Predicting survival in patients with advanced disease

Prognostic Factors in Patients With Advanced Cancer: Use of the Patient-Generated Subjective Global Assessment in Survival Prediction

Purpose

To determine whether elements of a standard nutritional screening assessment are independently prognostic of survival in patients with advanced cancer.

Patients and Methods

A prospective nested cohort of patients with metastatic cancer were accrued from different units of a Regional Palliative Care Program. Patients completed a nutritional screen on admission. Data included age, sex, cancer site, height, weight history, dietary intake, 13 nutrition impact symptoms, and patient- and physician-reported performance status (PS). Univariate and multivariate survival analyses were conducted. Concordance statistics (c-statistics) were used to test the predictive accuracy of models based on training and validation sets; a c-statistic of 0.5 indicates the model predicts the outcome as well as chance; perfect prediction has a c-statistic of 1.0.

Results

A training set of patients in palliative home care (n = 1,164) was used to identify prognostic variables. Primary disease site, PS, short-term weight change (either gain or loss), dietary intake, and dysphagia predicted survival in multivariate analysis (P < .05). A model including only patients separated by disease site and PS with high c-statistics between predicted and observed responses for survival in the training set (0.90) and validation set (0.88; n = 603). The addition of weight change, dietary intake, and dysphagia did not further improve the c-statistic of the model. The c-statistic was also not altered by substituting physician-rated palliative PS for patient-reported PS.

Conclusion

We demonstrate a high probability of concordance between predicted and observed survival for patients in distinct palliative care settings (home care, tertiary inpatient, ambulatory outpatient) based on patient-reported information.

Interconversion of three measures of performance status: an empirical analysis

PURPOSE

To construct empirically a conversion table to convert performance status scores among the Eastern Cooperative Oncology Group (ECOG), Karnofsky Performance Status (KPS) and Palliative Performance Scale (PPS) measures, using a large sample of patients with advanced cancer.

METHODS

Seven physicians completed assessments on 1385 consecutive patients attending an oncology palliative care clinic, or admitted to an acute cancer palliative care unit. The three measures were distributed as a questionnaire package; the order in which they were presented was randomly assigned for each week. Scales were compared using the hit rate and the weighted kappa coefficient (κ(w)). The KPS and PPS were compared directly; for comparisons of either scale with the ECOG, all 70 possible categorisations of KPS and PPS were computed. An 'ideal' categorisation was selected based on maximisation of both statistical methods.

RESULTS

The KPS and PPS matched in 1209 out of 1385 assessments (hit rate 87%; κ(w) 0.97). For both the KPS and the PPS, the categorisation of 100 (ECOG 0), 80-90 (1), 60-70 (2), 40-50 (3), 10-30 (4) had the highest hit rate (75%), and the second highest κ(w) (0.84, p<0.0001). One other combination had a slightly higher κ(w) (0.85 for both KPS and PPS), but a lower hit rate (73% for KPS, 72% for PPS).

CONCLUSIONS

We have derived empirically a conversion scale among the ECOG, KPS and PPS scales. The proposed scale provides a means of translating amongst these measures, which may improve accuracy of communication about performance status amongst oncology clinicians and researchers.

Use of intensive care in patients with nonresectable lung cancer

BACKGROUND

Admission of patients with lung cancer to the ICU has been criticized. We evaluated whether ICU admission improved 3-month survival in patients with nonresectable lung cancer. Factors associated with survival were identified.

METHODS

A retrospective study was conducted in consecutive nonsurgical patients with lung cancer admitted to three ICUs in France between 2000 and 2007, 2005 and 2007, and 2005 and 2006.

RESULTS

We included 103 patients with a median (interquartile range) Simplified Acute Physiology Score II of 33 (25-46) and logistic organ dysfunction (LOD) score of 3 (1-4). Invasive mechanical ventilation was required in 41 (40%) patients. Sixty-three (61%) patients had metastasis and 26 (25%) an Eastern Cooperative Oncology Group performance status (ECOG-PS) > 2. The reason for ICU admission was acute respiratory failure in 58 (56%) patients. Three-month survival rate was 37% (95% CI, 28%-46%). By multivariate analysis, variables associated with mortality were ECOG-PS > 2 (hazard ratio [HR], 2.65; 95% CI, 1.43-4.88), metastasis at admission (HR, 1.90; 95% CI, 1.08-3.33), and worse LOD score (HR, 1.19; 95% CI, 1.08-1.32). An LOD score decrease over the first 72 h was associated with survival.

CONCLUSIONS

Survival in nonsurgical patients with lung cancer requiring ICU admission was 37% after 90 days. Our results provide additional evidence that ICU management may be appropriate in patients with nonresectable lung cancer and organ failure.

Predictors of survival in patients with non-curative stage IV cancer and malignant bowel obstruction

PURPOSE

Malignant bowel obstruction (MBO) occurs in up to 15% of patients admitted to palliative care wards and management can be clinically challenging. Survival is generally poor with a reported median survival of 1-3 months; however, there are no studies describing predictors of survival for patients with MBO.

PATIENTS AND METHODS

All patients admitted to a tertiary care hospital with a MBO were approached between March 1, 2006 and March 31, 2008 to enter the study. Demographic, clinical, laboratory, and radiographic information were prospectively collected from patient charts and the patient's functional status (Eastern Cooperative Oncology Group score, ECOG) at admission was recorded. Follow-up was until death or the end of the study (August 2008). Survival was estimated using Kaplan-Meier plots and Cox regression models were used to evaluate prognostic factors for survival.

RESULTS

Thirty-five patients were recruited. Median patient age was 61% and 46% were female. Median survival of the cohort was 80 days (range 7-873). Median survival for patients with an ECOG performance status of 0-1 (n = 15) was 222 days, for ECOG 2 patients (n = 9), 63 days and for patients with an ECOG 3/4 score (n = 11) it was 27 days. ECOG status was the strongest predictor of survival on the multivariate analysis. In addition, a low blood urea nitrogen level or a high albumin on admission was also associated with prolonged survival.

CONCLUSION

An ECOG score of 0/1 for patients with MBO in the setting of Stage IV non-curative cancer is the strongest predictor of overall survival.

The association between autonomic dysfunction and survival in male patients with advanced cancer: a preliminary report

CONTEXT

Autonomic nervous system dysfunction (AD) is a common syndrome in patients with advanced cancer. It is associated with decreased survival in several patient populations, including diabetes mellitus, heart failure, and neurological diseases. Based on this evidence, we hypothesized that autonomic dysfunction is associated with decreased survival in patients with advanced cancer.

OBJECTIVES

The objective of this preliminary study was to test the association between AD, as measured by the standardized Ewing test and heart rate variability (HRV) measures, and survival in this patient population.

METHODS

We examined the relationship between survival and parameters of AD in subjects who participated in a prospective study of autonomic dysfunction and hypogonadism in male patients with advanced cancer. Eligibility criteria were defined based on the prospective study protocol. We collected demographic information, date of death (obtained from the online Social Security Death Index database), date of study entry, and Ewing and HRV scores. We defined survival as the interval between study entry and date of death. A survival analysis was used to test the association between survival (in days) and Ewing test (0-5) and measures of HRV, including time domain (standard deviation of normal to normal beat interval [SDNN]) and frequency domain (ultra low, very low, low, and high). Four patients were still alive at the time of this study and included in the survival analysis as being censored.

RESULTS

Forty-seven male patients were included in this study. Median age was 59 years (range: 20-79), and 30 out of 47 (63%) were Caucasians. AD, defined as Ewing score greater than 2, was present in 38 out of 47 (80%) of the patients. Median Ewing score was 3 (1-5), indicating moderate to severe AD. Spearman correlation for Ewing score and SDNN was 0.44 (P = 0.002). There was a significant association between abnormal Ewing score and survival (P < 0.0001) and abnormal SDNN HRV and survival (P = 0.056).

CONCLUSION

AD is associated with shorter survival in male patients with advanced cancer. Further longitudinal research in a large cohort is justified based on.

Determining prognosis and predicting survival in end-of-life care

PURPOSE OF REVIEW

The purpose of this article is to review some recent studies referred to prognosis factors and our capacity to predict death during the final stages of disease.

RECENT FINDINGS

Recent studies show significant approaches through the use of some instruments (especially self-assessment tools), which we will analyze herein.

SUMMARY

In many cases of clinical practice, this prediction capacity based on solid elements may be key to determine or contraindicate certain therapeutic resources. Such is the case, for example, when it is necessary to define the transfer of a patient to a proper specialized center, under family or legal circumstances demanding a clarification on this point, or for handling the dialog with the patients and/or their relatives. According to recent findings, we should include some elements of self-assessment in our instruments to predict death in palliative care.

Discussing prognosis with terminally ill cancer patients and relatives: a survey of physicians' intentions in seven countries

OBJECTIVE

To determine the extent to which physicians in different countries intend to inform terminal patients and relatives about prognosis, and to identify physician characteristics associated with an active approach to such discussions.

METHODS

In the context of a European research project, a study on disclosing prognosis was conducted in seven countries. A written questionnaire with questions regarding hypothetical cases and actual practices was sent to physicians from specialties involved in the care of dying patients.

RESULTS

10,139 questionnaires were studied. The response rate was greater than 50% in all countries except Italy (39%). The percentage of physicians who indicated that they would actively inform competent patients of their prognosis varied between countries from 52% in Italy to 99% in Sweden. For informing relatives of incompetent patients, rates were higher, ranging from 86% in Denmark to 98% in Australia. Younger physician age and training in palliative care were associated with an active intention to discuss prognosis.

CONCLUSION

Physicians' intentions to discuss prognosis with patients and families vary largely across countries. Physician age and training in palliative care may also affect intentions.

PRACTICE IMPLICATIONS

Continuing training should focus on improving physicians' ability to communicate responsibly about prognosis with patients and families.

Validation of a simplified anorexia questionnaire

CONTEXT

Anorexia is a common symptom in cancer and is usually assessed by multiple questions and multidimensional questionnaires. A simplified questionnaire would be less burdensome to patients and abbreviate the process.

OBJECTIVES

We compared the reliability at one point in time, sensitivity to change over time, and prognostic accuracy of a two-item questionnaire with the Functional Assessment of Anorexia and Cachexia Therapy shortened 12-question version (A/CS-12).

METHODS

Individuals with cancer, who were cognitively intact and verbally agreed to participate, completed a two-item questionnaire and A/CS-12 in random order and again seven days later. We compared the direction of response to the summated two-item questionnaire to the validated A/CS-12 score at a single point in time, then intra-patient changes over a seven-day period of time. Scores of both questionnaires were divided into poor, moderate and good appetite and compared to survival using Kaplan-Meyer curves. Bootstrapping was used to construct confidence intervals for estimated probability agreement. Survival analysis also used hazard ratios from a Cox Proportional Hazards model.

RESULTS

One hundred seventeen individuals from a single institution participated, who were either admitted to an inpatient palliative unit or seen in an outpatient/palliative medicine unit. Median age was 58.8 (range 10.7-87.1 years). Agreement at one point in time was 0.64 (95% confidence interval [CI] 0.63 - 0.66). Agreement over time was 0.53 (CI 0.41 - 0.64). The A/CS-12 predicted survival based on scores on Days 1 and 7 (P<0.001), (P=0.003) (HR 0.97 day 1, HR 0.95 day 7), whereas the simplified questionnaire failed to predict survival.

CONCLUSIONS

A simplified questionnaire has moderate correlation with the A/CS-12 at one point in time but loses sensitivity over time, and lacks the ability to predict survival. A change in the questionnaire may improve reliability. Changing question 2 of the simplified questionnaire to a neutral form (better, same or worse appetite) may improve sensitivity and prognostic capability.

A proposed prognostic 7-day survival formula for patients with terminal cancer

BACKGROUND

The ability to identify patients for hospice care results in better end-of-life care. To develop a validated prognostic scale for 7-day survival prediction, a prospective observational cohort study was made of patients with terminal cancer.

METHODS

Patient data gathered within 24 hours of hospital admission included demographics, clinical signs and symptoms and their severity, laboratory test results, and subsequent survival data. Of 727 patients enrolled, data from 374 (training group) was used to develop a prognostic tool, with the other 353 serving as the validation group.

RESULTS

Five predictors identified by multivariate logistic regression analysis included patient's cognitive status, edema, ECOG performance status, BUN and respiratory rate. A formula of the predictor model based on those five predictors was constructed. When probability was >0.2, death within 7 days was predicted in the training group and validation group, with sensitivity of 80.9% and 71.0%, specificity of 65.9% and 57.7%, positive predictive value of 42.6% and 26.8%, and negative predictive value (NPV) of 91.7% and 90.1%, respectively.

CONCLUSION

This predictor model showed a relatively high sensitivity and NPV for predicting 7-day survival among terminal cancer patients, and could increase patient satisfaction by improving end-of-life care.

Construction of a new, objective prognostic score for terminally ill cancer patients: a multicenter study

GOALS OF WORK

The goal of this study was to develop a new, objective prognostic score (OPS) for terminally ill cancer patients based on an integrated model that includes novel objective prognostic factors.

MATERIALS AND METHODS

A multicenter study of 209 terminally ill cancer patients from six training hospitals in Korea were prospectively followed until death. The Cox proportional hazard model was used to adjust for the influence of clinical and laboratory variables on survival time. The OPS was calculated from the sum of partial scores obtained from seven significant predictors determined by the final model. The partial score was based on the hazard ratio of each predictor. The accuracy of the OPS was evaluated.

MAIN RESULTS

The overall median survival was 26 days. On the multivariate analysis, reduced oral intake, resting dyspnea, low performance status, leukocytosis, elevated bilirubin, elevated creatinine, and elevated lactate dehydrogenase (LDH) were identified as poor prognostic factors. The range of OPS was from 0.0 to 7.0. For the above cutoff point of 3.0, the 3-week prediction sensitivity was 74.7%, the specificity was 76.5%, and the overall accuracy was 75.5%.

CONCLUSIONS

We developed the new OPS, without clinician's survival estimates but including a new prognostic factor (LDH). This new instrument demonstrated accurate prediction of the 3-week survival. The OPS had acceptable accuracy in this study population (training set). Further validation is required on an independent population (testing set).