A new palliative prognostic score: a first step for the staging of terminally ill cancer patients. Italian Multicenter and Study Group on Palliative Care

Chemotherapy and palliative care near end-of life: examining the appropriateness at a cancer institute for colorectal cancer patients

BACKGROUND

Appropriate cessation of chemotherapy and timely referral of patients to hospice services are crucial for the quality of care near death. We investigated the quality of care in our Cancer Institute in very advanced metastatic colorectal cancer patients treated in real life.

PATIENTS AND METHODS

We performed a retrospective analysis of electronic medical data of patients with metastatic colorectal cancer who were candidates for chemotherapy during the study period (1 January 2007-30 June 2014) and died before 31 December 2014. Quality-of-cancer-care indicators were calculated for the overuse of chemotherapy and referral to hospice. Predictive factors of chemotherapy discontinuation and hospice referral in end-of life care were investigated using parametric and nonparametric methods.

RESULTS

Of the 365 patients who died before 31 December 2014, 26 (7.1%) received chemotherapy in the last 14 days of life and 36 (9.8%) started a new chemotherapy regimen in the last 30 days of life. Factors associated with the overuse of chemotherapy were being < 70 years of age for both indicators and not having received advanced chemotherapy treatments for the former indicator. The majority of patients (74.7%) had access to hospice services, of whom only a small percentage (7.2%) accessed them very near to death.

CONCLUSIONS

According to the criteria used, our Institute provides a good quality of cancer care for dying colorectal cancer patients, measured by the use of chemotherapy and referral to hospice in their last days of life.

Physical Exercise: An Evaluation of a New Clinical Biomarker of Survival in Hospice Patients

PURPOSE

Survival analysis is an important issue in palliative care. However, there is a lack of quality clinical biomarkers for assessing survival, especially in bedridden patients. Recent research supports the benefit of physiotherapy in palliative care, as majority of hospice patients are able to perform physical therapy. We propose the hypothesis that the difference in activity during physical exercise can be used as a biomarker of survival in hospice care.

METHODS

We examined 536 consecutive patients who performed physical exercises in our hospice from March 2013 to July 2017. Univariate, multivariate, and Kaplan-Meier analysis were performed to explore the association between the level of physical exercise activity and survival.

RESULTS

Physical exercises were performed by almost 70% of our hospice patients. The patients who initially performed active exercises lived longer, on average, compared to patients who only managed passive exercises (15 days vs 6 days, hazard ratio 0.60, 0.49-0.74). Surprisingly, the difference in survival based on the level of physical activity remained consistent regardless of the patient performance score, emphasizing its usefulness as an independent survival biomarker in a hospice setting. This tool also gave us an option to recognize a significant proportion of bedridden patients performing active exercises (30%), previously unrecognized using standard performance scales, exhibiting longer survival compared to others with the same performance score.

CONCLUSION

Patients' level of activity during physical exercises has the potential to be a valuable new clinical biomarker in palliative care, whether used individually or combined with commonly used performance scales.

The 'surprise' question in paediatric palliative care: A prospective cohort study

BACKGROUND

The question 'would you be surprised if this patient died in the next 12-months' is widely used for identifying adult patients in the last year of life. However, this has not yet been studied in children.

AIM

To assess the prognostic accuracy of the surprise question when used by a multidisciplinary team to predict survival outcomes of children with life-limiting conditions over a 3 and 12 month period.

DESIGN

A prospective cohort study.

SETTING/PARTICIPANTS

Six multidisciplinary team members working in a children's hospice answered a 3 and 12 month surprise question about 327 children who were either newly referred or receiving care at the hospice between 2011 and 2013.

RESULTS

The prognostic accuracy of the multidisciplinary team for the 3 (and 12)month surprise question were: sensitivity 83.3% (83.3%), specificity 93.2% (70.7%), positive predictive value 41.7% (23.6%), negative predictive value 99% (97.5%) and accuracy 92.6% (71.9%). Patients with a 'no' response had an increased risk of death at 3 (hazard ratio, 22.94, p ⩽ 0.001) and 12 months (hazard ratio, 6.53, p ⩽ 0.001).

CONCLUSION

The surprise question is a highly sensitive prognostic tool for identifying children receiving palliative care who are in the last 3 and 12 months of life. The tool is accurate at recognising children during stable periods demonstrated through a high negative predictive value. In practice, this tool could help identify children who would benefit from specialist end of life care, act as a marker to facilitate communications on advance care planning and assist in resource allocation.

Reduced use of chemotherapy at the end of life in an integrated-care model of oncology and palliative care

Aims and Background

When there is little hope of a clinical benefit, too delayed a withdrawal from chemotherapy might be detrimental for a patient's quality of life. We evaluated appropriately timed cessation of chemotherapy in our Oncology Department after integration of a Supportive and Palliative Care Unit.

Methods

We carried out a review of deceased patients in our department from January 2006 to December 2009. Activities of the Supportive and Palliative Care Unit started in late 2007. We analyzed the characteristics of patients near the end of life and chemotherapy use within 30 days of death as an aggressiveness of cure index.

Results

During the considered period, 361 hospitalized patients died: 69 in 2006, 77 in 2007, 97 in 2008 and 118 in 2009; 102 never received chemotherapy. Sixty-one of the remaining 259 patients died within 30 days of the last drug administration. The percentage of patients receiving chemotherapy in their last 30 days fell from 19% in 2006 and 20% in 2007, to 16% in 2008 and 14% in 2009.

Conclusions

Supportive and Palliative Care Unit integration decreased chemotherapy use in the last 30 days of life. A careful evaluation of prognostic factors of advanced cancer patients and provision of appropriate supportive and palliative cares can reduce the use of futile anticancer chemotherapy and preserve a patient's qualify of life.

Home Artificial Nutrition in Advanced Cancer Patients

Aims and background

Malnutrition is over 50% in advanced cancer patients and is related to a decreased survival. Cachexia is the first reason for death in 4–23% of cases. The aim of the study was to estimate the appropriateness of the criteria to select patients for home artificial nutrition and its effectiveness to avoid death from cachexia and to improve quality of life in patients with advanced cancer assisted at home by the National Tumor Association (ANT) Foundation.

Methods and study design

The criteria for patient selection are: inadequate caloric intake ± malnutrition; life expectancy ≥6 weeks; suitable psycho-physical conditions; informed consent. The measured parameters were sex, age, tumor site, food intake, nutritional status, Karnofsky performance status, indication for home artificial nutrition, type of home artificial nutrition (enteral or parenteral), and survival after starting home artificial nutrition.

Results

The ANT Foundation assisted 29,348 patients in Bologna and its province from July 1990 to July 2012. Home artificial nutrition had been submitted to 618 patients (2.1%): enteral to 285/618 (46.1%) and parenteral to 333/618 (53.9%). Access routes for home artificial nutrition were: 39% nasogastric tube, 26% percutaneous endoscopic gastrostomy, 33% digiunostomy, and 2% gastrostomy. The central venous catheters used for home artificial nutrition were: 61% non-tunneled, 13 peripherally inserted, 8% partially tunneled, and 18% totally implanted. By July 2012, all the patients had died. Duration of life ≥6 weeks was 78% (484/618). Karnofsky performance status was related to survival (P <0.0001): one month after starting home artificial nutrition, it decreased in 73 patients (12%), was unchanged in 414 (67%), and increased in 131 (21%).

Conclusions

The low incidence of home artificial nutrition over all the patients assisted by the ANT Foundation and the achievement to avoid death from cachexia in 78% prove the efficacy of the criteria of patient selection in order to prevent its excessive and indiscriminate use. It was effective in maintaining and improving the performance status in 88% of patients. Karnofsky performance status is a reliable prognostic index to start home artificial nutrition.

Efficacy of Cancer Chemotherapy in Relation to the Pretreatment Number of Lymphocytes in Patients with Metastatic Solid Tumors

The evidence of lymphocytopenia has been demonstrated to predict a poor prognosis in terms of survival in advanced cancer patients. This finding is not surprising because of the fundamental role of lymphocytes in mediating tumor cell destruction. Despite the importance of lymphocytes in the pathogenesis of cancer, there are only few data about the profile and the function of lymphocytes during the various antitumor therapies, and in particular the relation between lymphocyte pretreatment number and response to chemotherapy remains to be established. The present study was performed to evaluate whether the evidence of lymphocytopenia before the onset of treatment may influence the efficacy of chemotherapy in metastatic cancer patients affected by the most frequent tumor types. The study included 183 patients (lung cancer: 89; colorectal cancer: 63; breast cancer: 31), 95 of whom had been previously treated with chemotherapy. The chemotherapeutic regimens consisted of oxaliplatin plus 5-fluorouracil and folates in untreated colorectal cancer, weekly irinotecan in pretreated colorectal cancer, cisplatin plus gemcitabine or etoposide in untreated lung cancer, weekly vinorelbine in pretreated lung cancer, and taxotere in breast cancer patients who had been previously treated with anthracyclines. Lymphocyte count was considered to be abnormally low for values below 1500/mm3. Lymphocytopenia was found in 79/183 (43%) patients, without any significant differences in relation to tumor histology. A complete response (CR) was achieved in 6/104 patients with a normal lymphocyte count and in none of the 79 lymphocytopenic patients. A partial response (PR) was obtained in 39 patients with a normal lymphocyte count and in only eight patients with a low lymphocyte count prior to therapy. Therefore, irrespective of the type of chemotherapy, the objective tumor response rate (CR + PR) in lymphocytopenic patients was significantly lower than in patients with normal pretreatment lymphocyte counts (8/79 vs 45/104; p<0. 001). This study shows that the evidence of lymphocytopenia prior to chemotherapy is associated with a lower efficacy of treatment in terms of objective tumor regression rates in patients with metastatic solid tumors, and suggests that the action of chemotherapy may depend at least in part on an interaction with the antitumor immunity. Pretreatment lymphocyte count may represent a new, simple biological marker to be taken into consideration by oncologists in the chemotherapeutic treatment of metastatic cancer.

Development and validation of a set of six adaptable prognosis prediction (SAP) models based on time-series real-world big data analysis for patients with cancer receiving chemotherapy: A multicenter case crossover study

Background

We aimed to develop an adaptable prognosis prediction model that could be applied at any time point during the treatment course for patients with cancer receiving chemotherapy, by applying time-series real-world big data.

Methods

Between April 2004 and September 2014, 4,997 patients with cancer who had received systemic chemotherapy were registered in a prospective cohort database at the Kyoto University Hospital. Of these, 2,693 patients with a death record were eligible for inclusion and divided into training (n = 1,341) and test (n = 1,352) cohorts. In total, 3,471,521 laboratory data at 115,738 time points, representing 40 laboratory items [e.g., white blood cell counts and albumin (Alb) levels] that were monitored for 1 year before the death event were applied for constructing prognosis prediction models. All possible prediction models comprising three different items from 40 laboratory items (₄₀C₃ = 9,880) were generated in the training cohort, and the model selection was performed in the test cohort. The fitness of the selected models was externally validated in the validation cohort from three independent settings.

Results

A prognosis prediction model utilizing Alb, lactate dehydrogenase, and neutrophils was selected based on a strong ability to predict death events within 1–6 months and a set of six prediction models corresponding to 1,2, 3, 4, 5, and 6 months was developed. The area under the curve (AUC) ranged from 0.852 for the 1 month model to 0.713 for the 6 month model. External validation supported the performance of these models.

Conclusion

By applying time-series real-world big data, we successfully developed a set of six adaptable prognosis prediction models for patients with cancer receiving chemotherapy.

How accurate is the 'Surprise Question' at identifying patients at the end of life? A systematic review and meta-analysis

BACKGROUND

Clinicians are inaccurate at predicting survival. The 'Surprise Question' (SQ) is a screening tool that aims to identify people nearing the end of life. Potentially, its routine use could help identify patients who might benefit from palliative care services. The objective was to assess the accuracy of the SQ by time scale, clinician, and speciality.

METHODS

Searches were completed on Medline, Embase, CINAHL, AMED, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Open Grey literature (all from inception to November 2016). Studies were included if they reported the SQ and were written in English. Quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 26 papers were included in the review, of which 22 reported a complete data set. There were 25,718 predictions of survival made in response to the SQ. The c-statistic of the SQ ranged from 0.512 to 0.822. In the meta-analysis, the pooled accuracy level was 74.8% (95% CI 68.6-80.5). There was a negligible difference in timescale of the SQ. Doctors appeared to be more accurate than nurses at recognising people in the last year of life (c-statistic = 0.735 vs. 0.688), and the SQ seemed more accurate in an oncology setting 76.1% (95% CI 69.7-86.3).

CONCLUSIONS

There was a wide degree of accuracy, from poor to reasonable, reported across studies using the SQ. Further work investigating how the SQ could be used alongside other prognostic tools to increase the identification of people who would benefit from palliative care is warranted.

TRIAL REGISTRATION

PROSPERO CRD42016046564 .

Consideration of patient and disease characteristics in selecting radiation regimens for treatment of bone metastases

PURPOSE

Radiation therapy is one of the mainstays of treatment for painful bone metastases; however, the optimal fractionation and dosing of radiation for a given patient and disease characteristics are still subject to debate.

METHODS AND MATERIALS

We retrospectively examined 475 patients who received radiation for bone metastases at our institution from 2009 through 2014 and evaluated survival outcomes based on parameters of their first treatment course and patient demographics. Kaplan-Meier analysis was used to analyze factors associated with overall survival (OS). A recursive partition analysis (RPA) was used to generate a decision tree of patient characteristics resulting in significant differences in survival. A Cox model was used to verify the RPA and evaluate the significance of biologically equivalent dose (BED) along with other factors.

RESULTS

In our cohort, median age was 62 years and median Karnofsky performance status (KPS) was 70. Survival time by primary tumor type: breast (median, 35.9 months), prostate (12.8 months), other (median, 11.0 months), lung (median, 5.3 months), and gastrointestinal (median, 4.0 months) (P < .0001). Primary tumor type and KPS significantly affected survival, whereas age was also significant for survival in certain primary tumor types. Pain control was not found to be significantly affected by primary tumor type (P = .72) or BED (P = .14).

CONCLUSION

Our data demonstrate that selection of radiation fractionation schedules should take into account primary tumor type, KPS, and age, and we have generated an RPA model including these factors to help guide decision making. We also found that shorter fractionation schedules are as effective as longer fractionation schedules for pain control, regardless of primary tumor type.

Simultaneous Resection of Multiple Metastatic Brain Tumors with Multiple Keyhole Craniotomies

BACKGROUND

The proper management of symptomatic patients with 2 or more brain metastases is not entirely clear, and the surgical outcomes of these patients undergoing multiple simultaneous craniotomies have not been well described. In this article, we describe patient outcomes after simultaneously resecting metastatic lesions through multiple keyhole craniotomies.

METHODS

We conducted a retrospective review of data obtained for all patients undergoing resection of multiple brain metastases in one operation between 2014 and 2016. We describe a technique for resecting multiple metastatic lesions and share the patient outcomes of this operation.

RESULTS

Twenty patients with 46 tumor resections were included in the study. The primary site of metastases for the majority of patients was lung, followed by melanoma, renal, breast, colon, and testes. Nine of 20 (45%) patients had 2 preoperative intracranial lesions, and 11 (55%) had three or more. Karnofsky performance scales were calculated for 14 patients: postoperatively 10 of 14 (71%) scores improved, 2 of 14 (14%) worsened, and 2 of 14 (14%) remained unchanged. After surgery, 9 of 14 (64%) patients were weaned off steroids by 2-month follow-up. The overall median survival time from date of surgery was 10.8 months.

CONCLUSIONS

We present patient outcomes after simultaneously resecting metastatic brain tumors through multiple keyhole craniotomies in symptomatic patients. Our results suggest comparable outcomes and similar surgical risk compared with those undergoing resection of a single brain metastasis. Resection of multiple brain metastases may improve Karnofsky Performance Scale scores in the early postoperative period and allow patients to be weaned from steroids.

A systematically structured review of biomarkers of dying in cancer patients in the last months of life; An exploration of the biology of dying

BACKGROUND

The Neuberger review made a number of recommendations to improve end of life care, including research into the biology of dying. An important aspect of the biology of dying is the identification of biomarkers as indices of disease processes. Biomarkers have the potential to inform the current, limited understanding of the dying process and assist clinicians in recognising dying, in particular how to distinguish dying from reversible acute deterioration.

OBJECTIVES

To critically appraise the literature on biological factors that may be used as prognostic indicators in advanced cancer patients and to identify candidate biomarkers of the dying process that can be measured serially in cancer patients' bodily fluids.

METHODS

A systematically structured review was conducted using three electronic databases. A hand search of six peer-reviewed journals and conference abstracts was also conducted. Studies reporting prognostic biomarkers in cancer patients with a median survival of ≤90 days and post-mortem studies were included. Final levels of evidence and recommendations were made using the Evidence Based Medicine modified GRADE system.

RESULTS

30 articles were included. Seven prognostic biological factors demonstrated Grade A evidence (lymphocyte count, white blood cell count, serum C-reactive protein, albumin, sodium, urea and alkaline phosphatase). An additional eleven prognostic factors were identified with Grade B evidence (platelet count, international normalised ratio, serum vitamin B12, prealbumin, bilirubin, cholesterol, aspartate aminotransferase, alanine transaminase, lactate dehydrogenase, pseudocholinesterase and urate). A number of biomarkers were specifically identified in the last two weeks of life but limitations exist. No post-mortem studies met the inclusion criteria.

CONCLUSION

The biology of dying is an important area for future research, with the evidence focused on signs, symptoms and prognostic factors. This review identifies a number of common themes shared amongst advanced cancer patients and highlights candidate biomarkers which may be indicative of a common biological process to dying.

The Use of the Chuang's Prognostic Scale to Predict the Survival of Metastatic Colorectal Cancer Patients Receiving Palliative Systemic Anticancer Therapy

BACKGROUND

With the increasing number of agents active against cancer, advanced cancer patients including metastatic colorectal cancer (mCRC) patients may continue receiving palliative systemic anticancer therapy (PSAT) near the end-of-life. Validated palliative prognostic models, such as the Chuang's prognostic scale (CPS), may be helpful in identifying mCRC patients with limited survival who are unlikely to benefit from PSAT.

AIM

To test the ability of the CPS to predict the survival of mCRC under treatment with PSAT.

METHODS

CPS was prospectively assessed in 36 mCRC patients who were receiving PSAT. The scale is based on eight items: ascites, edema, cognitive impairment, liver and lung metastases, performance status, tiredness, and weight loss. The total CPS score ranges from 0 to 8.5 with the higher score indicating worse prognosis.

RESULTS

Patients were divided into two groups using a CPS cutoff score of 5, Group 1 with a CPS score ≤5 and Group 2 with a CPS score >5. Using this cutoff value, 3-month mortality was predicted with a positive predictive value of 71%, a negative predictive value of 77%, a sensitivity of 67%, a specificity of 81% and an overall accuracy of 75%. Group 1 patients had a longer median survival of 149 days (95% confidence interval [CI]: 82-216) in comparison to Group 2 patients who had a median survival of 61 days (95% CI: 35-87). The difference in survival was statistically significant (P = 0.01).

CONCLUSION

CPS may be useful in identifying mCRC patients with limited survival who are unlikely to benefit from PSAT.

A Systematic Review of Predictions of Survival in Palliative Care: How Accurate Are Clinicians and Who Are the Experts?

Background

Prognostic accuracy in palliative care is valued by patients, carers, and healthcare professionals. Previous reviews suggest clinicians are inaccurate at survival estimates, but have only reported the accuracy of estimates on patients with a cancer diagnosis.

Objectives

To examine the accuracy of clinicians’ estimates of survival and to determine if any clinical profession is better at doing so than another.

Data Sources

MEDLINE, Embase, CINAHL, and the Cochrane Database of Systematic Reviews and Trials. All databases were searched from the start of the database up to June 2015. Reference lists of eligible articles were also checked.

Eligibility Criteria

Inclusion criteria: patients over 18, palliative population and setting, quantifiable estimate based on real patients, full publication written in English. Exclusion criteria: if the estimate was following an intervention, such as surgery, or the patient was artificially ventilated or in intensive care.

Study Appraisal and Synthesis Methods

A quality assessment was completed with the QUIPS tool. Data on the reported accuracy of estimates and information about the clinicians were extracted. Studies were grouped by type of estimate: categorical (the clinician had a predetermined list of outcomes to choose from), continuous (open-ended estimate), or probabilistic (likelihood of surviving a particular time frame).

Results

4,642 records were identified; 42 studies fully met the review criteria. Wide variation was shown with categorical estimates (range 23% to 78%) and continuous estimates ranged between an underestimate of 86 days to an overestimate of 93 days. The four papers which used probabilistic estimates tended to show greater accuracy (c-statistics of 0.74–0.78). Information available about the clinicians providing the estimates was limited. Overall, there was no clear “expert” subgroup of clinicians identified.

Limitations

High heterogeneity limited the analyses possible and prevented an overall accuracy being reported. Data were extracted using a standardised tool, by one reviewer, which could have introduced bias. Devising search terms for prognostic studies is challenging. Every attempt was made to devise search terms that were sufficiently sensitive to detect all prognostic studies; however, it remains possible that some studies were not identified.

Conclusion

Studies of prognostic accuracy in palliative care are heterogeneous, but the evidence suggests that clinicians’ predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other.

Implications of Key Findings

Further research is needed to understand how clinical predictions are formulated and how their accuracy can be improved.

Validation of 2 Prognostic Models in Hospitalized Patients With Advanced Hematological Malignancies in Japan

Patients with advanced hematological malignancies are less likely to be referred to specialist palliative care services compared with patients having solid tumors. It has been reported that one of the most important reasons for the lack of referral is difficulties in the prognostication of terminally ill patients with hematologic malignancies. The study objective was to evaluate the predictive accuracy of the Palliative Prognostic Index (PPI) and the prognostic model developed by Kripp et al in hospitalized patients under the care of a hematologist. Using clinical charts, we retrospectively calculated the above scores. We reviewed the records of 114 patients admitted to the hematology ward. The inclusion criterion was patient with disease considered incurable using standard treatments. The prognostic models were assessed according to the original reports. Using PPI cutoff points of 2 and 4, we divided the patients into 3 groups of significantly different survival times ( P < .01). Moreover, we confirmed the usefulness of predicting survival <3 and <6 weeks using PPI scores of 6 and 4 as cutoff points, respectively. When we classified patients according to the prognostic model of Kripp et al, the high-risk group survived significantly shorter times than the intermediate- and low-risk groups ( P < .001). However, there was no significant difference in survival between the intermediate- and low-risk groups. Use of these models might enable physicians to provide more appropriate end-of-life care and to refer patients to palliative care earlier.

Clinician prediction of survival versus the Palliative Prognostic Score: Which approach is more accurate?

BACKGROUND

Clinician prediction of survival (CPS) has low accuracy in the advanced cancer setting, raising the need for prediction models such as the palliative prognostic (PaP) score that includes a transformed CPS (PaP-CPS) and five clinical/laboratory variables (PaP-without CPS). However, it is unclear if the PaP score is more accurate than PaP-CPS, and whether PaP-CPS helps to improve the accuracy of PaP score. We compared the accuracy among PaP-CPS, PaP-without CPS and PaP-total score in patients with advanced cancer.

PATIENTS AND METHODS

In this prospective study, PaP score was documented in hospitalised patients seen by palliative care. We compared the discrimination of PaP-CPS versus PaP-total and PaP-without CPS versus PaP-total using four indices: concordance statistics, area under the receiver-operating characteristics curve (AUC), net reclassification index and integrated discrimination improvement for 30-day survival and 100-day survival.

RESULTS

A total of 216 patients were enrolled with a median survival of 109 d (95% confidence interval [CI] 71-133 d). The AUC for 30-day survival was 0.57 (95% CI 0.47-0.67) for PaP-CPS, 0.78 (95% CI 0.7-0.87) for PaP-without CPS, and 0.73 (95% CI 0.64-0.82) for PaP-total score. PaP-total was significantly more accurate than PaP-CPS according to all four indices for both 30-day and 100-day survival (P < 0.001). PaP-without CPS was significantly more accurate than PaP-total for 30-day survival (P < 0.05).

CONCLUSION

We found that PaP score was more accurate than CPS, and the addition of CPS to the prognostic model reduced its accuracy. This study highlights the limitations of clinical gestalt and the need to use objective prognostic factors and models for survival prediction.

Neutrophil/lymphocyte ratio has a prognostic value for patients with terminal cancer

Background

Determining prognosis in advanced cancer is of key importance. Various prognostic scores have been developed. However, they are often very complex. In this study, we evaluated the feasibility of neutrophil/lymphocyte ratio (NLR) as an index to estimate survival in terminal cancer patients.

Methods

NLR was calculated retrospectively based on blood tests performed at 3 months, 2 months, 4 weeks, 3 weeks, 2 weeks, 1 week, and within 3 days before death in 160 cancer patients (82 men, 78 women; age range, 33–99 years; mean age, 69.8 years).

Results

NLR increased significantly with time (P < 0.0001). Mean NLR was significantly higher in patients who died within 4 weeks (29.82) than in those who lived more than 4 weeks (6.15). The NLR cutoff point was set at 9.21 according to receiver operating characteristic curve analysis (area under the curve, 0.82; 95 % confidence interval, 0.79–0.85). We inferred that life expectancy would be <4 weeks when NLR >9.21. The sensitivity, specificity, positive predictive value, and negative predictive value were 65.6, 84.1, 90.6, and 51.1 %, respectively. The positive and negative likelihood ratios were 4.125 and 0.409, respectively.

Conclusions

NLR appears to be a useful and simple parameter to predict the clinical outcomes of patients with terminal cancer.

Change in Food Intake Status of Terminally Ill Cancer Patients during Last Two Weeks of Life: A Continuous Observation

BACKGROUND

The oral food intake of terminally ill cancer patients is known to gradually decrease, but there are few reports about how oral intake changes around the terminal stage. It is important to clarify changes in oral food intake, as such changes affect the support and care of terminally ill cancer patients.

OBJECTIVE

We aimed to clarify changes in oral food intake in terminally ill cancer patients during the last 2 weeks before death.

METHODS

This retrospective cohort study was conducted at a designated cancer center hospital in Japan from January 2013 to June 2013. The subjects were recognized as clinically terminally ill cancer patients who were hospitalized for ≥14 days, and who had death as their reason for hospital discharge. One researcher investigated basic patient information and the food intake status of the subjects using their medical records. The basic information investigated was gender, age, type of cancer, and the presence of gastrointestinal obstruction 14 days prior to death. The Food Intake LEVEL Scale (FILS) was prospectively recorded.

RESULTS

After applying the exclusion criteria, 108 subjects were finally included in the analysis (59 males aged 70.3 ± 13.3 years; 49 females aged 70.3 ± 14.5 years). The FILS gradually declined, and half of the subjects were unable to take food orally 6 days before death. In 81 subjects, after excluding subjects with gastrointestinal obstruction, the FILS gradually declined, and half of the subjects were unable to take food orally 4 days prior to death.

CONCLUSIONS

Many terminally ill cancer patients can take food orally up to a few days prior to their death. Therefore, various specialists should support the oral intake of terminally ill cancer patients until immediately before their death.

Neutrophil-Lymphocyte Ratio Predicts Survival in Terminal Cancer Patients

BACKGROUND

Neutrophil-lymphocyte count ratio (NLR) is a prognostic factor in cancer, although its prognostic significance in terminally ill cancer patients is not clear.

OBJECTIVE

We investigated the association of NLR with survival in patients with terminal cancer.

METHODS

We retrospectively investigated 205 consecutive patients with terminal cancer admitted to a palliative care unit during 2014.

RESULTS

The median value of NLR was 9.7. In univariable analysis, NLR of 10 or more was significantly associated with shorter survival and NLR further discriminated survival of each palliative prognostic index (PPI) group. In multivariable analysis, increased NLR (≥10) was associated with shorter survival (hazards ratio [HR] 1.54, p<0.005), along with poor performance status (HR 1.55, p < 0.011), high PPI score (HR 1.59, p<0.003), and hyperbilirubinemia (HR 1.84, p < 0.001).

CONCLUSION

Our results suggest that elevated NLR was an independent prognostic factor for poor survival in patients with terminal cancer.

One-Year Mortality in Older Patients with Cancer: Development and External Validation of an MNA-Based Prognostic Score

Purpose

The MNA (Mini Nutritional Assessment) is known as a prognosis factor in older population. We analyzed the prognostic value for one-year mortality of MNA items in older patients with cancer treated with chemotherapy as the basis of a simplified prognostic score.

Methods

The prospective derivation cohort included 606 patients older than 70 years with an indication of chemotherapy for cancers. The endpoint to predict was one-year mortality. The 18 items of the Full MNA, age, gender, weight loss, cancer origin, TNM, performance status and lymphocyte count were considered to construct the prognostic model. MNA items were analyzed with a backward step-by-step multivariate logistic regression and other items were added in a forward step-by-step regression. External validation was performed on an independent cohort of 229 patients.

Results

At one year 266 deaths had occurred. Decreased dietary intake (p = 0.0002), decreased protein-rich food intake (p = 0.025), 3 or more prescribed drugs (p = 0.023), calf circumference <31cm (p = 0.0002), tumor origin (p<0.0001), metastatic status (p = 0.0007) and lymphocyte count <1500/mm³ (0.029) were found to be associated with 1-year mortality in the final model and were used to construct a prognostic score. The area under curve (AUC) of the score was 0.793, which was higher than the Full MNA AUC (0.706). The AUC of the score in validation cohort (229 subjects, 137 deaths) was 0.698.

Conclusion

Key predictors of one-year mortality included cancer cachexia clinical features, comorbidities, the origin and the advanced status of the tumor. The prognostic value of this model combining a subset of MNA items and cancer related items was better than the full MNA, thus providing a simple score to predict 1-year mortality in older patients with an indication of chemotherapy.

Shock Index and Decreased Level of Consciousness as Terminal Cancer Patients' Survival Time Predictors: A Retrospective Cohort Study

CONTEXT

Predicting prognosis using noninvasive and objective tools may facilitate end-of-life decisions for terminal cancer patients, their families, and other health care professionals.

OBJECTIVES

To investigate if the shock index (SI), along with decreased level of consciousness (DLOC), is a reliable tool for predicting short-term survival time in terminal cancer patients.

METHODS

A two-part retrospective cohort study was performed on 670 consecutive adult hospice patients. Part 1 of the study was performed to investigate the reliability of SI and DLOC on admission and to make a simple tool for predicting survival time. Part 2 of the study was to validate the tool's reproducibility and analyze the correlation between SI, DLOC, and survival time.

RESULTS

In Part 1, multivariate Cox proportional hazards analyses for all study patients revealed that SI ≥ 1.0 in patients with DLOC was a significant risk factor of death (hazard ratio 3.08; 95% CI 1.72-5.53; P = 0.000). Generalized additive models confirmed that DLOC patients with SI = 1.0 had 9.58 days of mean survival time (MST). Receiver operating characteristic curve analyses of SI in patients with DLOC revealed that a survival time of less than three days was most reliably predicted. In Part 2, an increase in SI statistically decreased survival time. The upper 95% CIs of the calculated mean survival time for DLOC patients with SI ≥ 1.0 were less than one week. Bootstrap analyses revealed that the 95% CIs of the predicted survival time were 4.54-6.18 days in DLOC patients with SI = 1.0.

CONCLUSION

An SI ≥ 1.0 along with DLOC is a highly reliable tool for predicting short-term survival time in terminal cancer patients.

Validation of the Modified Glasgow Prognostic Score in Advanced Cancer Patients Receiving Palliative Care

CONTEXT

The modified Glasgow Prognostic Score (mGPS) is a well-known marker of systemic inflammatory response previously associated with poor prognoses in cancer.

OBJECTIVES

We investigated the relationships between mGPS and clinical variables and the prognostic impact of mGPS in patients with advanced cancer starting palliative care (PC).

METHODS

Data from two prospective studies conducted at a tertiary cancer center were analyzed (N = 459). Data regarding patient characteristics, Karnofsky Performance Status, and blood samples were collected at the initial evaluation. The mGPS was calculated as follows: C-reactive protein (CRP) < 10 mg/L = 0; CRP > 10 mg/L = 1, CRP > 10 mg/L and albumin < 35 g/L = 2. Chi-square or Fisher exact tests were used for comparisons of categorical variables; continuous variables were compared using the Mann-Whitney U test. For the survival analysis, Cox regression analyses were performed.

RESULTS

mGPS of 0, 1, and 2 were assigned to 79.7%, 6.8%, and 13.5% of the patients, respectively. A positive association between hepatic metastasis (P = 0.004), primary lung cancer (P = 0.021), PC only (P < 0.001), lower Karnofsky Performance Status (P < 0.001), and higher systemic inflammation (mGPS 1/2) was found. Median overall survival was 1, 3, and 5.7 months for mGPS of 2, 1, and 0, respectively. After multivariate analyses, mGPS remained an independent prognostic marker (mGPS 1, hazard ratio 2.066, P = 0.001; mGPS 2, hazard ratio 2.664, P < 0.001).

CONCLUSION

Systemic inflammatory response is associated with a low functional status, primary lung cancers, and tumors with hepatic metastasis. When starting PC, an mGPS definition may have clinical utility implications, by identifying three groups of patients with advanced cancer patients with distinct survival outcomes.

Prognostication of Survival in Patients With Advanced Cancer: Predicting the Unpredictable?

BACKGROUND

Prognosis is a key driver of clinical decision-making. However, available prognostication tools have limited accuracy and variable levels of validation.

METHODS

Principles of survival prediction and literature on clinician prediction of survival, prognostic factors, and prognostic models were reviewed, with a focus on patients with advanced cancer and a survival rate of a few months or less.

RESULTS

The 4 principles of survival prediction are (a) prognostication is a process instead of an event, (b) prognostic factors may evolve over the course of the disease, (c) prognostic accuracy for a given prognostic factor/ tool varies by the definition of accuracy, the patient population, and the time frame of prediction, and (d) the exact timing of death cannot be predicted with certainty. Clinician prediction of survival is the most commonly used approach to formulate prognosis. However, clinicians often overestimate survival rates with the temporal question. Other clinician prediction of survival approaches, such as surprise and probabilistic questions, have higher rates of accuracy. Established prognostic factors in the advanced cancer setting include decreased performance status, delirium, dysphagia, cancer anorexia-cachexia, dyspnea, inflammation, and malnutrition. Novel prognostic factors, such as phase angle, may improve rates of accuracy. Many prognostic models are available, including the Palliative Prognostic Score, the Palliative Prognostic Index, and the Glasgow Prognostic Score.

CONCLUSIONS

Despite the uncertainty in survival prediction, existing prognostic tools can facilitate clinical decision-making by providing approximated time frames (months, weeks, or days). Future research should focus on clarifying and comparing the rates of accuracy for existing prognostic tools, identifying and validating novel prognostic factors, and linking prognostication to decision-making.

Development of a User-Friendly Graphic Tool to Estimate Individualized Survival Curves for Advanced Cancer Patients in Hospice Care

This prospective study aimed to develop an individualized prognostic tool for predicting the survival probability at any given point for a hospice patient with advanced cancer. A total of 286 patients with advanced cancer were included in the study. Median observational time was 18 days (range: 1 to 60 days). Cox proportional hazards regression analysis revealed that faster heart rate (hazard ratio [HR] = 1.01), jaundice (HR = 2.32), poorer performance status (HR = 2.01), and antifungal treatment (HR = 1.62) were independent predictors of shorter survival time. Patients with infections who received aminoglycoside treatments (HR = 0.45) were associated with longer survival times. Based on this model, we could construct a covariate-adjusted individualized survival curve for a given patient according to his or her clinical condition. This user-friendly tool for estimating the survival probability of patients with advanced cancer in hospice settings could facilitate clinical decision making and medical care planning.

Patient-Reported Outcomes for Determining Prognostic Groups in Veterans With Advanced Cancer

CONTEXT

Physicians overestimate survival in patients with advanced cancer. Patient-reported outcomes could provide another way to estimate survival. We previously reported four prognostic groups based on Karnofsky Performance Status, Functional Assessment of Cancer Therapy physical well-being subscale, and Memorial Symptom Assessment Scale-Short Form physical symptom distress subscale scores.

OBJECTIVES

To determine the validity of these four prognostic groups.

METHODS

We performed prospective surveys. Data from a total of 880 Veterans Affairs Medical Center patients, 417 in the First Cohort and 463 in the Validation Cohort, were analyzed. Both inpatients and outpatients were prospectively recruited in Institutional Review Board-approved studies from August 1999 to September 2009. Survival was measured from the date of entry until death or December 1, 2009. Patients completed self-assessments with the Functional Assessment of Cancer Therapy and Memorial Symptom Assessment Scale-Short Form. Analysis of variance was used to test differences between groups in continuous variables; a generalized Wilcoxon test was used for differences between groups for survival.

RESULTS

The average age in the Validation Cohort was 66.5 years and 98% were men. The majority of patients had metastatic cancer (90%), with lung (28%) and prostate (26%) cancers being predominant. The median Karnofsky Performance Status was 70. Median survival was 33, 46.5, 124, and 209.5 days for the four prognostic groups (P < 0.0001, all pair-wise comparisons P < 0.02).

CONCLUSION

The four prognostic groups remained distinct in the prospective cohort. Small differences in patient-reported physical well-being can halve survival estimates. Patient-reported outcomes can correct for physician overestimate of prognosis. This study provides a way to use patient-reported outcomes for prognosis in patients with advanced cancer, with important implications for assessment.

Multidisciplinary Prognostication Using the Palliative Prognostic Score in an Australian Cancer Center

CONTEXT

Accurate prognostication is important in oncology and palliative care. A multidisciplinary approach to prognostication provides a novel approach, but its accuracy and application is poorly researched. In this study, we describe and analyze our experience of multidisciplinary prognostication in palliative care patients with cancer.

OBJECTIVES

To assess our accuracy of prognostication using multidisciplinary team prediction of survival (MTPS) alone and within the Palliative Prognostic (PaP) Score.

METHODS

This retrospective study included all new patients referred to a palliative care consultation service in a tertiary cancer center between January 2010 and December 2011. Initial assessment data for 421 inpatients and 223 outpatients were analyzed according to inpatient and outpatient groups to evaluate the accuracy of prognostication using MTPS alone and within the PaP score (MTPS-PaP) and their correlation with overall survival.

RESULTS

Inpatients with MTPS-PaP group A, B, and C had a median survival of 10.9, 3.4, and 0.7 weeks, respectively, and a 30-day survival probability of 81%, 40%, and 10%, respectively. Outpatients with MTPS-PaP group A and B had a median survival of 17.3 and 5.1 weeks, respectively, and a 30-day survival probability of 94% and 50%, respectively. MTPS overestimated survival by a factor of 1.5 for inpatients and 1.2 for outpatients. The MTPS-PaP score correlated better than MTPS alone with overall survival.

CONCLUSION

This study suggests that a multidisciplinary team approach to prognostication within routine clinical practice is possible and may substitute for single clinician prediction of survival within the PaP score without detracting from its accuracy. Multidisciplinary team prognostication can assist treating teams to recognize and articulate prognosis, facilitate treatment decisions, and plan end-of-life care appropriately. PaP was less useful in the outpatient setting, given the longer survival interval of the outpatient palliative care patient group.

Survival prediction for advanced cancer patients in the real world: A comparison of the Palliative Prognostic Score, Delirium-Palliative Prognostic Score, Palliative Prognostic Index and modified Prognosis in Palliative Care Study predictor model

PURPOSE

The aim of this study was to investigate the feasibility and accuracy of the Palliative Prognostic Score (PaP score), Delirium-Palliative Prognostic Score (D-PaP score), Palliative Prognostic Index (PPI) and modified Prognosis in Palliative Care Study predictor model (PiPS model).

PATIENTS AND METHODS

This multicentre prospective cohort study involved 58 palliative care services, including 19 hospital palliative care teams, 16 palliative care units and 23 home palliative care services, in Japan from September 2012 to April 2014. Analyses were performed involving four patient groups: those treated by palliative care teams, those in palliative care units, those at home and those receiving chemotherapy.

RESULTS

We recruited 2426 participants, and 2361 patients were finally analysed. Risk groups based on these instruments successfully identified patients with different survival profiles in all groups. The feasibility of PPI and modified PiPS-A was more than 90% in all groups, followed by PaP and D-PaP scores; modified PiPS-B had the lowest feasibility. The accuracy of prognostic scores was ⩾69% in all groups and the difference was within 13%, while c-statistics were significantly lower with the PPI than PaP and D-PaP scores.

CONCLUSION

The PaP score, D-PaP score, PPI and modified PiPS model provided distinct survival groups for patients in the three palliative care settings and those receiving chemotherapy. The PPI seems to be suitable for routine clinical use for situations where rough estimates of prognosis are sufficient and/or patients do not want invasive procedure. If clinicians can address more items, the modified PiPS-A would be a non-invasive alternative. In cases where blood samples are available or those requiring more accurate prediction, the PaP and D-PaP scores and modified PiPS-B would be more appropriate.

Surprise Questions for Survival Prediction in Patients With Advanced Cancer: A Multicenter Prospective Cohort Study

BACKGROUND

Predicting the short-term survival in cancer patients is an important issue for patients, family, and oncologists. Although the prognostic accuracy of the surprise question has value in 1-year mortality for cancer patients, the prognostic value for short-term survival has not been formally assessed. The primary aim of the present study was to assess the prognostic value of the surprise question for 7-day and 30-day survival in patients with advanced cancer.

PATIENTS AND METHODS

The present multicenter prospective cohort study was conducted in Japan from September 2012 through April 2014, involving 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services.

RESULTS

We recruited 2,425 patients and included 2,361 for analysis: 912 from hospital-based palliative care teams, 895 from hospital palliative care units, and 554 from home-based palliative care services. The sensitivity, specificity, positive predictive value, and negative predictive value of the 7-day survival surprise question were 84.7% (95% confidence interval [CI], 80.7%-88.0%), 68.0% (95% CI, 67.3%-68.5%), 30.3% (95% CI, 28.9%-31.5%), and 96.4% (95% CI, 95.5%-97.2%), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the 30-day surprise question were 95.6% (95% CI, 94.4%-96.6%), 37.0% (95% CI, 35.9%-37.9%), 57.6% (95% CI, 56.8%-58.2%), and 90.4% (95% CI, 87.7%-92.6%), respectively.

CONCLUSION

Surprise questions are useful for screening patients for short survival. However, the high false-positive rates do not allow clinicians to provide definitive prognosis prediction.

IMPLICATIONS FOR PRACTICE

The findings of this study indicate that clinicians can screen patients for 7- or 30-day survival using surprise questions with 90% or more sensitivity. Clinicians cannot provide accurate prognosis estimation, and all patients will not always die within the defined periods. The screened patients can be regarded as the subjects to be prepared for approaching death, and proactive discussion would be useful for such patients.

Associations between oral complications and days to death in palliative care patients

PURPOSE

Adverse oral symptoms gradually appear in advanced cancer patients as the disease progresses. We retrospectively investigated the associations between the incidence of oral problems and the days to death (DTD) in patients receiving palliative care.

METHODS

The dental assessment sheets and medical charts of 105 patients who had been admitted into the palliative care unit at our hospital were examined. Case data included evaluations of organic and functional oral conditions at the time of admission for all patients. The cohort was divided into two groups according to the DTD as the short group (<28 days from the time of dental assessment until death) and the long group (≥28 days). We compared the incidences of organic and functional oral problems between these groups.

RESULTS

Dry mouth, tongue inflammation, and bleeding spots were significantly more frequent in the short group than in the long group (78 vs. 54% for dry mouth, 67 vs. 46% for tongue inflammation, 35 vs. 14% for bleeding spots, respectively; p < 0.05). Tongue coating and candidiasis were comparable between the two groups. Dysphagia was significantly more common in the short group (43%) than in the long group (20%) (p = 0.01), as was assistance with oral health care (76 vs. 50%) (p = 0.01).

CONCLUSIONS

Our findings suggest that, during palliative care, oral complications appear more frequently when the DTD period is shorter. These symptoms may be useful indicators when deciding on the proper timing of intensive oral care intervention to decrease oral problems and pain in terminally ill patients.

Independent validation of the modified prognosis palliative care study predictor models in three palliative care settings

CONTEXT

Accurate prognostic information in palliative care settings is needed for patients to make decisions and set goals and priorities. The Prognosis Palliative Care Study (PiPS) predictor models were presented in 2011, but have not yet been fully validated by other research teams.

OBJECTIVES

The primary aim of this study is to examine the accuracy and to validate the modified PiPS (using physician-proxy ratings of mental status instead of patient interviews) in three palliative care settings, namely palliative care units, hospital-based palliative care teams, and home-based palliative care services.

METHODS

This multicenter prospective cohort study was conducted in 58 palliative care services including 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services in Japan from September 2012 through April 2014.

RESULTS

A total of 2426 subjects were recruited. For reasons including lack of followup and missing variables (primarily blood examination data), we obtained analyzable data from 2212 and 1257 patients for the modified PiPS-A and PiPS-B, respectively. In all palliative care settings, both the modified PiPS-A and PiPS-B identified three risk groups with different survival rates (P<0.001). The absolute agreement ranged from 56% to 60% in the PiPS-A model and 60% to 62% in the PiPS-B model.

CONCLUSION

The modified PiPS was successfully validated and can be useful in palliative care units, hospital-based palliative care teams, and home-based palliative care services.

Objective palliative prognostic score among patients with advanced cancer

CONTEXT

The accurate prediction of survival is one of the key factors in the decision-making process for patients with advanced illnesses.

OBJECTIVES

This study aimed to develop a short-term prognostic prediction method that included such objective factors as medical history, vital signs, and blood tests for use with patients with advanced cancer.

METHODS

Medical records gathered at the admission of patients with advanced cancer to the hospice palliative care unit at a tertiary hospital in Taiwan were reviewed retrospectively. The records included demographics, history of cancer treatments, performance status, vital signs, and biological parameters, Multivariate logistic regression analyses and receiver operating characteristic curves were used for model development.

RESULTS

The Objective Palliative Prognostic Score was determined by using six objective predictors identified by multivariate logistic regression analysis. The predictors include heart rate >120/min, white blood cells >11,000/mm(3), platelets <130,000/mm(3), serum creatinine level >1.3 mg/dL, serum potassium level >5 mg/dL, and no history of chemotherapy. The area under the receiver operating characteristic curve used to predict seven-day survival was 82.0% (95% confidence interval 75.2%-88.8%). If any three predictors of the six were reached, death within seven days was predicted with 68.8% sensitivity, 86.0% specificity, 55.9% positive predictive value, and 91.4% negative predictive value.

CONCLUSION

The Objective Palliative Prognostic Score consists of six objective predictors for the estimation of seven-day survival among patients with advanced cancer and showed a relatively high accuracy, specificity, and negative predictive value. Objective signs, such as vital signs and blood test results, may help clinicians make decisions at the end of life.

Going back to home to die: does it make a difference to patient survival?

Background

Many patients wish to stay at home during the terminal stage of cancer. However, there is concern that medical care provided at home may negatively affect survival. This study therefore explored whether the survival duration differed between cancer patients who received inpatient care and those who received home care.

Methods

We retrospectively investigated the place of care/death and survival duration of 190 cancer patients after their referral to a palliative care consultation team in a Japanese general hospital between 2007 and 2012. The patients were classified into a hospital care group consisting of those who received palliative care in the hospital until death, and a home care group including patients who received palliative care at home from doctors in collaboration with the palliative care consultation team. Details of the place of care, survival duration, and patient characteristics (primary site, gender, age, history of chemotherapy, and performance status) were obtained from electronic medical records, and analyzed after propensity score matching in the place of care.

Results

Median survival adjusted for propensity score was significantly longer in the home care group (67.0 days, n = 69) than in the hospital care group (33.0 days, n = 69; P = 0.0013). Cox’s proportional hazard analysis revealed that the place of care was a significant factor for survival following adjustment for covariates including performance status.

Conclusions

This study suggests that the general concern that home care shortens the survival duration of patients is not based on evidence. A cohort study including more known prognostic factors is necessary to confirm the results.

A brief review of survival prediction of advanced cancer patients

Survival prediction of advanced cancer patients remains an important task for palliative clinicians. It has transformed from an art form into a more scientific branch of the discipline with the evolution of palliative medicine and use of statistical estimates of survival. Both clinician predicted survival and actuarial estimation of survival have their uses and drawbacks. This article gives a practical and quick summary of the pros and cons of clinician survival prediction and actuarial-based prognostic tools used at the bedside.

Medical Manuscript

The role of total serum testosterone in the prognosis of terminal cancer is unclear. We retrospectively investigated the total serum testosterone level in 69 male patients with terminal cancer in a palliative care unit. The association between the serum testosterone level and survival was assessed using Cox proportional hazard model. The median value of serum total testosterone was 44.5 ng/dL, far lower than previously reported in patients with advanced cancer. Multivariate analysis revealed thrombocytopenia (adjusted hazard ratio [aHR], 2.68), hypoalbuminemia (aHR, 2.02), azotemia (aHR, 2.67), and lower serum testosterone level (aHR, 2.03) were significantly negatively prognostic of survival. Lower serum testosterone level was an independent unfavorable prognostic factor for life expectancy in male patients with terminal cancer.

Random Serum Cortisol as a Predictor for Survival of Terminally Ill Patients With Cancer: A Preliminary Study

Although previous research found that serum cortisol levels were associated with cancer prognosis, it is unclear whether this association remains robust even at the very end of life of patients with cancer. We conducted a retrospective chart review of 125 patients with terminal cancer to investigate the role of random serum cortisol levels in predicting the remaining life expectancy. The high random cortisol group had a significantly shorter survival time than the low random cortisol group (7.5 vs 26 days). After adjusting for potential confounders, key factors such as poor performance status, hypoalbuminemia, and high random cortisol level are associated with poor survival. Our results suggest that the random serum cortisol level is an independent predictor of survival time of patients with terminally ill cancer.

Comparison of Accuracy Among Prognostic Scores for Predicting Life Expectancy in Korean Patients With Cancer With Weeks of Survival

To compare the accuracy among 4 prognostic scores (Palliative Prognostic Score (PaP), Delirium-PaP (D-PaP), Palliative Prognostic Index (PPI), Objective Prognostic Score (OPS)) for predicting life expectancy in Korean cancer patients with weeks of survival, we conducted a retrospective study by reviewing medical records of 94 patients and compared the accuracy of 3-week and 30-day survival among the 4 prognostic scores. Three-week survival estimates were highest for the PaP and 30-day estimates were similar for the 4 prognostic scores. Area under the receiver operating characteristic curve was highest for the PaP and lowest for the PPI, but there were no significant differences. The prognostics scores did not differ from each other in a significant manner.

Variations in vital signs in the last days of life in patients with advanced cancer

CONTEXT

Few studies have examined variation in vital signs in the last days of life.

OBJECTIVES

We determined the variation of vital signs in the final two weeks of life in patients with advanced cancer and examined their association with impending death in three days.

METHODS

In this prospective, longitudinal, observational study, we enrolled consecutive patients admitted to two acute palliative care units and documented their vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature) twice a day serially from admission to death or discharge.

RESULTS

Of 357 patients, 203 (57%) died in hospital. Systolic blood pressure (P < 0.001), diastolic blood pressure (P < 0.001), and oxygen saturation (P < 0.001) decreased significantly in the final three days of life, and temperature increased slightly (P < 0.04). Heart rate (P = 0.22) and respiratory rate (P = 0.24) remained similar in the last three days. Impending death in three days was significantly associated with increased heart rate (odds ratio [OR] = 2; P = 0.01), decreased systolic blood pressure (OR = 2.5; P = 0.004), decreased diastolic blood pressure (OR = 2.3; P = 0.002), and decreased oxygen saturation (OR = 3.7; P = 0.003) from baseline readings on admission. These changes had high specificity (≥ 80%), low sensitivity (≤ 35%), and modest positive likelihood ratios (≤ 5) for impending death within three days. A large proportion of patients had normal vital signs in the last days of life.

CONCLUSION

Blood pressure and oxygen saturation decreased in the last days of life. Clinicians and families cannot rely on vital sign changes alone to rule in or rule out impending death. Our findings do not support routine vital signs monitoring of patients who are imminently dying.

An easy tool to predict survival in patients receiving radiation therapy for painful bone metastases

PURPOSE

Patients with bone metastases have a widely varying survival. A reliable estimation of survival is needed for appropriate treatment strategies. Our goal was to assess the value of simple prognostic factors, namely, patient and tumor characteristics, Karnofsky performance status (KPS), and patient-reported scores of pain and quality of life, to predict survival in patients with painful bone metastases.

METHODS AND MATERIALS

In the Dutch Bone Metastasis Study, 1157 patients were treated with radiation therapy for painful bone metastases. At randomization, physicians determined the KPS; patients rated general health on a visual analogue scale (VAS-gh), valuation of life on a verbal rating scale (VRS-vl) and pain intensity. To assess the predictive value of the variables, we used multivariate Cox proportional hazard analyses and C-statistics for discriminative value. Of the final model, calibration was assessed. External validation was performed on a dataset of 934 patients who were treated with radiation therapy for vertebral metastases.

RESULTS

Patients had mainly breast (39%), prostate (23%), or lung cancer (25%). After a maximum of 142 weeks' follow-up, 74% of patients had died. The best predictive model included sex, primary tumor, visceral metastases, KPS, VAS-gh, and VRS-vl (C-statistic = 0.72, 95% CI = 0.70-0.74). A reduced model, with only KPS and primary tumor, showed comparable discriminative capacity (C-statistic = 0.71, 95% CI = 0.69-0.72). External validation showed a C-statistic of 0.72 (95% CI = 0.70-0.73). Calibration of the derivation and the validation dataset showed underestimation of survival.

CONCLUSION

In predicting survival in patients with painful bone metastases, KPS combined with primary tumor was comparable to a more complex model. Considering the amount of variables in complex models and the additional burden on patients, the simple model is preferred for daily use. In addition, a risk table for survival is provided.

Consciousness levels one week after admission to a palliative care unit improve survival prediction in advanced cancer patients

BACKGROUND

Consciousness is an important factor of survival prediction in advanced cancer patients. However, effects on survival of changes over time in consciousness in advanced cancer patients have not been fully explored.

OBJECTIVE

This study evaluated changes in consciousness after admission to a palliative care unit and their correlation with prognosis in terminal cancer patients.

METHODS

This is a prospective observational study. From a palliative care unit in Taiwan, 531 cancer patients (51.8% male) were recruited. Consciousness status was assessed at admission and one week afterwards and recorded as normal or impaired.

RESULTS

The mean age was 65.28±13.59 years, and the average survival time was 23.41±37.69 days. Patients with normal consciousness at admission (n=317) had better survival than those with impaired consciousness at admission (n=214): (17.0 days versus 6.0 days, p<0.001). In the analysis on survival within one week after admission, those with normal consciousness at admission had a higher percentage of survival than the impaired (78.9% versus 44.3%, p<0.001). Patients were further classified into four groups according to consciousness levels: (1) normal at admission and one week afterwards, (2) impaired at admission but normal one week afterwards, (3) normal at admission but impaired one week afterwards, and (4) impaired both at admission and one week afterwards. The former two groups had significantly better survival than the latter two groups: (median survival counted from day 7 after admission), 25.5, 27.0, 7.0, and 7.0 days, respectively.

CONCLUSION

Consciousness levels one week after admission should be integrated into survival prediction in advanced cancer patients.

Patient's Factors at Entering Hospice Affecting Length of Survival in a Hospice Center

PURPOSE

In order to provide effective hospice care, adequate length of survival (LOS) in hospice is necessary. However the reported average LOS is much shorter. Analysis of LOS in hospice has not been reported from Korea. We evaluated the duration of LOS and the factors associated with LOS at our hospice center.

MATERIALS AND METHODS

We retrospectively examined 446 patients who were admitted to our hospice unit between January 2010 and December 2012. We performed univariate and multivariate analysis for analysis of factors associated with LOS.

RESULTS

The median LOS was 9.5 days (range, 1 to 186 days). The LOS of 389 patients (86.8%) was< 1 month. At the time of admission to hospice, 112 patients (25.2%) were completely bedridden, 110 patients (24.8%) had mouth care only without intake, and 134 patients (30.1%) had decreased consciousness, from confusion to coma. The median time interval between the day of the last anticancer treatment and the day of hospice admission was 75 days. By analysis of the results of multivariate analysis, decreased intake and laboratory results showing increased total white blood cell (WBC), decreased platelet count, increased serum creatinine, increased aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) level were poor prognostic factors for survival in hospice.

CONCLUSION

Before hospice admission, careful evaluation of the patient's performance, particularly the oral intake, and total WBC, platelet, creatinine, AST, ALT, and LDH level is essential, because these were strong predictors of shorter LOS. In the future, conduct of prospective controlled studies is warranted in order to confirm the relationship between potential prognostic factors and LOS in hospice.

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.