PORTLAND, ORE—Although surgical resection is a common procedure in lung cancer patients, few studies have examined quality of life after resection. Recently, John R. Handy, Jr, MD, and colleagues discovered that what physicians consider an important outcome after this procedure may be vastly different from what patients consider important.[1]

By focusing on mortality and complications in the immediate postoperative period, “physicians attempt to predict a transient state,” states Dr. Handy, Chief of Thoracic Surgery at the Oregon Clinic in Portland. Patients, on the other hand, worry about how surgery will change everyday life.

To assess what happens to patients after resection, the researchers administered surveys on both functional health status and quality of life at baseline (before surgery) and six months after surgery. Clinical data, including six-minute walk assessment, spirometry, and lung volume measurements, were also gathered, as was information on demographics, comorbid conditions, and operative variables, such as type of incision.

HOW WELL DO PATIENTS COPE?

Of the 139 patients who began the study, 103 were reevaluated after six months (eight died in the hospital, 16 died after discharge, and 12 others were unavailable or refused follow-up). Preoperatively, the lung cancer patients had less energy than did healthy, age-matched controls, and they had poorer mental health and physical and emotional functioning. Six months after surgery, the lung cancer patients showed significant persistent reductions (compared with baseline values) in physical and social functioning, and they had worsening body pain. However, their energy level was similar to that of healthy controls. And patients’ assessment of their quality of life did not differ in the preoperative and postoperative periods.

When investigators analyzed clinical data, they discovered that only the diffusion

capacity of the lung for carbon monoxide (DLCO) demonstrated prognostic value. Patients with DLCO below 45% of predicted values had significantly poorer postoperative scores for both functional health status and quality-of-life parameters.

IMPETUS FOR CHANGE

Because this is one of the few studies on the effects of lung cancer resection, it will likely come as news that impaired physical and emotional status persists long after surgery. “I was surprised to find out the degree of worsening of functional health six months after surgery,” said Dr. Handy, who is also Co-Director of the Thoracic Oncology Program at the Providence Cancer Center in Portland.

Thus, a change is necessary in clinical practice. In this study, postoperative pain was a significant problem. To minimize impairment, “we should explore surgical technique alterations and postoperative rehabilitation and pharmacology,” he said. Surgical modifications could include minimal rib spreading or performing a median sternotomy instead of thoracotomy. In a previous study, Dr. Handy and colleagues showed that 12% of patients who underwent thoracotomy had chronic pain afterward, versus 1% of median sternotomy patients.[2]

In addition, “I believe patients are poorly counseled,” he stated. “This is why this information is so critical.” Patients need to be told before surgery that significant physical, emotional, mental, and social impairments may persist for at least six months. Asked whether he thought this prognosis would deter patients from surgery, Dr. Handy responded, “Living, albeit impaired, is preferable to dying of lung cancer to most. Patients also do better if an outcome is expected.”

This study also opens the floodgates for additional research. “It would be important to determine the duration of this impairment,” he continued. “Nine months, one year, lifelong? We don’t know yet.” Postoperative drug therapy studies could include an investigation into antidepressant use after surgery. Finally, researchers should explore how DLCO affects quality of life.

—Lisa Pallatroni