Palliative stenting for relief of dysphagia in patients with inoperable esophageal cancer: impact on quality of life

The aim of palliation in patients with inoperable esophageal cancer is to relieve dysphagia with minimal morbidity and mortality, and thus improve quality of life (QOL). The use of a self‐expanding metal stent (SEMS) is a well‐established modality for palliation of dysphagia in such patients. We assessed the QOL after palliative stenting in patients with inoperable esophageal cancer. Thirty‐three patients with dysphagia due to inoperable esophageal cancer underwent SEMS insertion between October 2004 and December 2006. All patients had grade III/IV dysphagia and locally advanced unresectable cancer (n = 13), distant metastasis (n = 14), or comorbid conditions/poor general health status precluding a major surgical procedure (n = 6). Patients with grade I/II dysphagia and those with carcinoma of the cervical esophagus were excluded. The QOL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QLQ‐C30 (version 3) and EORTC QLQ‐Esophagus (OES) 18 questionnaire (a QOL scale specifically designed for esophageal diseases) before and at 1, 4, and 8 weeks after placement of the stent. The mean age of the patients was 56 (range 34–78) years, and 22 were men. A covered SEMS was used in all patients. The most common site of malignancy was the lower third of the esophagus (n = 18, 55%). In 23 (77%) patients, the stent crossed the gastroesophageal junction. Seven patients required a reintervention for stent block (n = 5) and stent migration (n = 2). Dysphagia improved significantly immediately after stenting, and this improvement persisted until 8 weeks (16.5 vs. 90.6; P < 0.01). The global health status (5.8 vs. 71.7; P < 0.01) and all functional scores improved significantly after stenting from baseline until 8 weeks. Except pain (14.1 vs. 17.7; P = 0.67), there was significant improvement in deglutition (22.7 vs. 2.0; P < 0.01), eating (48 vs. 12.6; P < 0.01), and other symptom scales (19.7 vs. 12.1; P = 0.04) following stenting. The median survival was 4 months (3–7 months). Palliative stenting using SEMS resulted in significant improvement in all scales of QOL without any mortality and acceptable morbidity.     

Effects of anti-emetic drug (tropisetron) on quality of life during chemotherapy: Use of a diary-type questionnaire and application of summary measures for assessment in a randomized, multicentre study

The role of tropisetron as an anti-emetic drug in the prevention of delayed nausea and vomiting remains unclear. Therefore, effectiveness of tropisetron in patients receiving cancer chemotherapy was evaluated by application of summary measures using a quality of life (QOL) questionnaire. The diary-type QOL self-rating questionnaire was constituted by seven scales. A double-blind randomized, multicentre study was performed in 33 hospitals. Quality of life was measured in 98 patients. Patients receiving cisplatin were randomized to group T (administration of tropisetron before and 4 days after cisplatin treatment) and group P (administration of tropisetron before cisplatin treatment and followed by placebo for 4 days). The rate of complete protection from delayed emesis in the groups T and P was 46.3 and 36.5%. All scales, except social wellbeing changed immediately in both groups and reached a nadir on days 2-3, after that returning to the control levels during 2 weeks after cisplatin treatment. Group T was significantly better than group P in physical wellbeing, mental wellbeing, functional wellbeing and global QOL scores summarized by area under the curve and Difmax (maximum differences of QOL scales' score from the best score throughout the entire period). These results indicate that continuous administration of tropisetron could contribute to preventing patient QOL influenced by cisplatin treatment, and the combined use of summary measures may be useful for the evaluation of QOL in cancer clinical trial.     

New developments in palliative therapy

Over the past 5 years, new developments in the palliative treatment of incurable cancer of the oesophagus and gastro-oesophageal junction have been introduced with the aim of palliating dysphagia and improving the survival of patients. Stent placement is currently the most widely used treatment for palliation of dysphagia from oesophageal cancer. A stent offers rapid relief of dysphagia; however, current recurrent dysphagia rates vary between 30 and 40%. Recently introduced new stent designs are likely to reduce recurrent dysphagia by decreasing stent migration and non-tumoral tissue overgrowth. Intraluminal radiotherapy (brachytherapy) has been demonstrated to compare favourably with stent placement in long-term effectiveness and safety. A disadvantage of brachytherapy, however, is that one-fifth of patients need an additional treatment because of persistent tumour growth in the oesophagus. A solution may be to administer brachytherapy not in a single fraction but in multiple fractions. Finally, efforts have been undertaken to improve survival of patients by using chemotherapy. In the future, a multimodal approach--for example by combining stent placement with chemotherapy or radiotherapy--may improve the prognosis of patients without jeopardizing their quality of life.     

A randomised prospective comparison of the Flamingo Wallstent and Ultraflex stent for palliation of dysphagia associated with lower third oesophageal carcinoma

BACKGROUND: Covered metallic oesophageal stents offer effective palliation of malignant oesophageal strictures. However, first generation devices were associated with a high rate of migration, particularly when used in the lower oesophagus. Aim: To compare the rate of complications and palliative effect of two newer covered metallic oesophageal stents. PATIENTS AND METHODS: We performed a prospective randomised study using two of these newer stent designs in the treatment of malignant lower third oesophageal tumours. Fifty three patients with dysphagia due to inoperable oesophageal carcinoma involving the lower third of the oesophagus were randomly selected to receive either a Flamingo covered Wallstent (Boston Scientific Inc., Watertown, Massachusetts, USA) or an Ultraflex covered stent (Boston Scientific Inc.). Dysphagia was scored on a five point scale, recorded before stent insertion, the day after, and at least one month later at follow up. Technical success, early and late complications (perforation, migration, severe gastro-oesophageal reflux, haematemesis, and reobstruction due to tumour overgrowth) were also recorded. RESULTS: In both stent groups, a significant improvement in dysphagia score was seen both the next day post stenting and at late follow up (p<0.05). No significant difference was seen in the improvement in dysphagia between the two groups (p>0.1). The frequency of complications encountered in the two groups was similar. Three patients in the Ultraflex group required two stents at primary stenting. CONCLUSION: The two types of stent are equally effective in the palliation of dysphagia associated with lower third oesophageal malignancy and the complication rates associated with their use are comparable.     

Oesophageal self expanding metal stents. Preliminary report about covered and non-covered types

OBJECTIVE: The aim of this study was to evaluate the effectiveness and complications rate of covered and non-covered self expanding metal stents in the palliative treatment of oesophageal dysphagia. DESIGN: In this retrospective non-randomized study, we evaluated 11 non-covered and 17 covered stents of different types. RESULTS: Grade of dysphagia and improvement after treatment were similar in both groups, all the seven fistulas were sealed by covered stents. Covered stents seem to be safer regarding the rate of life-threatening complications and reinterventions. In contrast to published studies, bleeding was our major complication with death related in half of these patients. Aorto-Oesophageal fistula was proved by autopsy in two of them. CONCLUSIONS: Covered stents lead to less drawbacks than non-covered ones and seem to be recommended in the palliation of oesophageal dysphagia even in the absence of fistula.     

A diary form quality of life questionnaire for Japanese patients with lung cancer and summarization techniques for longitudinal assessment

The aim of this study was to confirm the validity and reliability of a new diary-type quality of life (QOL) self-rating questionnaire tailored for use by Japanese inpatients with lung cancer receiving chemotherapy. Two kinds of summary statistics were tested in QOL analysis. The questionnaire has a four-scale structure; physical, psychological, daily activity and global scales. Fifty-three patients were enrolled to test the reliability and validity. Summary statistics were assessed using indices of the area under the curve (AUC) and the maximum fluctuations of QOL scores (Dif max) in patients receiving cisplatin or carboplatin. The questionnaire had satisfactory reliability and validity. The physical, psychological and global scales scores changed to the worst levels after treatment, continuing for 1 week in the cisplatin group, whereas those of the carboplatin group began to worsen from day 3, but returned to prechemotherapy levels by day 9. The cisplatin group showed significant decrease of QOL compared with the carboplatin group in the AUC of psychological and two global scales, in the Dif max of psychological and linear analogue global scales. These results suggested that this questionnaire reflects differences in the influence of chemotherapy, and that AUC and Dif max may be useful indices for the analysis of QOL as measures to assess multidimensional QOL.     

Advanced esophageal cancer: still a delayed diagnosis

BACKGROUND: Esophageal cancer is one of the 10 most common cancers in Brazil. Diagnosis is usually late and mean survival ranges from 4 to 6 months, no matter the treatment. Relief of dysphagia and increase in life quality are the main targets of palliative therapy. AIM: To evaluate patients with advanced esophageal tumor submitted to various palliative treatment options. PATIENTS AND METHOD: We prospectively evaluated 38 patients with advanced esophageal cancer, with dysphagia and no chance of curative treatment, between September 2001 and June 2005. Patients were treated according to available resources, patient or referring physician's preference: 14 patients were treated with esophageal stent (9 self-expandable metallic, 4 plastic, 1 expandable plastic), 4 with palliative surgery, 8 gastrostomy (7 surgical and 1 endoscopic) and 12 nasogastric tube. RESULTS: The mean dysphagia score 30 days after the procedure was improved in all groups except in the gastrostomy. Karnofsky score, reflecting quality of life, showed no improvement. The number of hospital admissions was not different among groups. Although the length of hospitalization was longer in the surgical group (42 days), it did not reach statistical significance. There was not statistically significant difference in the mean survival time among all patients. CONCLUSION: An ideal palliative treatment does not exist. The method must be individualized for each patient. Surgical treatment is the most expensive, once it requires longer periods in hospital. Unfortunately, the diagnosis of esophageal tumors is still delayed, limiting the benefits of top endoscopic palliation therapy.     

Health-related quality of life in nonsplenectomized immune thrombocytopenia patients receiving romiplostim or medical standard of care

Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by platelet destruction and insufficient platelet production. The resulting thrombocytopenia reduces patient health-related quality of life (HRQOL). In a randomized, open-label, 52-week study of non-splenectomized ITP patients treated with romiplostim or medical standard of care (SOC), patients completed the 10-scale ITP-patient assessment questionnaire (PAQ) at the start of the study and after 12, 24, 36, 48,and 52 weeks of treatment. HRQOL changes were examined for all patients in both treatment groups and by responder status, splenectomy status, and after the use of rituximab. Patients in both groups showed marked increases in all HRQOL scales over 52 weeks of treatment.These change scores exceeded the minimally important difference values (a measure of clinical relevance) for most of these scales,especially in responders to treatment. Compared with baseline,patients receiving romiplostim showed statistically significant improvements compared to SOC over 52 weeks for the ITP-PAQ scales of Symptoms, Bother, Activity, Psychological Health, Fear, Overall QOL,and Social QOL. Overall, treatment of ITP was associated with improvement in HRQOL. Patients receiving romiplostim had greater HRQOL improvements than those receiving SOC, but the magnitude ofthe difference is of uncertain clinical benefit.     

The SWAL–QOL and SWAL–CARE Outcomes Tool for Oropharyngeal Dysphagia in Adults: III. Documentation of Reliability and Validity

Advances in the measurement of swallowing physiologic parameters have been clinician-driven, as has the development of intervention techniques to modify swallowing pathophysiology. However, a critical element to determining the success of such efforts will be established by the patients themselves. We conceptualized, developed, and validated the SWAL–QOL, a 93-item quality-of-life and quality-of-care outcomes tool for dysphagia researchers and clinicians. With 93 items, the SWAL–QOL was too long for practical and routine use in clinical research and practice. We used an array of psychometric techniques to reduce the 93-item instrument into two patient-centered outcomes tools: (1) the SWAL–QOL, a 44-item tool that assesses ten quality-of-life concepts, and (2) the SWAL–CARE, a 15-item tool that assesses quality of care and patient satisfaction. All scales exhibit excellent internal-consistency reliability and short-term reproducibility. The scales differentiate normal swallowers from patients with oropharyngeal dysphagia and are sensitive to differences in the severity of dysphagia as clinically defined. It is intended that the standardization and publication of the SWAL–QOL and the SWAL–CARE will facilitate their use in clinical research and clinical practice to better understand treatment effectiveness as a critical step toward improving patients' quality of life and quality of care.     

Chemoradiation therapy is effective for the palliative treatment of malignant dysphagia

Between 1993 and 2001, 106 patients with esophageal cancer were reviewed at a multidisciplinary clinic and treated with palliative intent by chemoradiation therapy. This study assesses the palliative benefit on dysphagia and documents the toxicity of this treatment. The study population comprised 72 men and 34 women with a median age of 69 years. Patients were treated with a median radiation dose of 35 Gy in 15 fractions with a concurrent single course of 5 FU-based chemotherapy. Dysphagia was measured at the beginning and completion of treatment and at monthly intervals until death, using a modified DeMeester (4-point) score. Treatment was well tolerated, with only 5% of patients failing to complete therapy. The treatment-related mortality was 6%. The median survival for the study population was 7 months. The median baseline score at presentation was 2 (difficulty with soft food). Following treatment, 49% of patients were assessed as having a dysphagia score of 0 (no dysphagia). Seventy-eight per cent had an improvement of at least one grade in their dysphagia score after treatment. Only 14% of patients showed no improvement with treatment. Fifty-one per cent maintained improved swallowing until the time of last follow-up or death. This single-institution study shows that chemoradiation therapy administered for the palliation of malignant dysphagia is well tolerated and produces a sustainable normalization in swallowing for almost half of all patients.     

Stent insertion or endoluminal brachytherapy as palliation of patients with advanced cancer of the esophagus and gastroesophageal junction. Results of a randomized, controlled clinical trial

SUMMARY: Esophageal cancer often presents as advanced stage disease with a dismal prognosis, with only 10-15% of patients surviving 5 years. Therefore, in a large proportion of patients, palliative treatment is the only option available. The aim of this study was to prospectively compare the palliative effect of self-expandable stent placement with that of endoluminal brachytherapy regarding the effect on quality of life and on specific symptoms. Sixty-five patients with advanced cancer of the esophagus or gastroesophageal junction were randomized to treatment with either an Ultraflex expandable stent or high-dose-rate endoluminal brachytherapy with 7 Gy x 3 given in 2-4 weeks. Clinical assessment and health-related quality of life (HRQL) were measured at inclusion and 1, 3, 6, 9 and 12 months later. The HRQL was measured with standardized questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Oesophageal Module and Hospital Anxiety and Depression Scale). Twenty-eight patients completed the stent treatment and 24 patients the brachytherapy. The group of patients treated with stent reported significantly better HRQL scores for dysphagia (P < 0.05) at the 1-month follow-up, but most other HRQL scores, including functioning and symptom scales, deteriorated. Among brachytherapy-treated patients, improvement was found for the dysphagia-related scores at the 3-months follow-up, whereas other significant changes of scores were few. The median survival time was comparable in the two groups (around 120 days). In conclusion, insertion of self-expandable metal stents offered a more instant relief of dysphagia compared to endoluminal brachytherapy, but HRQL was more stable in the brachytherapy group.     

Quality of life during first-line palliative chemotherapy for recurrent and metastatic head and neck cancer with weekly cisplatin and docetaxel

Purpose  Quality of life (QOL) should be improved during palliative chemotherapy for end-stage recurrent head and neck cancer. Therefore, we evaluated QOL in head and neck cancer patients during palliative chemotherapy with cisplatin and docetaxel. Methods  Thirty patients were included in a prospective study between 2003 and 2007. Response, time-to-progression, overall survival, performance, and toxicity were estimated. QOL was assessed using the EORTC QLQ-C30 and the QLQ-H&N35 questionnaires at baseline, and after each chemotherapy cycle. Results  The response rate was 17%. Sixty-three percent had stable disease. The median time-to-progression was 3.5 months. The median overall survival was 9.2 months. The QLQ-C30 score constipation and the QLQ-H&N35 scores swallowing, senses problems, speech problems, coughing, weight gain showed significant improvement. Conclusions  Only some aspects of QOL are maintained or improved. The QLQ-H&N35 questionnaire seems to be more appropriate to measure QOL, but needs to be improved to account for the peculiarities of modern palliative chemotherapy.     

Radiotherapy enhances laser palliation of malignant dysphagia: a randomised study.

BACKGROUND/AIMS: A major drawback of laser endoscopy in the palliation of malignant dysphagia is the need for repeated treatments. This study was designed to test whether external beam radiotherapy would reduce the necessity for repeated laser therapy. PATIENTS/METHODS: Sixty seven patients with inoperable oesophageal or gastric cardia cancers and satisfactory swallowing after initial laser recanalisation were randomised to palliative external beam radiotherapy (30 Gy in 10 fractions) or no radiotherapy. All patients underwent a 'check' endoscopy five weeks after initial recanalisation and were subsequently reendoscoped only for recurrent dysphagia, which occurred in 59 patients. RESULTS: Dysphagia was relieved equally well in both groups and the improvement was maintained with further endoscopic treatment. The initial dysphagia controlled interval and the duration between procedures required to maintain lifelong palliation (treatment interval) increased from five to nine weeks (median) in the radiotherapy group (p < 0.01 both parameters). Radiotherapy was well tolerated in all but three patients. One perforation occurred and two fistulae opened after dilatation in patients who received radiotherapy. CONCLUSION: Additional radiotherapy reduces the necessity for therapeutic endoscopy for a patient's remaining life. It has an important role in relatively well patients who are likely to survive long enough to benefit.     

Intraluminal brachytherapy in the management of squamous carcinoma of the esophagus

Intraluminal high dose rate brachytherapy (ILHDR BT) is one of several effective modalities for palliation of advanced esophageal cancer. Thirty patients with endoscopic-proven, mostly locally advanced, squamous cell carcinoma of the esophagus, not involving the gastroesophageal junction and without distant metastases, were included in this analysis. Twenty-nine patients received two ILHDR BT sessions of 8 Gy within a week and one patient received only one session. All patients were followed monthly. Outcomes included quality of life (QOL), symptoms control: dysphagia, regurgitation, odynophagia, and chest or back pain, as well as, overall survival. Through 4 months of follow-up, QOL was statistically improved (having lowered scores) in regards to feelings ( P = 0.013), sleeping ( P = 0.032), eating ( P = 0.020), and social life ( P = 0.002). The most significantly improved symptom was dysphagia ( P < 0.006), with a reduction of 0.52 units or one-half grade. Regurgitation, odynophagia, and pain were lower during follow-up but were not statistically significant. The median overall survival from death of any cause was 165 days (with a 95% confidence interval of 128–195 days). In conclusion, ILHDR BT of advanced squamous esophageal cancer consisting of two out-patient procedures is very successful in achieving the primary objectives of the patients to reduce dysphagia and improve QOL.     

Role of oesophageal manometry in clinical practice

The present study evaluates the role of oesophageal manometry in clinical practice. Over 5 years, 347 consecutive patients were evaluated in our oesophageal laboratory. The reasons for referral were: dysphagia (11.5%), gastro-oesophageal reflux disease (GORD) (46.7%), non-cardiac chest pain (28.5%), connective tissue disease (6.9%) and other symptomatology (6.3%). Patients were classified into the following five groups according to the referral diagnosis: dysphagia (40 patients), gastro-oesophageal reflux disease (GORD) (162 patients), non-cardiac chest pain (99 patients), connective tissue disease (24 patients) and other symptomatology (22 patients). Abnormalities in oesophageal motility were detected in 90% of patients with dysphagia, in 40.1% of patients with GORD, in 47.5% of subjects with non-cardiac chest pain, in 45.8% of patients with connective tissue disease and in 18.2% of subjects with other symptomatology. The high prevalence of abnormalities in the dysphagia group was statistically significant (p < 0.001), and the range of 95% confidence intervals (0.81-0.99) suggests that the value found may be a reasonably good estimate of percentage of anomalies detectable in the dysphagia patient population. In the dysphagia group, the initial diagnosis was confirmed in 40% of patients and changed in 52.5%; in only 7.5% of cases were the manometry results not relevant for determining an appropriate diagnosis. Manometry substantially contributed to patients receiving the correct treatment in 82.5% of cases (p < 0.001 among all groups). In the GORD group and in the non-cardiac chest pain group, the results of manometry were not relevant for confirming or changing a diagnosis in 59.8% and 53.5% of cases respectively; nevertheless, in both groups, on the basis of manometry results, the treatment was changed in 42.5% of patients (p < 0.01 vs. other symptomatology group). In conclusion, on the basis of the present data, we can emphasize the usefulness of oesophageal manometry assessment in patients with dysphagia or non-cardiac chest pain, with negative routine examinations, and also in patients with refractory GORD who have been considered for antireflux surgery.     

Comparison of the two time schedules for endoscopic sclerotherapy: a prospective randomised controlled study.

To compare the efficacy and safety of one week versus three weeks interval treatment schedules of endoscopic sclerotherapy, injections were carried out in a prospective manner in 96 patients with variceal bleeding; 47 on a one week and 49 on a three weeks treatment schedule. Weekly endoscopic sclerotherapy eradicated oesophageal varices significantly (p less than 0.01) earlier (mean +/- SD 7.1 +/- 2.43 weeks) as compared with the three weeks regimen (mean +/- SD 14.86 +/- 4.86 weeks). The rebleeding rate was also significantly less (p less than 0.05) with weekly endoscopic sclerotherapy (8.5%) as compared with three weeks endoscopic sclerotherapy treatment (26.5%). The amount of alcohol and the number of endoscopic sclerotherapy courses required for complete variceal eradication did not differ significantly between the two groups. Patients undergoing weekly injections were seen to have significantly more oesophageal ulcers (p less than 0.01) as compared with the three weeks group, necessitating at times (23%) postponement of the procedure. There was, however, no difference between the two groups in the frequency of oesophageal stricture formation, dysphagia, retrosternal pain, and fever. Mortality was also similar in the two groups. It can be concluded that a weekly schedule of endoscopic sclerotherapy appears superior to a three weeks schedule.     

Combined stent insertion and single high-dose brachytherapy in patients with advanced esophageal cancer--results of a prospective safety study

Previous randomized studies comparing the two commonly used palliative treatments for incurable esophageal cancer, i.e. stent insertion and intraluminal brachytherapy, have revealed the pros and cons of each therapy. While stent treatment offers a more prompt effect, brachytherapy results in more long-lasting relief of dysphagia and a better health-related quality of life (HRQL) in those living longer. This prospective pilot study aimed to explore the feasibility and safety of combining these two regimes and incorporating a single high dose of internal radiation. Patients with newly diagnosed, incurable cancer of the esophagus and dysphagia were eligible for inclusion, and stent insertion followed by a single dose (12 Gy) of brachytherapy was performed as a two-stage procedure. Clinical parameters including HRQL and adverse events were registered at inclusion, and 1, 2, 3, 6, and 12 months later. Twelve patients (nine males) with a median age of 73 years (range 54-85) were included. Stent insertion followed by a single dose of brachytherapy was successfully performed in all but one patient who was treated with stent only. Relief of dysphagia was achieved in the majority of cases (10/11, P < 0.05), but HRQL did not improve except for dysphagia-related items. Only minor adverse events, including chest pain, reflux, and restenosis, were reported. The median survival time after inclusion was 6.6 months. Our conclusion is that the combination of stent insertion and single high-dose brachytherapy seems to be a feasible and safe palliative regime in patients with advanced esophageal cancer. Randomized trials comparing the efficacy of this strategy to stent insertion or brachytherapy alone are warranted.     

Endoscopic treatment of early oesophageal or gastric cancer.

BACKGROUND AND AIMS: Endoscopic treatment has become increasingly popular in recent years as an alternative to surgical treatment with the hope of offering superior quality of life (QOL) for the patient. The results of endoscopic treatment of mucosal lesions of mostly early oesophageal or gastric cancer performed in 145 patients (155 lesions) over the past eight years were reviewed from the standpoint of QOL. RESULTS: In 56 patients who underwent radical resection of the oesophageal mucosa, no serious complications and symptoms occurred, with epithelialisation completed within about a month. Patients also showed good results regarding dietary intake and performance status (PS), and all are currently alive without any sign of recurrence. One time fractionated endoscopic resection was carried out in about 40% of the 57 patients who underwent gastric mucosal resection. In these 57 patients, an artificial ulcer measuring 3 cm or more was formed, resulting in a favourable outcome after healing. An overwhelming proportion of these subjects had no symptoms and good PS after the treatment. CONCLUSIONS: The introduction of this method, endoscopic mucosal resection using a cap fitted panendoscope, is expected to permit additional indications for endoscopic treatment. Endoscopic Nd-YAG laser irradiation was applied mainly to early gastric cancer lesions (32 patients), usually for relative indications for endoscopic treatment. This procedure is safe and advantageous in that it requires no hospitalisation, permits fractionated irradiation, and secures good QOL.     

Impact of chronic obstructive pulmonary disease on respiratory status and quality of life in newly diagnosed patients with lung cancer

OBJECTIVE AND BACKGROUND: A significant proportion of patients with lung cancer have associated COPD, which is considered an independent risk factor and cause of morbidity and mortality. However, the effect of COPD on respiratory status and quality of life in lung cancer has not been evaluated. METHODS: Newly diagnosed patients with lung cancer were assessed at diagnosis before starting treatment, for detailed respiratory status, spirometry and World Health Organization-Bref Quality of Life questionnaire in Hindi (WHOQOL-Bref Hindi). RESULTS: One hundred and sixty patients were studied. Spirometry was abnormal in 92.7% patients, 42% had COPD, and the majority (88.6%) had advanced disease (stage III and IV). Patients scored poorly in all QOL domains, with social domain faring worst. Karnofsky Performance status (KPS) correlated significantly with all QOL domains. No significant differences were found in clinical profile, KPS, or QOL scores between patients with and without COPD. Chest pain and dyspnoea severity (assessed by Medical Research Council) grading and visual analogue scale correlated with physical QOL domain. CONCLUSION: Patients with lung cancer have a poor QOL that is affected by the severity of respiratory profile and KPS. The presence of COPD does not significantly affect QOL in lung cancer patients.     

Dysphagia and dysmotility of the pharynx and oesophagus in patients with primary Sjögren's syndrome

OBJECTIVES: To assess the prevalence of pharyngeal and oesophageal symptoms and dysmotility in patients with primary Sj?gren's syndrome (pSS) and relate these to autonomic nervous function. METHODS: Twenty consecutive pSS patients, according to the American-European Consensus Criteria (AECC), and 30 age- and sex-matched controls from the Swedish general population registry were studied. All subjects completed a pharyngeal and oesophageal symptoms questionnaire and were examined by pharyngeal and oesophageal video radiography. In addition, the pSS patients were examined by two different autonomic nervous function tests, the deep breathing test [calculating the expiration/inspiration (E/I) ratio] and the finger skin blood flow test [the vasoconstriction (VAC) index]. RESULTS: pSS patients experienced significantly more dysphagia compared with controls (65% vs. 3%; p<0.001). Pharyngeal (45% vs. 7%; p<0.01), oesophageal (80% vs. 7%; p<0.001) and gastro-oesophageal reflux symptoms (60% vs. 23%; p<0.01) were also more prevalent in pSS patients compared with controls while pharyngeal (15% vs. 17%; p = NS) and oesophageal dysmotility (40% vs. 30%; p = NS) were not. Dysphagia was not associated with dysmotility but was found to be associated with a decreased E/I ratio [-1.05 (-1.51 to -0.40) in patients with dysphagia vs. -0.21 (-0.39 to 0.65) in patients without dysphagia; p<0.01]. CONCLUSION: Subjective swallowing difficulties were more common in pSS patients than in controls while objective signs of pharyngeal and oesophageal dysmotility were not. Dysphagia in pSS patients does not seem to be related to video radiographical signs of dysmotility but may be related to an impaired parasympathetic function.