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Dr. Chen is Clinical Professor at the University of Hawaii and Chief of Cardiothoracic Surgery at the Hawaii Kaiser Foundation Hospital. Ms. Johnstone is RN Cardiothoracic Surgery Coordinator for the Division of Cardiothoracic Surgery at the Hawaii Kaiser Foundation Hospital.
Correspondence to: John C. Chen, MD, FCCP, Chief of Cardiothoracic Surgery, Kaiser Foundation Hospital, 3288 Moanalua Rd, Honolulu, HI 96819; email: Jchen{at}alum.mit.edu
Currently, surgery is the preferred treatment for resectable lung cancer. Most surgical reports have focused on preoperative risk factors and operative mortality along with long-term survival. Late functional disabilities following surgical resection are not widely reported and may be more important to the patient. There may exist patients in whom potential persistent impairments in functional status would lead them to consider less invasive approaches or alternative treatments. There are many tools available to measure functional status. These can serve as outcome measures and may also be used to guide patient counseling. One such tool, the Short-Form Health Survey (SF-36), was designed to be applicable in a wide range and severity of conditions. Its measures include behavioral functioning, perceived well being, social and role disability, and personal evaluations of general health. It aims to distinguish role changes attributable to physical limitations from those due to mental conditions.
The utility of the SF-36 in longitudinal studies of patients undergoing total hip arthroplasty, non-small cell lung cancer surgery, and thoracic aortic aneurysm repair have been reported.1 The SF-36 has been found to be a useful tool in the quantification of patient quality of life. It is brief and has gained general acceptance. More important to the researcher is its well-established reliability and validity in a variety of medical conditions and surgery-specific studies.
For the SF-36 to be useful in assessment of patients with lung cancer, it needs to be sensitive not only to the immediate postoperative physical and emotional consequences of surgery, but should also reflect the effects of uncertainty regarding long-term prognosis. At 6 months and 12 months after surgery, lung cancer patients have reported significantly poorer levels of health perception, physical function, bodily pain, and vitality as compared to their preoperative assessment. It has been found that the physical score of the SF-36 is more sensitive than other measures with which it was compared, but that the psychological score was less sensitive to change.2 It is often necessary to combine the SF-36 with an another tool such as the hospital anxiety and depression scale3 to better assess both physical and psychological well being of patients with cancer.
In this issue of CHEST (see page 21), Handy and colleagues report their prospective survey of 139 patients undergoing surgical resection for lung cancer. This was a study carried out at three hospitals. They compared functional health status and quality of life using the SF-36 and the quality of life index (QLI). They attempted to stratify outcomes and quality of life following thoracic surgery as a function of preoperative FEV1, 6-min walk distance, diffusing capacity of the lung for carbon monoxide (DLCO), use of chemoradiation, extent of resection, and postoperative complications comparing to age-matched control subjects without lung cancer. The authors found that preoperative functional health status in lung cancer patients is significantly impaired and persisted 6 months following lung resection. They further concluded that impaired DLCO, not FEV1, is a poor prognostic predictor of postoperative quality of life. Although the ability of the preoperative lung to perform gas exchange (DLCO) may in fact be more important than its mechanical behavioral properties (FEV1) in determining surgical results, we would caution against the use of DLCO as the sole preoperative measure of surgical candidacy based on the findings of this group. Traditional surgical literature has suggested poorer surgical prognosis with preoperative FEV1 < 60%, and a preoperative FEV1 < 40% should be considered a contraindication to resection.4 Handy and colleagues stratified their results into preoperative FEV1 of < 40%, 40 to 79%, and > 79% predicted groups. It would be interesting to see other supportive reports using traditional limits for FEV1 in a similar study.
The implications of the study by Handy and colleagues are many. Where surgeons often consider the probability of survival with regards to preoperative risk factors, patients may be more concerned with the possibility of needing home oxygen, poor exercise tolerance, and inability to perform activities of daily living. Information such as this should be reported in the literature and discussed during preoperative patient counseling. In the setting of surgical treatment for a chronic or potentially incurable disease, quality of life must be considered of prime concern and not forgotten.
References
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