Oesophageal cancer surgery : the role of co-morbidities

<p>The overall aim of this thesis was to produce information which can be used to improve clinical decision-making in order to optimise treatment and improve the well-being of patients with oesophageal cancer following surgery. Oesophageal cancer is a devastating disease with poor prognosis. The most established curatively intended treatment involves major surgery, often in combination with neoadjuvant therapy, and comes with a high risk of morbidity and limited chance of long-term survival.</p><p>The clinical decision process of determining which patients would benefit from surgery is critically important. Several factors are considered when evaluating whether a patient is suitable for surgery or not, but the main factors are tumour stage, general fitness and comorbidity. The focus of this thesis focus was to assess how co-morbidities in general, and specific co-morbidities in particular, influence mortality, morbidity and health related quality of life (HRQOL) after surgery for oesophageal cancer. A subjective outcome such as HRQOL is of great importance in this patient group which adds an extra dimension to more objective outcomes in determining the outcome of the treatment.</p><p>The four studies included in the thesis were cohort studies from Sweden and England. Studies I and III were based on a prospective cohort including patients operated on between 2001 and 2005 in Sweden, and study II was based on a retrospective cohort of patients who underwent surgery between 1987 and 2010 in Sweden. Study IV used a prospective cohort of patients who underwent oesophagectomy at St Thomas’ Hospital London between 2011 and 2014/2015.</p><p>In studies I and II, co-morbidity was examined in relation to mortality after oesophageal cancer surgery. There was an increased risk of mortality among patients with a Charlson co-morbidity index score ≥2 and among patients with a history of myocardial infarction and congestive heart failure. Study III assessed co-morbidity in relation to morbidity after surgery. Patients with ≥1 co-morbidities or cardiac disease had an increased risk of severe post-operative complications. In study IV, co-morbidity was assessed in relation to HRQOL. Before surgery, patients with co-morbidities had worse HRQOL for several aspects, while at 6 months following surgery, patients had deteriorated in most HRQOL aspect regardless of co-morbidity status, except for the fact that patients with several comorbidities had worse physical function, fatigue and more trouble with coughing compared to those with fewer co-morbidities.</p><p>In conclusion, this thesis provides additional information on how co-morbidities affect outcomes following surgery for oesophageal cancer and could help to improve clinical decision-making for these patients.</p><h3>List of scientific papers</h3><p>I. Backemar L, Djärv T, Wikman A, Johar A, Ross P, Lagergren P, Lagergren J. The role of diabetes and other co-morbidities on survival after esophageal cancer surgery in a population-based study. American journal of surgery 2013;206(4): 539-543. <br><a href="https://doi.org/10.1016/j.amjsurg.2013.01.035">https://doi.org/10.1016/j.amjsurg.2013.01.035</a><br><br> </p><p>II. Backemar L, Lagergren P, Johar A, Lagergren J. Impact of co-morbidity on mortality after oesophageal cancer surgery. The British journal of surgery 2015;102(9): 1097-1105 <br><a href="https://doi.org/10.1002/bjs.9854">https://doi.org/10.1002/bjs.9854</a><br><br> </p><p>III. Backemar L, Lagergren P, Djärv T, Johar A, Wikman A, Lagergren J. Comorbidities and Risk of Complications After Surgery for Esophageal Cancer: A Nationwide Cohort Study in Sweden. World journal of surgery 2015;39(9): 2282-2288. <br><a href="https://doi.org/10.1007/s00268-015-3093-6">https://doi.org/10.1007/s00268-015-3093-6</a><br><br> </p><p>IV. Backemar L, Johar A, Wikman A, Zylstra J, Gossage J, Davies A, Lagergren J, Lagergren P. Co-morbidity and recovery of health related quality of life after oesophageal cancer surgery. [Manuscript]</p>