Are current scales adequate for assessing quality of life after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?

Abstract

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are complex surgical procedures that are often used to treat advanced cancers of the abdominal cavity with peritoneal metastasis. Although these treatments can be lifesaving, patients often experience a significant decrease in their overall quality of life (QoL), especially in the early stages of recovery, owing to the physical burden of surgery and the effects of chemotherapy. Many traditional QoL questionnaires have been used to measure CRS and HIPEC. However, these classical current QoL assessment tools often fail to capture the unique challenges faced by this population, including bowel dysfunction, stoma-related distress, and long-term survivorship issues. Therefore, additional parameters that assess bowel function and stoma opening status and especially patient-reported outcome measures would be useful in QoL measurements to provide a more detailed understanding of recovery and general well-being in these patients.

Key Words: Cytoreductive surgery; Low anterior resection syndrome; Hyperthermic intraperitoneal chemotherapy; Quality of life; Hyperthermic intraperitoneal chemotherapy; Patient-reported outcome measures

Core Tip: It is important to evaluate and improve the preoperative and postoperative quality of life (QoL) in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Owing to the physical burden of surgery and the effects of chemotherapy, patients experience a significant decrease in their QoL, especially in the early stages of recovery. We believe that it would be more appropriate to evaluate QoL in a study conducted in a heterogeneous patient group, including patient-reported outcome measures with parameters that also evaluate bowel function and stoma-opening status.

TO THE EDITOR

Wang et al[1] recently published a prospective study examining quality of life (QoL) and symptom distress following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Complex techniques are often utilized in the treatment of advanced abdominal cancers. Although CRS/HIPEC can extend life, patients usually experience significant early recovery difficulties, including a noticeable decline in QoL from the physiological demands of large surgery and the systemic effects of intraperitoneal chemotherapy[2-4]. Still, studies now in hand point to a usually temporary drop; many patients finally reach QoL levels equal to or better than preoperative baselines[1].

In their prospective study, Wang et al[1] methodically assessed QoL utilizing serial evaluations from baseline to surgical follow-up. They used the Taiwanese version of the MD Anderson Symptom Inventory and European Organization Research and Treatment of Cancer Core Quality of Life Questionnaire. The participants completed the questionnaires before CRS/HIPEC, at the first outpatient follow-up, and 3 months after CRS/HIPEC. Their results showed that major symptom areas either got better or went back to baseline within three months following intervention. The study population mostly consisted of patients with an ECOG performance level of 0–1, reflecting a preoperatively high-functioning cohort, so it is crucial to highlight. The results' generalizability can be affected by this selection bias since the experiences of individuals with lower baseline functional status are underrepresented.

Recent studies have increased our knowledge of QoL results in CRS/HIPEC patients[5-13]. For example, Chia et al[6] prospectively evaluated colorectal cancer patients with peritoneal carcinomatosis, showing that baseline QoL measurements might forecast postoperative morbidity and survival. Likewise, systematic reviews by Piso et al[7] and Seretis et al[8] have highlighted the need of uniform assessment tools to enable cross-study comparisons by bringing together data of QoL recovery across several peritoneal cancer types. While qualitative research by Schlegel et al[10] and Falla-Zuniga et al[11] has clarified psychosocial issues, including survivorship and fertility worries, in this population, randomized trials such as the KOV-HIPEC-01 study[10] have also produced disease-specific insights on ovarian cancer patients.

Though Wang et al[1] mostly included gastric cancer patients, their group also included cases of colorectal-derived peritoneal carcinomatosis. Bowel dysfunction and stoma formation might greatly affect recovery given the technical complexity of CRS/HIPEC—which might include multivisceral resection, hyperthermic chemotherapy exposure, and anastomotic problems[3,4]. Their study's main drawback was the lack of thorough stoma rate data, especially for those caused by anastomotic leakage or prophylactic diversion. Clinically, this exclusion is significant since well-documented causes of lower QoL are stoma-related anxiety and functional limitations, particularly low anterior resection syndrome[13]. The absence of thorough studies on these issues draws attention to a major deficiency in present QoL measurements for CRS/HIPEC patients. To address these limitations, recent research advocates for the incorporation of patient-reported outcome measures (PROMs) that capture domain-specific challenges, such as bowel function, stoma adaptation, and survivorship concerns[5]. Such tools are essential for generating a multidimensional understanding of patient outcomes beyond conventional QoL metrics.

CONCLUSION

In conclusion, current QoL assessment instruments provide valuable insights into patient outcomes following CRS/HIPEC. However, to improve QoL assessments in the patient population undergoing CRS/HIPEC, it is important to adapt the integration of PROMs to include specific parameters such as bowel function, stoma-related quality of life, and disease-specific survival concerns to improve clinical decision-making and enhance patient care.