Oesophageal cancer : surgery, symptoms and survival

This thesis aimed to identify factors that can improve survival and reduce persisting symptoms among surgically treated oesophageal cancer patients. In Sweden there are approximately 450 new cases of oesophageal cancer and 200 new cases of gastric cardia cancer diagnosed every year. Surgical tumour resection is the mainstay of curatively intended treatment for oesophageal cancer, often preceded by neoadjuvant chemo- or chemoradiotherapy. Despite improvements in treatment, the prognosis of patients with oesophageal cancer remains poor, and even after successful tumour resection most patients suffer from residual symptoms.

The included studies are based on two population-based, nationwide Swedish cohorts (Studies I-IV) and one Dutch (Study V), hospital-based cohort. Studies I-II were based on a retrospective cohort of patients operated on between 1987-2010 and, Studies III-IV were based on a prospective cohort of patients who underwent surgery between 2001-2005. In Study V we used a prospective cohort of patients operated on between 1991-2010. Multivariable Cox regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI), adjusted for potential confounding factors.

Study I: Among 1044 patients the number of resected lymph nodes did not influence survival (HR 1.00, 95% CI 0.99-1.01).

Study II: Among 1822 patients, the 200 (11%) patients who underwent reoperation had an increased risk of mortality (HR 1.27, 95% CI 1.05-1.53).

Study III: Among 304 included patients, a cervical anastomosis (OR 0.86, 95% CI 0.33-2.23), creation of a fundoplication (OR 0.86, 95% CI 0.39-1.90) or performance of a pyloric drainage procedure (OR 1.49, 95% CI 0.86-2.58) did not influence patients’ experience of reflux 6 months after oesophagectomy.

Study IV: Among 277 patients followed up 6 months after surgery, those who suffered from an intrathoracic anastomotic leak were at increased risk of difficulties with eating (OR 4.05, 95% CI 1.47-11.16) and odynophagia OR 2.59, 95% CI 1.15-5.82), but not reflux or dysphagia. Study V: Among 922 patients, the 155 patients who had >10% preoperative weight loss, experienced an increased 5-year mortality (HR 1.34, 95% CI 1.02-1.74), but no increased risk of non- surgical or surgical complications.

List of scientific papers

I. M. van der Schaaf, A. Johar, B. Wijnhoven, P. Lagergren, J. Lagergren. No survival benefit from a more extensive lymph node removal during oesophageal cancer surgery in a population-based cohort study. [Submitted]

II. M. van der Schaaf, M. Derogar, A. Johar, M. Rutegård, J. Gossage, R. Mason, P. Lagergren, J. Lagergren. Reoperation after oesophageal cancer surgery in relation to longterm survival. BMJ Open. 2014 Mar 20;4(3):e004648
https://doi.org/10.1136/bmjopen-2013-004648.

III. M. van der Schaaf , A. Johar, J. Gossage, R. Mason, P. Lagergren, J. Lagergren. Surgical Prevention of Reflux after Esophagectomy for Cancer. Annals of Surgical Oncology. October 2013;20(11): 3655-61
https://doi.org/10.1245/s10434-013-3041-3

IV. M. van der Schaaf, P. Lagergren, J. Lagergren. Persisting symptoms after intrathoracic anastomotic leak following oesophagectomy for cancer. British Journal of Surgery. January 2012;99(1):95-9
https://doi.org/10.1002/bjs.7750.

V. M. van der Schaaf, H. Tilanus, J. van Lanschot, A. Johar, P. Lagergren, J. Lagergren, B. Wijnhoven The influence of preoperative weight loss on postoperative course after oesophageal cancer resection. Journal of Cardiovascular and Thoracic Surgery. January 2014;147(1):490-5.
https://doi.org/10.1016/j.jtcvs.2013.07.072.