Aspects on the management of patients with esophageal cancer

Abstract

Cancer of the esophagus is assessed to be the 8th most common cancer form in the world, with approximately 460.000 new cases annually. It is often diagnosed at a late stage, is related to severe morbidity and a poor prognosis, why treatment frequently has a palliative aim with the main objective to relieve dysphagia. The present thesis aims to explore some of the questions related to the management of these patients.

The two most common palliative strategies today, i.e. stent-treatment and brachytherapy, were compared in 65 patients with incurable cancer of the esophagus or gastro-esophageal junction (GEJ). Stent-treatment was found to offer a more prompt effect on dysphagia and was more cost-effective than brachytherapy. On the other hand, brachytherapy offered a less pronounced deterioration of health-related quality of life (HRQL) and an equal relief of dysphagia after 3 months, why it gives a viable alternative in patients with a longer survival (Paper I+II).

To evaluate if survival can be predicted, 96 patients with newly diagnosed incurable cancer of the esophagus or GEJ were included and their clinical variables and HRQL data were analyzed. In a univariate analysis, Karnofsky Index, M-stage, tumor-stage, CT derived size assessment of the primary tumor and 10 of 25 scales and items of the HRQL questionnaires (EORTC QLQ-C30 and QLQ-OES18) were found to relate to survival. However, in a multivariate analysis, only M-stage, physical functioning, fatigue and reflux scale were found to be independent predictors. Internal validation of the established predictors showed a high level of reliability (Paper III).

Psychiatric morbidity in patients with cancer of the esophagus or GEJ has previously not been evaluated. At diagnosis and during one year, we screened for anxiety disorder and depression in 94 patients with all stages of the disease using the HADS questionnaire. Anxiety and/or depression was found to be common at diagnosis (42% of the patients), regardless of sociodemographic background, tumor-stage or therapy given. The proportion of patients with anxiety disorder decreased during the first two months compared to at diagnosis (34%), while the proportion of patients with depression was comparatively stable over time (29% at diagnosis). Depression was, however, more common among patients who died during the study period compared to the survivors (Paper IV).

The long-term clinical and functional outcome of radical surgery with pharyngolaryngo¬esophagectomy and jejunal transposition following chemoradiotherapy in patients with proximal esophageal or hypopharyngeal cancer was evaluated. Promising long-term results with regard to survival was found. In addition, a generally good HRQL and mild dysphagia was found, in spite of a generally poor speech valve function and disturbed bolus-passage according to radiological evaluation (Paper V+VI).