The American Joint Committee on Cancer. Criteria for prognostic factors and for an enhanced prognostic system

Prognosis

Prognosis is defined as the likely outcome or course of a disease and is the result of a complex interplay between patient and tumor factors. Unfortunately, the prognosis of patients with laryngeal cancer has not changed significantly over the past several decades. However, as our understanding of these patient and tumor factors becomes more nuanced and the resulting treatment options become more precise, there is the potential to improve the prognosis for these patients.

Are Survival Outcomes Different for Young and Old Patients with Oral and Oropharyngeal Squamous Cell Carcinoma? A Systematic Review and Meta-Analysis

Simple Summary

Oral cancer was considered a disease of old age. However, there has been a recent surge in the incidence of oral cancer in young individuals. Age dependence on survival outcomes such as overall survival, disease-free survival, recurrence, distant metastasis and second primary in surgically treated oral cancer has been investigated several times and the results differ. This systematic review and meta-analysis has been conducted to address this concern. The results of the present research may facilitate age-dependent prognosis stratification, which would assist in treatment planning in oral cancer patients.

Abstract

This systematic review and meta-analysis aims to address whether age can be a determinant of overall survival (OS), disease-free survival (DFS), recurrence, distant metastasis (DM) and second primary (SP) in surgically treated oral and oropharyngeal squamous cell carcinoma (OOPSCC). A total of 4981 cases and 44254 controls from 25 comparative observational studies were included in the analysis. A significantly better OS (matched subgroup analysis: OR 1.64; 95% CI 1.31–2.04, overall analysis: OR 1.48; 95% CI 1.09–2.01) was observed in young patients compared to older adults, with heterogeneity ranging from moderate to severe. Worse DFS (unmatched subgroup analysis OR 0.43; 95% CI 0.27–0.68) was observed in young patients compared to older adults with minimal to moderate heterogeneity. The frequency of recurrence (OR 1.49; 95% CI 1.10–2.02) and DM (OR 1.83; 95% CI 1.10–3.03) was significantly higher in the young patients, as found in unmatched and matched subgroup analysis, with the least heterogeneities. Young age can be considered as an independent prognostic factor for recurrence and distant metastases in OOP-SCC. Larger and methodologically robust observational studies with longer follow-up are needed to establish the definitive role of age as an independent prognostic factor on OS and DFS in OOPSCC.

Using texture analysis as a predictive factor of subtype, grade and stage of renal cell carcinoma

OBJECTIVE

The aim of this study was to evaluate the correlation between the tissue texture analysis and the histological subtypes, grade and stage of the disease in patients with renal cell carcinoma (RCC).

MATERIALS AND METHODS

Seventy-seven patients who underwent computed tomography due to renal mass and diagnosed with RCC as a result of pathological examination were retrospectively analyzed. In these analyses, the demographic characteristics, pathological and radiological findings of the patients were evaluated. The masses were introduced to the Radiomics extension of the software and the first- and second-order texture analysis parameters were obtained. The correlation of these parameters with histological subtype, Fuhrman grade and TNM stage was investigated.

RESULTS

In the comparison of the Radiomics values by stages, "minimum", "Long Run Low Gray-level Emphasis" values were higher in the stage 1-2 group, while "Energy", "Total energy", "Range", "Joint Average", "Sum Average", "Gray-Level Non-Uniformity", "Short-Run High Gray-level Emphasis ", "Run Length Non-Uniformity "and "High Gray-Level Run Emphasis "values were higher in the stage 3-4 group. Of these parameters, only "Gray-Level Non-Uniformity" and "Run Length Non-Uniformity'' values were significantly lower in tumors with low Fuhrman grade (1-2) and low TNM stage (1-2). There was no statistically significant correlation between the parameters found to be significant in histological subtype differentiation and Fuhrman grade and TNM stage.

CONCLUSION

This study demonstrates that "Gray-Level Non-Uniformity" and "Run Length Non-Uniformity "parameters in the texture analysis method can be used to evaluate the prognosis in patients with RCC.

The pretreatment lymphocyte to monocyte ratio predicts clinical outcome for patients with urological cancers: A meta-analysis

BACKGROUND

The lymphocyte to monocyte ratio (LMR), a novel systematic biomarker of inflammation, has been reported to be associated with the progression and prognosis of many malignant cancers. However, the relationship between LMR and survival outcome of urological cancers (UCs) remains controversial. Herein, we conducted a meta-analysis to identify the prognostic value of pretreatment LMR in patients with UCs.

METHODS

A literature search was performed in PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials, Scopus, and CINAHL databases up to July 2018. The pooled hazard ratios (HRs) and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated to evaluate the association of LMR with survival outcome and clinicopathological characteristics in UCs.

RESULTS

A total of 17 articles containing 5552 patients were included in our study. The synthesized analysis showed that elevated pretreatment LMR level could predict favorable overall survival (OS) of UCs patients (pooled HR = 0.82, 95%CI: 0.77-0.87). Additionally, the decreased LMR level was correlated with tumor stage (OR = 1.72, 95%CI: 1.15-2.55), lymph node metastasis (OR = 1.46, 95%CI:1.06-1.99), grade (OR = 1.79, 95%CI:1.41-2.27), tumor size (OR = 2.21, 95%CI:1.81-2.68) and necrosis (OR = 1.71, 95%CI:1.36-2.16).

CONCLUSION

The high pretreatment LMR was associated with favorable prognosis, and could be a potential prognostic biomarker in patients with UCs.

The anatomy of the TNM for colon cancer

BACKGROUND

To visualize the anatomy as revealed by dendrograms of the tumor, lymph node, and metastasis (TNM) staging system for colon cancer and compare it with the Dukes' system.

METHODS

A hierarchical clustering algorithm generated tree-structured dendrograms that stratified patients according to survival only. The dendrograms were constructed with the same prognostic variables used for the TNM. Because combinations of prognostic factors were stratified only on survival, additional factors of any number and type could be integrated into the TNM without changing the TNM categories.

RESULTS

The algorithm provided a step-by-step visualization of the TNM and the Dukes' system for colon cancer. Dendrograms and associated 5-year survival rates were generated for the T category only, the N category only, the T, N combination, and combinations of the T, N, and M, and the T, N, M with histological grade. Dendrograms revealed visual differences between the structure of TNM and the Dukes' system of staging. Dendrograms also revealed how variations in prognostic factors changed survival. By cutting dendrograms along their dissimilarity axis, multiple prognostic subgroups could be created for colon cancer that may reflect outcomes that are more accurate to estimate.

CONCLUSIONS

Dendrograms provide a new way to view cancer patient staging. They reveal a visual step-by-step hierarchical relationship between survival rates and combinations of prognostic variables. The dendrograms also revealed fundamental differences between the TNM and the Dukes system of staging. By stratifying on survival only, additional factors including molecular factors can be added to the TNM, because it classifies patients according to survival rates only and not according to pre-set rules of prognostic factors and stage groups. The clinical implications of stratifying only survival are discussed.

Predicting Clinical Outcomes Using Molecular Biomarkers

Over the past 20 years, there has been an exponential increase in the number of biomarkers. At the last count, there were 768,259 papers indexed in PubMed.gov directly related to biomarkers. Although many of these papers claim to report clinically useful molecular biomarkers, embarrassingly few are currently in clinical use. It is suggested that a failure to properly understand, clinically assess, and utilize molecular biomarkers has prevented their widespread adoption in treatment, in comparative benefit analyses, and their integration into individualized patient outcome predictions for clinical decision-making and therapy. A straightforward, general approach to understanding how to predict clinical outcomes using risk, diagnostic, and prognostic molecular biomarkers is presented. In the future, molecular biomarkers will drive advances in risk, diagnosis, and prognosis, they will be the targets of powerful molecular therapies, and they will individualize and optimize therapy. Furthermore, clinical predictions based on molecular biomarkers will be displayed on the clinician’s screen during the physician–patient interaction, they will be an integral part of physician–patient-shared decision-making, and they will improve clinical care and patient outcomes.

An algorithm for expanding the TNM staging system

AIM

We describe a new method to expand the tumor, lymph node, metastasis (TNM) staging system using a clustering algorithm. Cases of breast cancer were used for demonstration.

MATERIALS & METHODS

An unsupervised ensemble-learning algorithm was used to create dendrograms. Cutting the dendrograms produced prognostic systems.

RESULTS

Prognostic systems contained groups of patients with similar outcomes. The prognostic systems based on tumor size and lymph node status recapitulated the general structure of the TNM for breast cancer. The prognostic systems based on tumor size, lymph node status, histologic grade and estrogen receptor status revealed a more detailed stratification of patients when grade and estrogen receptor status were added.

CONCLUSION

Prognostic systems from cutting the dendrogram have the potential to improve and expand the TNM.

The sirtuin 3 expression profile is associated with pathological and clinical outcomes in colon cancer patients

AIM

To investigate the correlation between Sirtuin 3 (SIRT3) expression and the clinical outcome of patients with colon cancer.

METHODS

The tumor specimens from 127 patients with colon cancer were obtained for SIRT3 immunohistochemical staining. Patients were followed up. In in vitro study, SIRT3 gene was inhibited to observe the effects of SIRT3 on the biological behavior of cultured colon cells.

RESULTS

The SIRT3 expression level was found to be significantly associated with the lymph node metastasis (P < 0.001) and tumor stages (P < 0.001). The colon cancer-specific survival was 64.6% among patients with high SIRT3 expressions and 88.6% among patients with low SIRT3 expressions (log-rank P = 0.016). The overall survival was 80.2% among patients with low SIRT3 expressions and 55.9% among patients with high SIRT3 expressions (log-rank P = 0.002). In vitro study showed that silencing of SIRT3 gene inhibited the proliferation, invasion, and cells migration but increased the apoptosis in the cultured colon cell lines.

CONCLUSION

This study provides evidence supporting that SIRT3 is closely associated with the clinical outcomes of colon cancer. SIRT3 may be considered as a marker for colon cancer.

Validation of the QTNM staging system for cancer-specific survival in patients with differentiated thyroid cancer

An Australian state database was used to test the validity of the Quantitative tumor/node/metastasis (QTNM) staging system for assessing prognosis of differentiated thyroid cancer (DTC) on the basis of four variables quantified at diagnosis (histopathology, age, node involvement, and tumor size). Using the Queensland Cancer Registry (QCR), we identified 788 cases of DTC diagnosed from 1982 to 2006 with complete staging information. Causes of death were ascertained by linking the QCR database with the Australian National Death Index. Subjects were staged according to AJCC TNM 7th edition and QTNM, and cancer-specific survival (CSS) was calculated by the Kaplan-Meier method. Cancer-specific mortality was observed in 22 (2.8 %) patients, with 10-year CSS for the cohort of 97.0 % at a median follow-up of 262.8 months. QTNM stage specific cancer survival at 10 years was 99.6, 97.0, and 78.6 % for low-, intermediate-, and high-risk groups, respectively. This was comparable to the original US dataset in which the QTNM was initially studied, and it fared better at discriminating survival than the standard TNM system, where there was overlap in survival between stages. The current study validates the QTNM system in an Australian cohort and shows at least equivalent discriminatory capacity to the current TNM staging system. The QTNM utilized prognostic variables of significance to produce an optimal three-stage stratification scheme. Given, its advantage in clearly discriminating between prognostic groups, clinical relevance and simplicity of use, we recommend that TNM be replaced with QTNM for risk stratification for both recurrence and CSS.

On an ensemble algorithm for clustering cancer patient data

BACKGROUND

The TNM staging system is based on three anatomic prognostic factors: Tumor, Lymph Node and Metastasis. However, cancer is no longer considered an anatomic disease. Therefore, the TNM should be expanded to accommodate new prognostic factors in order to increase the accuracy of estimating cancer patient outcome. The ensemble algorithm for clustering cancer data (EACCD) by Chen et al. reflects an effort to expand the TNM without changing its basic definitions. Though results on using EACCD have been reported, there has been no study on the analysis of the algorithm. In this report, we examine various aspects of EACCD using a large breast cancer patient dataset. We compared the output of EACCD with the corresponding survival curves, investigated the effect of different settings in EACCD, and compared EACCD with alternative clustering approaches.

RESULTS

Using the basic T and N definitions, EACCD generated a dendrogram that shows a graphic relationship among the survival curves of the breast cancer patients. The dendrograms from EACCD are robust for large values of m (the number of runs in the learning step). When m is large, the dendrograms depend on the linkage functions. The statistical tests, however, employed in the learning step have minimal effect on the dendrogram for large m. In addition, if omitting the step for learning dissimilarity in EACCD, the resulting approaches can have a degraded performance. Furthermore, clustering only based on prognostic factors could generate misleading dendrograms, and direct use of partitioning techniques could lead to misleading assignments to clusters.

CONCLUSIONS

When only the Partitioning Around Medoids (PAM) algorithm is involved in the step of learning dissimilarity, large values of m are required to obtain robust dendrograms, and for a large m EACCD can effectively cluster cancer patient data.

Prognostic factors in head and neck squamous cell carcinoma: comparison of CHAID decision trees technology and Cox analysis

BACKGROUND

The purpose of this study was to compare the risk factors obtained from a classical statistical method (Cox proportional hazards model) and the results obtained with classification trees (Chi-square Automatic Interaction Detection [CHAID] model) in head and neck squamous cell carcinoma (HNSCC).

METHODS

We conducted a retrospective study of 3373 patients with HNSCC and a follow-up longer than 2 years.

RESULTS

The most decisive variable classified by CHAID was T category. N classification was an important prognostic factor in the Cox analysis, but this was not considered in CHAID except in T2 and supraglottic T3. CHAID also indicated that women with oral cavity T3/T4 to N0 tumors had poorer prognosis (28%) than men (58.5%; p value < .001). In oropharynx location, men had lower survival than women (41% vs 72%; p value < .001).

CONCLUSIONS

The main benefit of CHAID analysis is that it identifies a relatively small number of patients with a singular behavior, which is more discriminatory for an optimal diagnosis and treatment.

Detection of prolactin inducible protein mRNA, a biomarker for breast cancer metastasis, using a molecular beacon-based assay

Mortality due to breast cancer is increasingly linked to early, undetected metastasis, making methods for earlier detection acutely necessary. We describe the development of an assay based on molecular beacon (MB) chemistry with fluorescence detection to monitor a breast cancer biomarker for the analysis of breast cancer metastasis. The MB assay is based on the complementary base-pairing interactions of the MB nucleic acid with mRNA indicative of breast cancer metastasis. The presence of mRNA is characterized by an increase in the fluorescence intensity of the molecular beacon. The assay gives a linear, reproducible response to prolactin inducible protein mRNA, with a limit of detection in the high picomolar range. This method sensitively and specifically identifies a biomarker directly in serum samples in minimal time and with a straightforward procedure, dramatically reducing the total time for sample analysis over current methods from days to hours. The potential impact of this work in detection and understanding of breast cancer metastasis lies in improvements in simplicity, accuracy, and speed over current methods, which could allow for improved patient treatment and prognoses. Ultimately, additional sample throughput will result in better understanding of disease progression.

The impact of comorbidity on the survival of patients with laryngeal squamous cell carcinoma

Abstract Conclusions: In survival analysis, the combined Charlson comorbidity index (CCI) can be considered as a prognostic factor independent of the tumor node metastasis (TNM) classification, tumor stage, and tumor location. Severe comorbidity was the factor that had the greatest impact on prognosis in cases of initial tumor.

OBJECTIVE

To study the influence of comorbidity on the survival of patients undergoing surgery for larynx cancer.

METHODS

This was a retrospective study of the survival of 231 patients with laryngeal cancer who underwent surgery between 1995 and 2002. The CCI was used to assess comorbidity, the Kaplan-Meier method was used for survival analysis, and the Cox proportional risk regression model was used to identify independent prognostic factors.

RESULTS

The multivariate analysis of specific mortality showed that patients classified as having severe comorbidity (CCI) were more likely to die (adjusted hazard ratio (adjHR) 1.85, 95% confidence interval (CI) 1.07-3.17). This difference was more important in patients with early tumor stages than in those with advanced stages.

Clinical significance of pretreatment serum C-reactive protein level in soft tissue sarcoma

BACKGROUND

The aim of this study was to determine whether circulating C-reactive protein (CRP) levels before treatment predict the overall survival and disease-free survival in soft tissue sarcoma patients.

METHODS

A total of 102 primary soft tissue sarcoma patients from 2003 to 2009 were retrospectively reviewed. The CRP levels were obtained before treatment for all patients. The patients who presented with metastases at diagnosis were excluded from this study.

RESULTS

Elevated CRP levels were seen in 18 patients. The tumor histological grade and American Joint Committee on Cancer stage in the patients with elevated CRP levels were significantly higher than those in patients with normal CRP levels. Patients with elevated CRP levels before initial treatment had a poorer overall survival than patients with normal CRP levels (P = .01). The overall survival estimates at 3 and 5 years were 75.3% and 53.8%, respectively, versus 90.3% and 81.3%, respectively. Patients with elevated CRP levels before initial treatment had poorer event-free survival after initial treatment than patients with normal CRP levels (P < .001). The event-free survival estimates at 2 and 5 years were 53.2% and 33.2%, respectively, versus 83.2% and 81.3%, respectively. A multivariate analysis also showed the preoperative CRP level to be an independent predictor of events.

CONCLUSIONS

The pretreatment serum CRP level may be a marker of aggressive tumor characteristics. Pretreatment elevated CRP levels were found to be a poor prognostic factor for overall survival in a univariate analysis, and for disease-free survival in a multivariate analysis, for soft tissue sarcoma patients.

Development and progression of colorectal neoplasia

A variety of genetic and molecular alterations underlie the development and progression of colorectal neoplasia (CRN). Most of these cancers arise sporadically due to multiple somatic mutations and genetic instability. Genetic instability includes chromosomal instability (CIN) and microsatellite instability (MSI), which is observed in most hereditary non-polyposis colon cancers (HNPCCs) and accounts for a small proportion of sporadic CRN. Although many biomarkers have been used in the diagnosis and prediction of the clinical outcomes of CRNs, no single marker has established value. New markers and genes associated with the development and progression of CRNs are being discovered at an accelerated rate. CRN is a heterogeneous disease, especially with respect to the anatomic location of the tumor, race/ethnicity differences, and genetic and dietary interactions that influence its development and progression and act as confounders. Hence, efforts related to biomarker discovery should focus on identification of individual differences based on tumor stage, tumor anatomic location, and race/ethnicity; on the discovery of molecules (genes, mRNA transcripts, and proteins) relevant to these differences; and on development of therapeutic approaches to target these molecules in developing personalized medicine. Such strategies have the potential of reducing the personal and socio-economic burden of CRNs. Here, we systematically review molecular and other pathologic features as they relate to the development, early detection, diagnosis, prognosis, progression, and prevention of CRNs, especially colorectal cancers (CRCs).

Can survival prediction be improved by merging gene expression data sets?

BACKGROUND

High-throughput gene expression profiling technologies generating a wealth of data, are increasingly used for characterization of tumor biopsies for clinical trials. By applying machine learning algorithms to such clinically documented data sets, one hopes to improve tumor diagnosis, prognosis, as well as prediction of treatment response. However, the limited number of patients enrolled in a single trial study limits the power of machine learning approaches due to over-fitting. One could partially overcome this limitation by merging data from different studies. Nevertheless, such data sets differ from each other with regard to technical biases, patient selection criteria and follow-up treatment. It is therefore not clear at all whether the advantage of increased sample size outweighs the disadvantage of higher heterogeneity of merged data sets. Here, we present a systematic study to answer this question specifically for breast cancer data sets. We use survival prediction based on Cox regression as an assay to measure the added value of merged data sets.

RESULTS

Using time-dependent Receiver Operating Characteristic-Area Under the Curve (ROC-AUC) and hazard ratio as performance measures, we see in overall no significant improvement or deterioration of survival prediction with merged data sets as compared to individual data sets. This apparently was due to the fact that a few genes with strong prognostic power were not available on all microarray platforms and thus were not retained in the merged data sets. Surprisingly, we found that the overall best performance was achieved with a single-gene predictor consisting of CYB5D1.

CONCLUSIONS

Merging did not deteriorate performance on average despite (a) The diversity of microarray platforms used. (b) The heterogeneity of patients cohorts. (c) The heterogeneity of breast cancer disease. (d) Substantial variation of time to death or relapse. (e) The reduced number of genes in the merged data sets. Predictors derived from the merged data sets were more robust, consistent and reproducible across microarray platforms. Moreover, merging data sets from different studies helps to better understand the biases of individual studies and can lead to the identification of strong survival factors like CYB5D1 expression.

Simplifying the TNM System for Clinical Use in Differentiated Thyroid Cancer

Purpose

The TNM stratification has been found useful at stratifying patients with differentiated thyroid carcinoma (DTC) into prognostic risk groups. However, it is cumbersome to implement clinically given the large number of bins within this system and the complicated system of arriving at stage information.

Patients and Methods

We decided to quantify each variable in this system to arrive at a simplified quantitative alternative to the TNM system (QTNM) and compare this with the conventional system. We used our electronic record system to identify 614 cases of DTC managed at our institution from 1987 to 2006. Cancer-specific survival (CSS) and disease-free survival (DFS) were calculated by the Kaplan-Meier method, and a simplified QTNM score was devised using a Cox proportional hazards model.

Results

We were able to quantify the TNM system as follows: 4 points each for age older than 45 years and presence of neck nodal metastases while 6 points for tumor size larger than 4 cm or extrathyroidal extension and 1 point for nonpapillary DTC. A sum of 0 to 5 points was low risk, 6 to 10 points intermediate, and 11 to 15 points high risk. Comparison with the conventional TNM system and two other systems revealed similar or better discrimination with the QTNM and this discrimination was maintained when this risk stratification was applied to a unique validation set.

Conclusion

The QTNM system as opposed to the conventional TNM system seems to be a simple and effective method for risk stratification for both recurrence and cancer-specific mortality.

Molecular markers and mortality in prostate cancer

OBJECTIVE

To evaluate prognosis in prostate cancer by assessing the independent effect of selected molecular factors (e.g. markers of cell-cycle regulation), in addition to the effect of traditional clinical factors (e.g. anatomical stage, histological grade), in predicting long-term mortality among men newly diagnosed with prostate cancer.

PATIENTS AND METHODS

In a community-based population of 64 545 USA veterans aged >/= 50 years and receiving ambulatory care during 1989-90 at nine Veterans Affairs (VA) medical centres in New England, 1274 had incident prostate cancer during 1991-95. We obtained the medical records and diagnostic tissue for these men, and then extracted demographic data and clinical information, and conducted immunohistochemical assays of molecular markers in biopsy tissue, as potential prognostic factors. In this interim analysis, data on 250 patients were analysed; the main outcome was overall mortality to 31 December 2003, providing 8-13 years of follow-up.

RESULTS

In 228 (91%) patients with available medical record and laboratory data, the median age was 72 years and the median prostate-specific antigen level was 10.4 ng/mL. In adjusted (multivariate) analyses that included traditional prognostic factors, bcl-2 staining (hazard ratio 2.14, 95% confidence interval 1.27-3.58, P = 0.004) and high microvessel density (1.76, 1.19-2.60; P = 0.005) had an independent effect on the outcome.

CONCLUSIONS

Bcl-2 and microvessel density are independent predictors of subsequent death among men with prostate cancer and might have a clinical role in assisting in deciding on treatment.

Biochemical disease-free survival rates following definitive low-dose-rate prostate brachytherapy with dose escalation to biologic target volumes identified with SPECT/CT capromab pendetide

PURPOSE

To report biochemical disease-free survival (bDFS) after conformal brachytherapy with dose escalation to biological target volumes (BTVs) identified by Capromab Pendetide with single photon emission computed tomography and computed tomography image fusion (SPECT/CT).

METHODS AND MATERIALS

Two hundred thirty-nine (T1c-T3b NxM0) consecutive patients were evaluated by SPECT/CT before treatment. Intraprostatic SPECT/CT BTVs were identified and targeted for 150% dose escalation during brachytherapy seed implant (SI). Patients received either SI alone (n = 150) or external beam radiation therapy (EBRT) plus SI boost (EBRT+SI) (n = 89), with (n = 50) and without (n = 189) neoadjuvant hormone ablation therapy. Risk factors (RF) (prostate-specific antigen [PSA] >10 ng/mL, Stage > or = T2b, and Gleason grade > or = 7) defined risk group (RG) categories [none, 1, and > or = 2 RF define low, intermediate, and high RG] for bDFS calculations using four failure criteria: American Society for Therapeutic Radiology and Oncology (ASTRO) consensus definition, PSA >1.0 ng/mL (PSA >1), PSA >0.5 ng/mL after nadir (PSA >0.5), and PSA nadir+2 ng/mL rise in PSA clinical nadir (CN+2). Median followup was 47.2 months (range, 24.8-96.1).

RESULTS

Seven-year actuarial bDFS rates were 88.0%, 82.1%, 80.4%, and 79.9% using the ASTRO, PSA >1, PSA >0.5, and CN+2 failure criteria, respectively. ASTRO-defined bDFS rates were 96.0%, 87.0%, and 72.5% for low, intermediate, and high RG's.

CONCLUSION

The data presented here demonstrate the feasibility of performing SPECT/CT BTV dose escalation in a mature series.

Prognostic factors in prostate cancer

In the nineteenth century the main goal of medicine was predictive: diagnose the disease and achieve a satisfying prognosis of the patient's chances. Today the effort has shifted to cure the disease. Since the twentieth century, the word prognosis has also been used in nonmedical contexts, for example in corporate finance or elections. The most accurate form of prognosis is achieved statistically. Based on different prognostic factors it should be possible to tell patients how they are expected to do after prostate cancer has been diagnosed and how different treatments may change this outcome. A prognosis is a prediction. The word prognosis comes from the Greek word (see text) and means foreknowing. In the nineteenth century this was the main goal of medicine: diagnose the disease and achieve a satisfying prognosis of the patient's chances. Today the effort has shifted towards seeking a cure. Prognostic factors in (prostate) cancer are defined as "variables that can account for some of the heterogeneity associated with the expected course and outcome of a disease". Bailey defined prognosis as "a reasoned forecast concerning the course, pattern, progression, duration, and end of the disease. Prognostic factors are not only essential to understand the natural history and the course of the disease, but also to predict possible different outcomes of different treatments or perhaps no treatment at all. This is extremely important in a disease like prostate cancer where there is clear evidence that a substantial number of cases discovered by prostate-specific antigen (PSA) testing are unlikely ever to become clinically significant, not to mention mortal. Furthermore, prognostic factors are of paramount importance for correct interpretation of clinical trials and for the construction of future trials. Finally, according to WHO national screening committee criteria for implementing a national screening programme, widely accepted prognostic factors must be defined before assessing screening.

Rectal morbidity after permanent prostate brachytherapy with dose escalation to biologic target volumes identified by SPECT/CT fusion

PURPOSE

To evaluate rectal morbidity after dose escalation to biologic target volumes identified by capromab pendetide (ProstaScint) single-photon emission tomography images coregistered with computed tomography (SPECT/CT).

METHODS AND MATERIALS

Two hundred thirty-nine consecutive patients diagnosed with T1c-T3b NxM0 adenocarcinoma of the prostate were treated with brachytherapy seed implant (SI) dose escalation to SPECT/CT-identified biologic target volumes, from February 1997 through December 2002. Patients received SI (n=150) or external beam radiation therapy plus SI (n=89). Rectal morbidity was evaluated by clinician scoring using the modified Radiation Therapy Oncology Group criteria. The median followup was 47.2 (range 24.8-96.1) months.

RESULTS

The rate of acute Grades I and II toxicity was 29.9% and 3.7%, respectively, and chronic Grade I toxicity was 15.4%, 12.4%, 2.3%, and 1.8% at 1, 2, 3, and 4 years postimplant, respectively. Chronic Grade II toxicities were 1.8%, 1.9%, 1.5%, and 0.9% at 1, 2, 3, and 4 years, respectively. No Grade III rectal toxicity was reported. Chronic Grade IV rectal toxicity was 0.5% and 0.6% at 1.5 and 2.5 years, respectively. Ninety-six percent of patients reported freedom from all rectal toxicity after 3 years.

CONCLUSIONS

Dose intensification to occult tumor targets without increasing rectal toxicity may be achieved using SPECT/CT ProstaScint. Additional research to define the role of molecular imaging in prostate cancer is warranted.

REporting recommendations for tumor MARKer prognostic studies (REMARK)

Despite years of research and hundreds of reports on tumor markers in oncology, the number of markers that have emerged as clinically useful is pitifully small. Often initially reported studies of a marker show great promise, but subsequent studies on the same or related markers yield inconsistent conclusions or stand in direct contradiction to the promising results. It is imperative that we attempt to understand the reasons that multiple studies of the same marker lead to differing conclusions. A variety of methodologic problems have been cited to explain these discrepancies. Unfortunately, many tumor marker studies have not been reported in a rigorous fashion, and published articles often lack sufficient information to allow adequate assessment of the quality of the study or the generalizability of study results. The development of guidelines for the reporting of tumor marker studies was a major recommendation of the National Cancer Institute-European Organisation for Research and Treatment of Cancer (NCI-EORTC) First International Meeting on Cancer Diagnostics in 2000. As for the successful CONSORT initiative for randomized trials and for the STARD statement for diagnostic studies, we suggest guidelines to provide relevant information about the study design, pre-planned hypotheses, patient and specimen characteristics, assay methods, and statistical analysis methods. In addition, the guidelines suggest helpful presentations of data and important elements to include in discussions. The goal of these guidelines is to encourage transparent and complete reporting so that the relevant information will be available to others to help them to judge the usefulness of the data and understand the context in which the conclusions apply.

Prognostic and predictive factors in prostate cancer: historical perspectives and recent international consensus initiatives

An understanding of prognosis in cancer medicine is important for patient care, research and cancer control programs. In prostate cancer, prognostic (predictive) factors are particularly important given the marked heterogeneity of this disease at clinical, morphologic and biomolecular levels. Clinical stage and histologic grade have historically played major roles in defining heterogeneity in prostate cancer. More recently, serum prostate-specific antigen measurement has assumed a significant prognostic role. Over the last two decades there has been an explosion of research into biomarkers, many of which have been purported to have prognostic significance. In this paper we present an overview of the various consensus initiatives that have transpired over the last dozen years. Criteria for evaluating prognostic factors and classifications of predictive factors have emerged that have proven useful and advanced our understanding of the biology of prostate cancer. The results of these consensus initiatives form a foundation on which the current international consultation on prognosis (prediction) in prostate cancer is built. Advances in our understanding of the new and promising prognostic factors will require a more rigorous evidence-based approach to the analysis of published studies. Furthermore, appropriate mathematical models for the analysis of the multiple factors that influence a prognostic system will have to be employed.

REporting recommendations for tumour MARKer prognostic studies (REMARK)

Despite years of research and hundreds of reports on tumour markers in oncology, the number of markers that have emerged as clinically useful is pitifully small. Often initially reported studies of a marker show great promise, but subsequent studies on the same or related markers yield inconsistent conclusions or stand in direct contradiction to the promising results. It is imperative that we attempt to understand the reasons that multiple studies of the same marker lead to differing conclusions. A variety of methodologic problems have been cited to explain these discrepancies. Unfortunately, many tumour marker studies have not been reported in a rigorous fashion, and published articles often lack sufficient information to allow adequate assessment of the quality of the study or the generalisability of study results. The development of guidelines for the reporting of tumour marker studies was a major recommendation of the National Cancer Institute-European Organisation for Research and Treatment of Cancer (NCI-EORTC) First International Meeting on Cancer Diagnostics in 2000. As for the successful CONSORT initiative for randomised trials and for the STARD statement for diagnostic studies, we suggest guidelines to provide relevant information about the study design, pre-planned hypotheses, patient and specimen characteristics, assay methods, and statistical analysis methods. In addition, the guidelines suggest helpful presentations of data and important elements to include in discussions. The goal of these guidelines is to encourage transparent and complete reporting so that the relevant information will be available to others to help them to judge the usefulness of the data and understand the context in which the conclusions apply.

REporting recommendations for tumour MARKer prognostic studies (REMARK)

Despite years of research and hundreds of reports on tumour markers in oncology, the number of markers that have emerged as clinically useful is pitifully small. Often initially reported studies of a marker show great promise, but subsequent studies on the same or related markers yield inconsistent conclusions or stand in direct contradiction to the promising results. It is imperative that we attempt to understand the reasons that multiple studies of the same marker lead to differing conclusions. A variety of methodological problems have been cited to explain these discrepancies. Unfortunately, many tumour marker studies have not been reported in a rigorous fashion, and published articles often lack sufficient information to allow adequate assessment of the quality of the study or the generalisability of the study results. The development of guidelines for the reporting of tumour marker studies was a major recommendation of the US National Cancer Institute and the European Organisation for Research and Treatment of Cancer (NCI-EORTC) First International Meeting on Cancer Diagnostics in 2000. Similar to the successful CONSORT initiative for randomised trials and the STARD statement for diagnostic studies, we suggest guidelines to provide relevant information about the study design, preplanned hypotheses, patient and specimen characteristics, assay methods, and statistical analysis methods. In addition, the guidelines suggest helpful presentations of data and important elements to include in discussions. The goal of these guidelines is to encourage transparent and complete reporting so that the relevant information will be available to others to help them to judge the usefulness of the data and understand the context in which the conclusions apply.

Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK)

Despite years of research and hundreds of reports on tumor markers in oncology, the number of markers that have emerged as clinically useful is pitifully small. Often, initially reported studies of a marker show great promise, but subsequent studies on the same or related markers yield inconsistent conclusions or stand in direct contradiction to the promising results. It is imperative that we attempt to understand the reasons that multiple studies of the same marker lead to differing conclusions. A variety of methodologic problems have been cited to explain these discrepancies. Unfortunately, many tumor marker studies have not been reported in a rigorous fashion, and published articles often lack sufficient information to allow adequate assessment of the quality of the study or the generalizability of study results. The development of guidelines for the reporting of tumor marker studies was a major recommendation of the National Cancer Institute-European Organisation for Research and Treatment of Cancer (NCI-EORTC) First International Meeting on Cancer Diagnostics in 2000. As for the successful CONSORT initiative for randomized trials and for the STARD statement for diagnostic studies, we suggest guidelines to provide relevant information about the study design, preplanned hypotheses, patient and specimen characteristics, assay methods, and statistical analysis methods. In addition, the guidelines suggest helpful presentations of data and important elements to include in discussions. The goal of these guidelines is to encourage transparent and complete reporting so that the relevant information will be available to others to help them to judge the usefulness of the data and understand the context in which the conclusions apply.

The American Society of Anesthesiologists' class as a comorbidity index in a cohort of head and neck cancer surgical patients

BACKGROUND

We assessed the American Society of Anesthesiologists' (ASA) class, as a measure of comorbidity in comparison to the commonly used Charlson index for prognostic ability in a HNCA population.

METHODS

Proportional hazards methods were applied to head and neck cancer patients whose treatment included surgery by the Johns Hopkins Otolaryngology service (n = 388).

RESULTS

The Charlson index and ASA class were modestly correlated (Spearman 0.36, p <.001). Compared with patients with ASA class 1 or 2, those with ASA class 3 or 4 had a two-fold elevated mortality rate (Relative Hazard (RH) = 2.00, 95% CI, 1.38-2.89). This association was stronger than observed for a Charlson index score of 1 or more compared with 0 (RH = 1.59, 95% CI, 1.17-2.17). Both the Charlson index and ASA class adjusted RHs displayed dose-response patterns (p value for trend <.001).

CONCLUSIONS

Compared with the Charlson index, the ASA class had comparable if not greater prognostic ability for mortality in this elderly HNCA population.

Comorbidity and survival of elderly head and neck carcinoma patients

BACKGROUND

Alcohol and tobacco, the primary etiologic agents for head and neck carcinoma (HNCA), cause other chronic diseases and may contribute to the high prevalence of comorbid conditions and generally poor survival of persons with HNCA.

METHODS

The authors explored the prognostic role of comorbidity in persons with HNCA using Health Care Finance Administration Medicare (HCFA) files linked with the appropriate files of the Surveillance, Epidemiology, and End Results (SEER) Program. The Charlson comorbidity index was applied to in-patient data from the HCFA files. The SEER data were used to ascertain survival and identify persons with HNCA diagnosed from 1985 to 1993 (n = 9386).

RESULTS

In a proportional hazards regression model adjusted for age and historic stage at diagnosis, race, gender, marital status, socioeconomic status, histologic grade, anatomic site, treatment, and pre-1991 diagnosis, Charlson index scores of 0, 1, and 2+ had estimated relative hazards (RHs) with 95 confidence intervals (CIs) of 1.00, 1.33 (95% CI, 1.21-1.47), and 1.83 (95% CI, 1.64-2.05), respectively (P value for trend < 0.0001). The adjusted RH for a Charlson index score of 1 or more compared with 0, using stratified models, was found to be greater in whites (RH, 1.55; 95% CI, 1.43-1.67) than blacks (RH, 1.24; 95% CI, 0.96-1.60), local (RH, 1.72; 95% CI, 1.50-1.96) versus distant stage (RH, 1.25; 95% CI, 1.00-1.56), and age 65-74 years (RH, 1.53; 95% CI, 1.38-1.69) versus age 85+ years (RH, 1.42; 95% CI, 1.09-1.84).

CONCLUSIONS

This study establishes comorbidity as a predictor of survival in an elderly HNCA population and lends support to the inclusion of comorbidity assessment in prognostic staging of patients with HNCA diagnosed after 65 years of age.

High-risk groups of patients with Stage II colon carcinoma

BACKGROUND

It is unclear whether patients with Stage II colon carcinoma should be offered adjuvant chemotherapy. Therefore, the authors analyzed the risk factors of these patients to identify high-risk subgroups who may benefit from such treatment.

METHODS

The data from 305 patients with Stage II colon carcinoma documented in the Erlangen Registry of Colorectal Carcinoma were analyzed to identify risk factors for distant metastasis and disease-related survival. The patients were divided into two subgroups: those in a low-risk group and those in a high-risk group. The data were then compared with those from 306 patients with Stage II colon carcinoma from the German Study Group for Colorectal Carcinoma (SGCRC).

RESULTS

Emergency presentation, a primary tumor site in the left colon, pT3 tumors with a depth of invasion of > 15 mm beyond the outer border of the muscularis propria, and pT4 lesions were identified as the major risk factors for Stage II colon carcinoma. On dividing patients into subgroups according to these risk factors, it was found that patients in the high-risk group had a significantly higher risk of distant metastases and a significantly lower disease-related survival rate compared with patients in the low-risk group. On analyzing the SGCRC data, the authors also found a significantly higher rate of distant metastases in the high-risk group, but the disease-related survival rate differed only marginally.

CONCLUSIONS

Among patients with Stage II colon carcinoma, it is possible to identify a high-risk group of patients who may be candidates for adjuvant chemotherapy. Stratification by the risk factors emergency presentation, tumor site, depth of tumor invasion, and surgical department should be employed in further clinical studies.

Prediction of survival in patients with head and neck cancer

BACKGROUND

In patients with head and neck squamous cell carcinoma (HNSCC) the estimated prognosis is usually based on the TNM classification. The relative weight of the three contributing parameters is often not completely clear. Moreover, the impact of other important clinical variables such as age, gender, prior malignancies, etc is very difficult to substantiate in daily clinical practice. The Cox-regression model allows us to estimate the effect of different variables simultaneously. The purpose of this study was to design a model for application in new HNSCC patients. In our historical data-base of patients with HNSCC, patient, treatment, and follow-up data are stored by trained oncological data managers. With these hospital-based data, we developed a statistical model for risk assessment and prediction of overall survival. This model serves in clinical decision making and appropriate counseling of patients with HNSCC.

PATIENTS AND METHODS

All patients with HNSCC of the oral cavity, the pharynx, and the larynx diagnosed in our hospital between 1981 and 1998 were included. In these 1396 patients, the prognostic value of site of the primary tumor, age at diagnosis, gender, T-, N-, and M-stage, and prior malignancies were studied univariately by Kaplan-Meier curves and the log-rank test. The Cox-regression model was used to investigate the effect of these variables simultaneously on overall survival and to develop a prediction model for individual patients.

RESULTS

In the univariate analyses, all variables except gender contributed significantly to overall survival. Their contribution remained significant in the multivariate Cox model. Based on the relative risks and the baseline survival curve, the expected survival for a new HNSCC patient can be calculated.

CONCLUSIONS

It is possible to predict survival probabilities in a new patient with HNSCC based on historical results from a data-set analyzed with the Cox-regression model. The model is supplied with hospital-based data. Our model can be extended by other prognostic factors such as co-morbidity, histological data, molecular biology markers, etc. The results of the Cox-regression may be used in patient counseling, clinical decision making, and quality maintenance.

Is the International Federation of Gynecology and Obstetrics staging system for cervical carcinoma able to predict survival in patients with cervical carcinoma?: an assessment of clinimetric properties

BACKGROUND

The objective of this article was to assess the clinimetric properties of the International Federation of Gynecology and Obstetrics (FIGO) staging system of cervical carcinoma to determine whether it is an adequate prognostic tool for the survival of patients with cervical carcinoma.

METHODS

The FIGO staging system for cervical carcinoma was evaluated with regard to item generation, item reduction, sensibility, reliability, and validity.

RESULTS

Many statistically significant and clinically important variables have been omitted from the current staging system for cervical carcinoma. The item-reduction step for the formulation of the prognostic tool has not been described by the authors of the FIGO staging system, but a consensus process is assumed. There are no studies currently available to assess the reliability of interobserver and intraobserver variability in applying the staging system to patients with cervical carcinoma. A trial to assess the reliability of this tool is proposed by the authors. Although there are no prospective trials to assess the criterion validity of the FIGO staging system, there is enough literature to suggest that the staging system is not capable of discriminating with regard to patient survival within and between stages.

CONCLUSIONS

The current FIGO staging system for cervical carcinoma does not fully meet the majority of methodologic criteria for a strong predictive tool. Developing an improved prognostic index containing a complete array of independently prognostic variables is suggested.

College of American Pathologists Conference XXXV: solid tumor prognostic factors-which, how and so what? Summary document and recommendations for implementation. Cancer Committee and Conference Participants

The College of American Pathologists convened a prognostic factor conference in June 1999 to consider prognostic and predictive factors in breast, colon, and prostate cancer, and to stratify these factors into categories reflecting the strength of published evidence. Because so little progress in prognostic factor clinical utility has been made in the last 5 years, the conference participants focused their attention on decreasing variation in methods, interpretation, and reporting of these factors so that greater clarity of value could be achieved. The conference was organized to promote discussion, broad input, and future planning. An initial plenary session provided an overview of the status of tumor marker research, the impact of variation in medicine and pathology, and statistical issues related to prognostic factor research. In working group sessions for each cancer type, participants interactively evaluated and refined the documents created by the expert panels. A second plenary session dealt with issues common to all 3 groups, including the problem of micrometastases in lymph nodes in these sites; statistical issues that arose during the breakout discussions; and issues of variation in methods, interpretation, and reporting of immunohistochemical assays. A faculty session brainstormed strategies that could be used to implement the changes recommended. This session included invited representatives of the Food and Drug Administration, Health Care Financing Administration, Centers for Disease Control and Prevention, National Cancer Institute, American Joint Committee on Cancer, and International Union Against Cancer. Cancer site and general recommendations were presented and discussed during a final session to achieve consensus of the conference participants and to address feasibility of implementation of these recommendations. A final discussion focused on future initiatives that might lead to implementation of the changes proposed in the conference by the various organizations represented. This report summarizes the general conference recommendations, cancer working group recommendations, and plans for implementation of the recommendations.