Asif Johar

Hospital and Surgeon Volume in Relation to Survival After Esophageal Cancer Surgery in a Population-Based Study

PURPOSE The influence of hospital and surgeon volume on survival after esophageal cancer surgery deserves clarification, particularly the prognosis after the early postoperative period. The interaction between hospital and surgeon volume, and the influence of known prognostic factors need to be taken into account. METHODS A nationwide Swedish population-based cohort study of 1,335 patients with esophageal cancer who underwent esophageal resection in 1987 to 2005, with follow-up for survival until February 2011, was conducted. The associations between annual hospital volume, annual surgeon volume, and cumulative surgeon volume and risk of mortality were calculated with multivariable parametric survival analysis, providing hazard ratios (HRs) with 95% CIs. HRs were mutually adjusted for the surgery volume variables and further adjusted for the prognostic factors age, sex, comorbidity, calendar period, tumor stage, tumor histology, and neoadjuvant therapy. RESULTS There was no independent association between annual hospital volume and overall survival, and hospital volume was not associated with short-term mortality after adjustment for hospital clustering effects. A combination of higher annual and cumulative surgeon volume reduced the mortality occurring at least 3 months after surgery (P trend < .01); the HR was 0.78 (95% CI, 0.65 to 0.92) comparing surgeons with both annual and cumulative volume above the median with those below the median. These results remained when hospital and surgeon clustering were taken into account. CONCLUSION Because surgeon volume rather than hospital volume independently influences the prognosis after esophageal cancer surgery, centralization of this surgery to fewer surgeons seems warranted.

Extent of Lymph Node Removal During Esophageal Cancer Surgery and Survival

BACKGROUND It is unclear how the extent of surgical lymph node clearance influences prognosis after surgery for esophageal cancer. METHODS This nationwide, population-based cohort study included 1044 esophageal cancer patients who had undergone esophagectomy between 1987 and 2010 in Sweden, with follow-up until 2012. The independent role of lymph node removal in relation to survival was analyzed using Cox proportional hazards regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, tumor (T) stage, neo-adjuvant treatment, surgeon volume, and calendar period. Statistical tests were two-sided, except tests for trend. RESULTS Analyzed as a linear variable, a higher number of lymph nodes removed did not influence the overall five-year mortality (adjusted HR = 1.00, 95% CI = 0.99 to 1.01). Patients in the third (7-15 nodes) and fourth (16-114 nodes) quartiles of removed nodes did not demonstrate any decreased overall five-year mortality compared with those in the lowest two quartiles (<7 nodes) (HR = 1.13, 95% CI = 0.95 to 1.35 and HR = 1.17, 95% CI = 0.94 to 1.46, respectively). In early T stages (Tis-T1) the hazard ratios indicated a worse survival with more lymphadenectomy using the median as cutoff (HR = 1.53, 95% CI = 1.13 to 2.06). Increased lymph node removal did not decrease mortality in any specific T stage. A greater number of metastatic nodes and a higher positive-to-negative node ratio were associated with strongly increased mortality. All results were similar when disease-specific mortality was analyzed. CONCLUSION This population-based study indicates that more extensive lymph node clearance during surgery for esophageal cancer may not improve survival. These results challenge current clinical guidelines, and further research is needed to change clinical practice.

Presence of symptom clusters in surgically treated patients with esophageal cancer: Implications for survival

It is not known whether symptoms cluster together after esophageal cancer surgery or whether such symptom clusters are associated with survival in patients with esophageal cancer who are treated surgically.

Impact of co‐morbidity on mortality after oesophageal cancer surgery

There is limited knowledge of how co‐morbidities influence survival after surgery for oesophageal cancer. This population‐based cohort study investigated how Charlson co‐morbidity index and specific co‐morbidities influenced all‐cause and disease‐specific mortality.

Poor health-related quality of life in the Swedish general population: The association with disease and lifestyle factors

Aim: Poor health-related quality of life (HRQoL) is associated with increased use of healthcare services, but it remains unclear which individuals have a heightened risk in the general population. Methods: A Swedish population-based cross-sectional survey was conducted in 2008. Predefined risk characteristics including sex, age, educational level, marital status, body mass index, diseases, physical activity, and tobacco smoking were collected by a self-report questionnaire. Five aspects of the EORTC QLQ-C30 were used to assess HRQoL: physical, role, emotional, social, and cognitive function. Participants were defined as having “poor HRQoL” if they scored ≥10 points (scale 0–100) lower than the mean score of the total sample. To assess the characteristics of individuals with poor HRQoL, classification and regression tree (CART) analysis was performed. Results: A total of 4910 (70.5% participation rate) randomly selected individuals participated in the study. The CART analysis showed that for each of the five functional aspects of HRQoL, the most important covariate HRQoL was the number of reported diseases, while the second strongest covariate was physical inactivity. Conclusion: This large population-based study indicates that a higher number of diseases and physical inactivity are the most important covariates of poor HRQoL in the Swedish general population.

Health‐related quality of life does not differ between short‐term, long‐term and very long‐term cancer survivors in the Swedish general population

Time since cancer diagnosis is rarely accounted for in population‐based studies of health‐related quality of life (HRQL) among cancer survivors. Therefore, this study aimed to assess the relationship between time since cancer diagnosis and impairments in HRQL among short‐term, long‐term and very long‐term cancer survivors in the general population.

Aspects of emotional functioning following oesophageal cancer surgery in a population-based cohort study.

The aim of this study was to establish the proportion of patients reporting emotional problems following oesophagectomy for cancer and identify the risk characteristics for emotional problems.

Psychiatric Morbidity and Survival After Surgery for Esophageal Cancer: A Population-Based Cohort Study

PURPOSE To determine the cumulative incidence of and risk factors for psychiatric morbidity and establish the impact on survival among surgically treated patients with esophageal cancer. PATIENTS AND METHODS A nationwide Swedish cohort of 1,615 patients who underwent surgery for esophageal cancer between 1987 and 2010 with follow-up until 2012 was linked to national health registries for information on psychiatric morbidity (inferred from mental health care use). Multivariable logistic regressions were used to determine potential risk factors for postoperative psychiatric morbidity. A multivariable-adjusted Cox proportional hazard model was used to analyze overall survival. RESULTS In patients without a history of psychiatric morbidity, the 2-year cumulative incidence for treatment in psychiatric in-patient care was 2.5%, for psychiatric out-patient care was 4.2%, and for treatment with psychotropic drugs was 32.3%. Married patients were less likely to be treated postoperatively in psychiatric in-patient care (odds ratio [OR], 0.42; 95% CI, 0.22 to 0.80) or out-patient care (OR, 0.41; 95% CI, 0.17 to 1.02), whereas patients with higher tumor stage were more likely to be treated in psychiatric out-patient care (OR, 4.99; 95% CI, 1.16 to 21.38) or with psychotropic drugs (OR, 2.78; 95% CI, 1.10 to 7.01). Bearing in mind possible residual confounding, new-onset psychiatric morbidity was associated with mortality (hazard ratio [HR], 1.65 [95% CI, 1.17 to 2.33] for treatment in psychiatric in-patient care; HR, 1.93 [95% CI, 1.18 to 3.16] for treatment in psychiatric out-patient care; and HR, 2.77 [95% CI, 1.72 to 4.44] for treatment with psychotropic drugs). CONCLUSION These results highlight the importance of recognizing and addressing psychiatric morbidity in surgically treated patients with esophageal cancer.

Reoperation after oesophageal cancer surgery in relation to long-term survival: a population-based cohort study

Objectives The influence of reoperation on long-term prognosis is unknown. In this large population-based cohort study, it was aimed to investigate the influence of a reoperation within 30 days of oesophageal cancer resection on survival even after excluding the initial postoperative period. Design This was a nationwide population-based retrospective cohort study. Setting All hospitals performing oesophageal cancer resections during the study period (1987–2010) in Sweden. Participants Patients operated for oesophageal cancer with curative intent in 1987–2010. Primary and secondary outcomes Adjusted HRs of all cause, early and late mortality up to 5 years after reoperation following oesophageal cancer resection. Results Among 1822 included patients, the 200 (11%) who were reoperated had a 27% increased HR of all-cause mortality (adjusted HR 1.27, 95% CI 1.05 to 1.53) and 28% increased HR of disease-specific mortality (adjusted HR 1.28, 95% CI 1.04 to 1.59), compared to those not reoperated. Reoperation for anastomotic insufficiency in particular was followed by an increased mortality (adjusted HR 1.82, 95% CI 1.19 to 2.76). Conclusions This large and population-based nationwide cohort study shows that reoperation within 30 days after primary oesophageal resection was associated with increased mortality, even after excluding the initial 3 months after surgery. This finding stresses the need to consider any actions that might prevent complications and reoperation after oesophageal cancer resection.

The role of diabetes and other co-morbidities on survival after esophageal cancer surgery in a population-based study

BACKGROUND There is limited knowledge on how diabetes and other comorbidities influence the survival of patients undergoing curative esophageal cancer surgery. METHODS A population-based and prospective cohort study included patients who underwent surgical resection for esophageal or cardia cancer in Sweden from 2001 to 2005, with follow-up until 2011. Associations between diabetes and other comorbidities in relation to postoperative mortality were analyzed using Cox proportional-hazards regression with adjustment for potential confounding factors. RESULTS Among 609 patients, 67 (11%) with diabetes had no increased risk for mortality compared with those without diabetes (hazard ratio, .81; 95% confidence interval, .60 to 1.09). Compared with patients without any predefined comorbidities, those with 1 (hazard ratio, 1.15; 95% confidence interval, .93 to 1.43) or ≥2 comorbidities (hazard ratio, 1.05; 95% confidence interval, .83 to 1.33) had no statistically significantly increased risk for mortality. CONCLUSIONS This study revealed no strongly increased risk for mortality in patients with diabetes or other comorbidities selected for esophageal cancer surgery.