Patterns of Symptoms After Surgery for Esophageal Cancer
Patterns of Symptoms After Surgery for Esophageal Cancer
Data from 218 participants were included in this analysis. In the four-year study period, 359 patients underwent a curative esophagectomy, and 308 patients (86%) were recruited for and consented to the study. Of these, 42 did not meet surgical eligibility criteria (for example, esophagectomy not completed because of metastatic disease that was found at the time of resection), 44 did not complete the assessment forms, and four withdrew from the study, leaving 218 participants. Demographics of these 218 participants are provided in Table 1. The mean age of participants was 62.5 years, with most being male. The majority of participants (83%) had adenocarcinoma and underwent an Ivor Lewis esophagectomy (92%). Patients who received preoperative chemotherapy and radiation completed this treatment, on average, 4–6 weeks prior to surgery.
Symptom prevalence was assessed at the four time points (three are reported here: baseline, postsurgery, and at 12 months), and selected symptoms are noted in Figure 1. The most frequently reported symptoms at baseline were lack of energy, difficulty sleeping, difficulty concentrating, pain, and cough, whereas the most bothersome symptoms at baseline were problems with sexual activity or interest, swelling, weight change, not looking like self, and change in the taste of food. Postsurgery, the most frequent symptoms were lack of energy, pain, feeling full too quickly, weight change, and sleep disturbances; and the most bothersome symptoms were lack of energy, sleep disturbance, problems with sexual activity or interest, change in the taste of food, and weight change. At one year, lack of energy, feeling full too quickly, drowsiness, difficulty sleeping, and reflux were the most frequently noted symptoms, whereas problems with sexual activity or interest, lack of energy, cough, feeling full too quickly, and reflux were the most bothersome symptoms.
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Figure 1.
Selected Symptom Prevalence (N = 218)
Variables were selected for additional frequency analysis if at least 25% of respondents reported the symptom as bothersome in at least one of the four time points. Variables excluded from analysis include changes in skin, numbness or tingling in the hands or feet, problems with urination, vomiting, sweats, mouth sores, itching, dizziness, and swelling. For most symptoms, the proportion of participants who reported each symptom was larger postoperatively and then lessened at months 6 and 12 postoperatively to levels similar to preoperative.
In McNemar c testing, symptoms followed one of four patterns: (a) symptom worsened after surgery from baseline, then recovered to baseline at one year; (b) symptom worsened after surgery from baseline, and did not recover by one year; (c) symptom did not change from baseline to postoperative, but worsened in one year; or (d) no change in symptom severity.
Symptom patterns were developed using the following guidelines.
Symptoms in the first pattern included pain, lack of energy, cough, shortness of breath, difficulty sleeping, dry mouth, change in the taste of food, weight loss, and not looking like self. Symptoms in the second pattern were feeling full too quickly, bloated, drowsiness, nausea, and diarrhea. Reflux was the only symptom that did not worsen from baseline to postoperative but did worsen from postoperative to one year. Symptoms that did not significantly change in the study period were difficulty swallowing, difficulty concentrating, and problems with sexual activity or interest. Table 2 reports p values for the McNemar test for each scenario.
Results
Data from 218 participants were included in this analysis. In the four-year study period, 359 patients underwent a curative esophagectomy, and 308 patients (86%) were recruited for and consented to the study. Of these, 42 did not meet surgical eligibility criteria (for example, esophagectomy not completed because of metastatic disease that was found at the time of resection), 44 did not complete the assessment forms, and four withdrew from the study, leaving 218 participants. Demographics of these 218 participants are provided in Table 1. The mean age of participants was 62.5 years, with most being male. The majority of participants (83%) had adenocarcinoma and underwent an Ivor Lewis esophagectomy (92%). Patients who received preoperative chemotherapy and radiation completed this treatment, on average, 4–6 weeks prior to surgery.
Symptom prevalence was assessed at the four time points (three are reported here: baseline, postsurgery, and at 12 months), and selected symptoms are noted in Figure 1. The most frequently reported symptoms at baseline were lack of energy, difficulty sleeping, difficulty concentrating, pain, and cough, whereas the most bothersome symptoms at baseline were problems with sexual activity or interest, swelling, weight change, not looking like self, and change in the taste of food. Postsurgery, the most frequent symptoms were lack of energy, pain, feeling full too quickly, weight change, and sleep disturbances; and the most bothersome symptoms were lack of energy, sleep disturbance, problems with sexual activity or interest, change in the taste of food, and weight change. At one year, lack of energy, feeling full too quickly, drowsiness, difficulty sleeping, and reflux were the most frequently noted symptoms, whereas problems with sexual activity or interest, lack of energy, cough, feeling full too quickly, and reflux were the most bothersome symptoms.
(Enlarge Image)
Figure 1.
Selected Symptom Prevalence (N = 218)
Variables were selected for additional frequency analysis if at least 25% of respondents reported the symptom as bothersome in at least one of the four time points. Variables excluded from analysis include changes in skin, numbness or tingling in the hands or feet, problems with urination, vomiting, sweats, mouth sores, itching, dizziness, and swelling. For most symptoms, the proportion of participants who reported each symptom was larger postoperatively and then lessened at months 6 and 12 postoperatively to levels similar to preoperative.
In McNemar c testing, symptoms followed one of four patterns: (a) symptom worsened after surgery from baseline, then recovered to baseline at one year; (b) symptom worsened after surgery from baseline, and did not recover by one year; (c) symptom did not change from baseline to postoperative, but worsened in one year; or (d) no change in symptom severity.
Symptom patterns were developed using the following guidelines.
Pattern 1: A statistically significant increase (p < 0.05) in the proportion of patients reporting the symptom from test point 1 to test point 2, followed by an insignificant McNemar c test from test point 1 to test point 3, indicating a failure to reject the null hypothesis of no change in proportion
Pattern 2: A statistically significant increase in the proportion of patients reporting the symptom from test point 1 to test point 2, and a statistically significant increase in the proportion of patients reporting the symptom from test point 1 to test point 3
Pattern 3: An insignificant McNemar c test from test point 1 to test point 2, with a statistically significant increase in the proportion of patients reporting the symptom from test point 2 to test point 3
Pattern 4: Insignificant McNemar c tests between proportions at all test points.
Symptoms in the first pattern included pain, lack of energy, cough, shortness of breath, difficulty sleeping, dry mouth, change in the taste of food, weight loss, and not looking like self. Symptoms in the second pattern were feeling full too quickly, bloated, drowsiness, nausea, and diarrhea. Reflux was the only symptom that did not worsen from baseline to postoperative but did worsen from postoperative to one year. Symptoms that did not significantly change in the study period were difficulty swallowing, difficulty concentrating, and problems with sexual activity or interest. Table 2 reports p values for the McNemar test for each scenario.