Performance Status

As with other tumor types, the overall health status of the patient prior to treatment correlates with how well treatment is tolerated. Studies continue to demonstrate that this variable—performance status—remains the single most important predictor of outcome in cancer patients. Patients with EC most commonly present with dysphagia, weight loss, and pain, all factors that contribute to decreased performance status. These combined with the aggressive—and often toxic—nature of treatment, especially for the 50% of patients who present with potentially curable disease, can create a significant management challenge. As such, performance status is paramount as both a factor to be treated primarily and a factor that significantly impacts the therapeutic approach to the cancer.

Treating Performance Status

Regarding performance status as a factor to be treated, the initial therapy often involves an intervention designed to improve performance status. Pain is assessed and treated at the initial visit. Nutritional deficiency, usually related to dysphagia, is also addressed. Each patient is introduced to a nutritionist who helps to jointly determine the best way to supplement nutrition in order to mitigate weight loss and hopefully achieve weight gain. For patients with metastatic disease, oral intake can often be restored with an esophageal stent. If this is inadequate or not possible, a percutaneous gastrostomy (PEG) or surgical jejunostomy tube is placed. For patients triaged to undergo curative therapy, stents are avoided. There is some concern for esophageal perforation when a stent is present in the radiation field. If neoadjuvant therapy followed by esophagectomy is planned, a surgically placed jejunostomy tube is preferable to a PEG so as not to violate the gastric wall.

Determining Treatment Aggressiveness

Determining appropriate level of treatment aggressiveness in the setting of performance status may be challenging even to the most experienced clinician. in this case, consideration includes the above as well as medical comorbidities relating to fitness for surgery, aggressive chemoradiother-apy, or cytotoxic drugs. As a general rule, combined modality approaches (chemoradiotherapy ± surgery) are reserved for the healthiest patients with curable disease. For those less healthy but still curable, surgical colleagues may consider primary esophagectomy. However, esophagectomy, even in the absence of preoperative treatment, is a major procedure with significant morbidity and mortality.

Concomitant chemoradiotherapy without surgery may be as difficult to tolerate as esophagectomy, especially given issues of mucositis and cytopenias. Therefore, in those patients with curative disease but poor performance status, the same palliative approaches that are usually reserved for those with metastatic disease are often pursued. For both curable patients with poor performance status as well as in those with primary metastatic disease, the palliative modality and regimen again must be tailored to the patient's performance status. Further discussion of this follows in the section of palliative chemotherapy.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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