Postoperative QoL in patients undergoing gastrectomy depends on various factors such as the type of reconstruction, the extent of gastric resection, and the surgical approach. Several research groups using various instruments (Short Form Health Survey [SF-36], D15, Spitzer Quality of Life Index, EORTC QLQ-C30 and -STO22) reported a decrease in QoL in similar populations even after different curative surgical techniques [19–23]. Although many studies on surgery-related QoL have been published, data on QoL in patients treated with multimodal therapy are scarce despite its frequent clinical use.
Kassam et al. evaluated the QoL of 33 patients who received postoperative adjuvant CRT using the EORTC QLQ-30 at 5 different times (baseline, RT completion, and 4 weeks, 6–12 months, and 2–3 years after CRT completion). They reported clinically and statistically significant worsening of median scores for global health status, social, role, and emotional functioning, nausea and vomiting, and fatigue at RT completion. All QoL scores that were reduced at RT completion were shown to be able to return to baseline at 6–12 months. However, up to 45% of patients remained below baseline in at least 1 domain. The worsening in nausea/vomiting scores was attributed to the high CT doses. The authors concluded that although QoL worsens during CRT and most scores return to baseline, recovery may take 6–12 months and subscale scores may remain lower than baseline in a significant proportion of patients [6]. In another study, the EORTC QLQ-30 and STO22 were administered to 30 patients who received adjuvant CRT after surgery at 4 time points similar to those used in our study (before and after CRT and at 1month and 6month follow-up). Worsening was only detected in QLQ-C30 scores for global health status, emotional functioning, fatigue, nausea and vomiting, and dyspnea, and in QLQ-STO22 scores for dysphagia, pain, and taste at CRT completion [7]. Consequently, both of these studies demonstrated that QoL decreased after CRT but returned to baseline levels at 1 and 6 months of follow-up, suggesting that CRT as adjuvant therapy in gastric cancer cases undergoing curative resection is well-tolerated and safe in terms of QoL [6,7]. In contrast to these two studies, we observed worsening in almost all domains of the QLQ-C30 and QLQ-STO22 (except for dry mouth and hair loss) at RT completion. As in the other studies, however, nearly all QoL scores that were negatively impacted in our patients started to improve after the first month. At 6 months, almost all QLQ-C30 scores except for emotional functioning and nausea/vomiting were improved over baseline. In the QLQ-STO22, scores for reflux, eating, dry mouth, and taste remained higher than baseline. We believe that reassessment at a later date may reveal further improvements in these scores.
A study evaluating 408 patients treated for gastric cancer showed that they had more difficulty doing housework and staying employed and worked fewer hours than the general population [24]. Some of the patients in that study also received RT (12%) and CT (26%), but this was shown to have no additional effect on work ability when patients receiving additional treatment were compared to those treated with surgery alone [24]. Another study evaluated the effect of demographics (gender, age, marital status, education, religion, employment, monthly family income, smoking and drinking habits) and treatment-related factors on QoL among gastric cancer survivors using a demographic questionnaire, the QLQ-C30, and the QLQ-STO22 administered to 391 patients who were disease-free for at least 1 year after surgery [25]. It was found that CT and RT did not significantly affect any QLQ-C30 or QLQ-STO22 scores, whereas older age was associated with improved role and emotional functioning and reduced stomach specific symptoms (pain, eating limitations, and anxiety). Men, compared to women, were shown to have better physical and role functioning. Selected demographic characteristics such as age, sex, comorbidities, and income were found to have a greater impact on postoperative gastric cancer patients’ QoL than the type of treatment [25]. In our study, we observed that global health status was lower at all time points and was more negatively affected in women than men. Men also showed a decrease in global health status score at 1 month, but their score in this domain improved faster than in women. In addition, physical and role functioning scores and fatigue, pain, and insomnia symptom scores were more negatively affected in women compared to men. The conditions of the environment in which the patient lives can also influence their QoL. Therefore, our findings may be attributable to women’s concerns about not receiving family support, not sharing their workload, and having poor access to factors that could increase their QoL. In patients with weight loss during CRT, statistically significant worsening was observed only in their emotional functioning scores. QoL scores did not differ according to the presence of comorbidity, age (< 65 years vs. ≥65 years), ECOG performance status (ECOG 0 vs. ECOG 1–2), a decrease in performance status during CRT, or RT modality (3DCRT vs. TomoTherapy).
Ultimately, it is known that all therapeutic modalities used in the treatment of gastric cancer impact QoL. However, although we have more information related to surgical procedures for abdominal malignancies, there are insufficient data on the complex relationship between long-term treatment-related toxicity and QoL after adjuvant CRT. Instead of simply comparing treatment, there is a need for randomized controlled studies that focus on QoL data and comprehensively evaluate toxicity and other potential patient- and treatment-related factors that adversely affect QoL. These studies may provide guidance for individualizing treatment and facilitate the selection of the optimal treatment modality for each patient. Our findings indicate that multimodal therapy has less of a long-term and permanent adverse effect on quality of life than expected and is a feasible treatment. However, they also show that there are various functional and symptomatic problems that health care professionals must manage in the early period. It is important to inform patients about treatment-related toxicity and possible QoL outcomes when providing information about the planned treatment.