ASO Author Reflections: A Systematic Review of Factors Affecting Quality of Life After Cytoreductive Surgery with Hypert
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: A Systematic Review of Factors Affecting Quality of Life After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy B. L. Van Leeuwen, MD, and S. Kruijff, MD Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
PAST
PRESENT
Only 3 decades ago, patients with peritoneal metastasis, either metachronous or synchronous, were considered incurable and suitable only for palliative treatment. Back then, if left untreated, peritoneal metastasized patients had poor prognosis, high morbidity, and reduced quality of life (QoL).1 Fortunately, a curative-intent treatment option arose: cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). This suddenly gave patients with resectable peritoneal metastasis (PM) the option of undergoing a potentially curative treatment. CRS/HIPEC combines surgical removal of all macroscopically visible disease with perfusion of the abdominal cavity with heated chemotherapy to eradicate residual microscopic disease. After its introduction, cumulative scientific evidence seemed to illustrate improved survival outcomes when compared with systemic chemotherapy alone.2 If selected carefully, e.g., without distant metastases, aggressive CRS/HIPEC seemed to be a potentially curative treatment for 30–40% of patients. Unfortunately, today, this invasive procedure is still accompanied by a high treatment-related mortality of 0–8%, a grade 3–4 morbidity of 18–52%, and a negative impact on QoL of patients up to 1 year after.3 Since the majority of patients undergoing CRS/HIPEC will not be cured by this procedure, the high morbidity rates are an ongoing concern.
In literature, published systematic reviews regarding QoL after CRS/HIPEC concluded that patients, after experiencing a significant decrease in QoL, usually return to baseline QoL levels within 12 months after surgery.3,4 However, a high proportion of patients lost to follow-up in these studies probably led to underrepresentation of the most frail patients in these cohorts. Also, most of these reviews rely on limited literature searches, seldomly reporting a wide range of QoL domains.3,4 Often little consideration was given to the specific determinants of QoL after CRS/HIPEC such as stoma placement, disease recurrence, and drop-out rates. Therefore, this systematic review analyzed the primary outcomes reflecting the shortterm (\ 6 months) and medium-term (6–12 months) determinants of QoL after CRS/HIPEC. Secondary outcomes were QoL and reported symptoms over time.5 We included 14 studies that used 12 different questionnaires, and reported data were collected for 1556 patients (dropout \ 50% in 4 studies). Overall, collected data showed indeed a diminished QoL within 3 months after surgery but with a recovery to baseline by 12 months. For the specific determinants, we noted that QoL was negatively influenced by higher age, female sex, prolonged operation time, extensive disease (high PCI), resi
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