Lung cancer info

Objective: To compare baseline preoperative and 6-month postoperative functional health status and quality of life in patients undergoing lung cancer resection.

Methods: Lung cancer surgery patients from three hospitals were administered the Short-Form 36 Health Survey (SF-36) and the Ferrans and Powers' quality-of-life index (QLI) before surgery and 6 months after surgery. Preoperative, intraoperative, hospital stay, and 6-month postoperative clinical data were collected. All p values [less than or equal to] 0.05 were considered significant.

Results: One hundred thirty-nine patients were studied; 131 patients were discharged and 8 patients (5.8%) died. One hundred three patients (78.6%) who survived underwent an evaluation at 6 months, 16 patients (12.2%) died during follow-up, 2 patients refused follow-up, 4 patients were unavailable for follow-up, and 6 patients are awaiting an evaluation at 6 months. Compared with matched healthy subjects, preoperative lung cancer patients had worse results on the SF-36 physical functioning, role-emotional, mental health, and energy subscales. At 6 months, SF-36 subscales for physical functioning, role-physical, bodily pain, and mental health were significantly worse than preoperative values. The visual analog pain scale was significantly worse at follow-up. The QLI with all subscales and SF-36 for role-emotional, energy, and general health subscales were unaffected by lung cancer resection. Whereas preoperative FE[V.sub.1] and 6-min walk results did not predict postoperative functional health status or QLI, a low preoperative diffusion capacity of the lung for carbon monoxide (DLCO) predicted poor postoperative QLI. Preoperative chemoradiation, extent of resection, postoperative complications, or adjuvant therapy did not negatively affect the results of the 6-month QLI or SF-36.

Conclusions: Preoperative functional health status in patients who undergo lung cancer surgery is significantly impaired. A significant number of patients die during the 6 months after surgery. Pain and impairment of functional health status persists for 6 months after lung cancer resection. DLCO, not FE[V.sub.1], predicts postoperative quality of life. Preoperative chemoradiation, extent of resection, postoperative complications, or adjuvant therapy do not adversely affect functional health status or quality of life 6 months after surgery. Future studies should focus on risk prediction, technical improvements, and postoperative intervention to improve the functional outcomes and quality of life after lung cancer surgery.

Key words: functional health status; lung cancer surgery; outcomes; quality of life

Abbreviations: DLCO = diffusion capacity of the lung for carbon monoxide; QLI = quality-of-life index; SF-36 = Short-Form 36 Health Survey; VA = Veterans Administration; VATS = video-assisted thoracic surgery

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While physicians are trying to predict which patients undergoing lung cancer surgery will die or have complications, patients are worried about the risk of long-term disability associated with lung surgery. (1) This distinction is important because surgical resection remains the mainstay of curative therapy for lung cancer, (2) the most common cancer killer for both genders in the United States. (3) After consideration of tumor stage, surgical candidacy is dependent on severity of comorbidities, most of which are tobacco-related lung, heart, and peripheral vascular diseases. Multiple surgical series have examined such preoperative risk factors and patient cardiopulmonary physiologic parameters in relation to operative mortality. (4-6)

The long-term goal of surgical therapy includes not only improvement in survival, but also quality of life. (7) A trend is now developing to objectively measure the quality of extended life gained with such therapy. (8) It is predicted that functional assessment of patients after health-care interventions will play a more prominent role in the future. (9) Little is known about the functional capacity and quality of life of patients after resection of lung cancer. Thus, a need exists for a more comprehensive understanding of the effects of thoracic surgery on patients' functional and quality-of-life outcomes. The potential benefit (survival and/or symptom relief) of an operation must be weighed against these outcomes, a difficult task in the face of sparse data. Follow-up of patients with cancer to determine not only raw survival data but postsurgical quality of life has been advocated. (10)

The objective of this study was to characterize the preoperative and 6-month postoperative functional health status and quality of life in patients undergoing lung cancer resection. Patients' clinical characteristics and operative outcomes were correlated to preoperative and postoperative functional health status and quality of life.

MATERIALS AND METHODS

We collected preoperative demographics, comorbidities, respiratory variables, and intraoperative and postoperative variables for patients referred for lung cancer resection. Functional assessment included Karnofsky performance status, American Society of Anesthesiology classification, and a 6-min walk. Respiratory variables included room air arterial blood gas analysis, complete spirometry, lung volumes and diffusion capacity of the lung for carbon monoxide (DLCO) measurement, Medical Research Council dyspnea scale results, and smoking history. Intraoperative variables included type of incision, extent of resection and lymph node dissection, operating time, estimated blood loss, and type/volume of intraoperative fluid administered. Postoperative variables included stage and cell type, complications, length of stay, discharge site, and mortality. Similar data were collected 6 months postoperatively. The Appendix details the complete listing of the > 90 demographic and clinical variables collected for each patient.

Functional health status was measured by administration of the Short-Form 36 Health Survey (SF-36), a standardized, validated, widely used instrument. (11) The SF-36 measures eight scales: physical functioning, role functioning-physical, bodily pain, general health, energy, social functioning, role functioning--emotional, and mental health. Scoring is from 0 (worst) to 100 (best). Data for healthy population scores on the SF-36 are available for comparison with study populations. Quality of life was evaluated with administration of the Ferrans and Powers quality-of-life index (QLI). The QLI is a validated instrument (12) with 5 subscales. The QLI subscales include overall quality of life, health and functioning, socioeconomic status, psychological/spiritual status, and family status. Scores are from 0 (worst) to 30 (best). Finally, a visual analog pain scale, a widely used and valid instrument, (13) was administered with a scale of 0 (no pain) to 10 (worst). Patients completed these instruments preoperatively and 6 months postoperatively. All data were entered into a computerized database (Epi-info; CDC Shareware; Atlanta, GA).

Multiple thoracic surgeons performed pulmonary resections on lung cancer patients at three medical centers. The geographically and clinically diverse participating medical centers included an academic medical center, a Veterans Administration (VA) hospital, and a community tertiary-care medical center. Incisions for pulmonary resection were dictated by surgeon preference or anatomic imperatives. (14) Lobectomy was the preferred extent of resection. Pneumonectomy was performed if oncologically necessary. Less-than-lobectomy resections were performed only if mandated by preoperative physiologic impairment.

Statistical analysis consisted of serial performance of multivariate analysis of variance tests. Independent variables were the clinical characteristics or outcomes, whereas the SF-36 or QLI subscale scores were the dependent variables. When comparing preoperative and postoperative performance on a variable, repeated-measures analysis of variance was used. To compare preoperative and postoperative scores, a matched-pairs t test was used. Analysis was carried out using software (SPSS version 10.0; SPSS; Chicago, IL); p [less than or equal to] 0.05 was considered significant.

To facilitate analysis, continuous variables were divided into clinically logical categories. FE[V.sub.1] was divided into < 39% predicted values, 40% to 79% predicted values, and > 80% predicted values. The 6-min walk was divided into < 1,000 feet or > 1,000 feet. DLCO was divided into < 45% predicted values, 45% to 75% predicted values, and > 75% predicted values. Age was divided into decades.

RESULTS

Patient Population