Thomas Küchler

Ten-Year Historic Cohort of Quality of Life and Sexuality in Patients With Rectal Cancer

PURPOSEIn various studies, type of surgery, age, and gender had different impact on sexuality and quality of life in patients with rectal cancer. This study was designed to investigate how sexuality and quality of life are affected by age, gender, and type of surgery.METHODSA total of 516 patients who had undergone surgery for rectal cancer in our department from 1992 to 2002 were included. Within one year after the operation, 117 patients died. Questionnaires were sent to 373 patients 12 to 18 months after surgery. We received quality of life data from 261 patients. Comparisons were made after adjusting age, gender, and type of surgical procedure.RESULTSFor patients receiving abdominoperineal resection sexuality was most impaired. Significant differences were seen in symptom and function scales between males and females. Females reported more distress from the medical treatment insomnia, fatigue, and constipation. Both genders had impaired sexual life; however, males had significantly higher values and felt more distressed by this impairment. Younger females felt more distress through impaired sexuality. In males sexuality was impaired independent of age. Adjuvant therapy had no influence on sexuality but on quality of life one year after surgery.CONCLUSIONSAssessing quality of life with general and specific instruments is helpful to determine whether patients improved through the treatment. The study showed that gender, age, and type of surgery influence sexuality and that quality of life after surgery for rectal cancer is impacted. Because quality of life is a predictor for complications and survival, availability of such data may help to direct supportive treatment to improve outcome.

Impact of Psychotherapeutic Support for Patients With Gastrointestinal Cancer Undergoing Surgery: 10-Year Survival Results of a Randomized Trial

PURPOSE The impact of psychotherapeutic support on survival for patients with gastrointestinal cancer undergoing surgery was studied. PATIENTS AND METHODS A randomized controlled trial was conducted in cooperation with the Departments of General Surgery and Medical Psychology, University Hospital of Hamburg, Germany, from January 1991 to January 1993. Consenting patients (N = 271) with a preliminary diagnosis of cancer of the esophagus, stomach, liver/gallbladder, pancreas, or colon/rectum were stratified by sex and randomly assigned to a control group that received standard care as provided on the surgical wards, or to an experimental group that received formal psychotherapeutic support in addition to routine care during the hospital stay. From June 2003 to December 2003, the 10-year follow-up was conducted. Survival status for all patients was determined from our own records and from three external sources: the Hamburg cancer registry, family doctors, and the general citizen registration offices. RESULTS Kaplan-Meier survival curves demonstrated better survival for the experimental group than the control group. The unadjusted significance level for group differences was P = .0006 for survival to 10 years. Cox regression models that took TNM staging or the residual tumor classification and tumor site into account also found significant differences at 10 years. Secondary analyses found that differences in favor of the experimental group occurred in patients with stomach, pancreatic, primary liver, or colorectal cancer. CONCLUSION The results of this study indicate that patients with gastrointestinal cancer, who undergo surgery for stomach, pancreatic, primary liver, or colorectal cancer, benefit from a formal program of psychotherapeutic support during the inpatient hospital stay in terms of long-term survival.

Quality of life and nutritional state in patients on home enteral tube feeding

OBJECTIVE We assessed quality of life (QOL) in patients on home enteral tube feeding (HETF). The data should contribute to ethically justified decision making. METHODS We used a prospective cross-sectional study (study 1) in 155 consecutive patients and a prospective longitudinal study (study 2) with a follow-up of 4 mo in 56 patients. QOL was assessed by proxy rating (Karnofsky and Spitzer indices) and self-rating (European Organization for Research and Treatment of Cancer [EORTC] QLQ C30) extended by a specific module. RESULTS In study 1, weight losses 3 mo before HETF were 10.5 +/- 8.4% and 7.9 +/- 6.3% in competent (P < 0.05) and non-competent (P < 0,05) patients, respectively. The prevalences of severe malnutrition and weight loss were 50% and 73%, respectively. When compared with EORTC reference data for a general population, QOL was lower in HETF patients. The lowest QOL was seen in non-competent patients. Nutrition status explained up to 13% of the variance in QOL. In study 2, nutrition status stabilized or increased slightly in response to HETF. This was true for competent and non-competent patients and for patients with malignant and benign diseases. Concomitantly, physical functioning improved, whereas fatigue decreased. QOL increased in response to HETF in competent and non-competent patients, and 50% of the non-competent patients became competent CONCLUSIONS . Measures of QOL research can be used in HETF patients. QOL is reduced in patients on HETF. Part of this effect is explained by malnutrition. HETF can prevent further weight loss and improve some aspects of QOL, thus allowing physicians to focus on patients.

Prospective Evaluation of Quality of Life of Patients Receiving Either Abdominoperineal Resection or Sphincter-Preserving Procedure for Rectal Cancer

BackgroundStudy results on quality of life (QoL) between patients receiving an anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer vary greatly. A main reason is grounded in unequal methodology. The aims of this study were to assess differences in perceived QoL over time among patients treated with AR or APR with a recommended study design and methodology.MethodsIn a prospective study, the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and a tumor-specific module were administered to patients with rectal cancer before surgery, at discharge, and 3, 6, and 12 months after the operation. Comparisons were made between patients receiving an AR and those receiving an APR.ResultsTwo hundred forty-nine patients were included; 46 patients received an APR and 203 an AR. QoL data were available for 212 patients, of which 112 were female and 100 male. No differences in the distribution of age, sex, or tumor stage were observed between groups. EORTC function scales showed no significant differences, including body image scales, between patients receiving an AR and those receiving an APR. In symptom scores, AR patients had more difficulty with diarrhea and constipation, whereas patients with APR experienced more impaired sexuality and pain in the anoperineal region. At discharge, patients receiving an AR were more confident about their future.ConclusionsQoL in patients receiving an AR and those receiving an APR is not different. Although patients with APR experience more impaired sexuality, patients receiving an AR experience decreases in QoL because of impaired bowel function.

Gender Differences in Quality of Life of Patients with Rectal Cancer. A Five-Year Prospective Study

To determine how quality of life changes over time and to assess gender-related differences in quality of life of rectal cancer patients we conducted a 5-year study. Little is known about how quality of life (QoL) changes over time in patients after surgery for rectal cancer, and whether gender of the patients is associated with a different perception of QoL. The aim of this study was to assess prospectively, changes in quality of life after surgery for rectal cancer, with a focus on gender related differences. Over a 5-year period, the EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12, and 24 months postoperatively. Comparisons were made between female and male patients. A total of 519 patients participated in the study, 264 men and 255 women. The two groups were comparable in terms of surgical procedures, adjuvant treatment, tumor stage, and histology. Most QoL scores dropped significantly below baseline in the early postoperative period. From the third month onward, global health, emotional and physical functioning, improved. Female gender was associated with significantly worse global health and physical functioning and with higher scores on treatment strain and fatigue. Men reported difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men, worse than baseline levels in the early postoperative period. These problems tended to continue over the course of time. The findings in this study confirm that QoL changes after surgery and differs between men and women. Women appear to be affected by impaired physical functioning and global health. Female gender is associated with significantly higher fatigue levels and increased strain values after surgery. Through impaired sexual enjoyment, men are put more under strain than woman.

Impact of Age on Quality of Life in Patients with Rectal Cancer

Some studies indicate that age at the time of surgery has a general effect on outcomes. The impact of age on the quality of life (QOL) of patients with rectal cancer, however, has not been investigated. The present study was conducted to address this issue. Over a 5-year period the European Organization for Research and Treatment of Cancer (EORTC)-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, and at 3, 6, 12, and 24 months postoperatively. Comparisons were made between age groups. A total of 519 patients participated in the study. QOL data were available for 253 patients. Significant differences were observed only between patients aged 69 years and younger (≤69 years) (169/253) and those aged 70 years and older (≥70 years) (85/253). Physical and role functioning was better for patients ≤69 years; patients ≥70 years suffered from increased pain and fatigue. Younger patients had more difficulty with sexual enjoyment, and over time sexual strain was worse for patients aged ≥70 years during the early postoperative period but improved, whereas patients aged ≤69 years had increasing levels of strain over time. The findings in this study confirmed that QOL is dynamic over time and that age has an impact on QOL and sexuality. Patients aged ≥70 years are affected by impaired physical functioning, global health, and fatigue, whereas increased treatment strain during the early postoperative period improves over time. Patients aged ≤69 years experience increased strain because of impaired sexual function.

Palliation of Metastatic Gastric Cancer: Impact of Preoperative Symptoms and the Type of Operation on Survival and Quality of Life

Patients with advanced, incurable gastric cancer may present with mild symptoms or require immediate therapeutic intervention. The influence of the intensity of preoperative symptoms on postoperative survival and quality of life (QoL) was evaluated in a palliative setting. In a historical cohort analysis of 492 patients with gastric cancer treated between 1992 and 2001, a total of 169 (34.4%) patients had incurable disease (i.e., pTxNxM1). Patients were classified as having major symptoms if they presented with upper gastrointestinal bleeding (i.e., hematemesis or bloody stools), gastric inlet or outlet obstruction (i.e., symptomatic and endoscopically proven stenosis), or perforation caused by the tumor. All other patients were defined as having minor symptoms. QoL was assessed prospectively using the EORTC questionnaire. The questionnaire was given to the patients before operation, before discharge, and 3 months after operation; and it was analyzed by the Mann-Whitney U-test. Survival, demographic data, and histopathologic characteristics were assessed and analyzed by the log-rank test and the χ2 test, respectively. Of the 169 patients, 75 (44.3%) presented with major symptoms and 94 (55.7%) with minor symptoms. The distribution of patients undergoing resection or exploration was comparable for the two groups [major: 61 (81.5%)/14 (18.5%); minor: 77 (81.9%)/17 (18.1%)]. Despite comparable demographic and histopathologic characteristics with equal hospital mortality and morbidity (14.6% vs. 8.5%/49.3% vs. 40.4%), the median survival rates in two groups were 4 and 6 months, respectively (p < 0.05). This was not influenced by the type of operation. QoL was not different in patients with major or minor symptoms before operation or 3 months thereafter. However, preoperative symptoms such as nausea/vomiting and melena were rated significantly higher in patients with major symptoms. In patients with incurable gastric cancer the preoperative intensity of symptoms has a significant impact on survival and QoL, which is not influenced by the operation. The necessity of surgery in patients with minor symptoms requires careful consideration.

Quality of life associated with surgery for esophageal cancer: differences between collar and intrathoracic anastomoses.

Postoperative survival and complication rates have traditionally been the standard parameters of outcome after oncologic surgery. In tumors with poor patient survival, such as esophageal cancer, studies about quality of life are rare. The objectives of this study were to assess outcomes in terms of quality of life in patients with esophageal cancer when investigating differences between two surgical reconstructive procedures: intrathoracic anastomosis and collar anastomosis. A total of 108 patients with esophageal cancer had undergone surgery for esophageal cancer in our department from 1992 to 2000. Median survival was 36 months with no significant differences between patients undergoing collar or intrathoracic anastomosis. After determining the survival status, questionnaires on quality of life were sent to all patients 1 to 2 years after surgery. We received data from 46 patients. The responders were divided into groups of intrathoracic anastomosis (n = 24) and collar anastomosis (n = 22). Patients with the collar anastomosis showed significantly better physical and social functioning and global health status. From the viewpoint of postoperative quality of life, reflux-related symptoms were the major problem for patients with an intrathoracic anastomosis. These symptoms cause significant insomnia and impair social and physical function. The study showed that assessing quality of life with specific and general instruments is helpful for determining the differences between surgical procedures where standard parameters such as survival have their limitations.

Health-Related Quality of Life Measurement in Long-Term Survivors and Outcome Following Radical Radiotherapy for Localized Prostate Cancer

Purpose:To report long-term outcomes in terms of health-related quality of life (HRQoL) and survival of a dose-escalating radiotherapy protocol and to validate a new disease-specific HRQoL instrument.Patients and Methods:189 consecutive men with prostate cancer were analyzed; 127 patients had T1–2 (1% T1, 66% T2) and 62 patients (33%) T3 tumors. The pelvic lymphatics were treated to a dose of 50 Gy by external-beam irradiation. The prostate dose was limited to 40 Gy using compensators. The prostate was treated to the total nominal dose of 70 Gy using high-dose-rate (HDR) brachytherapy. The fraction dose was 15 Gy in the McNeal zone (planning target volume [PTV] 1), while 8–9 Gy were applied in the entire prostate (PTV 2). The HRQoL of the 145 long-term survivors was assessed using the EORTC QLQ-C30 and a new prostate-specific instrument (PSM-G 1.0). The reliability of the instruments used and HRQoL scale scores were calculated. Uni-/multivariate analyses of variance were performed.Results:At a mean follow-up of 6.5 years 86.3% of the patients were disease-free, and 78% were biochemically controlled. The mean Cronbach’s α-values were 0.81 for the QLQ-C30, and 0.74 for the prostate-specific module. Univariate analyses of variance by T-stage, grading, prostata-specific antigen (PSA) status after therapy and adjuvant androgen suppression (AS) revealed that PSA elevation after irradiation and AS were associated with significantly diminished HRQoL. In multivariate analyses AS significantly lowered the HRQoL without survival benefit.Conclusion:The described radiotherapy regimen represents a curative and well-tolerated treatment for localized prostate cancer. The HRQoL assessment with both instruments used was reliable. Adjuvant AS and PSA elevation were associated with diminished HRQoL.Ziel:Bericht von Langzeitergebnissen in Bezug auf gesundheitsorientierte Lebensqualität (LQ) und Überleben nach dosiseskalierter Strahlentherapie und Validierung eines neuen krankheitsspezifischen LQ-Instruments.Patienten und Methodik:189 konsekutive Patienten mit Prostatakarzinom wurden analysiert: 127 Patienten hatten einen T1–2- (1% T1, 66% T2) und 62 Patienten (33%) einen T3-Tumor. Die pelvinen Lymphabflusswege wurden bis zur Dosis von 50 Gy perkutan behandelt. Mittels Kompensatoren wurde die Dosis in der Prostataregion auf 40 Gy limitiert. Diese wurde mit Hilfe der High-Dose-Rate-(HDR-)Brachytherapie bis zur kumulativen Dosis von 70 Gy bestrahlt. Die Fraktionsdosis betrug 15 Gy in der McNeal-Zone (Planungszielvolumen [PTV] 1). In der Gesamtprostata wurden pro Fraktion 8–9 Gy appliziert (PTV 2). Die LQ der 145 Langzeitüberlebenden wurde mittels EORTC QLQ-C30 und eines neuen prostataspezifischen Instrumentes (PSM-G 1.0) gemessen. Die Reliabilität der verwendeten Instrumente und die LQ-Skalenmittelwerte wurden berechnet. Uni-/multivariate Varianzanalysen wurden durchgeführt.Ergebnisse:Nach einem mittleren Nachbeobachtungszeitraum von 6,5 Jahren waren 86,3% der Patienten krankheitsfrei sowie 78% klinisch und biochemisch rezidivfrei. Die mittleren Cronbach-α-Werte betrugen 0,81 für den QLQ-C30-Fragebogen und 0,74 für das prostataspezifische LQ-Modul. Univariate Varianzanalysen in Bezug auf T-Stadium, Grading, posttherapeutischen Status Indes prostataspezifischen Antigens (PSA) und adjuvante Androgensuppression (AS) ergaben, dass posttherapeutische PSA-Erhöhung und AS mit einer signifikant reduzierten LQ assoziiert waren. In multivariaten Analysen reduzierte allein die AS signifikant die LQ der Patienten ohne einen Überlebensvorteil.Schlussfolgerung:Das beschriebene Radiotherapieprotokoll stellt eine kurative und schonende Behandlungsmethode beim lokalisierten Prostatakarzinom dar. Die LQ-Messung war mit beiden Instrumenten reliabel. Adjuvante AS und posttherapeutische PSA-Erhöhung waren mit einer reduzierten gesundheitsorientierten LQ assoziiert.

Significant Negative Impact of Adjuvant Chemotherapy on Health-Related Quality of Life (HR-QoL) in Women with Breast Cancer Treated by Conserving Surgery and Postoperative 3-D Radiotherapy

Purpose:To prospectively assess health-related quality of life (HR-QoL) in women after conserving surgery for breast cancer during/after postoperative 3-D radiotherapy.Patients and Methods:109 consecutively treated patients were analyzed. HR-QoL was assessed at initiation (t1), end (t2), and 6 weeks after radiotherapy (t3) using the EORTC modules QLQ-C30/BR23. Patients were divided into three therapy groups. Group I comprised 41 patients (radiotherapy and adjuvant chemotherapy), group II 45 patients (radiotherapy and adjuvant hormonal therapy), and group III 23 patients (radiotherapy alone). Reliability was tested. Scale means were calculated. Univariate (ANOVA) and multivariate (MANCOVA) analyses were performed.Results:Reliability testing revealed mean Cronbach’s α> 0.70 at all measurement points. ANOVA/MANCOVA statistics revealed significantly better HR-QoL for patients in group II versus I. Patients receiving radiotherapy alone (group III) showed the best results in HR-QoL. However, scale mean differences between groups II and III were not significant.Conclusion:HR-QoL measurement using EORTC instruments during/after radiotherapy is reliable. Adjuvant chemotherapy significantly lowered HR-QoL versus hormones or radiotherapy alone. Chemotherapy patients did not recover longitudinally (from t1 to t3).Ziel:Die gesundheitsbezogene Lebensqualität (LQ) bei Patientinnen mit einem Mammakarzinom nach brusterhaltender Operation sollte prospektiv während/nach postoperativer 3-D-Radiotherapie erfasst werden.Patienten und Methodik:109 konsekutiv behandelte Patientinnen wurden analysiert. Die gesundheitsbezogene LQ wurde mit Hilfe der EORTC-Instrumente QLQ-C30 und BR23 bei Beginn (t1), Abschluss (t2) und 6 Wochen nach Radiotherapie (t3) gemessen. Die Studienpopulation wurde in drei Therapiegruppen stratifiziert: Gruppe I mit 41 Patientinnen (Radiotherapie und adjuvante Chemotherapie), Gruppe II mit 45 Patientinnen (Radiotherapie und adjuvante Hormontherapie) und Gruppe III mit 23 Patientinnen (alleinige Radiotherapie). Die Reliabilität wurde ermittelt. Die mittleren Skalenwerte wurden berechnet. Univariate (ANOVA) und multivariate (MANCOVA) Analysen wurden durchgeführt.Ergebnisse:Die Ermittlung der Reliabilität ergab durchschnittliche Cronbach-α-Werte > 0,70 bei allen Messzeitpunkten. Die ANOVA/MANCOVA-Analysen zeigten eine signifikant bessere gesundheitsbezogene LQ bei Patientinnen der Gruppe II versus I. Die beste Lebensqualität zeigte sich bei den Patientinnen (Gruppe III), die sich einer alleinigen postoperativen Radiotherapie unterzogen. Die Differenzen der Skalenmittelwerte zwischen den Gruppen II und III waren jedoch nicht signifikant.Schlussfolgerung:Die Messung der gesundheitsbezogenen LQ mit den EORTC-Instrumenten während/nach Radiotherapie ist reliabel. Die adjuvante Chemotherapie schränkte die LQ gegenüber Hormon- oder alleiniger Radiotherapie signifikant ein. Die chemotherapierten Patientinnen erholten sich nicht longitudinal (von t1 bis t3).