors.[7] QoL declined gradually with deteriorating nutritional status and home enteral nutrition can be applied to overcome this problem. Zalina et al. described similar results, showing a significant relationship between QoL and nutrition.[8] Those with higher nutritional status have better outcomes. Good appetite played major role in our study. All the cases who were able to eat satisfactorily showed better QoL scores. We can comment that good appetite may affect the QoL in a positive way.

In our study, advanced stage and chemotherapy, especially neoadjuvant therapy, make a major contribution to the deterioration of the QoL. Older age and high ASA score were other factors contributing to impairment of QoL in some scales.

The most important limitation of our study was that we had no QoL assessment of the patients preoperatively; if QoL information could be conveyed to patients in the preoperative setting, we could make more informed decisions regarding their health care. We believe that future research and clinical trials in surgery options in patients should routinely include analysis of QoL as an outcome measure.


   Conclusions Top


QoL explanations do not usually have special attention through surgeons. In our opinion, every surgeon should be able to give detailed information to the patients about their expected condition of postoperative QoL. In the light of our study's findings, advanced stage, application of neoadjuvant therapy, low BMI level, and bad postoperative appetite may deteriorate the postoperative QoL of the patients with gastric cancer.

Ethics approval and consent to participate

All study protocol and contact documents were approved by the Ethics Committee of Kartal Training and Research Hospital. Before being asked the patients to participate and fill out QoL questionnaire, a formal consent was obtained from all of them.

Open access

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Availability of data and materials

All datasets on which the conclusions of the manuscript rely were provided as additional supporting file.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Jemal A, Siegel R, Ward E. Cancer statistics. Cancer J Clin 2009;59:225-49.  Back to cited text no. 1
    
2.
Available from: http://www.who.int/about/mission/en/. [Last accessed on 2019 Feb 18].  Back to cited text no. 2
    
3.
Whistance RN, Blazeby JM. Systematic review: Quality of life after treatment for upper gastrointestinal cancer. Curr Opin Support Palliat Care 2011;5:37-46.  Back to cited text no. 3
    
4.
Karanicolas PJ, Bickenbach K, Jayaraman S, Pusic AL, Coit DG, Guyatt GH. Measurement and interpretation of patient-reported outcomes in surgery: An Opportunity for improvement. J Gastrointest Surg 2011;15:682-9.  Back to cited text no. 4
    
5.
Eypasch E, Williams JI, Wood-Dauphine S, Ure BM, Schmülling C, Neugebauer E, et al. Gastrointestinal quality of life index: Development, validation, and application of a new instrument. Br J Surg 1995;82:216-22.  Back to cited text no. 5
    
6.
Wu CW, Chiou JM, Ko FS, Lo SS, Chen JH, Lui WY, et al. Quality of life after curative gastrectomy for gastric cancer in a randomised controlled trial. Br J Cancer 2008;98:54-9.  Back to cited text no. 6
    
7.
Qian Z, Sun Y, Ye Z, Shao Q, Xu X, Xu J. Application of home enteral nutrition and its impact on the quality of life in patients with advanced gastric cancer. Zhonghua Wei Chang Wai Ke Za Zhi 2014;17:158-62.  Back to cited text no. 7
    
8.
Zalina AZ, Lee VC. Relationship between nutritional status, physical activity and quality of life among gastrointestinal cancer survivors. Malays J Nutr 2012;18:255-64.  Back to cited text no. 8
    
9.
Harrison LE, Karpeh MS, Brennan MF. Total gastrectomy is not necessary for proximal gastric cancer. Surgery 1998;123:127-30.  Back to cited text no. 9
    
10.
Karanicolas PJ, Graham D, Gönen M, Strong VE, Brennan MF, Coit DG. Quality of life after gastrectomy for adenocarcinoma: A prospective cohort study. Ann Surg 2013;257:1039-46.  Back to cited text no. 10
    
11.
National Comprehensive Cancer Network. Gastric Cancer. Version 3. 2015. Available from: https://www.nccn.org/professionals/physician_gls/. [Last accessed on 2019 Apr 10].  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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