Abstract
Background
The coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare and worsened quality of life (QOL). Advanced esophageal cancer is often accompanied by malnutrition and poor QOL; chemoradiotherapy (CRT) remains the mainstay of treatment. We evaluated nutrition and QOL pre- and post-CRT immediately before and during the pandemic.
Methods
Patients with esophageal cancer who underwent neoadjuvant or definitive CRT between April 2019 and December 2020 were enrolled. Disease severity, treatment timing, and outcomes were compared for cohorts treated pre-COVID-19 and during COVID-19. Nutritional status was measured with the Patient-Generated Subjective Global Assessment (PG-SGA). QOL was measured with the Mandarin Chinese version of the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) and the esophageal site-specific module (QLQ-OES18). In the pandemic cohort, pre-/post-CRT paired analyses were performed.
Results
Eighty-four patients were enrolled. The median diagnosis to treatment interval lengthened during COVID-19 (17.8 days vs. 24.2 days, p=0.04). Among the patients treated during the COVID-19 pandemic, nutritional status improved significantly following CRT (p=0.003). In the EORTC QLQ-C30, post-CRT scores for global health status (p<0.01) and emotional functioning (p<0.01) showed significant improvement. Additionally, symptom scores, including fatigue (p=0.02) and nausea and vomiting (p=0.02), decreased. However, financial difficulties worsened after CRT (p=0.02). In the EORTC QLQ-OES18, post-CRT symptom scores for eating (p<0.01), reflux (p=0.03), and pain (p<0.01) showed significant improvement.
Conclusion
Despite COVID-19-related delays, CRT enhanced nutrition, global health, and symptom control in esophageal cancer, although financial burdens increased. Integrating socioeconomic support with oncologic care is vital during health crises.
Keywords: Chemoradiotherapy, COVID-19, Esophageal neoplasms, Nutrition, Quality of life
Introduction
Since the emergence of coronavirus disease 2019 (COVID- 19), in December 2019, the infection has rapidly spread from Asia throughout the world. The COVID-19 pandemic has led to frequent delays in cancer-related care, which may have increased cancer-related morbidity [1]. These delays have also impacted the diagnosis and staging of esophageal cancer, resulting in a higher proportion of patients being diagnosed with incurable disease [2,3]. Although esophageal cancer has a high mortality rate and poor long-term survival, patient outcomes have improved considerably with multimodal therapies [4]. Chemoradiotherapy (CRT) is a cornerstone in the treatment of advanced esophageal cancer. For locally advanced cases in patients fit for surgery, neoadjuvant CRT followed by esophagectomy is the preferred curative approach [5]. Definitive CRT remains a curative option for cervical esophageal cancers or for patients who are not surgical candidates [5].
Malnutrition frequently occurs in patients with esophageal cancer due to both mechanical obstruction and cancer- induced cachexia, which progressively deplete nutritional reserves [6]. Symptoms such as dysphagia and significant weight loss further aggravate nutritional decline in these patients [7]. While CRT can help reduce tumor burden, its side effects may further compromise nutritional status [7-12]. Maintaining adequate nutrition during CRT is essential for reducing postoperative complications and improving survival outcomes [10-12]. Therefore, monitoring and managing nutritional changes during CRT are crucial for optimizing treatment tolerance and outcomes in esophageal cancer patients.
Quality of life (QOL), which includes multiple functional and symptom domains, provides valuable insight into patients’ subjective well-being. Beyond clinical tumor response, QOL is a critical factor influencing treatment decisions for patients with advanced cancer [13]. QOL assessments also allow for early symptom detection and may serve as predictors of clinical outcomes in oncology populations [14]. QOL frequently fluctuates over the course of cancer therapy. In esophageal cancer patients receiving CRT, QOL typically declines during or soon after treatment, but generally improves in the weeks following CRT completion [15-17].
The overall impact of the COVID-19 pandemic on QOL among cancer patients remains uncertain; however, adverse effects have been reported in specific subgroups [18-20]. In particular, there are limited data regarding changes in nutritional status and QOL among esophageal cancer patients during the pandemic. This observational study aimed to evaluate the effects of CRT on nutritional status and QOL in patients with esophageal cancer during the COVID-19 pandemic.
Methods
Study design
This study utilized a 1-group pretest-posttest design and employed purposive sampling to recruit participants from Chang Gung Memorial Hospital at Linkou. Data collection was conducted between April 2019 and December 2020. Patients treated prior to December 2019 were classified as belonging to the pre–COVID-19 pandemic group. The study was approved by the Ethics Committee of Chang Gung Memorial Hospital (IRB No., 201802337A3).
Participants and procedures
Patients with locally advanced esophageal cancer were included, except for those who (1) were unable to tolerate CRT due to comorbidities or poor functional status, (2) had a trachea-esophageal fistula, or (3) were unable to communicate verbally or in writing. The staging workup included biopsies, endoscopic ultrasound, a barium esophagram, and both chest and abdominal computed tomography and positron emission tomography scans. Tumors were staged according to the American Joint Committee on Cancer Staging Manual, seventh edition. Nutritional and QOL assessments were performed within 2 weeks prior to initiation of CRT and again 4 weeks after completing CRT, but prior to surgery.
Patients with locally advanced esophageal cancer who were deemed good surgical candidates received neoadjuvant CRT as the first-line approach. Definitive CRT was reserved for patients with cervical esophageal malignancy or those who were poor surgical candidates. CRT chemotherapy regimens consisted of cisplatin with 5-fluorouracil or carboplatin with paclitaxel. The radiation dose was 4,500 cGy for neoadjuvant CRT and 5,040 cGy for definitive CRT. The typical duration of CRT was approximately 2 months.
The study procedures and participants’ right to withdraw at any time were explained to all patients by the first author. After providing informed consent, patients completed the initial questionnaire prior to CRT. Subsequent questionnaires were completed during outpatient clinic visits or by telephone follow-up 1 month after CRT. Sample size was calculated using G*Power ver. 3.1 (Heinrich-Heine- Universität Düsseldorf) [21], with a medium effect size of 0.50 [22], statistical power of 80%, and significance level of 0.05. The minimum required sample size was 34 patients.
Nutritional assessment
Nutritional assessments included measurement of body mass index (BMI), serum albumin, and the Patient-Generated Subjective Global Assessment (PG-SGA). The PG-SGA evaluation was conducted by a specialized dietitian. The PG-SGA includes questions regarding the presence of nutritional symptoms and short-term weight loss. The scored PG-SGA is composed of 2 parts: 4 patient-generated historical components (weight loss, nutrition impact symptoms, intake, and functional capacity), and a clinician section (diagnosis, age, metabolic stress, and physical examination). The PG-SGA assigns a numerical score and provides a global rating of well-nourished, moderately or suspected of being malnourished, or severely malnourished. Each component of the scored PG-SGA is awarded points (0–3) according to the impact of symptoms on nutritional status. The total score indicates the required level of nutrition intervention and facilitates quantitative outcome data collection. A higher score indicates a greater risk of malnutrition. Based on evaluation, patients are classified as well-nourished (A: score 0–1), suspected of being or moderately malnourished (B: score 2–8), or severely malnourished (C: score ≥9). A score of 9 or above signals a critical need for nutrition intervention [23]. Nutritional interventions—such as nutritional counseling, oral nutritional supplements, dietary fortification, and enteral nutrition—were provided according to the patient’s nutritional status and the multidisciplinary team’s consensus.
Quality of life
QOL was assessed using the Mandarin Chinese version of the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30, version 3.0) and the esophageal site-specific module (QLQ-OES18) [24,25]. The EORTC QLQ-C30 includes several domains: 5 functional scales (physical, role, cognitive, emotional, and social), 3 symptom scales (fatigue, pain, and nausea/vomiting), a global health scale, and 6 single items (dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties). The EORTC QLQ-OES18 includes 4 symptom scales (dysphagia, eating, reflux, and pain) and 6 single items (trouble swallowing saliva, choking, dry mouth, taste disorder, cough, and speech). The global health scale consists of 7 response options, ranging from 1 (very poor) to 7 (excellent). Other items use a 4-point scale from 1 (not at all) to 4 (very much). All responses were transformed to scores ranging from 0 to 100 [26]. Higher scores on the functional and global health scales reflect better functioning and overall QOL, whereas higher symptom scores indicate more severe symptoms.
Statistical analysis
Categorical variables were summarized using counts and percentages, while means and standard deviations (SDs) were calculated for continuous variables. Paired t-tests were used to compare pre- and post-CRT variables. A p-value less than 0.05 was considered statistically significant (2-tailed test). Because of the small sample size, a post hoc power analysis was conducted to assess statistical power. Statistical analyses were performed using IBM SPSS ver. 22.0 (IBM Corp.).
Results
Patient characteristics
A total of 84 patients were included in the study, with a mean age at CRT initiation of 57.2 years. The majority of patients were male (92.9%). The study cohort comprised patients undergoing CRT during the study period, with 52.4% receiving neoadjuvant CRT and 47.6% receiving definitive CRT. Most patients reported cigarette use (77.4%) and alcohol consumption (78.6%). Squamous cell carcinoma was the predominant histology (94%), and tumors were most commonly located in the lower thoracic esophagus (39.3%). No patients were lost to follow-up.
The median interval from diagnosis to treatment initiation was 20.6 days, and the average duration of CRT was 47.1 days in this cohort. Patients treated before the COVID- 19 pandemic experienced a significantly shorter time to treatment initiation than those treated during the pandemic (17.8 days vs. 24.2 days, p=0.04). While the duration of the CRT course was shorter in the pre-pandemic group (45.9 days vs. 48.9 days), this difference was not statistically significant (p=0.12). Detailed baseline characteristics are presented in Table 1.
Table 1.
Demographic and clinical characteristics stratified by the COVID-19 pandemic
| Characteristic | Total (n=84) | Pre-COVID-19 (n=47) | COVID-19 (n=37) | p-value |
|---|---|---|---|---|
| Age (yr) | 57.2±9.2 | 56.9±10.2 | 57.5±7.8 | 0.78 |
| Sex | 0.22 | |||
| Male | 78 (92.9) | 42 (89.4) | 36 (97.3) | |
| Female | 6 (7.1) | 5 (10.6) | 1 (2.7) | |
| Smoking | 0.1 | |||
| Yes | 66 (78.6) | 40 (85.1) | 26 (70.3) | |
| No | 18 (21.4) | 7 (14.9) | 11 (29.7) | |
| Drinking | 0.39 | |||
| Yes | 65 (77.4) | 38 (80.9) | 27 (73) | |
| No | 19 (22.6) | 9 (19.1) | 10 (27) | |
| Pathology | 0.65 | |||
| Squamous cell carcinoma | 79 (94) | 45 (95.7) | 33 (89.2) | |
| Adenocarcinoma | 2 (6) | 2 (4.3) | 4 (10.8) | |
| Tumor location | 0.23 | |||
| Cervical | 8 (9.5) | 6 (12.8) | 2 (5.4) | |
| Upper thoracic | 14 (16.7) | 9 (19.1) | 5 (13.5) | |
| Middle thoracic | 29 (34.5) | 12 (25.5) | 17 (45.9) | |
| Lower thoracic | 33 (39.3) | 20 (42.6) | 13 (35.1) | |
| Clinical staging | 0.12 | |||
| II | 4 (4.8) | 2 (4.3) | 2 (5.4) | |
| III | 47 (56) | 22 (46.8) | 25 (67.6) | |
| IV | 33 (39.3) | 23 (48.9) | 10 (27) | |
| Diagnosis-to-treatment interval (day) | 20.6±14 | 17.8±8.1 | 24.2±18.6 | 0.04 |
| Treatment | < 0.01 | |||
| Definitive CRT | 40 (47.6) | 31 (66) | 9 (24.3) | |
| Neoadjuvant CRT | 44 (52.4) | 16 (34) | 28 (75.7) | |
| CRT duration (day) | 47.1±8.9 | 45.9±8.5 | 48.9±9.2 | 0.12 |
Values are presented as mean±standard deviation for continuous variables or number (%) for categorical variables.
COVID-19, coronavirus disease 2019; CRT, chemoradiotherapy.
Change in nutritional status after CRT during the COVID-19 pandemic
PG-SGA scores showed significant improvement after CRT (6 vs. 3, p=0.003). In contrast, other nutritional parameters—including BMI and albumin—remained relatively stable, with only a slight decrease observed post-CRT (Table 2). Additional details regarding nutritional changes stratified by treatment protocol are provided in Supplementary Tables 1 and 2.
Table 2.
Changes in nutritional status after chemoradiotherapy during the COVID-19 pandemic (n=37)
| Variable | Pre-CRT | Post-CRT | p-value |
|---|---|---|---|
| Body mass index (kg/m2) | 23.8±4.2 | 23.7±4 | 0.24 |
| Albumin (g/dL) | 4.3±0.4 | 4.1±0.4 | 0.57 |
| PG-SGA | 6±3 | 3±3 | <0.01 |
| Feeding tube | 0.32 | ||
| Yes | 5 (3.5) | 6 (16.2) | |
| No | 32 (86.5) | 31 (83.8) |
Values are presented as mean±standard deviation or number (%).
COVID-19, coronavirus disease 2019; CRT, chemoradiotherapy; PG-SGA, Patient-Generated Subjective Global Assessment.
Change in quality of life after CRT during the COVID-19 pandemic
Patients reported improvements in multiple aspects of QOL following CRT. Prior to CRT, the global health status subscale of the EORTC QLQ-C30 showed lower scores (mean±SD, 58.1±18.2) compared to other domains, but scores improved after CRT (mean difference, 12.2; 95% CI, 4.0–20.4; p<0.01). Emotional functioning also improved post-CRT (mean difference, 11; 95% CI, 5.5–16.6; p<0.01). An overview of all EORTC QLQ-C30 domains is provided in Table 3 and Fig. 1.
Table 3.
Changes in quality of life (EORTC QLQ-C30) after chemoradiotherapy during the COVID-19 pandemic (n=37)
| Variable | Pre-CRT | Post-CRT | Difference in pooled mean scores (95% CI) | p-value |
|---|---|---|---|---|
| Global health statusa) | 58.1±18.2 | 70.3±22.1 | 12.2 (4.0 to 20.4) | <0.01 |
| Functional scalesa) | ||||
| Physical | 84.7±13.6 | 87.4±11.4 | 2.7 (–1.7 to 7.1) | 0.22 |
| Role | 82.9±17.8 | 85.1±17.9 | 2.3 (–5.1 to 9.6) | 0.54 |
| Emotional | 81.8±15.3 | 92.8±13.2 | 11 (5.5 to 16.6) | <0.01 |
| Cognitive | 86.0±13.9 | 90.1±13.9 | 4.1 (–0.6 to 8.7) | 0.08 |
| Social | 75.2±23.4 | 77.9±19.7 | 2.7 (–4.3 to 9.7) | 0.41 |
| Symptom scalesb) | ||||
| Fatigue | 21.3±15.1 | 13.5±14.8 | –7.8 (–14.2 to –1.4) | 0.02 |
| Nausea and vomiting | 11.3±15.7 | 4.1±8.2 | –7.2 (–13.3 to –1.1) | 0.02 |
| Pain | 18.0±20.2 | 12.1±15.0 | –5.8 (–12.7 to 1.0) | 0.09 |
| Dyspnea | 9.0±16.9 | 9.0±15.0 | 0 (–6.9 to 6.9) | 1 |
| Insomnia | 27.0±25.9 | 23.4±23.4 | –3.6 (–12.6 to 5.4) | 0.42 |
| Appetite loss | 18.9±26.7 | 18.9±24.3 | 0 (–10.1 to 10.1) | 1 |
| Constipation | 8.1±16.5 | 8.1±19.9 | 0 (–6.4 to 6.4) | 1 |
| Diarrhea | 8.1±16.5 | 6.3±15.4 | –1.8 (–8.7 to 5.1) | 0.6 |
| Financial difficulties | 82.9±26.8 | 90.1±17.3 | 7.2 (1.3 to 13.1) | 0.02 |
Values are presented as mean±standard deviation, unless otherwise stated.
EORTC QLQ-C30, European Organization for Research and Cancer-Specific Core Questionnaire; COVID-19, coronavirus disease 2019; CRT, chemoradiotherapy; CI, confidence interval.
a)Function score: scores range from 1 to 100 (a high score represents better quality of life or higher level of functioning). b)Symptom score: scores range from 0 to 100 (a high score represents more severe symptoms).
Fig. 1.
EORTC QLQ-C30 mean scores with standard deviations after chemoradiotherapy (CRT) during the coronavirus disease 2019 (COVID-19) pandemic: global health status (A), emotional function (B), fatigue (C), nausea and vomiting (D), and financial difficulties (E). EORTC QLQ-OES18, European Organization for Research and Treatment of Cancer Core Questionnaire Esophageal-Specific Module Questionnaire.
Among symptom domains of the EORTC QLQ-C30 after CRT, fatigue (mean difference, –7.8; 95% CI, –14.2 to –1.4; p=0.02) and nausea and vomiting (mean difference, –7.2; 95% CI, –13.3 to –1.1; p=0.02) showed significant declines compared to pre-intervention scores. However, patients reported increased financial difficulties following CRT (mean difference, 7.2; 95% CI, 1.3–13.1; p=0.02).
Within the EORTC QLQ-OES18, dysphagia and eating problems were prominent before CRT. Although post-CRT dysphagia showed some improvement, the change was not statistically significant. Eating (mean difference, –18.5; 95% CI, –26.1 to –10.9; p<0.01), reflux (mean difference, –6.8; 95% CI, –12.7 to –0.8; p=0.03), and pain (mean difference, –7.2; 95% CI, –12.5 to –1.9; p<0.01) all improved significantly following CRT compared to pre-CRT. Other symptoms—including trouble swallowing saliva, choking, dry mouth, and cough—showed slight improvement post-CRT, but these differences were not significant (Table 4, Fig. 2).
Table 4.
Changes in quality of life (EORTC QLQ-OES18) after chemoradiotherapy during the COVID-19 pandemic (n=37)
| Variable | Pre-CRT | Post-CRT | Difference in pooled mean scores (95% CI) | p-value |
|---|---|---|---|---|
| Dysphagia | 39.6±24.4 | 33.9±25.1 | –5.7 (–15.1 to 3.64) | 0.22 |
| Eating problems | 34.5±22.8 | 16±14.5 | –18.5 (–26.1 to –10.9) | <0.01 |
| Reflux | 11.7±18.8 | 5.0±11.0 | –6.8 (–12.7 to –0.8) | 0.03 |
| Oral pain | 16.8±17.1 | 9.6±12.9 | –7.2 (–12.5 to –1.9) | <0.01 |
| Swallowing problems | 23.4±24.7 | 15.3±18.6 | –8.1 (–17.7 to 1.5) | 0.1 |
| Choking | 10.8±20.9 | 4.5±11.6 | –6.3 (–14.5 to 1.9) | 0.13 |
| Dry mouth | 21.6±26.3 | 18.0±23.0 | –3.6 (–13 to 5.8) | 0.44 |
| Taste disorders | 3.6±10.5 | 5.4±14.7 | 1.8 (–2.7 to 6.3) | 0.42 |
| Coughing | 22.5±26.1 | 18.9±21.6 | –3.6 (–14 to 6.8) | 0.49 |
| Talking | 5.4±12.5 | 8.1±19.9 | 2.7 (–2.8 to 8.2) | 0.32 |
Values are presented as mean±standard deviation, unless otherwise stated. Scores range from 0 to 100 (a high score represents more severe symptoms).
EORTC QLQ-OES18, European Organization for Research and Treatment of Cancer Core Questionnaire Esophageal-Specific Module Questionnaire; COVID-19, coronavirus disease 2019; CRT, chemoradiotherapy; CI, confidence interval.
Fig. 2.
EORTC QLQ-OES18 mean scores with standard deviations after chemoradiotherapy (CRT) during the coronavirus disease 2019 (COVID-19) pandemic: eating (A), reflux (B), and pain (C). EORTC QLQ-OES18, European Organization for Research and Treatment of Cancer Core Questionnaire Esophageal-Specific Module Questionnaire.
A post hoc power analysis was conducted based on the observed effect sizes (Cohen d) for key outcomes. The PG-SGA demonstrated a large effect size (d=1.00). Several QOL domains—including global health status, emotional function, fatigue, nausea and vomiting, and eating problems—also showed medium to large effect sizes (d=0.54–0.97), all of which were statistically significant (p<0.05) (Supplementary Tables 3, 4).
Discussion
For patients with locally advanced esophageal cancer, neoadjuvant CRT followed by surgery or definitive CRT remains the standard curative-intent treatment [5]. However, the effects of CRT on nutritional status and QOL remain inconclusive [7-12,15,16]. Although QOL generally declined during the COVID-19 pandemic [20], our observational study demonstrated that CRT improved PG-SGA scores, global health status, emotional functioning, and most QOL symptoms. Notably, financial burden was the only domain that worsened.
Delays in the diagnosis and treatment of esophageal cancer were frequently observed during the COVID-19 pandemic [2,3]. Following the emergence of the first global COVID-19 cases, several public health policies were implemented to reduce viral transmission, such as the suspension of non-emergency medical procedures, restrictions on outpatient visits, self-screening using rapid test kits, and requirements for vaccination or polymerase chain reaction testing prior to hospital admission. In our cohort, patients treated before the COVID-19 pandemic experienced a shorter interval from diagnosis to treatment initiation. However, the overall duration of CRT was similar, regardless of pandemic period.
Malnutrition is common in patients with advanced esophageal cancer due to both reduced oral intake and cancer-related cachexia [6]. CRT reduces tumor burden, with favorable responses observed in 48.9% of patients after definitive CRT and complete responses in 29% after neoadjuvant CRT [27,28]. While tumor shrinkage may relieve obstructive symptoms and improve swallowing function, adverse effects such as mucositis, dysphagia, and anorexia may still worsen nutritional status during treatment [7,11]. Given these opposing influences, aggressive nutritional assessment and intervention during CRT are essential to prevent or mitigate malnutrition [7,8].
The PG-SGA is a comprehensive tool that incorporates patient-reported symptoms together with clinician-assessed physical findings. This multidimensional evaluation enables the PG-SGA to provide a more accurate assessment of nutritional status compared to single-dimension parameters like BMI or serum albumin, which may be confounded by non-nutritional factors [23]. In a study by Chen et al. [12], 45% of patients showed improvement in PG-SGA scores after neoadjuvant CRT, while 29% experienced deterioration. Consistent with these findings, our cohort demonstrated significant improvements in PG-SGA scores following CRT, despite no significant changes in BMI or albumin levels. This improvement is likely attributable to proactive nutritional counseling and individualized support provided throughout the CRT period.
The effect of the COVID-19 pandemic on QOL remains uncertain, with inconsistent findings across different populations. In the general population, COVID-19 significantly reduced QOL worldwide, with the most affected domains being social relationships, mental health, and financial well-being [20]. Among cancer patients, the impact of COVID- 19 on QOL is broader, affecting global health status, as well as physical, emotional, and social functioning. These effects are multifactorial, involving fear of infection, delayed treatment, reduced emotional support, inadequate symptom management, and increased financial burden [18,19].
The QOL of esophageal cancer patients varies throughout the course of treatment [15-17]. During CRT, global health status, physical function, fatigue, and odynophagia typically worsen but gradually improve 4–16 weeks after CRT completion [15,16]. For patients undergoing surgery, QOL usually declines postoperatively but recovers within 3–6 months [15,17]. Despite the negative impact of the COVID-19 pandemic on QOL [18-20], we observed that QOL in esophageal cancer patients improved after CRT during the pandemic in several domains, including fatigue, nausea and vomiting, emotional function, and global health status (EORTC QLQ-C30), as well as eating, reflux, and pain (EORTC QLQ-OES18). However, despite improvements in these areas, financial difficulty scores worsened markedly, underscoring a persistent socioeconomic burden.
In our study, global health status, emotional functioning, and various symptom scores improved 4 weeks after CRT, in line with previous reports [15,16]. However, in contrast to other studies, we observed a pronounced worsening in financial difficulty scores. In both Taiwan and Korea, squamous cell carcinoma accounts for more than 90% of esophageal cancer cases, with a strong male predominance [29,30]. Additionally, 45.5% of these patients are classified as having low socioeconomic status [29]. During the COVID-19 pandemic, financial burdens increased due to reductions in household income, higher transportation and healthcare access costs, and increased caregiver responsibilities [18-20]. Given the predominance of squamous cell carcinoma and the high proportion of patients with low socioeconomic status in our cohort, these factors likely contributed to the observed increase in financial difficulties following CRT during the pandemic.
There are several inherent limitations to this study. First, although 2 CRT regimens were used, with only minor differences in radiation dose, subgroup analysis was limited by small sample size. The higher rate of neoadjuvant CRT during the COVID-19 period may also have been a potential confounder affecting treatment initiation time. Second, CRT-related complications such as radiation esophagitis, pneumonitis, and myelosuppression were not evaluated, which may have influenced outcomes. Third, as squamous cell carcinoma accounted for nearly 90% of cases, findings may not be generalizable to other histologic types. Lastly, although multiple QOL domains were analyzed, adjustments for multiple comparisons were not applied to reduce the risk of type II error and to avoid overlooking potentially meaningful findings. Larger, multi-center studies are necessary to validate these results.
Treatment initiation for esophageal cancer was delayed during the COVID-19 pandemic. Nevertheless, patients experienced improvements in global health, emotional function, and several symptoms after CRT. In contrast, financial burden significantly worsened, likely due to reduced income, disrupted access to care, and increased caregiver demands. These findings highlight the urgent need to address financial hardship during future public health emergencies.
Supplementary materials
Supplementary materials can be found via https://doi.org/10.5090/jcs.25.048. Supplementary Table 1. Changes in nutritional status after definitive chemoradiotherapy during the COVID-19 pandemic. Supplementary Table 2. Changes in nutritional status after neoadjuvant chemoradiotherapy during the COVID-19 pandemic. Supplementary Table 3. Standardized difference between mean scores (post minus pre) for nutrition variables during the COVID- 19 pandemic. Supplementary Table 4. Standardized difference between mean scores (post minus pre) for quality of life during the COVID-19 pandemic.
Acknowledgments
We sincerely thank all healthcare professionals for their dedication and perseverance during the COVID-19 pandemic. Their commitment to patient care and clinical research made the completion of this study possible.
Funding Statement
Funding This work was supported by the Ministry of Science and Technology (MOST 108-2314-B-182A-061).
Article information
Author Contributions
Conceptualization: CHC, YKC, YLC. Data curation: CHC, MRY, SCH, PLC, YTT, CTH, HHL. Funding acquisition: CHC. Methodology: CHC, YKC, YLC. Visualization: CHC, YKC, YLC. Formal analysis: CHC, MRY. Writing–original draft: CHC, MRY. Project Supervision: YKC, YLC. Writing–review & editing: all authors. Final approval of the manuscript: all authors.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
References
- 1.Keim-Malpass J, Vavolizza RD, Cohn WF, Kennedy EM, Showalter SL. Cancer screening and treatment delays during the COVID-19 pandemic and the role of health literacy in care re-engagement: findings from an NCI-designated comprehensive cancer center sample. J Cancer Educ 2023;38:1405-12. https://doi.org/10.1007/s13187-023-02312-w 10.1007/s13187-023-02312-w [DOI] [PMC free article] [PubMed]
- 2.Fialka NM, El-Andari R, Jogiat U, Bedard EL, Laing B, Nagendran J. Impact of the COVID-19 pandemic on esophageal cancer resource allocation: a systematic review. J Thorac Dis 2024;16:1576-89. https://doi.org/10.21037/jtd-23-1232 10.21037/jtd-23-1232 [DOI] [PMC free article] [PubMed]
- 3.Doeve BH, Bakx JA, Siersema PD, et al. The impact of the COVID-19 pandemic on the diagnosis, stage, and treatment of esophagogastric cancer. J Gastroenterol 2023;58:965-77. https://doi.org/10.1007/s00535-023-02009-3 10.1007/s00535-023-02009-3 [DOI] [PMC free article] [PubMed]
- 4.Njei B, McCarty TR, Birk JW. Trends in esophageal cancer survival in United States adults from 1973 to 2009: a SEER database analysis. J Gastroenterol Hepatol 2016;31:1141-6. https://doi.org/10.1111/jgh.13289 10.1111/jgh.13289 [DOI] [PMC free article] [PubMed]
- 5.Ajani JA, D'Amico TA, Bentrem DJ, et al. Esophageal and esophagogastric junction cancers, version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019;17:855-83. https://doi.org/10.6004/jnccn.2019.0033 10.6004/jnccn.2019.0033 [DOI] [PubMed]
- 6.Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22:235-9. https://doi.org/10.1016/s0261-5614(02)00215-7 10.1016/S0261-5614(02)00215-7 [DOI] [PubMed]
- 7.Movahed S, Norouzy A, Ghanbari-Motlagh A, et al. Nutritional status in patients with esophageal cancer receiving chemoradiation and assessing the efficacy of usual care for nutritional managements. Asian Pac J Cancer Prev 2020;21:2315-23. https://doi.org/10.31557/APJCP.2020.21.8.2315 10.31557/APJCP.2020.21.8.2315 [DOI] [PMC free article] [PubMed]
- 8.Kimura Y, Gakuhara A, Fukuda S, et al. Nutritional management during chemotherapy and chemoradiotherapy for advanced esophageal cancer. Esophagus 2025;22:279-88. https://doi.org/10.1007/s10388-025-01117-8 10.1007/s10388-025-01117-8 [DOI] [PMC free article] [PubMed]
- 9.Awad S, Tan BH, Cui H, et al. Marked changes in body composition following neoadjuvant chemotherapy for oesophagogastric cancer. Clin Nutr 2012;31:74-7. https://doi.org/10.1016/j.clnu.2011.08.008 10.1016/j.clnu.2011.08.008 [DOI] [PubMed]
- 10.Ida S, Watanabe M, Karashima R, et al. Changes in body composition secondary to neoadjuvant chemotherapy for advanced esophageal cancer are related to the occurrence of postoperative complications after esophagectomy. Ann Surg Oncol 2014;21:3675-9. https://doi.org/10.1245/s10434-014-3737-z 10.1245/s10434-014-3737-z [DOI] [PubMed]
- 11.Huang TT, Li SH, Lu HI, et al. Nutritional status during concurrent chemoradiotherapy (CCRT) is critical for survival in patients with locally advanced unresectable esophageal cancer. Int J Radiat Oncol Biol Phys 2019;105(1 Supplement):E185-6. https://doi.org/10.1016/j.ijrobp.2019.06.2089 10.1016/j.ijrobp.2019.06.2089 [DOI]
- 12.Chen MF, Hsieh CC, Chen PT, Lu MS. Role of nutritional status in the treatment outcome for esophageal squamous cell carcinoma. Nutrients 2021;13:2997. https://doi.org/10.3390/nu13092997 10.3390/nu13092997 [DOI] [PMC free article] [PubMed]
- 13.Shrestha A, Martin C, Burton M, Walters S, Collins K, Wyld L. Quality of life versus length of life considerations in cancer patients: a systematic literature review. Psychooncology 2019;28:1367-80. https://doi.org/10.1002/pon.5054 10.1002/pon.5054 [DOI] [PMC free article] [PubMed]
- 14.Chang YL, Tsai YF, Chao YK, Wu MY. Quality-of-life measures as predictors of post-esophagectomy survival of patients with esophageal cancer. Qual Life Res 2016;25:465-75. https://doi.org/10.1007/s11136-015-1094-4 10.1007/s11136-015-1094-4 [DOI] [PubMed]
- 15.van Meerten E, van der Gaast A, Looman CW, Tilanus HW, Muller K, Essink-Bot ML. Quality of life during neoadjuvant treatment and after surgery for resectable esophageal carcinoma. Int J Radiat Oncol Biol Phys 2008;71:160-6. https://doi.org/10.1016/j.ijrobp.2007.09.038 10.1016/j.ijrobp.2007.09.038 [DOI] [PubMed]
- 16.Noordman BJ, Verdam MG, Onstenk B, et al. Quality of life during and after completion of neoadjuvant chemoradiotherapy for esophageal and junctional cancer. Ann Surg Oncol 2019;26:4765-72. https://doi.org/10.1245/s10434-019-07779-w 10.1245/s10434-019-07779-w [DOI] [PMC free article] [PubMed]
- 17.Safieddine N, Xu W, Quadri SM, et al. Health-related quality of life in esophageal cancer: effect of neoadjuvant chemoradiotherapy followed by surgical intervention. J Thorac Cardiovasc Surg 2009;137: 36-42. https://doi.org/10.1016/j.jtcvs.2008.09.049 10.1016/j.jtcvs.2008.09.049 [DOI] [PubMed]
- 18.Jeppesen SS, Bentsen KK, Jørgensen TL, et al. Quality of life in patients with cancer during the COVID-19 pandemic: a Danish cross- sectional study (COPICADS). Acta Oncol 2021;60:4-12. https://doi.org/10.1080/0284186X.2020.1830169 10.1080/0284186X.2020.1830169 [DOI] [PubMed]
- 19.Witwaranukool P, Seedadard R, Krongthaeo S, Leaungsomnapa Y. Quality of life and associated factors among cancer patients receiving chemotherapy during the COVID-19 pandemic in Thailand. Int J Environ Res Public Health 2024;21:317. https://doi.org/10.3390/ijerph21030317 10.3390/ijerph21030317 [DOI] [PMC free article] [PubMed]
- 20.Nshimirimana DA, Kokonya D, Gitaka J, Wesonga B, Mativo JN, Rukanikigitero JM. Impact of COVID-19 on health-related quality of life in the general population: a systematic review and meta-analysis. PLOS Glob Public Health 2023;3:e0002137. https://doi.org/10.1371/journal.pgph.0002137 10.1371/journal.pgph.0002137 [DOI] [PMC free article] [PubMed]
- 21.Altman DG. Practical statistics for medical research. Taylor & Francis; 1990. https://doi.org/10.1201/9780429258589 10.1201/9780429258589 [DOI]
- 22.Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Lawrence Erlbaum Associates; 1988.
- 23.Bauer J, Capra S, Ferguson M. Use of the scored patient-generated subjective global assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr 2002;56:779-85. https://doi.org/10.1038/sj.ejcn.1601412 10.1038/sj.ejcn.1601412 [DOI] [PubMed]
- 24.Chie WC, Hong RL, Lai CC, Ting LL, Hsu MM. Quality of life in patients of nasopharyngeal carcinoma: validation of the Taiwan Chinese version of the EORTC QLQ-C30 and the EORTC QLQ-H&N35. Qual Life Res 2003;12:93-8. https://doi.org/10.1023/a:1022070220328 10.1023/A:1022070220328 [DOI] [PubMed]
- 25.Chie WC, Tsai CJ, Chiang C, Lee YC. Quality of life of patients with oesophageal cancer in Taiwan: validation and application of the Taiwan Chinese (Mandarin) version of the EORTC QLQ-OES18: a brief communication. Qual Life Res 2010;19:1127-31. https://doi.org/10.1007/s11136-010-9675-8 10.1007/s11136-010-9675-8 [DOI] [PubMed]
- 26.Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A. EORTC QLQ-C30 scoring manual. 3rd ed. European Organization for Research and Treatment of Cancer; 2001.
- 27.van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012;366:2074-84. https://doi.org/10.1056/NEJMoa1112088 10.1056/NEJMoa1112088 [DOI] [PubMed]
- 28.Zhao Z, Zhang Y, Wang X, Geng X, Zhu L, Li M. Clinical response to chemoradiotherapy in esophageal carcinoma is associated with survival and benefit of consolidation chemotherapy. Cancer Med 2020;9:5881-8. https://doi.org/10.1002/cam4.3273 10.1002/cam4.3273 [DOI] [PMC free article] [PubMed]
- 29.Chen HY, Chen IC, Chen YH, Chen CC, Chuang CY, Lin CH. The influence of socioeconomic status on esophageal cancer in Taiwan: a population-based study. J Pers Med 2022;12:595. https://doi.org/10.3390/jpm12040595 10.3390/jpm12040595 [DOI] [PMC free article] [PubMed]
- 30.Kim HW, Park SY. Current trends in the epidemiology and treatment of esophageal cancer in South Korea. J Chest Surg 2025;58:15-20. https://doi.org/10.5090/jcs.24.078 10.5090/jcs.24.078 [DOI] [PMC free article] [PubMed]
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