assessment of quality of life of patients with gastric cancer after surgery: a systematic review a...
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Assessment of quality of life of Assessment of quality of life of patients with gastric cancer after patients with gastric cancer after
surgery:surgery:
a systematic review a systematic review
Ana Marques; Mylene Costa; Natália Ferreira; Paula Campelo; Paula Moreira;
Paulo Leandro; Pedro Barbosa; Pedro Mendes [Class 17 – 1st year]
Supervisors: Claúdia Dias and Mário Ribeiro MD, PhDFMUP/ Serviço de Bioestatística e Informática Médica
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IntroductionIntroduction
Meta-analysis, a final step in a systematic review:
“(…) statistical pooling of data across studies to generate summary estimates of effects .” [1]
“(…) the term “effect” refers to any measure of association between exposure and outcome” [1]
[1] Pai M, The National Medical Journal of India Vol.17 No.2,2004
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Gastric cancer as:
•A malignant cell growth in the stomach;•Second leading cause of cancer deaths worldwide [2];
Surgery as the major way for treatment [3]:
• Distal gastrectomy without or with pylorus preservation;• Total gastrectomy without or with pouch;• Endoscopic mucosal resection or limited resections • Proximal gastrectomy
[2] Plummer M, Epidemiology of gastric cancer IARC Sci Publ. 2004;(157):311-26.[3] Roukos DH. Ann Surg Oncol. 1999 Jan-Feb;6(1):46-56. Review.
IntroductioIntroductionn
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IntroductioIntroductionn
Rate of death is decreasing
GASTRIC CANCER IN CANCER DEATH RATE (1973-92)
http://plan1998.cancer.gov/PRGRES.html (National Cancer Institute)
Quality of life (QoL) is then particularly important in health care. Quality of life (QoL) is then particularly important in health care. [4][4]
[4] Kaptein AA, Morita S, Sakamoto J. Quality of life in gastric cancer World J Gastroenterol 2005
-60 -40 -20 0 20 40 60
Lung
prostate
lymphoma
liver
brain
colon and rectum
breast
pancreas
leucemia
stomach
ovary
uterus
Can
cer
loca
lizat
ion
Percent Change
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Quality of life (QoL):
“The functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient.” [5]
“The degree to which a person enjoys the important possibilities of his or her life.” [6]
Instruments for studying QoL:
• Questionnaires• Interviews • Physical examination and laboratory tests
[5]Schipper H. Spilker B Philadelphia: Lippincott-Raven, 1996[6]Qualitty of life Research Unit, University of Toronto, www.gdrc.org/uem/qol-define.html.
IntroductionIntroduction
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•Clarify reproducibility and validity of the instruments used to assess QoL in studies evaluating patients submitted to surgery for gastric adenocarcinoma.
•Summarize QoL in studies using validated questionnaires.
AimsAims
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MethodsMethods
Type of study:
• Systematic review
Target population:
• Population with gastric cancer that have been submitted to a gastrectomy;
Inclusion criteria of the articles:
Include a population with gastric cancer that have been submitted to a gastrectomy;
Include post-surgery QoL evaluation; With abstracts.
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MethodsMethods
Exclusion criteria of the articles:
Title: Refer to radiotherapy / chemotherapy exclusively
Abstract:• If there is only one case in study• Not refer to a post-operative instrument • Not approach QoL in a global view• If patients with gastric cancer were part of a large group of patients
with various other types of cancer
Full article: Not have access to article Not describe the patients studied Not refer QoL assessment Not have retrievable data
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MethodMethodss
Quality of articles:
Consider a valid article if:- describe the patients studied;- refer the stage of disease;- refer the instrument used;- questionnaire is valid.
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MethodMethodssArticles searchArticles search
1.1. PubmedPubmed• Key words
MESH (Medical Subject Headings) terms:
. Quality of life
. Gastrectomy
. Stomach neoplasm
Limits of the research:
Language: EnglishHumansPublication Date: from 1950 to September 2005Only items with abstracts
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Methods : Methods : Query's Query's DefinitionDefinition
Pubmed
("Quality of Life" [MeSH] OR quality of life) AND ("Stomach Neoplasms" [MeSH]
OR stomach neoplasms OR gastric cancer OR stomach carcinoma) NOT
intestinal cancer AND ("Gastrectomy" [MeSH] OR gastrectomy OR gastric
surgery) NOT chemotherapy NOT radiotherapy
173 articles found
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MethodsMethods
2. Scopus2. Scopus
Limits of the research:
- year: until 2005; - areas: "health" e "life sciences";
- document type: "review" e "article"
Query´s definition:Query´s definition:
TITLE-ABS-KEY("Quality of life") AND TITLE-ABS-KEY(("stomach neoplasms")
OR ("gastric cancer") OR ("stomach carcinoma")) AND NOT (intestinal cancer)
AND TITLE-ABS-KEY(("gastrectomy") OR ("gastric surgery")) AND NOT
(chemotherapy) AND NOT (radiotherapy)
189 articles found
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Articles reachedArticles reached173 + 189 = 362173 + 189 = 362
362 - 102 (found in both searches) = 260362 - 102 (found in both searches) = 260
Pubmed173
Scopus189
10271 87
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Methods : Methods : Flow chartFlow chart
Start
Pubmed search
Scopus search
Read titles and abstracts
No Yes
Apply exclusion criteria
Include articles not found at Pubmed
search
Excluded by 2 revisors?
76 Articles included
184 Articles excluded
Read full article
Apply exclusion criteria
Excluded by 2 revisors?
5 Articles included
71 Article excluded
NoYes
End
260 articlesreached
· Patients without gastric cancer or not gastrectomized (44,0 %)
· QoL after surgery wasn't evaluated (38,0 %)
· Refer to radio/chemotherapy (0,5 %)
· There is only one case in study (0,5 %)
· Do not use a instrument (questionnaire) (14,7 %)
· Do not approach QoL in a global view (0,5 %)
· Do not have abstract (1,6 %)
· Questionnaire is not validated (45,1%)
· Not refer QoL assessment (4,2%)
· Not have retrievable data (7,0%)
· Not have access to article (43,7%)
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Methods - Methods - Extracted dataExtracted data
Extracted data:
- Geographical setting
- Characteristics of patients: - stage of disease at diagnosis
- Number of patients studied
- Questionnaires
- Type of surgery
- Timing of assessment of QoL
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Results Results - - Description of questionnaires: validation
Validated questionnaires
Non-validated questionnaires
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Results Results - - Description of questionnaires: validation
• Validity of the instruments used
• We found 40 different questionnaires.
• Only a minor part of them were validated (18%).
• There was a great a number of single time used questionnaires (19).
• In the 5 included articles were represented only 2 kinds of questionnaires: EORTC QLQ-C30 and Gastrointestinal QoL Index.
Questionnaires Validation
18%
82%
Validatedquestionnaires
Non-validatedquestionnaires
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Author Year Type of Surgery Instruments
Kahlke V. 2004 Total gastrectomy EORTC QLQ-C30
Hoksch B. 2002Total gastrectomy with Longmire's
reconstruction without pouchEORTC QLQ-C30 / FoodConsumption Patterns
Kalmar K. 2001
Total gastrectomy with esophagojejunostomy and aboral pouch
reconstruction and Total gastrectomy with simple Roux-en-Y reconstruction
Gastrointestinal QoL Index
Jentschura D.
1997Total gastrectomy with Roux-en-Y and Longmire's reconstruction and subtotal
gastrectomy with Billroth I and IIGastrointestinal QoL Index
Spector NM. 2002Total gastrectomy with Roux-en-Y
reconstruction and esophagogastrectomy
Gastrointestinal QoL Index / Life After
Gastroesophageal Surgery
ResultsResultsDescription of questionnaires: main characteristics
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ResultsResultsSummary of QoL in validated questionaires
QoL according to type of surgery and time after treatment * mean * (Preop. - preoperative values)
Total Gastrectomy Distal Gastrectomy
Without pouch With pouch Without pylorus preservation
Preop. 6 months12
monthsPreop. 6 months
12 months
Preop. 6 months12
months
EORTC QLQ-C30 (0-100)
Kahlke V., 2004 [20]
48 53 - - - - - - -
Hoksch B., 2002 [21]
66 47 49 55 52 65 - - -
Gastrointestinal QoL Índex (0-144)
Jentschura D., 1997 [22]
- - 105 - - - - - 113
Spector NM., 2002 [23]
- 95 - - - - - - -
Kalmar K., 2001 [24]
- 96 - - - - - - -
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Clarify reproducibility and validity of the instruments used to assess QoL in studies evaluating patients submitted to surgery for gastric adenocarcinoma.
1.There is a great diversity of questionnaires used to assess QoL after surgery for gastric cancer;
2.Most studies use questionnaires that were not previously validated (82%).
3.The same questionnaire is used across different studies rarely.
ConclusionsConclusions
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Summarize QoL in studies using validated questionnaires.
4.A summary pooled result for QoL after surgery for gastric adenocarcinoma was not possible to obtain.
5.Nevertheless, by observing the preoperative values, we can conjecture the existence of a slight decreasing of QoL after surgery followed by a more or less obvious recovery.
6.It is possible to see some benefit in the use of a pouch after total gastrectomy.
7.Further studies would be needed in order to give a more conclusive answer to the questions we raise, preferably using validated EORTC QLQ-C30 or Gastrointestinal QoL Index where the collected data could be fully used in further reviews.
ConclusionsConclusions
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GGanttantt ChartChart
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