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Sia J, Paul E, Dally M, Ruben J. Stereotactic radiosurgery for 318 brain metastases in a single Australian centre: the impact of histology and other factors. J Clin Neurosci 2014; 22:303-7. [PMID: 25304434 DOI: 10.1016/j.jocn.2014.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 07/10/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
While melanoma brain metastases (BM) are consistently associated with worse survival compared to other histologies, whether they correlate with worse local control (LC) following stereotactic radiosurgery (SRS) is not yet well-defined. In this study of prospectively and retrospectively collected data we investigated the impact of histology and other host, tumour and treatment factors on overall survival (OS) and LC. We analysed 162 patients and 318 BM lesions from various histologies treated with SRS between 2005 and 2011. We included patients who received SRS as first-line treatment, as well as patients who received SRS for residual or recurrent BM following prior surgery, whole brain radiotherapy (WBRT) or both. Median OS for the entire cohort was 8.4 months. Median OS for tumour histologies of melanoma, lung and breast cancer were 5.1, 12.2, and 14.7 months, respectively. On multivariate analysis, melanoma predicted for worse OS (hazard ratio [HR] 1.515, p = 0.003) together with performance status (HR 1.662, p < 0.001) and uncontrolled systemic disease (HR 1.755, p = 0.003). Melanoma histology was also negatively predictive for LC (HR 1.828, p = 0.021) together with increasing tumour size (HR 1.038, p = 0.017). Other factors, including the use of WBRT with SRS, the use of planning treatment volume margins, and prescription dose were not significantly predictive for OS and LC. We conclude melanoma histology also portends poorer LC in the SRS setting. While survival depends significantly on the systemic behaviour of the disease, treatment refinements to reduce local failure still merit exploration, especially in the era of targeted therapies.
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Affiliation(s)
- Joseph Sia
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Eldho Paul
- Department of Epidemiology and Preventative Medicine, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Michael Dally
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Surgery, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Jeremy Ruben
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Surgery, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
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Hannon B, Swami N, Pope A, Rodin G, Dougherty E, Mak E, Banerjee S, Bryson J, Ridley J, Zimmermann C. The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer. Support Care Cancer 2014; 23:1073-80. [DOI: 10.1007/s00520-014-2460-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 09/22/2014] [Indexed: 12/25/2022]
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Abstract
In the last years the management of patients with liver cancer has been improved. The BCLC staging/treatment strategy identifies the optimal candidates for each treatment option and sorafenib is the only effective systemic treatment. Others (sunitinib, brivanib, linifanib, everolimus, ramucirumab) have failed in terms of safety/survival benefit. Some patients at intermediate/early stage, may be considered for systemic therapy when options of higher priority may have failed or not be feasible. The 800 mg/day is the recommended starting dose. Close follow-up and easy access for the patients so that they can report any adverse event and implement dose adjustments is the key point in the management of them. Development of early dermatologic adverse events has been correlated with better outcome and the pattern of radiologic progression characterizes better the prognosis/outcome of these patients. Treatment beyond progression may be considered if there is no option for a second line research trial.
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104
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Myers J, Kim A, Flanagan J, Selby D. Palliative performance scale and survival among outpatients with advanced cancer. Support Care Cancer 2014; 23:913-8. [PMID: 25228018 DOI: 10.1007/s00520-014-2440-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/09/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE Previous studies have examined the association between the Palliative Performance Scale (PPS) and survival duration; however, few have examined patients with incurable cancer in the outpatient setting. In addition to exploring this association further, the purpose of this study was to identify key PPS markers that could serve as triggers to signify the need for key care discussions. METHODS Study subjects were followed prospectively from the time of referral for a specialist palliative care consultation until death. PPS ratings and survival estimates were determined for each visit. RESULTS For the final study population of 368 patients, at baseline, the median PPS rating was 60. Overall median and mean survival duration were approximately 4 and 6 months, respectively. Median survival duration for patients with PPS ratings of 70, 60, and 50 were found to be approximately 6, 3, and 2 months, respectively. Twenty-four percent of all survival estimates were found to be accurate. CONCLUSIONS Given the ongoing challenge of inaccurate survival estimates, this data suggests what may be of greatest clinical utility is to use specific PPS ratings as triggers for key care discussions among patients with incurable and progressive cancer.
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Affiliation(s)
- Jeff Myers
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Palliative Care Consult Team, Sunnybrook Health Sciences Centre, Rm H336, 2075 Bayview Avenue, Toronto, Ontario, M4N 3 M5, Canada,
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Hamaker ME, Stauder R, van Munster BC. Exclusion of older patients from ongoing clinical trials for hematological malignancies: an evaluation of the National Institutes of Health Clinical Trial Registry. Oncologist 2014; 19:1069-75. [PMID: 25170014 DOI: 10.1634/theoncologist.2014-0093] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Cancer societies, research cooperatives, and countless publications have urged the development of clinical trials that facilitate the inclusion of older patients and those with comorbidities. We set out to determine the characteristics of currently recruiting clinical trials with hematological patients to assess their inclusion and exclusion of elderly patients. METHODS The NIH clinical trial registry was searched on July 1, 2013, for currently recruiting phase I, II or III clinical trials with hematological malignancies. Trial characteristics and study objectives were extracted from the registry website. RESULTS Although 5% of 1,207 included trials focused exclusively on elderly or unfit patients, 69% explicitly or implicitly excluded older patients. Exclusion based on age was seen in 27% of trials, exclusion based on performance status was seen in 16%, and exclusion based on stringent organ function restrictions was noted in 51%. One-third of the studies that excluded older patients based on age allowed inclusion of younger patients with poor performance status; 8% did not place any restrictions on organ function. Over time, there was a shift from exclusion based on age (p value for trend <.001) toward exclusion based on organ function (p = .2). Industry-sponsored studies were least likely to exclude older patients (p < .001). CONCLUSION Notably, 27% of currently recruiting clinical trials for hematological malignancies use age-based exclusion criteria. Although physiological reserves diminish with age, the heterogeneity of the elderly population does not legitimize exclusion based on chronological age alone. Investigators should critically review whether sufficient justification exists for every exclusion criterion before incorporating it in trial protocols.
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Affiliation(s)
- Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, The Netherlands; Department of Oncology and Hematology, Innsbruck Medical University, Innsbruck, Austria; Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands; Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Reinhard Stauder
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, The Netherlands; Department of Oncology and Hematology, Innsbruck Medical University, Innsbruck, Austria; Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands; Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Barbara C van Munster
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, The Netherlands; Department of Oncology and Hematology, Innsbruck Medical University, Innsbruck, Austria; Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands; Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
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106
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Jang RW, Caraiscos VB, Swami N, Banerjee S, Mak E, Kaya E, Rodin G, Bryson J, Ridley JZ, Le LW, Zimmermann C. Simple prognostic model for patients with advanced cancer based on performance status. J Oncol Pract 2014; 10:e335-41. [PMID: 25118208 DOI: 10.1200/jop.2014.001457] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Raymond W Jang
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Valerie B Caraiscos
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Subrata Banerjee
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ernie Mak
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ebru Kaya
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gary Rodin
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - John Bryson
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Julia Z Ridley
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Lisa W Le
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- University of Toronto; and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Dagher J, Dugay F, Rioux-Leclercq N, Verhoest G, Oger E, Bensalah K, Cabillic F, Jouan F, Kammerer-Jacquet SF, Fergelot P, Vigneau C, Arlot-Bonnemains Y, Belaud-Rotureau MA. Cytoplasmic PAR-3 protein expression is associated with adverse prognostic factors in clear cell renal cell carcinoma and independently impacts survival. Hum Pathol 2014; 45:1639-46. [DOI: 10.1016/j.humpath.2014.03.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 02/20/2014] [Accepted: 03/27/2014] [Indexed: 01/18/2023]
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Comparison of the Freiburg and Charlson comorbidity indices in predicting overall survival in elderly patients with newly diagnosed multiple myeloma. BIOMED RESEARCH INTERNATIONAL 2014; 2014:437852. [PMID: 25114902 PMCID: PMC4119725 DOI: 10.1155/2014/437852] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 05/29/2014] [Accepted: 06/18/2014] [Indexed: 11/23/2022]
Abstract
Multiple myeloma occurs primarily in elderly patients. Considering the high prevalence of comorbidities, comorbidity is an important issue for the management of myeloma. However, the impact of comorbidity on clinical outcomes has not been fully investigated. We retrospectively analyzed patients with newly diagnosed myeloma. Comorbidities were assessed based on the Charlson comorbidity index (CCI) and the Freiburg comorbidity index (FCI). The CCI is a summary measure of 19 comorbid conditions. FCI is determined by performance status, renal impairment, and lung disease. This study included 127 patients with a median age of 71 years. Approximately half of the patients had additional disorders at the time of diagnosis, and diabetes mellitus was the most frequent diagnosis (18.9%). The most significant factors for prognosis among patient-related conditions were a history of solid cancer and performance status (ECOG ≥ 2). The FCI score was divided into 3 groups (0, 1, and 2-3), and the CCI score was divided into 2 groups (2-3 and ≥4). FCI was a strong prognostic tool for OS (P > 0.001) and predicted clinical outcome better than CCI (P = 0.059). In conclusion, FCI was more useful than CCI in predicting overall survival in elderly patients with myeloma.
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de Glas NA, Hamaker ME, Kiderlen M, de Craen AJM, Mooijaart SP, van de Velde CJH, van Munster BC, Portielje JEA, Liefers GJ, Bastiaannet E. Choosing relevant endpoints for older breast cancer patients in clinical trials: an overview of all current clinical trials on breast cancer treatment. Breast Cancer Res Treat 2014; 146:591-7. [DOI: 10.1007/s10549-014-3038-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 06/18/2014] [Indexed: 11/25/2022]
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Grossman D, Rootenberg M, Perri GA, Yogaparan T, DeLeon M, Calabrese S, Grief CJ, Moore J, Gill A, Stilos K, Daines P, Zimmermann C, Mazzotta P. Enhancing Communication in End-of-Life Care: A Clinical Tool Translating Between the Clinical Frailty Scale and the Palliative Performance Scale. J Am Geriatr Soc 2014; 62:1562-7. [DOI: 10.1111/jgs.12926] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Daphna Grossman
- Department of Family and Community Medicine; Baycrest Health Sciences; Toronto Ontario Canada
- Division of Palliative Care; Department of Family and Community Medicine; University of Toronto; Toronto Ontario Canada
| | - Mark Rootenberg
- Department of Family and Community Medicine; Baycrest Health Sciences; Toronto Ontario Canada
- Department of Psychology; Faculty of Health; York University; Toronto Ontario Canada
| | - Giulia-Anna Perri
- Department of Family and Community Medicine; Baycrest Health Sciences; Toronto Ontario Canada
- Division of Palliative Care; Department of Family and Community Medicine; University of Toronto; Toronto Ontario Canada
| | - Thirumagal Yogaparan
- Department of Medicine; Baycrest Health Sciences; Toronto Ontario Canada
- Department of Medicine; University of Toronto; Toronto Ontario Canada
| | - Maria DeLeon
- Department of Nursing; Baycrest Health Sciences; Toronto Ontario Canada
- Department of Nursing; Ryerson University; Toronto Ontario Canada
| | - Sue Calabrese
- Department of Nursing; Baycrest Health Sciences; Toronto Ontario Canada
- Department of Nursing; Ryerson University; Toronto Ontario Canada
| | - Cindy J. Grief
- Department of Psychiatry; Baycrest Health Sciences; Toronto Ontario Canada
- Department of Psychiatry; University of Toronto; Toronto Ontario Canada
| | - Jennifer Moore
- Division of Palliative Care; Department of Family and Community Medicine; University of Toronto; Toronto Ontario Canada
- Division of Long Term Care; Department of Family and Community Medicine; Sunnybrook Health Sciences; Toronto Ontario Canada
| | - Ashlinder Gill
- Division of Long Term Care; Department of Family and Community Medicine; Sunnybrook Health Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
| | - Kalli Stilos
- Department of Nursing; Sunnybrook Health Sciences; Toronto Ontario Canada
- Faculty of Nursing; University of Toronto; Toronto Ontario Canada
| | - Patricia Daines
- Faculty of Nursing; University of Toronto; Toronto Ontario Canada
- Department of Nursing; Sunnybrook Health Sciences; Toronto Ontario Canada
| | - Camilla Zimmermann
- Division of Medical Oncology and Hematology; Department of Medicine; University of Toronto; Toronto Ontario Canada
- Department of Psychosocial Oncology and Palliative Care; Princess Margaret Cancer Centre; University Health Network; Toronto Ontario Canada
| | - Paolo Mazzotta
- Division of Palliative Care; Department of Family and Community Medicine; University of Toronto; Toronto Ontario Canada
- Division of Long Term Care; Department of Family and Community Medicine; Sunnybrook Health Sciences; Toronto Ontario Canada
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111
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Magnitude of score change for the palliative prognostic index for survival prediction in patients with poor prognostic terminal cancer. Support Care Cancer 2014; 22:2725-31. [PMID: 24798755 DOI: 10.1007/s00520-014-2274-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The use of the palliative prognostic index (PPI) when used only at an initial assessment might be inappropriate as a prognostic tool because it does not reflect the patient's clinical course. The purpose of this study was to assess the utility of PPI score change (∆score) between two assessments as a prognostic tool in terminally ill cancer patients categorized as having a poor prognosis. METHODS A total of 1,035 terminally ill cancer patients categorized as having a poor prognosis (initial PPI score >6) under palliative care between January 2006 and December 2011 at a single medical center in Taiwan were selected. Patients were categorized by magnitude of ∆score between the initial PPI and week 1 PPI assessments into five groups (<-20, -20 to 0, 0, 0 to 20, and >20 %) for survival analysis. RESULTS The median survival was 22 days (range, 8-180 days) in all patients. Median survival duration was 78, 32, 23, 17, and 14 days, and the death rate at the study end was 78.9, 87.1, 96.2, 100, and 100 % in each group, respectively. The c-statistic value for predicting life expectancy less than 30, 60, and 90 days was significantly higher with magnitude of ∆score than with the initial PPI score (p < 0.05). CONCLUSIONS Magnitude of PPI score change within 1-week interval provides a significant difference in survival prediction and is more reliable than initial PPI alone to identify terminally ill cancer patients with better outcome potential in those patients considered to have a poor prognosis.
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112
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Pérez-Larraya JG, Ducray F. Treating glioblastoma patients with poor performance status: where do we go from here? CNS Oncol 2014; 3:231-41. [PMID: 25055131 PMCID: PMC6124361 DOI: 10.2217/cns.14.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Approximately one third of all glioblastoma patients exhibit an impaired functional status in the perioperative setting. Their optimal management is difficult to define. The only available prospective study in poor performance status (PS) patients has been performed in elderly patients (≥ 70 years). In this population, treatment with temozolomide was shown to be safe and to be associated with a clinically significant improvement of PS in one third of patients. In young patients (<70 years), daily clinical experience and retrospective data show that some patients can benefit from temozolomide radiochemotherapy, abbreviated radiation courses, upfront chemotherapy or early use of bevacizumab. However, prospective studies are needed to correctly evaluate these strategies, namely their impact on functional status and quality of life.
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Affiliation(s)
| | - François Ducray
- Service de Neuro-Oncologie, Hôpital Neurologique, Hospices Civils de Lyon, Lyon Neuroscience Research Center INSERM U1028/CNRS UMR 5292, Université de Lyon - Université Claude Bernard Lyon 1 Lyon, France
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113
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Paiva CE, Carneseca EC, Barroso EM, de Camargos MG, Alfano ACC, Rugno FC, Paiva BSR. Further evaluation of the EORTC QLQ-C30 psychometric properties in a large Brazilian cancer patient cohort as a function of their educational status. Support Care Cancer 2014; 22:2151-60. [PMID: 24652051 DOI: 10.1007/s00520-014-2206-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 03/09/2014] [Indexed: 01/04/2023]
Abstract
PURPOSE The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) is considered a valid instrument for use in Brazil. However, the previous Brazilian validation study included only 30 lung cancer patients and only measured test-retest reliability. The aim of this study was to evaluate the psychometric properties of the EORTC QLQ-C30 in a sample of cancer patients at different educational levels who completed the instrument administered by an interviewer. METHODS Data from six prospective studies conducted by the same group of researchers were combined in this study (N = 986). RESULTS Reliability was assessed using Cronbach's alpha coefficient, all values of which were >0.7, with the exception of cognitive functioning, social functioning, and nausea and vomiting (α = 0.57, α = 0.69, and α = 0.68, respectively). In multi-trait scaling analysis, convergent and divergent validity were considered adequate (validity indices were 91.6 and 97.4%). In general, moderate to strong correlations were found between the subscales of the EORTC QLQ-C30 and its respective dimensions from the WHOQOL-bref, the hospital anxiety and depression scale, and the Edmonton Symptom Assessment System (ESAS) instruments. In addition, the EORTC QLQ-C30 was able to differentiate groups of patients with distinct performance statuses and types of treatment (known-group validation). Statistical analyses were also performed on educational status, yielding similar results. CONCLUSIONS Detailed psychometric property data using the EORTC QLQ-C30 in Brazil are added by this study. In addition, we demonstrated that this instrument is in general reliable and valid regardless of the patient educational level.
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Affiliation(s)
- Carlos Eduardo Paiva
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos, São Paulo, Brazil,
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114
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Hamaker ME, Stauder R, van Munster BC. On-going clinical trials for elderly patients with a hematological malignancy: are we addressing the right end points? Ann Oncol 2014; 25:675-681. [PMID: 24458474 PMCID: PMC4433524 DOI: 10.1093/annonc/mdt592] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 12/06/2013] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Cancer societies and research cooperative groups worldwide have urged for the development of cancer trials that will address those outcome measures that are most relevant to older patients. We set out to determine the characteristics and study objectives of current clinical trials in hematological patients. METHOD The United States National Institutes of Health clinical trial registry was searched on 1 July 2013, for currently recruiting phase I, II or III clinical trials in hematological malignancies. Trial characteristics and study objectives were extracted from the registry website. RESULTS In the 1207 clinical trials included in this overview, patient-centered outcome measures such as quality of life, health care utilization and functional capacity were only incorporated in a small number of trials (8%, 4% and 0.7% of trials, respectively). Even in trials developed exclusively for older patients, the primary focus lies on standard end points such as toxicity, efficacy and survival, while patient-centered outcome measures are included in less than one-fifth of studies. CONCLUSION Currently on-going clinical trials in hematological malignancies are unlikely to significantly improve our knowledge of the optimal treatment of older patients as those outcome measures that are of primary importance to this patient population are still included in only a minority of studies. As a scientific community, we cannot continue to simply acknowledge this issue, but must all participate in taking the necessary steps to enable the delivery of evidence-based, tailor-made and patient-focused cancer care to our rapidly growing elderly patient population.
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Affiliation(s)
- M E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, Utrecht.
| | - R Stauder
- Department of Oncology and Hematology, Innbruck Medical University, Innsbruck, Austria
| | - B C van Munster
- Department of Internal Medicine, Academic Medical Center, Amsterdam; Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
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Laird BJ, McMillan DC, Fayers P, Fearon K, Kaasa S, Fallon MT, Klepstad P. The systemic inflammatory response and its relationship to pain and other symptoms in advanced cancer. Oncologist 2013; 18:1050-5. [PMID: 23966223 DOI: 10.1634/theoncologist.2013-0120] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Inflammation has been identified as a hallmark of cancer and may be necessary for tumorgenesis and maintenance of the cancer state. Inflammation-related symptoms are common in those with cancer; however, little is known about the relationship between symptoms and systemic inflammation in cancer. The aim of the present study was to examine the relationship between symptoms and systemic inflammation in a large cohort of patients with advanced cancer. METHODS Data from an international cohort of patients with advanced cancer were analyzed. Symptoms and patient-related outcomes were recorded using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire--Core Questionnaire. Systemic inflammation was assessed using C-reactive protein levels. The relationship between these symptoms and systemic inflammation was examined using Spearman rank correlation (ρ) and the Mann-Whitney U test. RESULTS Data were available for 1,466 patients across eight European countries; 1,215 patients (83%) had metastatic disease at study entry. The median survival was 3.8 months (interquartile range [IQR] 1.3-12.2 months). The following were associated with increased levels of inflammation: performance status (ρ = .179), survival (ρ = .347), pain (ρ = .154), anorexia (ρ = .206), cognitive dysfunction (ρ = .137), dyspnea (p= .150), fatigue (ρ = .197), physical dysfunction (ρ = .207), role dysfunction (ρ = .176), social dysfunction (ρ = .132), and poor quality of life (ρ = .178). All were statistically significant at p < .001. CONCLUSION The results show that the majority of cancer symptoms are associated with inflammation. The strength of the potential relationship between systemic inflammation and common cancer symptoms should be examined further within the context of an anti-inflammatory intervention trial.
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Affiliation(s)
- Barry J Laird
- European Palliative Care Research Centre, Norwegian University of Science and Technology, Trondheim, Norway
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Laird BJ, Kaasa S, McMillan DC, Fallon MT, Hjermstad MJ, Fayers P, Klepstad P. Prognostic factors in patients with advanced cancer: a comparison of clinicopathological factors and the development of an inflammation-based prognostic system. Clin Cancer Res 2013; 19:5456-64. [PMID: 23938289 DOI: 10.1158/1078-0432.ccr-13-1066] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE In advanced cancer, oncological treatment is influenced by performance status (PS); however, this has limitations. Biomarkers of systemic inflammation may have prognostic value in advanced cancer. The study compares key factors in prognosis (performance status, patient-reported outcomes; PRO) with an inflammation-based score (Glasgow Prognostic Score, mGPS). A new method of prognosis in advanced cancer (combining performance status and mGPS) is tested and then validated. EXPERIMENTAL DESIGN Two international biobanks of patients with advanced cancer were analyzed. Key prognostic factors [performance status, PROs (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C-30), and mGPS (using C-reactive protein and albumin concentrations)] were examined. The relationship between these and survival was examined using Kaplan-Meier and Cox regression methods, in a test sample before independent validation. RESULTS Data were available on 1,825 patients (test) and 631 patients (validation). Median survival ranged from 3.2 months (test) to 7.03 months (validation). On multivariate analysis, performance status (HR 1.62-2.77) and mGPS (HR 1.51-2.27) were independently associated with, and were the strongest predictors of survival (P < 0.01). Survival at 3 months varied from 82% (mGPS 0) to 39% (mGPS 2) and from 75% (performance status 0-1) to 14% (performance status 4). When used together, survival ranged from 88% (mGPS 0, PS 0-1) to 10% (mGPS 2, performance status 4), P < 0.001. CONCLUSION A systemic inflammation-based score, mGPS, and performance status predict survival in advanced cancer. The mGPS is similar to performance status in terms of prognostic power. Used together, performance status and mGPS act synergistically improving prognostic accuracy. This new method may be of considerable value in the management of patients with advanced cancer.
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Affiliation(s)
- Barry J Laird
- Authors' Affiliations: European Palliative Care Research Centre; Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology; Departments of Oncology and Anaesthesiology and Emergency Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim; Department of Oncology, Regional Centre for Excellence in Palliative Care, Oslo University Hospital, Oslo, Norway; University of Edinburgh, Edinburgh; and University of Glasgow, Glasgow, United Kingdom
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Maclean J, Fersht N, Singhera M, Mulholland P, McKee O, Kitchen N, Short SC. Multi-disciplinary management for patients with oligometastases to the brain: results of a 5 year cohort study. Radiat Oncol 2013; 8:156. [PMID: 23806042 PMCID: PMC3702492 DOI: 10.1186/1748-717x-8-156] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/01/2013] [Indexed: 11/19/2022] Open
Abstract
Background The incidence of oligometastases to the brain in good performance status patients is increasing due to improvements in systemic therapy and MRI screening, but specific management pathways are often lacking. Methods We established a multi-disciplinary brain metastases clinic with specific referral guidelines and standard follow-up for good prognosis patients with the view that improving the process of care may improve outcomes. We evaluated patient demographic and outcome data for patients first seen between February 2007 and November 2011. Results The clinic was feasible to run and referrals were appropriate. 87% of patients referred received a localised therapy during their treatment course. 114 patients were seen and patient numbers increased during the 5 years that the clinic has been running as relationships between clinicians were developed. Median follow-up for those still alive was 23.1 months (6.1-79.1 months). Primary treatments were: surgery alone 52%, surgery plus whole brain radiotherapy (WBRT) 9%, radiosurgery 14%, WBRT alone 23%, supportive care 2%. 43% received subsequent treatment for brain metastases. 25%, 11% and 15% respectively developed local neurological progression only, new brain metastases only or both. Median overall survival following brain metastases diagnosis was 16.0 months (range 1–79.1 months). Breast (32%) and NSCLC (26%) were the most common primary tumours with median survivals of 26 and 16.9 months respectively (HR 0.6, p=0.07). Overall one year survival was 55% and two year survival 31.5%. 85 patients died of whom 37 (44%) had a neurological death. Conclusion Careful patient selection and multi-disciplinary management identifies a subset of patients with oligometastatic brain disease who benefit from aggressive local treatment. A dedicated joint neurosurgical/ neuro-oncology clinic for such patients is feasible and effective. It also offers the opportunity to better define management strategies and further research in this field. Consideration should be given to defining specific management pathways for these patients within general oncology practice.
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Affiliation(s)
- Jillian Maclean
- Department of Radiotherapy, University College London Hospital, Euston Road, London NW12BU, UK.
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118
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Kellogg RG, Munoz LF. Selective excision of cerebral metastases from the precentral gyrus. Surg Neurol Int 2013; 4:66. [PMID: 23776752 PMCID: PMC3683173 DOI: 10.4103/2152-7806.112189] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 04/01/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The surgical management of cerebral metastases to the eloquent cortex is a controversial topic. Precentral gyrus lesions are often treated with whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) because of the concern for causing new or worsened postoperative neurological deficits. However, there is evidence in the literature that radiation therapy carries significant risk of complication. We present a series of patients who were symptomatic from a precentral gyrus metastasis and underwent surgical excision. METHODS During a 2-year period from 2010 to 2012, 17 consecutive patients harboring a cerebral metastasis within the precentral gyrus underwent microsurgical resection. All patients were discussed at a multi-disciplinary tumor board. The prerequisite for neurosurgical treatment was stable systemic disease and life expectancy greater than 6 months as determined by the patient's oncologist. Patients also were required to harbor a symptomatic lesion within the motor cortex, defined as the precentral gyrus. RESULTS We present the 3-month neurological outcome for this group of patients. Surgery was uneventful and without any severe perioperative complications in all 17 patients. At 3 month follow up, symptoms had improved or been stabilized in 94.1% of patients and were worsened in 5.9%. CONCLUSION Our results have shown that surgery for cerebral metastases in the precentral gyrus can be done safely and improve or stabilize the neurological function of most patients. Microsurgical resection of precentral gyrus metastases should be a treatment option for patients with single or multiple lesions who present a focal neurologic deficit. This can be performed safely and without intraoperative cortical mapping.
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Affiliation(s)
- Robert G Kellogg
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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119
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Oermann EK, Kress MAS, Collins BT, Collins SP, Morris D, Ahalt SC, Ewend MG. Predicting Survival in Patients With Brain Metastases Treated With Radiosurgery Using Artificial Neural Networks. Neurosurgery 2013; 72:944-51; discussion 952. [DOI: 10.1227/neu.0b013e31828ea04b] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Artificial neural networks (ANNs) excel at analyzing challenging data sets and can be exceptional tools for decision support in clinical environments. The present study pilots the use of ANNs for determining prognosis in neuro-oncology patients.
OBJECTIVE:
To determine whether ANNs perform better at predicting 1-year survival in a group of patients with brain metastasis compared with traditional predictive tools.
METHODS:
ANNs were trained on a multi-institutional data set of radiosurgery patients to predict 1-year survival on the basis of several input factors. A single ANN, an ensemble of 5 ANNs, and logistic regression analyses were compared for efficacy. Sensitivity analysis was used to identify important variables in the ANN model.
RESULTS:
A total of 196 patients were divided up into training, testing, and validation data sets consisting of 98, 49, and 49 patients, respectively. Patients surviving at 1 year tended to be female (P = .001) and of good performance status (P = .01) and to have favorable primary tumor histology (P = .001). The pooled voting of 5 ANNs performed significantly better than the multivariate logistic regression model (P = .02), with areas under the curve of 84% and 75%, respectively. The ensemble also significantly outperformed 2 commonly used prognostic indexes. Primary tumor subtype and performance status were identified on sensitivity analysis to be the most important variables for the ANN.
CONCLUSION:
ANNs outperform traditional statistical tools and scoring indexes for predicting individual patient prognosis. Their facile implementation, robustness in the presence of missing data, and ability to continuously learn make them excellent choices for use in complicated clinical environments.
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Affiliation(s)
- Eric K. Oermann
- Department of Neurosurgery and the Lineberger Comprehensive Cancer Center
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Marie-Adele S. Kress
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Brian T. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - Sean P. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | | | - Stanley C. Ahalt
- Department of Computer Science, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Renaissance Computing Institute, Chapel Hill, North Carolina
| | - Matthew G. Ewend
- Department of Neurosurgery and the Lineberger Comprehensive Cancer Center
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Utilidad del Palliative Performance Scale v2 para la estimación de supervivencia en enfermos con cáncer avanzado. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.medipa.2012.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Rudra S, Narang AK, Pawlik TM, Wang H, Jaffee EM, Zheng L, Le DT, Cosgrove D, Hruban RH, Fishman EK, Tuli R, Laheru DA, Wolfgang CL, Diaz LA, Herman JM. Evaluation of predictive variables in locally advanced pancreatic adenocarcinoma patients receiving definitive chemoradiation. Pract Radiat Oncol 2012; 2:77-85. [PMID: 23585823 DOI: 10.1016/j.prro.2011.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To analyze a single-center experience with locally advanced pancreatic cancer (LAPC) patients treated with chemoradiation (CRT) and to evaluate predictive variables of outcome. METHODS AND MATERIALS LAPC patients at our institution between 1997 and 2009 were identified (n = 109). Progression-free survival (PFS) and overall survival (OS) were assessed using Kaplan-Meier analysis. Cox proportional hazard models were used to evaluate predictive factors for survival. Patterns of failure were characterized, and associations between local progression and distant metastasis were explored. RESULTS Median OS was 12.1 months (2.5-34.7 months) and median PFS was 6.7 months (1.1-34.7 months). Poor prognostic factors for OS include Karnofsky performance status ≤80 (P = .0062), treatment interruption (P = .0474), and locally progressive disease at time of first post-therapy imaging (P = .0078). Karnofsky performance status ≤80 (P = .0128), pretreatment CA19-9 >1000 U/mL (P = .0224), and treatment interruption (P = .0009) were poor prognostic factors for PFS. Both local progression (36%) and distant failure (62%) were common. Local progression was associated with a higher incidence of metastasis (P < .0001) and decreased time to metastasis (P < .0001). CONCLUSIONS LAPC patients who suffer local progression following definitive CRT may experience inferior OS and increased risk of metastasis, warranting efforts to improve control of local disease. However, patients with poor pretreatment performance status, elevated CA19-9 levels, and treatment interruptions may experience poor outcomes despite aggressive management with CRT, and may optimally be treated with induction chemotherapy or supportive care. Novel therapies aimed at controlling both local and systemic progression are needed for patients with LAPC.
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Affiliation(s)
- Sonali Rudra
- Department of Radiation and Cellular Oncology University of Chicago, Chicago, Illinois
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Niegisch G, Fimmers R, Siener R, Park SI, Albers P. Prognostic Factors in Second-Line Treatment of Urothelial Cancers With Gemcitabine and Paclitaxel (German Association of Urological Oncology Trial AB20/99). Eur Urol 2011; 60:1087-96. [DOI: 10.1016/j.eururo.2011.07.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 07/26/2011] [Indexed: 10/17/2022]
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Manola J, Royston P, Elson P, McCormack JB, Mazumdar M, Négrier S, Escudier B, Eisen T, Dutcher J, Atkins M, Heng DYC, Choueiri TK, Motzer R, Bukowski R. Prognostic model for survival in patients with metastatic renal cell carcinoma: results from the international kidney cancer working group. Clin Cancer Res 2011; 17:5443-50. [PMID: 21828239 DOI: 10.1158/1078-0432.ccr-11-0553] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To develop a single validated model for survival in metastatic renal cell carcinoma (mRCC) using a comprehensive international database. EXPERIMENTAL DESIGN A comprehensive database of 3,748 patients including previously reported clinical prognostic factors was established by pooling patient-level data from clinical trials. Following quality control and standardization, descriptive statistics were generated. Univariate analyses were conducted using proportional hazards models. Multivariable analysis using a log-logistic model stratified by center and multivariable fractional polynomials was conducted to identify independent predictors of survival. Missing data were handled using multiple imputation methods. Three risk groups were formed using the 25th and 75th percentiles of the resulting prognostic index. The model was validated using an independent data set of 645 patients treated with tyrosine kinase inhibitor (TKI) therapy. RESULTS Median survival in the favorable, intermediate and poor risk groups was 26.9 months, 11.5 months, and 4.2 months, respectively. Factors contributing to the prognostic index included treatment, performance status, number of metastatic sites, time from diagnosis to treatment, and pretreatment hemoglobin, white blood count, lactate dehydrogenase, alkaline phosphatase, and serum calcium. The model showed good concordance when tested among patients treated with TKI therapy (C statistic = 0.741, 95% CI: 0.714-0.768). CONCLUSIONS Nine clinical factors can be used to model survival in mRCC and form distinct prognostic groups. The model shows utility among patients treated in the TKI era.
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Affiliation(s)
- Judith Manola
- Eastern Cooperative Oncology Group Statistical Office, Dana-Farber Cancer Institute, Boston, MA 02215, USA.
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Owusu C, Koroukian SM, Schluchter M, Bakaki P, Berger NA. Screening older cancer patients for a Comprehensive Geriatric Assessment: A comparison of three instruments. J Geriatr Oncol 2011; 2:121-129. [PMID: 21927633 DOI: 10.1016/j.jgo.2010.12.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND: The Vulnerable Elders Survey (VES-13) has been validated for screening older cancer patients for a Comprehensive Geriatric Assessment (CGA). To identify a widely acceptable approach that encourages oncologists to screen older cancer patients for a CGA, we examined the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and Karnofsky Index of Performance Status (KPS) scales' ability to identify abnormalities on a CGA and compared the performance of the two instruments with the VES-13. METHODS: We enrolled 117 participants, ≥65 years with stage I-IV cancer into this cross-sectional study. Our primary outcome variable was ≥two abnormalities on the CGA, (Yes or No). We employed receiver operating characteristic curve analysis to compare the discriminatory abilities of the three instruments to identify ≥two abnormalities on the CGA. RESULTS: Of the 117 participants, 43% had ≥two abnormalities on the CGA. The VES-13 was predictive of ≥two abnormalities on the CGA, area under the curve (AUC)=0.85 [(95% CI: 0.78-0.92); sensitivity=88%, specificity=69%, at cut-off ≥3]. The ECOG-PS and KPS showed similar discriminatory powers, AUC=0.88 [(95% CI: 0.83-0.94); sensitivity=94%, specificity=55%, at cut-off ≥1]; and AUC=0.90 [(95% CI: 0.84-0.96); sensitivity=78%, specificity=91%, at cut-off ≤80%], respectively. CONCLUSION: The ECOG-PS and KPS were equivalent to the VES-13 in identifying older cancer patients with at least two abnormalities on the CGA. Given that oncologists are already conversant with the KPS and ECOG-PS, these two instruments offer medical oncologists a widely acceptable approach for screening older patients for a CGA.
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Affiliation(s)
- Cynthia Owusu
- Division of Hematology/Oncology, University Hospitals of Cleveland, Cleveland, USA
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