Cancer negatively affects the quality of life (QoL) owing to the disease itself but also adverse effects of cancer therapy and the possibility of relapse. The best treatment for gastric cancer is determined by the survival rate and the QoL in patient after the treatment. Therefore, many studies have continued to evaluate the QoL in cancer patients [1]. Gastric cancer is the second most common cancer in Korea and the first among Koream men [2]. From an early stage of cancer development, gastric cancer patients experience malnutrition and weight loss mainly due to loss of appetite and decrease in bowel function. In addition, there are considerable changes in the physical symptoms and emotional status depending on the timing and the method of the treatment. Since these conditions greatly affects the QoL, the demands on shortand long-term QoL assessment is getting increased [3]. In fact, studies on the QoL of Korean gastric patients have been conducted according to the type of reconstruction surgery, resection extent, and the status of long-term survival [456]. These studies have demonstrated that enhanced level of QoL with increasing survival rate of cancer patients was closely related with the treatment methods or conditions. Cancer recurrence is different for each type of cancer. Usually recurrence of gastric cancer is confirmed one year after surgery. On the other hand, the malnutrition rate in patients after gastrectomy is still high and several problems co-exist, including dumping syndrome, anemia, and nutrient malabsorption.

Therefore, it is very important to devlop a method to identify the malnutrition early and to improve nutritional status because it is directly linked to patient symptoms and the QoL [7]. However, studies that simultaneously assess the nutritional status and QoL are limited in Korea. Therefore, we conducted this study to help improve the QoL of gastric cancer patients by investigating the malnutrition rate of gastric cancer patients through the evaluation of nutritional status and the QoL, and to determine whether the QoL is different in gastric cancer patients depending on the postoperative survival period or nutritional status.

The subjects were 222 gastric cancer survivors who underwent gastrectomy at the Surgery Department of Soonchunhyang University Hospital, and had no evidence of relapse and no disease in other organs. The goal of the study was thoroughly explained to the patients, who then signed the consent form. The results were obtained through one-on-one interviews. Clinicopathological factors including disease stage, surgical methods, extent of resection, and chemotherapy status were investigated by using the medical records, and the nutritional status was evaluated by the score of patient generated-subjective global assessment (PG-SGA), which the attending dietitian of the gastric cancer surgical team commonly uses for cancer patients. Using the evaluation score, the nutritional status was divided into three stages (SGA-A: well nourished, SGA-B: moderate malnutrition, SGA-C: severe malnutrition). Korean versions of the European Organization for Research and Treatment of Cancer Core Questionnaire (EORTC) QLQ-C30 and the EORTC QLQ-STO22, corresponding to the gastric cancer module, were used to evaluate the QoL. The score was calculated by investigating 15 scales from the EORTC QLQ-C30 and 9 scales from the EORTC QLQ-STO22. In the EORTC QLQ-C30, the QoL is higher when the general health and functional scale score is higher, and the QOL is lower when the symptom scale score is higher. In the EORTC QLQ-STO22, the QoL is lower when the score of each category is higher. In this study, the postoperative survival period was divided into two groups (the less-than-1-year group and the more-than-1-year group) and the nutritional status into three groups (SGA-A, B, and C), and each indicator was analyzed comparatively. Statistical analysis for all data collected from the investigation were performed by using the SPSS program (ver. 18.0, SPSS Inc., Chicago, IL, USA). The Soonchunhyang University Medical School IRB approved the study protocol. The general information of the patients was presented as means and standard deviation, and the postoperative malnutrition rate was analyzed by using the chi-square test. Analysis of covariance (ANCOVA), adjusted for gender and follow up duration, was conducted for comparison of QoL between groups according to postoperative elapsed time period. Among the groups divided by the nutritional status, the differences of QoL were also tested by ANCOVA adjusted for extent of gastric resection which showed the significant differences. Then, post hoc comparison was performed among groups of different nutritional status. For all analyses, p < 0.05 was considered statistically significant.

The results from QoL studies in gastric cancer patients are diverse [489]. In studies of the QoL according to resection extent, patients who underwent partial resection showed a significant difference in the overall health status at 3 months after the surgery compared to the patients who underwent total resection [4]. In addition, the QoL was reported to be lower in patients whose diagnosed disease stage was higher and who underwent total resection [8], and the QoL was higher in patients who underwent laparoscopic surgery than in patients who underwent laparotomy [9]. In this study, when the QoL categories were evaluated according to the postoperative survival period, a significant difference was observed only in symptoms of fatigue, loss of appetite, reflux, and body image. This is somewhat different from the results reported by Park et al. [10], that the QoL score of both groups was lower than the mean score for overall health status and that significant differences were shown regarding the physical function, dyspnea, constipation, diarrhea, financial difficulties, loss of appetite, and body image between two groups.

The malnutrition rate of the subjects in our study was 34.5% in the less-than-1-year group but this number was decreased to 19.8% in the more-than-1-year group. This was slightly higher than the rate reported by Ryu & Kim [11] and similar to the result of Wu et al. [12]. As the postoperative nutritional status of patients are getting worse and manifested with weight loss and hypoalbuminemia even at 6 months after the surgery, continuous nutritional management is recommended [13]. From up to date studies which explored the relationship between the nutritional status and QoL are very rare. In a study by Seo et al. [14], there was no association between the QoL and nutritional indicators such as the total serum protein and albumin levels, prognostic nutrition index (PNI), and a body weight. Regarding nutrient intake, the group with a lower QoL had significantly less intake of nutrients such as proteins, iron, and zinc, and such a problem was more severe in women than in men; thus, a balanced nutrient intake is emphasized to improve the post-operative QoL [15]. In our study, the QoL was significantly lower in the SGA-C group than in the SGA-A group considering the overall health status including functional scales (physical functioning), and symptom scales (fatigue, pain, and loss of appetite) of the EORTC QLQ-C30, and the QoL in the SGA-C group was lower for considering reflux, eating restriction, anxiety, and body image scales of the QLQ-STO22. This is consistent with the results from other study for the nunutritional evaluation by using the nutritional risk screening (NRS) 2002, in which the QoL of the high-risk group with NRS ≥ 3 was significantly lower than that of other groups [16]. The association between the nutritional status and the QoL of cancer patients was well described in a study by Marín Caro et al. [17]. Therefore, as QoL markedly decreases when the nutritional status deteriorates, great efforts to prevent malnutrition to enhance early recovery from post-surgery need to be made.

This study has some limitations. Different recovery patterns among patients owing to variations in the elapsed time from the surgery could result in differences in QoL, but our classification might have been somewhat broad owing to a criterion value of 1 year. Unfortunately, QoL comparison or adjusting the results with the surgical method or range could not be performed. Though many studies has been performed to associate the surgical method and QoL, this study is still meaningful because the study involved nutritional evaluation methods commonly used by dietitians. The results of this study implicate the relationship between nutritional status and QoL. Therefore, these two indicators could be included in the management protocol of postoperative gastric cancer and also be utilized in the care system of long-term survivals from gastric cancer.

Our results indicate that the QoL of gastric cancer patients is getting lower with lesser elapsed time of post-gastrectomy and with a worsening of nutritional status. To improve the QoL when treating cancer, active nutritional management must be performed and continuous studies that integrate the effect of the long-term outcome and diet quality on the QoL are required.