Utility of Prognostic Prediction Models in the Terminal Stage of Gastrointestinal Cancer

Performance of the Palliative Prognostic Index for cancer patients: A systematic review and meta-analysis

BACKGROUND

Clinician predicted survival for cancer patients is often inaccurate, and prognostic tools may be helpful, such as the Palliative Prognostic Index (PPI). The PPI development study reported that when PPI score is greater than 6, it predicted survival of less than 3 weeks with a sensitivity of 83% and specificity of 85%. When PPI score is greater than 4, it predicts survival of less than 6 weeks with a sensitivity of 79% and specificity of 77%. However, subsequent PPI validation studies have evaluated various thresholds and survival durations, and it is unclear which is most appropriate for use in clinical practice. With the development of numerous prognostic tools, it is also unclear which is most accurate and feasible for use in multiple care settings.

AIM

We evaluated PPI model performance in predicting survival of adult cancer patients based on different thresholds and survival durations and compared it to other prognostic tools.

DESIGN

This systematic review and meta-analysis was registered in PROSPERO (CRD42022302679). We calculated the pooled sensitivity and specificity of each threshold using bivariate random-effects meta-analysis and pooled diagnostic odds ratio of each survival duration using hierarchical summary receiver operating characteristic model. Meta-regression and subgroup analysis were used to compare PPI performance with clinician predicted survival and other prognostic tools. Findings which could not be included in meta-analyses were summarised narratively.

DATA SOURCES

PubMed, ScienceDirect, Web of Science, CINAHL, ProQuest and Google Scholar were searched for articles published from inception till 7 January 2022. Both retrospective and prospective observational studies evaluating PPI performance in predicting survival of adult cancer patients in any setting were included. The Prediction Model Risk of Bias Assessment Tool was used for quality appraisal.

RESULTS

Thirty-nine studies evaluating PPI performance in predicting survival of adult cancer patients were included (n = 19,714 patients). Across meta-analyses of 12 PPI score thresholds and survival durations, we found that PPI was most accurate for predicting survival of <3 weeks and <6 weeks. Survival prediction of <3 weeks was most accurate when PPI score>6 (pooled sensitivity = 0.68, 95% CI 0.60-0.75, specificity = 0.80, 95% CI 0.75-0.85). Survival prediction of <6 weeks was most accurate when PPI score>4 (pooled sensitivity = 0.72, 95% CI 0.65-0.78, specificity = 0.74, 95% CI 0.66-0.80). Comparative meta-analyses found that PPI performed similarly to Delirium-Palliative Prognostic Score and Palliative Prognostic Score in predicting <3-week survival, but less accurately in <30-day survival prediction. However, Delirium-Palliative Prognostic Score and Palliative Prognostic Score only provide <30-day survival probabilities, and it is uncertain how this would be helpful for patients and clinicians. PPI also performed similarly to clinician predicted survival in predicting <30-day survival. However, these findings should be interpreted with caution as limited studies were available for comparative meta-analyses. Risk of bias was high for all studies, mainly due to poor reporting of statistical analyses. while there were low applicability concerns for most (38/39) studies.

CONCLUSIONS

PPI score>6 should be used for <3-week survival prediction, and PPI score>4 for <6-week survival. PPI is easily scored and does not require invasive tests, and thus would be easily implemented in multiple care settings. Given the acceptable accuracy of PPI in predicting <3- and <6-week survival and its objective nature, it could be used to cross-check clinician predicted survival especially when clinicians have doubts about their own judgement, or when clinician estimates seem to be less reliable. Future studies should adhere to the reporting guidelines and provide comprehensive analyses of PPI model performance.

Development and internal validation of laboratory prognostic score to predict 14-day mortality in terminally ill patients with gastrointestinal malignancy

BACKGROUND

Few studies have developed an easy scoring system for the short-term survival of patients with gastrointestinal (GI) malignancy.

METHODS

A total of 816 terminally ill patients with GI malignancy were admitted to our palliative care unit. They were randomly divided into the investigation (n = 490) and validation (n = 326) groups. A total of 19 laboratory blood parameters were analyzed. Receiver-operating characteristic analysis was performed for each blood factor, and the area under the curve was calculated to determine the predictive value for 14-day survival after the blood test. Multivariable logistic regression analysis was performed to identify significant independent prognostic factors for 14-day mortality. To develop a scoring system for 14-day mortality, the laboratory prognostic score for gastrointestinal malignancy (GI-LPS) was calculated using the sum of indices of the independent prognostic factors.

RESULTS

Multivariable analysis showed that 5 of 19 indices, namely total bilirubin ≥ 2.1 mg/dL, blood urea nitrogen ≥ 28 mg/dL, eosinophil percentage ≤ 0.5%, neutrophil-to-lymphocyte ratio ≥ 9.2, and platelet count ≤ 194 × 10³/μL, were significant independent factors of 14-day survival. GI-LPS showed acceptable accuracy for 14-day mortality in the investigation and validation groups. GI-LPS 3 (including any three factors) predicted death within 14 days, with a sensitivity of 56-58%, a specificity of 82-87%, a positive predictive value of 48-50%, and a negative predictive value of 87-90%.

CONCLUSIONS

GI-LPS showed an acceptable ability to predict 14-day survival and can provide additional information to conventional prognostic scores.