Predicting survival in patients with advanced disease

Changes in health-related quality of life and quality of care among terminally ill cancer patients and survival prediction: Multicenter prospective cohort study

Objective:

This study examined changes in health-related quality of life (HRQoL) and quality of care (QoC) as perceived by terminally ill cancer patients and a stratified set of HRQoL or QoC factors that are most likely to influence survival at the end of life (EoL).

Method:

We administered questionnaires to 619 consecutive patients immediately after they were diagnosed with terminal cancer by physicians at 11 university hospitals and at the National Cancer Center in Korea. Subjects were followed up over 161.2 person-years until their deaths. We measured HRQoL using the core 30-item European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and QoC using the Quality Care Questionnaire–End of Life (QCQ–EoL). We evaluated changes in HRQoL and QoC issues during the first three months after enrollment, performing sensitivity analysis by using data generated via four methods (complete case analysis, available case analysis, the last observation carried forward, and multiple imputation).

Results:

Emotional and cognitive functioning decreased significantly over time, while dyspnea, constipation, and pain increased significantly. Dignity-conserving care, care by healthcare professionals, family relationships, and QCQ–EoL total score decreased significantly. Global QoL, appetite loss, and Eastern Cooperative Oncology Group Performance Status (ECOG–PS) scores were significantly associated with survival.

Significance of results:

Future standardization of palliative care should be focused on assessment of these deteriorated types of quality. Accurate estimates of the length of life remaining for terminally ill cancer patients by such EoL-enhancing factors as global QoL, appetite loss, and ECOG–PS are needed to help patients experience a dignified and comfortable death.

Simple prognostic model for patients with advanced cancer based on performance status

PURPOSE

Providing survival estimates is important for decision making in oncology care. The purpose of this study was to provide survival estimates for outpatients with advanced cancer, using the Eastern Cooperative Oncology Group (ECOG), Palliative Performance Scale (PPS), and Karnofsky Performance Status (KPS) scales, and to compare their ability to predict survival.

METHODS

ECOG, PPS, and KPS were completed by physicians for each new patient attending the Princess Margaret Cancer Centre outpatient Oncology Palliative Care Clinic (OPCC) from April 2007 to February 2010. Survival analysis was performed using the Kaplan-Meier method. The log-rank test for trend was employed to test for differences in survival curves for each level of performance status (PS), and the concordance index (C-statistic) was used to test the predictive discriminatory ability of each PS measure.

RESULTS

Measures were completed for 1,655 patients. PS delineated survival well for all three scales according to the log-rank test for trend (P < .001). Survival was approximately halved for each worsening performance level. Median survival times, in days, for each ECOG level were: EGOG 0, 293; ECOG 1, 197; ECOG 2, 104; ECOG 3, 55; and ECOG 4, 25.5. Median survival times, in days, for PPS (and KPS) were: PPS/KPS 80-100, 221 (215); PPS/KPS 60 to 70, 115 (119); PPS/KPS 40 to 50, 51 (49); PPS/KPS 10 to 30, 22 (29). The C-statistic was similar for all three scales and ranged from 0.63 to 0.64.

CONCLUSION

We present a simple tool that uses PS alone to prognosticate in advanced cancer, and has similar discriminatory ability to more complex models.

Patients surviving six months in hospice care: who are they?

BACKGROUND

On January 1, 2011, the Centers for Medicare and Medicaid Services (CMS) began requiring U.S. hospices to conduct a "face-to-face" (F2F) assessment of eligibility for continued hospice care with patients entering their third certification period (180 days after initial enrollment). Understanding which patient populations require F2F assessment is important for evaluating the impact of the CMS regulation and gauging the appropriateness of the 6-month prognosis criteria for different patient groups.

METHODS

Retrospective program records were obtained for patients enrolled in a large hospice 6 months prior to implementation of the CMS regulation (N=375). Patients who remained in hospice and received a F2F (n=140) were compared to patients who were no longer in hospice (n=235) on demographics, terminal condition (categorized as debility/dementia, cancer, or other), presence of serious comorbidity, length of stay, setting of care prior to admission, and hospice outcome using bivariate statistics. Predictors of F2F recertification were examined using a multivariable logistic regression model controlling for demographics, setting of care prior to admission, comorbidity, and primary terminal diagnosis.

RESULTS

At the bivariate level, patients who received an F2F were older (p<0.001), and more likely to have lived in a facility care setting prior to hospice admission (p<0.001) than their non-F2F counterparts. Findings from the logistic regression analysis indicate that initial setting of care (odds ratio [OR] for inpatient versus home=0.20; p=0.01), presence of serious comorbidity (OR=2.84; p<0.001), and primary diagnosis (OR for debility/dementia versus cancer=3.35; p<0.001) were significant predictors of F2F recertification.

CONCLUSIONS

Unlike hospice patients with cancer, patients with a primary diagnosis of dementia or debility are more likely to remain in hospice care beyond 6 months and require F2F recertification. Still, these patients need the services provided by hospice care and may be limited by the 6-month recertification criteria.

Can oncologists predict survival for patients with progressive disease after standard chemotherapies?

BACKGROUND

Prediction of prognosis is important for patients so that they can make the most of the rest of their lives. Oncologists could predict survival, but the accuracy of such predictions is unclear.

METHODS

In this observational prospective cohort study, 14 oncologists treating 9 major adult solid malignancies were asked to complete questionnaires predicting survival based on performance status, oral intake, and other clinical factors when patients experienced progressive disease after standard chemotherapies. Clinically predicted survival (cps) was calculated by the oncologists from the date of progressive disease to the predicted date of death. Actual survival (as) was compared with cps using Kaplan-Meier survival curves, and factors affecting inaccurate prediction were determined by logistic regression analysis. The prediction of survival time was considered accurate when the cps/as ratio was between 0.67 and 1.33.

RESULTS

The study cohort consisted of 75 patients. Median cps was 120 days (interquartile range: 60-180 days), and median as was 121 days (interquartile range: 40-234 days). The participating oncologists accurately predicted as within a 33% range 36% of the time; the survival time was overestimated 36% of time and underestimated 28% of the time. The factors affecting the accuracy of the survival estimate were the experience of the oncologist, patient age, and information given about the palliative care unit.

CONCLUSIONS

Prediction of cps was accurate for just slightly more than one third of all patients in this study. Additional investigation of putative prognostic factors with a larger sample size is warranted.

Impact of Eastern Cooperative Oncology Group Performance Status on hospital mortality in critically ill patients

INTRODUCTION

This study evaluates the association between the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and hospital mortality in general critically ill patients.

MATERIALS AND METHODS

This is a retrospective cohort study that analyzes prospective collected data from the Validation of Simplified acute physiology score 3 in Korean Intensive care unit study. The study population comprised patients who were consecutively admitted to participating intensive care units from July 1, 2010, to January 31, 2011. Univariate and multivariate logistic regression models were used to evaluate the effect of ECOG-PS on hospital mortality.

RESULTS

A total of 3868 patients were included in the analysis. There was a significant trend for increasing hospital mortality as the ECOG-PS grade became higher (P<.001). There was a trend of increasing adjusted odds ratio for hospital mortality, with grade 1 of PS 1.4 (95% confidence intervals [CIs], 1.0-1.8), grade 2 of PS 2.0 (95% CIs, 1.5-2.7), grade 3 of PS 2.9 (95% CIs, 2.1-4.1), and grade 4 of PS 2.5 (95% CIs, 1.6-3.9). Also, there was a significant difference in all grades. Subgroup analysis showed a trend of increasing hospital mortality regardless of the presence of cancer.

CONCLUSION

Preadmission PS, assessed with ECOG-PS in critically ill patients, has prognostic value in general critically ill patients.

Decision-making in patients with cancer and kidney disease

Thoughtful decision-making in a patient with cancer and kidney disease requires a comprehensive discussion of prognosis and therapy options for both conditions framed by the individual's preferences and goals of care. An estimate of overall prognosis is generated that includes the patient's clinical presentation and parameters associated with adverse outcomes, such as age, performance status, frailty, malnutrition, and comorbidities. Empathic communication of this information using a shared decision-making approach can lead to an informed decision that respects patient autonomy and is consistent with the patient's "big-picture" goals and personal values.

The median informs the message: accuracy of individualized scenarios for survival time based on oncologists' estimates

PURPOSE

To determine the accuracy and usefulness of oncologists' estimates of survival time in individual patients with advanced cancer.

PATIENTS AND METHODS

Twenty-one oncologists estimated the "median survival of a group of identical patients" for each of 114 patients with advanced cancer. Accuracy was defined by the proportions of patients with an observed survival time bounded by prespecified multiples of their estimated survival time. We expected 50% to live longer (or shorter) than their oncologist's estimate (calibration), 50% to live from half to double their estimate (typical scenario), 5% to 10% to live ≤ one quarter of their estimate (worst-case scenario), and 5% to 10% to live three or more times their estimate (best-case scenario). Estimates within 0.67 to 1.33 times observed survival were deemed precise. Discriminative value was assessed with Harrell's C-statistic and prognostic significance with proportional hazards regression.

RESULTS

Median survival time was 11 months. Oncologists' estimates were relatively well-calibrated (61% shorter than observed), imprecise (29% from 0.67 to 1.33 times observed), and moderately discriminative (Harrell C-statistic 0.63; P = .001). The proportion of patients with an observed survival half to double their oncologist's estimate was 63%, ≤ one quarter of their oncologist's estimate was 6%, and three or more times their oncologist's estimate was 14%. Independent predictors of observed survival were oncologist's estimate (hazard ratio [HR] = 0.92; P = .004), dry mouth (HR = 5.1; P < .0001), alkaline phosphatase more than 101 U/L (HR = 2.8; P = .0002), Karnofsky performance status ≤ 70 (HR = 2.3; P = .007), prostate primary (HR = 0.23; P = .002), and steroid use (HR = 2.4; P = .02).

CONCLUSION

Oncologists' estimates of survival time were relatively well-calibrated, moderately discriminative, independently associated with observed survival, and a reasonable basis for estimating worst-case, typical, and best-case scenarios for survival.

Predicting 7-day survival using heart rate variability in hospice patients with non-lung cancers

BACKGROUND

A simple and accurate survival prediction tool can facilitate decision making processes for hospice patients with advanced cancers. The objectives of this study were to explore the association of cardiac autonomic functions and survival in patients with advanced cancer and to evaluate the prognostic value of heart rate variability (HRV) in 7-day survival prediction.

METHODS

A prospective study was conducted on 138 patients with advanced cancer recruited from the hospice ward of a regional hospital in southern Taiwan. Information on functional status and symptom burden of the patients was recorded. Frequency-domain HRV was obtained for the evaluation of cardiac autonomic functions at admission. The end point of the study was defined as the survival status at day 7 after admission to the hospice ward. Multivariate logistic regression analyses were performed to evaluate the independent associations between HRV indices and survival of 7 days or less.

RESULTS

The median survival time of the patients was 20 days (95% CI, 17-28 days). Results from the multivariate logistic regression analysis indicated that the natural logarithm-transformed high-frequency power (lnHFP) of a value less than 2 (OR = 3.8, p = 0.008) and ECOG performance status of 3 or 4 (OR = 3.4, p = 0.023) were significantly associated with a higher risk of survival of 7 days or less. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve was 0.71 (95% CI, 0.61-0.81).

CONCLUSIONS

In hospice patients with non-lung cancers, an lnHPF value below 2 at hospice admission was significantly associated with survival of 7 days or less. HRV might be used as a non-invasive and objective tool to facilitate medical decision making by improving the accuracy in survival prediction.

Retrospective Assessment of Objective Prognostic Score in Terminally Ill Korean Patients With Cancer

We conducted a retrospective study by reviewing the medical records of 104 patients to assess the usefulness of the objective prognostic score (OPS) in an independent population of Korea. The median survival time (±standard error) of the high OPS group (≥3) was 9.0 ± 1.31 days and that of the low OPS group (<3) was 26.0 ± 3.3 days. The former was significantly shorter than the latter ( P < .001). Only delirium (hazard ratio 1.751, P = .032) was related to shorter survival time independent of the OPS. This study demonstrates that the OPS is a valid and useful prognostic tool for predicting survival in terminally ill Korean patients with cancer, and that inclusion of delirium into the OPS may improve its prognostic value.

Prevalence, intensity, and prognostic significance of common symptoms in terminally ill cancer patients

BACKGROUND

Quality of life and palliative management of end-stage cancer patients should improve with greater understanding of the prevalence, intensity, and prognostic significance of their symptoms.

OBJECTIVE

We investigated the association between prevalence and intensity of common symptoms and overall survival in Chinese end-stage cancer patients.

DESIGN

For this cross-sectional study, 163 Chinese patients with end-stage cancer completed an Edmonton Symptom Assessment questionnaire, and each was given a Karnofsky Performance Status (KPS) score. Overall survival was estimated via the Kaplan-Meier method. Factors affecting overall survival were determined by univariate and multivariate Cox regression analyses.

RESULTS

Mean survival of these patients was 51 days. Pain, lack of appetite, and poor well-being were the most frequent symptoms, in 90.2%, 88.3%, and 87.7%, respectively. The most severe symptoms were fatigue, lack of appetite, drowsiness, and poor well-being. Fatigue, lack of appetite, drowsiness, shortness of breath, poor well-being, depression, and KPS score significantly affected overall survival rate, with a relative risk of dying of 1.560, 2.320, 1.684, 1.295, 1.912, 1.414, and 0.487, respectively (Cox regression coefficients: 0.361, 0.827, 0.539, 0.185, 0.694, 0.318, and -0.602). Fatigue, lack of appetite, shortness of breath, age, and KPS score were independent risk factors of overall survival, with a relative risk of dying of 1.581, 1.122, 1.123, 1.022, and 0.797, respectively (Cox regression coefficients: 0.458, 0.115, 0.116, 0.022, and -0.227).

CONCLUSION

Fatigue, shortness of breath, lack of appetite, age, and KPS score were associated with overall survival of end-stage Chinese cancer patients.

Analysis of ECOG performance status in head and neck squamous cell carcinoma patients: association with sociodemographical and clinical factors, and overall survival

PURPOSE

In the present study, we analyzed sociodemographical and clinical factors, and the Eastern Cooperative Oncology Group performance status (ECOG-PS) scale in head and neck squamous cell carcinoma (HNSCC) patients. We evaluated the impact of a range of variables on overall survival.

METHODS

We investigated a sample of HNSCC patients (n = 671), using sociodemographical and clinical information, and survival data collected from a review of epidemiological, clinical, and treatment reports. Statistical associations were analyzed by bivariate and multivariate statistical tests. Statistical significance was set at p < 0.05.

RESULTS

Of patients 85.4% recorded good ECOG-PS scores. Poor ECOG-PS scores were associated with the covariates indicative of dysphagia [odd ratios (OR) = 2.660, CI 95% = 1.661–4.260, p = 0.000] and large-size malignant disease (T3–T4; OR = 5.337, CI 95% = 2.251–12.652, p = 0.000). Overall survival analysis revealed that ECOG-PS scores (OR = 1.879, CI 95% = 1.162–3.038, p = 0.010), tumor size (OR = 1.665, CI 95% = 1.035–2.680, p = 0.036), and the presence of cervical metastasis (OR = 3.145, CI 95% = 2.008–4.926, p = 0.000) were independent predictors.

CONCLUSION

Evaluation of physical consumption in head and neck cancer patients at diagnosis may indicate a more aggressive type of malignant disease. Thus, the ECOG-PS scale may help to identify HNSCC patients in need of rapid referral, who may benefit from specific therapeutic and rehabilitative interventions.

Towards a classification model to identify hospice candidates in terminally ill patients

This paper presents a Rough Set Theory (RST) based classification model to identify hospice candidates within a group of terminally ill patients. Hospice care considerations are particularly valuable for terminally ill patients since they enable patients and their families to initiate end-of-life discussions and choose the most desired management strategy for the remainder of their lives. Unlike traditional data mining methodologies, our approach seeks to identify subgroups of patients possessing common characteristics that distinguish them from other subgroups in the dataset. Thus, heterogeneity in the data set is captured before the classification model is built. Object related reducts are used to obtain the minimum set of attributes that describe each subgroup existing in the dataset. As a result, a collection of decision rules is derived for classifying new patients based on the subgroup to which they belong. Results show improvements in the classification accuracy compared to a traditional RST methodology, in which patient diversity is not considered. We envision our work as a part of a comprehensive decision support system designed to facilitate end-of-life care decisions. Retrospective data from 9105 patients is used to demonstrate the design and implementation details of the classification model.

Prognostic factors of survival in patients with advanced cancer admitted to home care

CONTEXT

Data regarding prognostication of life expectancy in patients with advanced cancer are of paramount importance to patients, families, and clinicians. However, data regarding patients followed at home are lacking.

OBJECTIVES

The aim of this study was to evaluate the correlation between various factors recorded at the beginning of home care assistance and survival.

METHODS

A sample of consecutive patients admitted to two home care programs was surveyed. A preliminary consensus was achieved as to the possible variables easy to be recorded at home. These included age at the time of home care admission, gender, residence, marital status, primary cancer diagnosis, Karnofsky Performance Status (KPS) score, measures of systolic blood pressure and heart rate, cyanosis, use of oxygen, and body temperature. The Edmonton Symptom Assessment System was used to record the intensity of each symptom. Patients were divided into two groups: patients with a survival of less than 10 days (short survival) and patients with a survival of 10 days or more (medium-long survival).

RESULTS

Three hundred seventy-four consecutive patients admitted to home care programs were surveyed, of which 187 were male. The mean±SD age was 72.1±12.7 years. The mean survival was 56.2±65 days. Mean survival was 71.5±67 days (287 patients) and 5.6±2.7 days (87 patients) in the short and medium-long survival groups, respectively. No association between type of tumor and survival was observed (P=0.162). Univariate logistic regression analysis revealed that male gender (P=0.020), older age (P=0.012), lower KPS scores (P<0.0005), systolic blood pressure less than 100 mmHg (P=0.003), heart rate greater than 100 beats per minute (P=0.0006), delirium (P=0.004), the use of oxygen (P=0.002), intensity of fatigue (P=0.006), drowsiness (P<0.0005), anorexia (P<0.0005), dyspnea (P<0.0005), poor sense of well-being (P<0.0005), and distress score (P<0.0005) were associated with a survival of less than 10 days. Marital status, residence, cognitive function, fever, pain, depression, and anxiety were not found to be significantly correlated with survival. In a multiple logistic regression model, low systolic blood pressure and high heart rate, gender, delirium, use of oxygen, KPS score, drowsiness, anorexia, and dyspnea were significantly correlated with a shorter survival.

CONCLUSION

Low systolic blood pressure and high heart rate, male gender, poor KPS score, anorexia, and dyspnea were correlated with a shorter survival. Moreover, patients with low systolic blood pressure and high heart rate, male gender, poor KPS score, and greater intensity of anorexia and dyspnea are more likely to die within one week. The combination of physical symptoms from the Edmonton Symptom Assessment System and other parameters included in this study, which are simple to assess and are repeatable at home, should be further explored in future studies to provide a simple tool for use with patients with advanced cancer admitted to a home care program.

Early identification of palliative care patients in general practice: development of RADboud indicators for PAlliative Care Needs (RADPAC)

BACKGROUND

According to the World Health Organization (WHO) definition, palliative care should be initiated in an early phase and not be restricted to terminal care. In the literature, no validated tools predicting the optimal timing for initiating palliative care have been determined.

AIM

The aim of this study was to systematically develop a tool for GPs with which they can identify patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and cancer respectively, who could benefit from proactive palliative care.

DESIGN

A three-step procedure, including a literature review, focus group interviews with input from the multidisciplinary field of palliative healthcare professionals, and a modified Rand Delphi process with GPs.

METHOD

The three-step procedure was used to develop sets of indicators for the early identification of CHF, COPD, and cancer patients who could benefit from palliative care.

RESULTS

Three comprehensive sets of indicators were developed to support GPs in identifying patients with CHF, COPD, and cancer in need of palliative care. For CHF, seven indicators were found: for example, frequent hospital admissions. For COPD, six indicators were found: such as, Karnofsky score ≤50%. For cancer, eight indicators were found: for example, worse prognosis of the primary tumour.

CONCLUSION

The RADboud indicators for PAlliative Care Needs (RADPAC) is the first tool developed from a combination of scientific evidence and practice experience that can help GPs in the identification of patients with CHF, COPD, or cancer, in need of palliative care. Applying the RADPAC facilitates the start of proactive palliative care and aims to improve the quality of palliative care in general practice.

A qualitative analysis of the elements used by palliative care clinicians when formulating a survival estimate

OBJECTIVE

For patients with advanced and/or incurable disease, clinicians are often called upon to formulate and communicate an estimate of likely survival duration. The objective of this study was to gain a deeper appreciation of this process by identifying and exploring the specific elements that may inform and/or impact a clinician's estimate of survival (CES).

METHODS

Semistructured interviews were conducted among a group of palliative care clinicians in the setting of a tertiary academic health sciences centre. Qualitative data were subsequently analysed using a grounded theory approach.

RESULTS

Five major themes were identified as being central to the process of CES formulation: use of objective patient-specific elements, strength of the patient-clinician relationship, purpose and context of an individual CES, perceived role of hope and the overall likelihood of CES inaccuracy.

CONCLUSIONS

For any given patient, several elements have the potential to inform and/or impact the process of CES formulation. Study participants were aware of objective clinical factors known to correlate with actual survival duration and likely integrate this information when formulating a CES. Formulation occurs within a larger context comprised of a number of elements that may influence individual estimates. These elements exist against a background of awareness of the overall likelihood of CES inaccuracy. Clinicians are encouraged to develop a personalised and standardised approach to CES formulation whereby an awareness of the menu of potentially impacting elements is consciously integrated into an individual process.

Follow-up study of survival of patients with advanced cancer in a hospice setting

OBJECTIVE

This study was to present the survival of advanced cancer patients and explore the influence of various factors on survival time as well as survival rate. The results provide guidelines for clinical practice of cancer treatment.

METHODS

Follow-up of 674 advanced cancer patients was performed in a hospice. The median survival time and survival rate were calculated, and survival analysis was carried out.

RESULTS

The median survival time of all patients dying from cancer was 12.0 months and the average survival time was 25.1 months. The 1-year cumulative survival rate was 0.518±0.020 and the 5-year cumulative survival rate was 0.088±0.012. The following factors showed significant impacts on survival rate: gender, age, primary diagnosis, surgery and the time when pain appeared.

CONCLUSIONS

The survival time of patients with advanced cancer was relatively short. Major approaches to extend the survival time include early detection, early diagnosis, effective surgical treatment, pain control, reasonable supply of nutrients and multiple interventions.

Prognostication in advanced cancer: a study examining an inflammation-based score

CONTEXT

Prognostication in advanced cancer is challenging. Biomarkers of systemic inflammation (C-reactive protein and albumin) combined in the modified Glasgow Prognostic Score (mGPS) have been used to assist prognostication in various cancer types.

OBJECTIVES

The aim of this study was to examine whether an inflammation-based prognostic score (mGPS) is useful in prognostication in advanced cancer patients.

METHODS

Cancer patients who had biomarkers (C-reactive protein and albumin) recorded were allocated an mGPS ranging from 0-2. Groups were compared using Jonckheere-Terpstra and Chi-squared tests. Survival analyses were carried out using Kaplan-Meier and multivariate Cox regression models.

RESULTS

A total of 296 patients were included, and a representative subgroup of 102 had biomarkers recorded. The mGPS was predictive of death (P=0.014) adjusted for sex, cancer site, age, hemoglobin, and white cell count. Patients with an mGPS of 2 had 2.7 times the risk of death of those with an mGPS of 0 (P=0.011). Patients with an mGPS less than 2 had an 86.1% and 74.3% chance of being alive at two and four weeks, respectively.

CONCLUSION

A role for the mGPS in prognostication near the end of life is suggested. Biomarkers (e.g., mGPS) may assist clinical decisions as to whether intensive treatments are appropriate and may facilitate end-of-life care planning.

[Survival and its influencing factors of the lung cancer patients with hospice service]

BACKGROUND

Survival and the quality of life more comprehensively evaluates the survival conditions of cancer patients. This paper aims to analyze the survival time and quality of life (QOL) of hospice lung cancer patients and discusses the influencing factors to provide a basis for ameliorating their survival conditions.

METHODS

Advanced lung cancer patients who are receiving hospice care in the Shengjing Hospital were retrospectively analyzed and followed-up. The data were analyzed using SPSS 13.0. The median survival of patients was determined using the Kaplan-Meier method, and their QOL were evaluated using the tumor patient's QOL scale. Finally, the relationship between the survival index and the various factors were determined.

RESULTS

For 269 patients, the average QOL score was 28.76 and the median survival was 10 months. Awareness of their illness, pain relief, Karnofsky performance status (KPS) score, and nutritional status are the independent factors of QOL. Surgery, time of the occurrence of pain, pain relief, and KPS score are the independent factors of survival time.

CONCLUSIONS

The survival of patients with advanced cancer is poor; hence, we should strengthen and improve hospice care in terms of the influencing factors to enhance the QOL of patients and prolong their survival.

Symptoms tell it all: a systematic review of the value of symptom assessment to predict survival in advanced cancer patients

PURPOSE

To determine the prognostic meaning of symptoms in patients with advanced cancer.

DESIGN

Medline, Embase, Cochrane and Cinahl databases were systematically explored. The predicting symptoms were also evaluated in the three stages of palliative care: disease-directed palliation, symptom-oriented palliation and palliation in the terminal stage.

RESULTS

Out of 3167 papers, forty-four papers satisfied all criteria. Confusion, anorexia, fatigue, cachexia, weight loss, cognitive impairment, drowsiness, dyspnea, dysphagia, dry mouth and depressed mood were associated with survival in ≥ 50% of the studies evaluating these symptoms. Multivariate analysis showed confusion, anorexia, fatigue, cachexia, weight loss, dyspnea and dysphagia as independent prognostic factors in 30-56% of the studies. In the stage of disease-directed palliation anorexia, cachexia, weight loss, dysphagia and pain and in the stage of symptom-oriented palliation confusion, fatigue, cachexia, weight loss, dyspnea, dysphagia and nausea were shown to be independent predictors of survival in >30% of the studies.

CONCLUSION

Symptoms with independent predictive value are confusion, anorexia, fatigue, cachexia, weight loss, dyspnea and dysphagia. New insights are added by the variance between the three palliative stages.

Survival duration among patients with a noncancer diagnosis admitted to a palliative care unit: a retrospective study

BACKGROUND

Palliative care unit (PCU) beds are a limited resource in Canada, so PCU admission is restricted to patients with a short prognosis. Anecdotally, PCUs further restrict admission of patients with noncancer diagnoses out of fear that they will "oversurvive" and reduce bed availability. This raises concerns that noncancer patients have unequal access to PCU resources.

PURPOSE/METHODS

To clarify survival duration of patients with a noncancer diagnosis, we conducted a retrospective review of all admissions to four PCUs in Toronto, Canada, over a 1-year period. We measured associations between demographic data, prognosis, Palliative Performance Score (PPS), length of stay (LOS), and waiting time.

RESULTS

We collected data for 1000 patients, of whom 21% had noncancer diagnoses. Noncancer patients were older, with shorter prognoses and lower PPS scores on admission. Noncancer patients had shorter LOS (14 versus 24, p<0.001) than cancer patients and a similar likelihood of being discharged alive to cancer patients. Noncancer patients had a trend to lower LOS across a broad range of demographic, diagnostic, prognostic, and PPS categories. Multivariable analysis showed that LOS was not associated with the diagnosis of cancer (p=0.36).

DISCUSSION/CONCLUSION

Noncancer patients have a shorter LOS than cancer patients and a similar likelihood of being discharged alive from a PCU than cancer patients, and the diagnosis of cancer did not correlate with survival in our study population. Our findings demonstrate that noncancer patients are not "oversurviving," and that referring physicians and PCUs should not reject or restrict noncancer referrals out of concern that these patients are having a detrimental impact on PCU bed availability.

A Literature Review on Care at the End-of-Life in the Emergency Department

The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.

Recognition by family members that relatives with neurodegenerative disease are likely to die within a year: a meta-ethnography

OBJECTIVE

To synthesize evidence of family members recognizing that their relative is likely to die within the year, and identifying the need for palliative care.

DESIGN

A meta-ethnography of studies of family members in multiple sclerosis (MS), Parkinson's disease (PD) and motor neuron disease (MND).

REVIEW METHODS

Systematic search in electronic databases; thematic synthesis guided by the principles of meta-ethnography, which is a method for thematic synthesis of qualitative studies.

RESULTS

Nine articles were included. The results of the synthesis identified two key themes. First, family members are intimately aware of changes in their relative's health and well-being. Sub-themes include family member awareness of different and progressive stages of the disease, noticing deterioration, noticing decline in functional abilities and recognizing that their relative will die. The second key theme is dilemmas of being involved in prognostication. Sub-themes include family member ambivalence toward hearing about prognostication, health professionals not being knowledgeable of the disease and family reluctance to receive palliative care.

CONCLUSIONS

Family members monitor and recognize changes in their relative with PD, MND and MS and in themselves. Thus, drawing on the expertise of family members may be a useful tool for prognostication.

Prospective comparison of prognostic scores in palliative care cancer populations

PURPOSE

Predicting prognosis in advanced cancer aids physicians in clinical decision making and can help patients and their families to prepare for the time ahead.

MATERIALS AND METHODS

This multicenter, observational, prospective, nonrandomized population-based study evaluated life span prediction of four prognostic scores used in palliative care: the original palliative prognostic score (PaP Score), a variant of PaP Score including delirium (D-PaP Score), the Palliative Performance Scale, and the Palliative Prognostic Index.

RESULTS

A total of 549 patients were enrolled onto the study. Median survival of the entire group was 22 days (95% confidence intervals [95% CI] = 19-24). All four prognostic models discriminated well between groups of patients with different survival probabilities. Log-rank tests were all highly significant (p < .0001). The PaP and D-PaP scores were the most accurate, with a C index of 0.72 (95% CI = 0.70-0.73) and 0.73 (95% CI = 0.71-0.74), respectively.

CONCLUSION

It can be confirmed that all four prognostic scores used in palliative care studies accurately identify classes of patients with different survival probabilities. The PaP Score has been extensively validated and shows high accuracy and reproducibility in different settings.

Factors influencing survival after discharge from an Australian palliative care unit to residential aged care facilities: a retrospective audit

BACKGROUND

Increasing demand for palliative care unit (PCU) beds has led to shorter inpatient stays and a requirement to transfer some patients from a PCU to a residential aged care facility (RACF). Concerns have been raised regarding this move with suggestion that patients often die shortly after transfer. Published data investigating this patient group are limited. The aim of the current study was to audit discharges from a PCU to RACFs specifically looking at predictive factors for survival following discharge.

METHODS

A retrospective audit was undertaken of all discharges from the Barwon Health PCU to RACFs between July 2007 and July 2010. Data on patient demographics, clinical and functional status, admission and discharge details, and survival times were examined. Factors influencing survival were evaluated by Cox proportional-hazards regression analysis.

RESULTS

Sixty-two discharges from a PCU to an RACF were included in the analysis. The mean age at discharge was 76 and the majority of patients had malignant disease. Mean and median survival times post-transfer were 106 and 42.5 days, respectively, and 16% of subjects survived more than 100 days. From univariate analyses age, PCU length of stay, admission Resource Utilization Groups-Activities of Daily Living (RUG-ADL) score, dependent mobility, having lung cancer or cancer of unknown primary, and living alone or in an RACF pre PCU admission affected survival. Multivariate analyses showed age, PCU length of stay, RUG-ADL score, and living situation prior to PCU admission together were associated with postdischarge survival times.

CONCLUSIONS

This study is one of the largest investigating this cohort and suggests a number of factors that may predict survival for patients after discharge from a PCU to an RACF.

Wound outcomes in patients with advanced illness

A prospective case series was studied to assess the potential for complete healing of wounds among patients with advanced illness referred to a regional palliative care program in Toronto, Canada. Two hundred and eighty-two patients, of which 148 were primarily diagnosed with cancer and 134 with non cancer advanced illness, were assessed and followed until their deaths. On the baseline initial referral date, 823 wounds were documented. The wound classes assessed included pressure ulcers, malignant wounds, skin tears, venous leg ulcers, diabetic foot ulcers and arterial leg/foot ulcers. Proportions of patients showing complete healing of at least one wound were calculated, stratified by patient's survival time post-baseline (1 week, 1 month, 3 months and 6 months). Proportions of patients showing complete healing of at least one wound increased the longer patients lived and ranged between 12·9% and 43·5% for stage I pressure ulcers, 0% and 60% for stage II pressure ulcers, 2·4% and 100% for skin tears, 10% and 100% for venous leg ulcers and 0% and 50% for diabetic foot ulcers. Only one person showed complete healing of a stage III pressure ulcer and no complete healing was observed with stage IV pressure ulcers, unstageable pressure ulcers, malignant wounds and arterial leg/foot ulcers.

Physician, patient and family attitudes regarding information on prognosis: a Brazilian survey

BACKGROUND

Communication between physicians and patients is a fundamental aspect of cancer care, yet most physicians' perceptions are often inconsistent with the patients' stated preferences while prognostic information is the most misunderstood.

PATIENTS AND METHODS

Members of the Brazilian Society of Oncology Physicians (n=609) were identified and asked to complete a mailed questionnaire. Outpatients (n=150) and their family members (n=150), oncologists and fellows (n=55) from a public healthcare hospital and a tertiary cancer hospital in Sao Paulo were also personally invited to participate.

RESULTS

A total of 202 physicians, 150 outpatients and 150 family members were participated. The majority of patients (92%) believe they should know about their terminal stage compared with 79.2% of physicians and 74.7% of families (P=0.0003). Cancer patients were most likely to support disclosure of diagnosis and terminality (P=0.001), to consider that this disclosure was not stressful (P<0.0001) and that this knowledge would improve their quality of life (P<0.0001).

CONCLUSIONS

Cancer patients seen in these centers in Southeastern Brazil prefer to know the truth about their poor prognosis more than their physicians and families think. Further studies with larger samples of patients and physicians are necessary to show if our results are representative of all Brazilian situations.

Early identification of and proactive palliative care for patients in general practice, incentive and methods of a randomized controlled trial

Background

According to the Word Health Organization, patients who can benefit from palliative care should be identified earlier to enable proactive palliative care. Up to now, this is not common practice and has hardly been addressed in scientific literature. Still, palliative care is limited to the terminal phase and restricted to patients with cancer. Therefore, we trained general practitioners (GPs) in identifying palliative patients in an earlier phase of their disease trajectory and in delivering structured proactive palliative care. The aim of our study is to determine if this training, in combination with consulting an expert in palliative care regarding each palliative patient's tailored care plan, can improve different aspects of the quality of the remaining life of patients with severe chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure and cancer.

Methods/Design

A two-armed randomized controlled trial was performed. As outcome variables we studied: place of death, number of hospital admissions and number of GP out of hours contacts.

Discussion

We expect that this study will increase the number of identified palliative care patients and improve different aspects of quality of palliative care. This is of importance to improve palliative care for patients with COPD, CHF and cancer and their informal caregivers, and to empower the GP. The study protocol is described and possible strengths and weaknesses and possible consequences have been outlined.

Trial Registration

The Netherlands National Trial Register: NTR2815

Survival prediction for terminally ill cancer patients: revision of the palliative prognostic score with incorporation of delirium

PURPOSE

An existing and validated palliative prognostic (PaP) score predicts survival in terminally ill cancer patients based on dyspnea, anorexia, Karnofsky performance status score, clinical prediction of survival, total WBC, and lymphocyte percentage. The PaP score assigns patients to three different risk groups according to a 30-day survival probability--group A, >70%; group B, 30%-70%; group C, <30%. The impact of delirium is known but was not incorporated into the PaP score.

MATERIALS AND METHODS

Our aim was to incorporate information on delirium into the PaP score based on a retrospective series of 361 terminally ill cancer patients. We followed the approach of "validation by calibration," proposed by van Houwelingen and later adapted by Miceli for achieving score revision with inclusion of a new variable. The discriminating performance of the scores was estimated using the K statistic.

RESULTS

The prognostic contribution of delirium was confirmed as statistically significant (p < .001) and the variable was accordingly incorporated into the PaP score (D-PaP score). Following this revision, 30-day survival estimates in groups A, B, and C were 83%, 50%, and 9% for the D-PaP score and 87%, 51%, and 16% for the PaP score, respectively. The overall performance of the D-PaP score was better than that of the PaP score.

CONCLUSION

The revision of the PaP score was carried out by modifying the cutoff values used for prognostic grouping without, however, affecting the partial scores of the original tool. The performance of the D-PaP score was better than that of the PaP score and its key feature of simplicity was maintained.

Development and validation of a prognostic nomogram for terminally ill cancer patients

BACKGROUND

Determining life expectancy in terminally ill cancer patients is a difficult task. We aimed to develop and validate a nomogram to predict the length of survival in patients with terminal disease.

METHODS

From February 1, 2003, to December 31, 2005, 406 consecutive terminally ill patients were entered into the study. We analyzed 38 features prognostic of life expectancy among terminally ill patients by multivariable Cox regression and identified the most accurate and parsimonious model by backward variable elimination according to the Akaike information criterion. Five clinical and laboratory variables were built into a nomogram to estimate the probability of patient survival at 15, 30, and 60 days. We validated and calibrated the nomogram with an external validation cohort of 474 patients who were treated from June 1, 2006, through December 31, 2007.

RESULTS

The median overall survival was 29.1 days for the training set and 18.3 days for the validation set. Eastern Cooperative Oncology Group performance status, lactate dehydrogenase levels, lymphocyte levels, albumin levels, and time from initial diagnosis to diagnosis of terminal disease were retained in the multivariable Cox proportional hazards model as independent prognostic factors of survival and formed the basis of the nomogram. The nomogram had high predictive performance, with a bootstrapped corrected concordance index of 0.70, and it showed good calibration. External independent validation revealed 68% predictive accuracy.

CONCLUSIONS

We developed a highly accurate tool that uses basic clinical and analytical information to predict the probability of survival at 15, 30, and 60 days in terminally ill cancer patients. This tool can help physicians making decisions on clinical care at the end of life.

Clinician accuracy when estimating survival duration: the role of the patient's performance status and time-based prognostic categories

CONTEXT

Although shown to be an independent predictor of actual survival (AS) duration, previous reports have identified significant inaccuracy in clinician estimates of survival (CES).

OBJECTIVES

This study aimed to both examine demographic and clinical factors potentially impacting CES accuracy and explore possible strategies for improvement in a patient population with advanced incurable disease.

METHODS

At the time of initial assessment by a specialist palliative care team, CES for each patient was chosen from one of the following time-based categories: <24 hours, one to seven days, one to four weeks, one to three months, three to six months, three to 12 months, or >12 months. Survival estimates were then classified as an accurate (AS=CES), overestimate (AS<CES), or underestimate (AS>CES). Demographic data were analyzed using descriptive statistics, and both univariate and stepwise multivariate logistic regression analyses were used to identify any associated demographic and/or clinical factors significantly impacting accuracy.

RESULTS

Within the total study population of 1835, both CES and AS data were available for 1622 patients among whom mean and median survival was 26.5 and 88 days, respectively. The remaining 213 patients (12% of the total population) remained alive at the time of analysis. Of the total study population, CES was accurate for 34% of patients and an overestimate for 51% of patients. CES of <24 hours and one to seven days were significantly more likely to be accurate than any other prognostic category (P<0.0001). Additionally, a CES of either one to four weeks or >12 months was significantly more likely to be accurate than CES of one to three months, three to six months, and six to 12 months (P<0.0001). Finally, multivariate analyses indicated CES to be significantly more likely to be accurate for males (P=0.0407) and for patients with baseline Palliative Performance Scale (PPS) ratings of either "30 and less" (P<0.0001) or "70 and greater" (P<0.0001).

CONCLUSION

In a patient population referred for specialist palliative care consultation with diverse diagnoses and a wide range of CES, time-based categorization of survival estimates along with PPS and possibly gender could be used to inform the CES process for individual patients. Intentionally incorporating these objective elements into what has historically been the subjective process of CES may lead to improvements in accuracy.

Association between symptoms and their severity with survival time in hospitalized patients with far advanced cancer

OBJECTIVE

To assess the significance of symptoms and their severity for predicting survival of hospitalized patients with far advanced cancer.

METHODS

Two hundred fifty-six patients with far advanced cancer at the Cancer Center of Tongji Hospital, China were assessed by the Chinese version of the M.D. Anderson Symptom Inventory (MDASI-C). A Cox regression model was used to determine symptoms that could predict survival time. The log-rank test was used to compare the survival of patients accompanied by significant symptoms at different intensities.

RESULTS

Median survival was 49 days. Fatigue was the most common and severe symptom, followed by lack of appetite, disturbed sleep, and pain. Multivariate analysis showed that fatigue, shortness of breath, lack of appetite, and feeling sad were independent prognostic factors for survival time (p  < 0.05), with a hazard ratio of dying of 1.39, 1.13, 1.33, and 1.16, respectively. The survival time for patients with different intensities of the four symptoms showed significant differences (p  <  0.01).

CONCLUSIONS

Fatigue, lack of appetite, feeling sad, and shortness of breath could be predictive factors for survival time of hospitalized patients with far advanced cancer. The more severe these symptoms are, the shorter will be survival time.

Patterns of depression in cancer patients: an indirect test of gender-specific vulnerabilities to depression

BACKGROUND

Higher rates of depression in women compared to men have been attributed to intrinsic biological or psychological vulnerabilities, to their disproportionate exposure to stressful events and circumstances, or to the combined contributions of these factors.

PURPOSE

This study aimed to determine if there is a gender disparity in depression rates in patients with advanced cancer, a circumstance associated with multiple stressors and a high prevalence of depression.

METHOD

Data were collected from 569 patients, assessing demographic characteristics, depressive symptoms, physical symptoms, and social support.

RESULTS

Clinically significant symptoms of depression (BDI-II scores ≥16) were reported by more than 20% of the sample, with no significant gender differences in depression. There were no significant gender differences in potentially confounding factors such as social support or physical symptom burden.

CONCLUSION

The results indicated that men and women may be equally likely to develop depression when faced with a highly stressful circumstance.

Facing haematopoietic stem-cell transplantation: do patients and their physicians agree regarding the prognosis?

OBJECTIVE

To evaluate the correlation and concordance between patients' and physicians' estimations of prognoses before initiation of the conditioning regimen for allogeneic haematopoietic stem-cell transplantation.

METHODS

A total of 123 patients and their attending physicians were asked to estimate a prognosis on a six-point scale. The patients were also asked to fill out questionnaires addressing their psychological state and coping.

RESULTS

The mean prognostic estimations differed by 1.17 points (p<0.001), with the patients being more optimistic than the physicians. With respect to concordance: Pearson correlation r=0.024 (ns); unweighted kappa and kappa with linear weighting are 0.115 and 0.068, respectively. The prognostic estimates of the patients correlated with their psychological state, but not with the objective disease- or treatment-related variables, whereas the physicians' estimates were partially based on such objective factors.

CONCLUSIONS

A clear significant association between actual survival and the physicians' estimates, but not the patients' estimates, was observed. If agreement regarding the prognosis exists, the relationship between physicians' and patients' estimates is probably non-linear. Assessing one's chances of being cured is a highly emotional task, and psychological processes such as denial or repression most likely play a decisive role. Moreover, collusion between the patient and physician may be inevitable in this situation. Whether it is desirable to gain concordance and who will benefit from such efforts must be discussed and empirically studied.

Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature

Background

There are several methods of assessing nutritional status in cancer of which serum albumin is one of the most commonly used. In recent years, the role of malnutrition as a predictor of survival in cancer has received considerable attention. As a result, it is reasonable to investigate whether serum albumin has utility as a prognostic indicator of cancer survival in cancer. This review summarizes all available epidemiological literature on the association between pretreatment serum albumin levels and survival in different types of cancer.

Methods

A systematic search of the literature using the MEDLINE database (January 1995 through June 2010) to identify epidemiologic studies on the relationship between serum albumin and cancer survival. To be included in the review, a study must have: been published in English, reported on data collected in humans with any type of cancer, had serum albumin as one of the or only predicting factor, had survival as one of the outcome measures (primary or secondary) and had any of the following study designs (case-control, cohort, cross-sectional, case-series prospective, retrospective, nested case-control, ecologic, clinical trial, meta-analysis).

Results

Of the 29 studies reviewed on cancers of the gastrointestinal tract, all except three found higher serum albumin levels to be associated with better survival in multivariate analysis. Of the 10 studies reviewed on lung cancer, all excepting one found higher serum albumin levels to be associated with better survival. In 6 studies reviewed on female cancers and multiple cancers each, lower levels of serum albumin were associated with poor survival. Finally, in all 8 studies reviewed on patients with other cancer sites, lower levels of serum albumin were associated with poor survival.

Conclusions

Pretreatment serum albumin levels provide useful prognostic significance in cancer. Accordingly, serum albumin level could be used in clinical trials to better define the baseline risk in cancer patients. A critical gap for demonstrating causality, however, is the absence of clinical trials demonstrating that raising albumin levels by means of intravenous infusion or by hyperalimentation decreases the excess risk of mortality in cancer.

Perspectives from the frontlines: palliative care providers' expectations of Canada's compassionate care benefit programme

Recognising their valuable role as key informants, this study examines the perspectives of front-line palliative care providers (FLPCP) regarding a social benefit programme in Canada designed to support family caregivers at end-of-life, namely the Compassionate Care Benefit (CCB). The CCB's purpose is to provide income assistance and job security to family caregivers who take temporary leave from employment to care for a dying family member. Contributing to an evaluative study that aims to provide policy-relevant recommendations about the CCB, this analysis draws on semi-structured interviews undertaken in 2007/2008 with FLPCPs (n = 50) from across Canada. Although participants were not explicitly asked during interviews about their expectations of the CCB, thematic content analysis revealed 'expectations' as a key finding. Through participants' discussions of their knowledge of and familiarity with the CCB, specific expectations were identified and grouped into four categories: (1) temporal; (2) financial; (3) informational; and (4) administrative. Findings demonstrate that participants expect the CCB to provide: (1) an adequate length of leave time from work, which is reflective of the uncertain nature of caregiving at end-of-life; (2) adequate financial support; (3) information on the programme to be disseminated to FLPCPs so that they may share it with others; and (4) a simple, clear, and quick application process. FLPCPs hold unique expertise, and ultimately the power to shape uptake of the CCB. As such, their expectations of the CCB contribute valuable knowledge from which relevant policy recommendations can be made to better meet the needs of family caregivers and FLPCPs alike.

Preferences for active and aggressive intervention among patients with advanced cancer

Background

Intrinsic to "Patient-Centered Care" is being respectful and responsive to individual patient preferences, expressed needs, and personal values. Establishing a patient's preferences for active and aggressive intervention is imperative and foundational to the development of advance care planning. With the increasing awareness and acceptance of palliative philosophies of care, patients with advanced cancer are increasingly transitioning from active and aggressive medical management (AAMM) to conservative palliative management (CPM).

Methods

A cross-sectional study based on a prospective and sequential case series of patients referred to a regional palliative medicine consultative program was assembled between May 1, 2005 and June 30, 2006. Patients and/or their substitute decision makers (SDM) completed a questionnaire, at baseline, that assessed their preferences for AAMM en route to their eventual deaths. Seven common interventions constituting AAMM were surveyed: cardiopulmonary resuscitation (CPR) & mechanical ventilation (MV), chemotherapy, antibiotics, anticoagulants, blood transfusions, feeding tubes, and artificial hydration. Multivariable analyses were conducted on the seven interventions individually as well as on the composite score that summed preferences for the seven interventions.

Results

380 patients with advanced cancer agreed to participate in the study. A trend to desire a mostly conservative palliative approach was noted as 42% of patients desired one or fewer interventions. At baseline, most patients and their SDM's were relatively secure about decisions pertaining to the seven interventions as the rates of being "undecided" ranged from a high of 23.4% for chemotherapy to a low of 3.9% for feeding tubes. Multivariable modeling showed that more AAMM was preferred by younger patients (P < 0.0001), non-Caucasians (P = 0.042), patients with higher baseline Palliative Performance Scale scores (P = 0.0002) and where a SDM was involved in the decision process (p = 0.027). Non-statistically significant trends to prefer more AAMM was observed with male gender (p = 0.077) and higher levels of the Charlson Comorbidity index (p = 0.059). There was no association between treatment preferences and cancer class.

Conclusions

Although the majority of patients with advanced cancer in this study expressed preferences for CPM, younger age, higher baseline PPSv2, and involvement of SDMs in the decision process were significantly associated with preferences for AAMM.