Validation of a Predictive Model for Survival in Metastatic Cancer Patients Attending an Outpatient Palliative Radiotherapy Clinic

A Systematic Review of Prognostic Factors in Patients with Cancer Receiving Palliative Radiotherapy: Evidence-Based Recommendations

(1) Background: Prognostication in patients with cancer receiving palliative radiotherapy remains a challenge. To improve the process, we aim to identify prognostic factors in this population from the literature and offer evidence-based recommendations on prognostication in patients undergoing palliative radiotherapy for non-curable or advanced cancers. (2) Methods: A systematic review was performed on the medical literature from 2005 to 2023 to extract papers on the prognosis of palliative radiotherapy patients with advanced cancer. The initial selection was performed by at least two authors to determine study relevance to the target area. Studies were then classified based on type and evidence quality to determine final recommendations. (3) Results: The literature search returned 57 papers to be evaluated. Clinical and biological prognostic factors were identified from these papers to improve clinical decision making or construct prognostic models. Twenty prognostic models were identified for clinical use. There is moderate evidence supporting (i) evidence-based factors (patient, clinical, disease, and lab) in guiding decision making around palliative radiation; (ii) that certain biological factors are of importance; (iii) prognostication models in patients with advanced cancer; and that (iv) SBRT or re-irradiation use can be guided by predictions of survival by prognostic scores or clinicians. Patients with more favorable prognoses are generally better suited to SBRT or re-irradiation, and the use of prognostic models can aid in this decision making. (4) Conclusions: This evaluation has identified several factors or tools to aid in prognosis and clinical decision making. Future studies should aim to further validate these tools and factors in a clinical setting, including the leveraging of electronic medical records for data availability. To increase our understanding of how causal factors interact with palliative radiotherapy, future studies should also examine and include prediction of response to radiation as an outcome.

Deterioration of Performance Status during Palliative Radiotherapy Suggests a Significant Short Survival Duration: Indicating the Necessities for Considering Radiotherapy Discontinuation

Discontinuation of palliative radiotherapy due to a patient's declining general condition poses a clinical dilemma for palliative care physicians. This study aimed to investigate the survival duration of patients whose performance status (PS) deteriorated during palliative radiotherapy and inform decisions regarding early treatment discontinuation. We retrospectively analyzed data from patients referred from our institute's palliative care department who underwent ≥10 fractions of palliative radiotherapy between March 2017 and December 2021. PS was assessed using the Eastern Cooperative Oncology Group (ECOG) scale. Survival duration was calculated from the final day of palliative radiotherapy to death using the Kaplan-Meier method. A total of 35 patients underwent palliative radiotherapy. Seven (20%) experienced deterioration in ECOG PS during treatment. Their median survival duration was significantly shorter at 22 days (95% confidence interval: 1-94 days) compared to 125 days (95% confidence interval: 82-150 days) for the 28 patients whose PS remained stable (p = 0.0007). Deterioration in ECOG PS during palliative radiotherapy signifies a markedly shorter survival duration. Careful assessment of a patient's condition throughout treatment is crucial, and early discontinuation should be considered if their general health worsens rather than strictly adhering to the initial schedule.

Palliative radiotherapy: survival prognostic factors - single-centre retrospective cohort study

OBJECTIVE

Patients with non-curative malignancy can receive palliative radiotherapy (PR) to alleviate symptoms. However, choosing the right patient to receive PR can be challenging, as some patients may not survive long enough to gain benefit. This study aims to identify prognostic factors for overall survival (OS) and 30-day mortality (30DM) following PR and to test these in a real-world cohort.

METHOD

A retrospectively collected data set of all adults completing PR between 1 August 2018 and 31 December 2018 at a single centre (n=214, Southend University Hospital NHS Foundation Trust, UK) was used to test prognostic factors. Factors such as demographics, tumour primary, treatment area, fractionation regime, performance status (PS), progressive disease (PD), opioid or steroid use and haemoglobin level, as well as overall survival, were collected. Cox regression was used to examine survival predictors, and logistic regression was used to determine the predictive strength of factors for 30DM.

RESULTS

Overall 30DM was 14%. There was significantly worse survival in patients with poor PS (HR 1.2406, 95% CI 0.94 to 1.64. p=0.01). Patients with PS 3 had a median OS of 75 days and were more likely to experience 30DM (OR 6.2, 95% CI 1.226 to 45.42, p=0.03). Patients with PD outside of the radiation field (46%, 30 out of 65 documented) had significantly worse OS (HR 5.24, 95% CI 2.19 to 12.5, p<0.001).

CONCLUSION

Poor PS and PD were prognostic of OS and 30DM. Future work should include validation with a prospectively collected cohort.

Radiation Therapy in the Last Month of Life: Association With Aggressive Care at the End of Life

CONTEXT

Half of the patients with cancer who undergo radiation therapy do so with palliative intent.

OBJECTIVES

To determine the proportion of undergoing radiation in the last month of life, patient characteristics, cancer course, the type and duration of radiation, whether palliative care was involved, and the of radiation with aggressive cancer care metrics.

METHODS

One thousand seven hundred twenty-seven patients who died of cancer between January 1, 2018, and December 31, 2019, were included. Demographics, cancer stage, palliative care referral, advance directives, use of home health care, radiation timing, and survival were collected. Type of radiation, course, and intent were reviewed. Chi-square analysis was utilized for categorical variables, and Kruskal-Wallis tests for continuous variables. A stepwise selection was used to build a Cox proportional hazard model.

RESULTS

Two hundred thirty-three patients underwent radiation in the last month of life. Younger patients underwent radiation 67.3 years (SD 11.52) versus 69.2 years (SD 11.96). 42.6% had radiation within two weeks of death. The average fraction number was 5.5. Individuals undergoing radiation were more likely to start chemotherapy within the last 30 days of life, continue chemotherapy within two weeks of death, be admitted to the ICU, and have two or more hospitalizations or emergency room visits. Survival measured from the date of diagnosis was shorter for those undergoing radiation, 122 days (IQR 58-462) versus 474 days (IQR 225-1150). Palliative care consultations occurred later in those undergoing radiation therapy.

CONCLUSION

Radiation therapy in the last month of life occurs in younger patients with rapidly progressive cancer, who are subject to more aggressive cancer care, and have late palliative care consults.

Palliative appropriateness criteria: external validation of a new method to evaluate the suitability of palliative radiotherapy fractionation

BACKGROUND

Recently, the palliative appropriateness criteria (PAC) score, a novel metric to aid clinical decision-making between different palliative radiotherapy fractionation regimens, has been developed. It includes baseline parameters including but not limited to performance status. The researchers behind the PAC score analyzed the percent of remaining life (PRL) on treatment. The latter was accomplished by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. The purpose of the present study was to validate this novel metric.

PATIENTS AND METHODS

The retrospective validation study included 219 patients (287 courses of palliative radiotherapy). The methods were identical to those employed in the score development study. The score was calculated by assigning 1 point each to several factors identified in the original study and using the online calculator provided by the PAC developers.

RESULTS

Median survival was 6 months and death within 30 days from start of radiotherapy was recorded in 13% of courses. PRL on treatment ranged from 1 to 23%, median 8%. Significant associations were confirmed between online-calculated PAC score, observed survival, and risk of death within 30 days from the start of radiotherapy. Patients with score 0 had distinctly better survival than all other groups. The score-predicted median risk of death within 30 days from start of radiotherapy was 22% in our cohort. A statistically significant correlation was found between predicted and observed risk (p < 0.001). The original and present study were not perfectly concordant regarding number and type of baseline parameters that should be included when calculating the PAC score.

CONCLUSION

This study supports the dual strategy of PRL and risk of early death calculation, with results stratified for fractionation regimen, in line with the original PAC score study. When considering multifraction regimens, the PAC score identifies patients who may benefit from shorter courses. Additional work is needed to answer open questions surrounding the underlying components of the score, because the original and validation study were only partially aligned.

Prognostication in palliative radiotherapy—ProPaRT: Accuracy of prognostic scores

Background

Prognostication can be used within a tailored decision-making process to achieve a more personalized approach to the care of patients with cancer. This prospective observational study evaluated the accuracy of the Palliative Prognostic score (PaP score) to predict survival in patients identified by oncologists as candidates for palliative radiotherapy (PRT). We also studied interrater variability for the clinical prediction of survival and PaP scores and assessed the accuracy of the Survival Prediction Score (SPS) and TEACHH score.

Materials and methods

Consecutive patients were enrolled at first access to our Radiotherapy and Palliative Care Outpatient Clinic. The discriminating ability of the prognostic models was assessed using Harrell’s C index, and the corresponding 95% confidence intervals (95% CI) were obtained by bootstrapping.

Results

In total, 255 patients with metastatic cancer were evaluated, and 123 (48.2%) were selected for PRT, all of whom completed treatment without interruption. Then, 10.6% of the irradiated patients who died underwent treatment within the last 30 days of life. The PaP score showed an accuracy of 74.8 (95% CI, 69.5–80.1) for radiation oncologist (RO) and 80.7 (95% CI, 75.9–85.5) for palliative care physician (PCP) in predicting 30-day survival. The accuracy of TEACHH was 76.1 (95% CI, 70.9–81.3) and 64.7 (95% CI, 58.8–70.6) for RO and PCP, respectively, and the accuracy of SPS was 70 (95% CI, 64.4–75.6) and 72.8 (95% CI, 67.3–78.3).

Conclusion

Accurate prognostication can identify candidates for low-fraction PRT during the last days of life who are more likely to complete the planned treatment without interruption.

All the scores showed good discriminating capacity; the PaP had the higher accuracy, especially when used in a multidisciplinary way.

Prediction of post-radiotherapy survival for bone metastases: a comparison of the 3-variable number of risk factors model with the new Katagiri scoring system

We investigated patient survival after palliative radiotherapy for bone metastases while comparing the prognostic accuracies of the 3-variable number of risk factors (NRF) model and the new Katagiri scoring system (Katagiri score). Overall, 485 patients who received radiotherapy for bone metastases were grouped as per the NRF model (groups I, II and III) and Katagiri score (low-, intermediate- and high-risk). Survival was compared using the log-rank or log-rank trend test. Independent prognostic factors were identified using multivariate Cox regression analyses (MCRA). MCRA and receiver operating characteristic (ROC) curves were used to compare both models' accuracy. For the 376 evaluable patients, the overall survival (OS) rates decreased significantly in the higher-tier groups of both models (P < 0.001). All evaluated factors except 'previous chemotherapy status' differed significantly between groups. Both models exhibited independent predictive power (P < 0.001). Per NRF model, hazard ratios (HRs) were 1.44 (P = 0.099) and 2.944 (P < 0.001), respectively, for groups II and III, relative to group I. Per Katagiri score, HRs for intermediate- and high-risk groups were 4.02 (P < 0.001) and 7.09 (P < 0.001), respectively, relative to the low-risk group. Areas under the curve (AUC) for predicting 6-, 18- and 24-month mortality were significantly higher when using the Katagiri score (P = 0.036, 0.039 and 0.022). Both models predict survival. Prognostic accuracy of the Katagiri score is superior, especially in patients with long-term survival potential; however, in patients with short prognosis, no difference occurred between both models; simplicity and patient burden should also be considered.

Prognostic tools for survival prediction in advanced cancer patients: A systematic review

Survival prediction for palliative cancer patients by physicians is often optimistic. Patients with a very short life expectancy (<4 weeks) may not benefit from radiation therapy (RT), as the time to maximal symptom relief after treatment can take 4-6 weeks. We aimed to identify a prognostic tool (or tools) to predict survival of less than 4 weeks and less than 3 months in patients with advanced cancer to guide the choice of radiation dose and fractionation. We searched Embase, Medline (EBSCOhost) and CINAHL (EBSCOhost) clinical databases for literature published between January 2008 and June 2018. Seventeen studies met the inclusion criteria and were included in the review. Prediction accuracy at less than 4 weeks and less than 3 months were compared across the prognostic tools. Reporting of prediction accuracy among the different studies was not consistent: the Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI) and Number of Risk Factors (NRF) best-predicted survival duration of less than 4 weeks. The PPI, performance status with Palliative Prognostic Index (PS-PPI), NRF and Survival Prediction Score (SPS) may predict 3-month survival. We recommend PPI and PaP tools to assess the likelihood of a patient surviving less than 4 weeks. If predicted to survive longer and RT is justified, the NRF tool could be used to determine survival probability less than 3 months which can then help clinicians select dose and fractionation. Future research is needed to verify the reliability of survival prediction using these prognostic tools in a radiation oncology setting.

Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care

BACKGROUND

Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals.

MATERIALS AND METHODS

All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed.

RESULTS

In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045).

CONCLUSIONS

Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.

External Validation of the Bone Metastases Ensemble Trees for Survival (BMETS) Machine Learning Model to Predict Survival in Patients With Symptomatic Bone Metastases

PURPOSE

The Bone Metastases Ensemble Trees for Survival (BMETS) model uses a machine learning algorithm to estimate survival time following consultation for palliative radiation therapy for symptomatic bone metastases (SBM). BMETS was developed at a tertiary-care, academic medical center, but its validity and stability when applied to external data sets are unknown.

PATIENTS AND METHODS

Patients treated with palliative radiation therapy for SBM from May 2013 to May 2016 at two hospital-based community radiation oncology clinics were included, and medical records were retrospectively reviewed to collect model covariates and survival time. The Kaplan-Meier method was used to estimate overall survival from consultation to death or last follow-up. Model discrimination was estimated using time-dependent area under the curve (tAUC), which was calculated using survival predictions from BMETS based on the initial training data set.

RESULTS

A total of 216 sites of SBM were treated in 182 patients. Most common histologies were breast (27%), lung (23%), and prostate (23%). Compared with the BMETS training set, the external validation population was older (mean age, 67 v 62 years; P < .001), had more primary breast (27% v 19%; P = .03) and prostate cancer (20% v 12%; P = .01), and survived longer (median, 10.7 v 6.4 months). When the BMETS model was applied to the external data set, tAUC values at 3, 6, and 12 months were 0.82, 0.77, and 0.77, respectively. When refit with data from the combined training and external validation sets, tAUC remained > 0.79.

CONCLUSION

BMETS maintained high discriminative ability when applied to an external validation set and when refit with new data, supporting its generalizability, stability, and the feasibility of dynamic modeling.

The influence of breast cancer subtype on survival after palliative radiation for osseous metastases

Background

Among patients with osseous metastases, breast cancer (BC) patients typically have the best prognosis. In the palliative setting, BC is often considered a single disease, but based on receptor status there are four distinct subtypes: luminal A (LA), luminal B (LB), triple negative (TN), and HER2‐enriched (HER2). We hypothesize that survival and palliative outcomes following palliative RT for osseous metastases correlate with breast cancer subtype (BCS).

Methods

We identified 3,895 BC patients with known receptor status who received palliative RT for osseous metastases from 2004–2013 in the National Cancer Database. Kaplan–Meier method with log‐rank testing and univariate/multivariate Cox‐regression was used to identify survival factors. Incomplete radiation courses, 30‐day mortality rate, and percentage remaining life spent receiving RT (PRLSRT) were calculated.

Results

Subtypes were 54% LA, 33% LB, 8% TN, and 5% HER2 with median survival of 34.1, 28.2, 5.3, and 15.7 months, respectively (p < 0.001). Overall 82% of patients received ≥10 fractions. Although BCS had limited effect on radiation regimens, TN received nearly twice as many single or hypofractionated (≤5 fractions) treatments, but the overall rate of these fraction schemes was low at 3.7 and 13.7%, respectively. Compared to LA and LB, TN and HER2 patients had worse palliative outcomes; higher rates of incomplete courses at 18.8% and 18.3% versus 12.7%–14.4%; higher 30‐day mortality post‐radiotherapy at 21.5% and 16.0% versus 6.3%–7.9%, and higher median PRLSRT of 7.7% and 3.7% versus 2.2%–2.4% for LA and LB. On multivariate analysis, BCS was associated with overall survival with TN (HR 3.7), HER2 (HR 1.75), and LB (HR 1.28) fairing worse than LA (p < 0.001).

Conclusions

BCS correlated with survival and palliative outcome following radiation to osseous metastases. BCS should be considered by physicians when planning palliative RT to maximize quality‐of‐life, avoid unnecessary treatment, and ensure palliative benefits.

Dealing with prognostic uncertainty: the role of prognostic models and websites for patients with advanced cancer

PURPOSE OF REVIEW

To provide an updated overview of prognostic models in advanced cancer and highlight the role of prognostic calculators.

RECENT FINDINGS

In the advanced cancer setting, many important healthcare decisions are driven by a patient's prognosis. However, there is much uncertainty in formulating prognosis, particularly in the era of novel cancer therapeutics. Multiple prognostic models have been validated for patients seen by palliative care and have a life expectancy of a few months or less, such as the Palliative Performance Scale, Palliative Prognostic Score, Palliative Prognostic Index, Objective Prognostic Score, and Prognosis in Palliative Care Study Predictor. However, these models are seldom used in clinical practice because of challenges related to limited accuracy when applied individually and difficulties with model selection, computation, and interpretation. Online prognostic calculators emerge as tools to facilitate knowledge translation by overcoming the above challenges. For example, www.predictsurvival.com provides the output for seven prognostic indexes simultaneously based on 11 variables.

SUMMARY

Prognostic models and prognostic websites are currently available to augment prognostication in the advanced cancer setting. Further studies are needed to examine their impact on prognostic accuracy, confidence, and clinical outcomes.

Translational and basic science opportunities in palliative care and radiation oncology

Radiation therapy is commonly used in the metastatic setting to palliate pain, neurological deficits, bleeding and other complications of metastatic disease, allowing patients to live longer and have better quality of life. Despite the effective use of radiation and other palliative treatment modalities, many patients continue to experience poorly controlled pain and other serious sequelae of their disease, underscoring the need for additional research in this area. In this review we highlight recent developments impacting the fields of palliative care and radiation oncology and describe opportunities for research and innovation including studies of tumor microenvironment, identification of effective biomarkers of tumor response and combinatorial treatments with new systemic agents. It is our hope that progress in these fields will improve the lives of patients living with advanced malignancies.

Patient-reported symptoms before palliative radiotherapy predict survival differences

BACKGROUND

Widely used prognostic scores, e. g., for brain or bone metastases, are based on disease- and patient-related factors such as extent of metastases, age and performance status, which were available in the databases used to develop the scores. Few groups were able to include patient-reported symptoms. In our department, all patients were assessed with the Edmonton Symptom Assessment System (ESAS, a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) at the time of treatment planning since 2012. Therefore, we analyzed the prognostic impact of baseline ESAS symptom severity.

METHODS

Retrospective review of 102 patients treated with palliative radiotherapy (PRT) between 2012 and 2015. All ESAS items were dichotomized (below/above median). Uni- and multivariate analyses were performed to identify prognostic factors for survival.

RESULTS

The most common tumor types were prostate, breast and non-small cell lung cancer, predominantly with distant metastases. Median survival was 6 months. Multivariate analysis resulted in six significant prognostic factors. These were ESAS pain while not moving (median 3), ESAS appetite (median 5), Eastern Cooperative Oncology Group (ECOG) performance status, pleural effusion/metastases, intravenous antibiotics at start or within 2 weeks before PRT and no systemic cancer treatment.

CONCLUSIONS

Stronger pain while not moving and reduced appetite (below/above median) predicted significantly shorter survival. Development of new prognostic scores should include patient-reported symptoms and other innovative parameters because they were more important than primary tumor type, age and other traditional baseline parameters.

Frequency and Prognostic Impact of Consistently Low Edmonton Symptom Assessment System Score in the Patients Treated with Palliative Radiotherapy

Introduction

Our department's standard work-flow includes assessment of all the patients with the Edmonton Symptom Assessment System (ESAS), a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of zero-10, before the palliative radiotherapy (PRT). Based on previous research, we hypothesized that the patients with minimal or moderate total symptom burden might have better overall survival after the PRT than those with at least one higher symptom score.

Methods

We performed a retrospective analysis of 94 patients and calculated actuarial survival from the first day of the PRT (Kaplan-Meier method). We identified the patients with the score zero for all ESAS items (no symptoms), at least one item with score one-two (minimal symptoms), and at least one item with the score three (moderate symptoms).

Results

High proportions of the patients had ESAS scores zero- two for nausea (80%), sadness/depression (65%) and constipation (64%). The mean values were often in the range of two-four. Only one patient reported scores of zero throughout the questionnaire. He was treated for hematuria, a symptom that is not part of the ESAS. Three patients reported scores of zero-two throughout the questionnaire. Except for the performance status zero-one, their baseline characteristics were heterogeneous. Two patients reported scores not exceeding three for all items. These patients had excellent performance status, too. None of the six patients (6%) with relatively low ESAS scores of zero-three received care by the hospital's multidisciplinary palliative team. Only one was using opioid analgesics. The median survival for this small subset of six patients was six months, identical to the result for all the patients with higher symptom burden (p = 0.62).

Conclusion

The proportion of the patients with ESAS scores zero-three throughout the questionnaire was 6%, which resulted in the limited statistical power for the survival comparisons. The survival outcomes were similar. Before PRT, 94% of the patients reported at least one ESAS item of severity four-10. The symptoms not included in the questionnaire, e.g., hematuria might result in erroneous assignment to the low-symptom-burden group and obscure the prognostic impact of low ESAS symptom burden.

Prognostic value of parameters derived from white blood cell and differential counts in patients receiving palliative radiotherapy

The aim of the present study was to identify white blood cell (WBC) parameters with high prognostic value for the survival of patients receiving palliative radiotherapy. The prognostic value of seven parameters derived from WBC and differential counts was retrospectively evaluated in patients who underwent palliative radiotherapy between October, 2010 and June, 2013. The analyzed parameters were the total WBC count, the absolute and relative lymphocyte count, the absolute and relative neutrophil count, and the neutrophil-to-lymphocyte and lymphocyte-to-monocyte ratios. Following univariate analysis, multivariate Cox regression analysis was performed to adjust for gender, age, disease type, previous chemotherapy, previous radiotherapy and the levels of albumin and lactate dehydrogenase. A total of 220 patients with a median survival of 4.7 months were identified. All seven parameters were found to be statistically significant predictors of survival on univariate Cox regression analysis (P<0.05). Of these parameters, the low relative lymphocyte and high relative neutrophil counts were consistent predictors of poor survival in patients who received chemotherapy within 1 month prior to blood sampling (n=68) and in patients who received steroid treatment at the time of sampling (n=49). Multivariate Cox regression analysis revealed that the relative lymphocyte and neutrophil counts were independent predictors of survival in all 220 patients (P<0.05). In conclusion, relative lymphocyte and neutrophil counts were of high prognostic value for the survival of patients receiving palliative radiotherapy, even in those receiving medications that affect WBC and differential counts.

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.

Predictive model for survival in patients having repeat radiation treatment for painful bone metastases

PURPOSE

To establish a survival prediction model in the setting of a randomized trial of re-irradiation for painful bone metastases.

METHODS

Data were randomly divided into training and testing sets with an approximately 3:2 ratio. Baseline factors of gender, primary cancer site, KPS, worst-pain score and age were included with backward variable selection to derive a model using the training set. A partial score was assigned by dividing the value of each statistically significant regression coefficient by the smallest statistically significant regression coefficient. The survival prediction score (SPS) was obtained by adding together partial scores for the variables that were statistically significant. Three risk groups were modelled.

RESULTS

The training set included 460 patients and the testing set 351 patients. Only KPS and primary cancer site reached the 5%-significance level. Summing up the partial scores assigned to KPS (90-100, 0; 70-80, 1; 50-60, 2) and primary cancer site (breast, 0; prostate, 1.3; other, 2.6; lung, 3) totalled the SPS. The 1/3 and 2/3 percentiles of the SPS were 2 and 3.6. For the testing set, the median survival of the 3 groups was not reached, 11.3 (95% C.I. 8.5 - not reached) and 5.2 months (95% C.I. 3.7-6.5). The 3, 6 and 12 month survival rates for the worst group were 64.4% (95% C.I. 55.3-72.1%), 43.0% (95% C.I. 34.0-51.8%) and 19.7% (95% C.I. 12.4-28.1%) respectively, similar to that in the training set.

CONCLUSION

This survival prediction model will assist in choosing dose fractionation. We recommend a single 8 Gy in the worst group identified.

Palliative whole-brain radiotherapy and health- related quality of life for patients with brain metastasis in cancer

OBJECTIVE

To assess the use of palliative whole-brain radiotherapy (WBRT) in the treatment of brain metastases (BMs) and to evaluate the health-related quality of life (HRQOL) of these patients.

MATERIALS AND METHODS

We conducted a retrospective study of 46 patients with BMs who were treated with WBRT at the First Affiliated Hospital of Xi'an Jiaotong University between January 2013 and January 2015. External beam radiotherapy techniques were used to deliver 40 Gy in 20 fractions or 30 Gy in ten fractions with a 10 MV photon beam from a linear accelerator to the whole brain. Data were stored and analyzed using SPSS version 17.0.

RESULTS

Of the 46 patients, the survival time of patients in our study was 10.8±0.55 months: 11.8±0.46 months in patients with WBRT, 11.75±1.00 in patients with WBRT + chemotherapy, and 3±0.79 months in patients with supportive care, respectively (P<0.01). The HRQOL scores of all the patients were 70±1.16 (before therapy) and 76.83±1.04 (after therapy) (P<0.01). The HRQOL scores of the patients with WBRT were 72.23±0.88 (before therapy) and 78.49±0.87 (after therapy) (P<0.01). There was no central nervous system toxicity; only two (4.3%) patients were found to have BM hemorrhage. Radiation necrosis happened in one patient (2.2%).

CONCLUSION

Effective treatment options for patients with BMs are important. WBRT was evaluated to ensure survival outcomes and QOL were enhanced after therapy for patients with BMs.

Palliative radiotherapy: current status and future directions

For nearly 100 years, palliative radiotherapy has been a time-efficient, effective treatment for patients with metastatic or advanced cancer in any area where local tumors are causing symptoms. Short courses including a single fraction of radiotherapy may be effective for symptom relief with minimal side effects and maximization of convenience for patient and family. With recent advances in imaging, surgery, and other local therapies as well as systemic cancer therapies, palliative radiotherapy has been used frequently in patients who may not yet have symptoms of advanced or metastatic cancer. In this setting, more prolonged radiotherapy courses and advanced radiotherapy techniques including intensity-modulated radiotherapy (IMRT) or stereotactic radiotherapy (SRT) may be useful in obtaining local control and durable palliative responses. This review will explore the use of radiotherapy across the spectrum of patients with advanced and metastatic cancer and delineate an updated, rational approach for the use of palliative radiotherapy that incorporates symptoms, prognosis, and other factors into the delivery of palliative radiotherapy.

Development of a score predicting survival after palliative reirradiation

Purpose. To develop a prognostic model for predicting survival after palliative reirradiation (PR). Methods and Materials. We analyzed all 87 PR courses administered at a dedicated palliative radiotherapy facility between 20.06.2007 (opening) and 31.12.2009. Uni- and multivariate survival analyses were performed, the previously published survival prediction score (SPS) was evaluated, and a PR-specific prognostic score was calculated. Results. In multivariate analysis, four parameters significantly influenced survival: performance status, use of steroids, presence of liver metastases, and pleural effusion. Based on these parameters, a 4-tiered score was developed. Median survival was 24.5 months for the favorable group, 9.7 and 2.8 months for the two intermediate groups, and 1.1 months for the unfavorable group (P = 0.019 for comparison between the two favorable groups and P ≤ 0.002 for all other pair-wise comparisons). All patients in the unfavorable group died within 2 months. Conclusion. The performance of PR-specific score was promising and might facilitate identification of patients who survive long enough to benefit from PR. It should be validated in independent patient groups, ideally from several institutions and countries.

Palliative radiotherapy at the end of life: a critical review

When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life.

Survival prediction score: a simple but age-dependent method predicting prognosis in patients undergoing palliative radiotherapy

Purpose. Validation of a Canadian three-tiered prognostic model (survival prediction score, SPS) in Norwegian cancer patients referred for palliative radiotherapy (PRT), and evaluation of age-dependent performance of the model. Patients and Methods. We analyzed all 579 PRT courses administered at a dedicated PRT facility between 20.06.07 and 31.12.2009. SPS was assigned as originally described, That is, by taking into consideration three variables: primary cancer type, site of metastases, and performance status. Results. Patients with poor prognosis (non-breast cancer, metastases other than bone, and Karnofsky performance status (KPS) ≤ 60) had median survival of 13 weeks. Those with intermediate prognosis (two of these parameters) survived for a median of 29 weeks, and patients with good prognosis for a median of 114 weeks, P < 0.001. While this model performed well in patients who were 60 years or older, it was less satisfactory in younger patients (no significant difference between the good and intermediate prognosis groups). Conclusion. SPS should mainly be used to predict survival of elderly cancer patients. However, even in this group accuracy is limited because the good prognosis group contained patients with short survival, while the poor prognosis group contained long-term survivors. Thus, improved models should be developed.

Predicting 2-year survival for radiation regimens in advanced non-small cell lung cancer

AIMS

Total dose, dose per fraction, number of fractions and treatment time are important determinants of the biological effect of a radiation regimen. Several randomised clinical trials (RCTs) have tested a variety of dosing regimens in advanced unresected non-small cell lung cancer, but survival remains poor. This work used past RCT data to develop and validate a predictive model that could help in designing new radiation regimens for successful testing in RCTs.

MATERIALS AND METHODS

Eleven RCTs that compared radiation regimens alone were used to define the relationship between radiation regimens and 2-year survival. On the basis of this relationship, predictive models were developed. Predicted values were internally and externally validated against observed values from the same 11 RCTs and 21 other RCTs. Scatter plots and Pearson's correlation coefficient (r) were used for validation. Finally, regimens were explored that could improve survival.

RESULTS

Increments in the total dose, dose per day and the number of treatment days were associated with improved survival; increments in dose-squared and treatment weeks were associated with reduced survival. The observed and predicted values were similar on internal (r = 0.96) and external validation (r = 0.76). Regimens that delivered a higher total dose over a shorter time had higher survival rates compared with the standard (60 Gy, 30 fractions, 6 weeks); survival may be improved by delivering the standard treatment in 5 weeks rather than 6 weeks.

CONCLUSION

The developed model can predict the effect of thoracic radiation on survival in advanced non-small cell lung cancer patients. It is a useful tool for designing new radiation regimens for clinical trials.

A score to identify patients with metastatic spinal cord compression who may be candidates for best supportive care

BACKGROUND

The objective of the current study was to develop a scoring system that identifies those patients with metastatic spinal cord compression who may be candidates for best supportive care or single-fraction radiotherapy.

METHODS

Ten potential prognostic factors were retrospectively analyzed in 2029 patients, including age, gender, Eastern Cooperative Oncology Group performance status, tumor type, number of involved vertebrae, further bone metastases, visceral metastases, interval from time of cancer diagnosis to the development of MSCC, time to the development of motor deficits, and ambulatory status.

RESULTS

On multivariate analysis, Eastern Cooperative Oncology Group performance status, tumor type, bone metastases, visceral metastases, interval from cancer diagnosis to the development of metastatic spinal cord compression, time to the development of motor deficits, and ambulatory status were found to be significantly associated with survival. The risk score represented the sum of the scores for each of these factors, obtained from the probability of the patient dying within 2 months (shown as the percentage) divided by 10. Risk scores ranged between 6 and 25 points. At a cutoff value of ≥ 24 points, the specificity was 99.8% and the positive predictive value was 96.0%, which indicates that approximately 4% of the patients predicted to die within 2 months survived > 2 months.

CONCLUSIONS

This score identifies patients who have a very poor survival with a high specificity and a high positive predictive value. Patients with a score of ≥ 24 points have a very high probability of dying within 2 months. Thus, overtreatment with intensive therapies can be avoided in these patients, who are very unlikely to benefit.

Prospective comparison of prognostic scores in palliative care cancer populations

PURPOSE

Predicting prognosis in advanced cancer aids physicians in clinical decision making and can help patients and their families to prepare for the time ahead.

MATERIALS AND METHODS

This multicenter, observational, prospective, nonrandomized population-based study evaluated life span prediction of four prognostic scores used in palliative care: the original palliative prognostic score (PaP Score), a variant of PaP Score including delirium (D-PaP Score), the Palliative Performance Scale, and the Palliative Prognostic Index.

RESULTS

A total of 549 patients were enrolled onto the study. Median survival of the entire group was 22 days (95% confidence intervals [95% CI] = 19-24). All four prognostic models discriminated well between groups of patients with different survival probabilities. Log-rank tests were all highly significant (p < .0001). The PaP and D-PaP scores were the most accurate, with a C index of 0.72 (95% CI = 0.70-0.73) and 0.73 (95% CI = 0.71-0.74), respectively.

CONCLUSION

It can be confirmed that all four prognostic scores used in palliative care studies accurately identify classes of patients with different survival probabilities. The PaP Score has been extensively validated and shows high accuracy and reproducibility in different settings.

Surgery improves pain, function and quality of life in patients with spinal metastases: a prospective study on 118 patients

PURPOSE

There are few prospective studies on surgical outcomes and survival in patients with metastatic disease to the spine. The magnitude and duration of effect of surgery on pain relief and quality of life remains uncertain. Therefore, the aim of this clinical study was to prospectively evaluate clinical, functional, quality of life and survival outcomes after palliative surgery for vertebral metastases.

METHODS

118 consecutive patients who underwent spinal surgery for symptomatic vertebral metastases were prospectively followed up for 12 months or until death. Clinical data and data from the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire were obtained pre- and post-operatively and at regular follow-up intervals.

RESULTS

Surgery was effective in achieving rapid improvement in axial and radicular pain, neurological deficit, sphincteric dysfunction and ambulatory status, with a complication rate of 26% and a 12 month mortality rate of 48%. Almost 50% of patients had complete resolution of back pain, radiculopathy and neurological deficit. Of the patients who were non-ambulant and incontinent, over 50% regained ambulatory ability and recovered urinary continence. The overall incidence of wound infection or breakdown was 6.8% and the local recurrence rate was 8.5%. There was a highly significant improvement in physical, role, cognitive and emotional functioning and global health status post-operatively. Greatest improvement in pain, function and overall quality of life occurred in the early post-operative period and was maintained until death or during the 12 month prospective follow-up period.

CONCLUSION

The potential for immediate and prolonged improvement in pain, function and quality of life in patients with symptomatic vertebral metastases should be considered during the decision-making process when selecting and counselling patients for surgery.

Patterns of care and course of symptoms in palliative radiotherapy: a multicenter pilot study analysis

BACKGROUND AND PURPOSE

To evaluate patterns of care as well as effectiveness and side effects of palliative treatment in four German radiation oncology departments.

PATIENTS AND METHODS

All referrals in four German radiation oncology departments (two university hospitals, one academic hospital, one private practice) were prospective documented for 1 month in 2008 (2 months at one of the university hospitals). In palliatively irradiated patients, treatment aims and indications as well as treated sites and fractionation schedules were recorded. In addition, symptoms and side effects were analyzed with standardized questionnaires before and at the end of radiotherapy.

RESULTS

During the observation period, 603 patients underwent radiation therapy in the four centers and 153 (24%, study population) were treated with palliative intent. Within the study, patients were most frequently treated for bone (34%) or brain (27%) metastases. 62 patients reported severe or very severe pain, 12 patients reported severe or very severe dyspnea, 27 patients reported neurological deficits or signs of cranial pressure, and 43 patients reported a poor or very poor sense of well-being. The most frequent goals were symptom relief (53%) or prevention of symptoms (46%). Life prolongation was intended in 37% of cases. A wide range of fractionation schedules was applied with total doses ranging from 3-61.2 Gy. Of the patients, 73% received a slightly hypofractionated treatment schedule with doses of > 2.0 Gy to ≤ 3.0 Gy per fraction and 12% received moderate to highly hypofractionated therapy with doses of > 3.0 Gy to 8.0 Gy. Radiation therapy led to a significant improvement of well-being (35% of patients) and reduction of symptoms, especially with regard to pain (66%), dyspnea (61%), and neurological deficits (60%). Therapy was very well tolerated with only 4.5% grade I or II acute toxicities being observed. Unscheduled termination was observed in 19 patients (12%).

CONCLUSIONS

Palliative radiation therapy is effective in reducing symptoms, increases subjective well-being, and has minimal side effects. More studies are necessary for subgroup analyses and for clarifying the different goals in palliative radiotherapy.

Edmonton symptom assessment scale as a prognosticative indicator in patients with advanced cancer

BACKGROUND

Few studies incorporate patient self-assessment scales in prognostic models of survival prediction. The Edmonton Symptom Assessment Scale (ESAS) is commonly used as a symptom screening tool in cancer patients.

OBJECTIVE

The goal of this study was to evaluate the prognostic value of the ESAS for survival prediction in the advanced cancer population.

MATERIALS AND METHODS

Patients completed the ESAS and demographic information prior to palliative radiotherapy consultation and at follow-up at the Odette Cancer Centre between 1999 and 2009. Generalized estimating equation (GEE) methodology was applied to analyze ESAS trends within the last months of life. One-way analysis of variance (ANOVA) with repeated measurements was used to characterize trends between time periods.

RESULTS

ESAS records (2377) from 808 patients (433 male and 375 female) were included in this cohort. Median age was 68 years (range 32-95) with median Karnofsky performance status (KPS) of 60 (range 10-100). Primary cancer sites were of the lung (36%), breast (20%), and prostate (19%). All nine ESAS symptoms significantly deteriorated in the last 4 weeks immediately before death when compared with those scores in the preceding months. At one week prior to death, the worst ESAS symptoms experienced by patients were fatigue, appetite, and well-being with mean scores of 7.4, 6.9, and 6.1, respectively.

CONCLUSIONS

All ESAS scores significantly worsened in the last 4 weeks prior to death compared with those in the previous months. Sudden deterioration of the global ESAS symptoms may predict impending death. Future studies on a prognostic model should incorporate both ESAS symptom severity and trends.

Survival prognostic factors and clinical outcomes in patients with spinal metastases

PURPOSE

In patients with metastatic disease to the spine, patient selection for surgery and the extent of surgery to perform thereafter remains controversial, with the patient's survival prognosis the most important consideration. For this reason, we conducted a prospective study investigating prognostic factors and clinical outcomes in a consecutive series of patients with vertebral metastases.

METHODS

A total of 142 consecutive patients with vertebral metastases referred to us for consideration of surgery were prospectively enrolled into this study. Of these, 118 patients subsequently underwent palliative surgery for intractable pain or radiculopathy, bony instability or spinal cord compression. Patients were followed up for 12 months or until death. A multivariate analysis of the patients was conducted using the Cox proportional hazards model. The survival predictive accuracy of the Tokuhashi score was also investigated. For the patients who underwent surgery, pre- and post-operative outcomes were assessed on pain, neurological deficit, function and overall quality of life.

RESULTS

The overall 12-month mortality rate was 50.7% and the median survival was 5 months. Multivariate analysis showed that independent prognostic factors for survival after spinal metastases include primary tumour type, Karnofsky functional status, ASA score and pain. Neither the original nor revised Tokuhashi scores were reliable in predicting survival in our European population. In the patients who underwent operative intervention, there was an immediate and prolonged improvement in pain, neurological deficit, function and quality of life in the majority of cases.

CONCLUSIONS

The potential for rapid and maintained improvement in clinical outcome and quality of life should be considered when selecting patients with metastatic disease to the spine for surgery rather than basing decisions solely on survival prognostic factors comprising current scoring systems.

Survival prognostic factors and clinical outcomes in patients with spinal metastases

PURPOSE

In patients with metastatic disease to the spine, patient selection for surgery and the extent of surgery to perform thereafter remains controversial, with the patient's survival prognosis the most important consideration. For this reason, we conducted a prospective study investigating prognostic factors and clinical outcomes in a consecutive series of patients with vertebral metastases.

METHODS

A total of 142 consecutive patients with vertebral metastases referred to us for consideration of surgery were prospectively enrolled into this study. Of these, 118 patients subsequently underwent palliative surgery for intractable pain or radiculopathy, bony instability or spinal cord compression. Patients were followed up for 12 months or until death. A multivariate analysis of the patients was conducted using the Cox proportional hazards model. The survival predictive accuracy of the Tokuhashi score was also investigated. For the patients who underwent surgery, pre- and post-operative outcomes were assessed on pain, neurological deficit, function and overall quality of life.

RESULTS

The overall 12-month mortality rate was 50.7% and the median survival was 5 months. Multivariate analysis showed that independent prognostic factors for survival after spinal metastases include primary tumour type, Karnofsky functional status, ASA score and pain. Neither the original nor revised Tokuhashi scores were reliable in predicting survival in our European population. In the patients who underwent operative intervention, there was an immediate and prolonged improvement in pain, neurological deficit, function and quality of life in the majority of cases.

CONCLUSIONS

The potential for rapid and maintained improvement in clinical outcome and quality of life should be considered when selecting patients with metastatic disease to the spine for surgery rather than basing decisions solely on survival prognostic factors comprising current scoring systems.

Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: reality or myth?

BACKGROUND

The purpose of the study was to investigate the adequacy of palliative radiation treatment in end-stage cancer patients.

METHODS

Of 216 patients referred for palliative radiotherapy, 33 died within 30 days and constitute the population of the study. Symptoms, Karnofsky Performance Status (KPS), laboratory tests, and survival estimates were obtained. Treatment course was evaluated by medical records. Univariate analyses were performed by using the 2-sided chi-square test. With significant variables, multiple regression analysis was performed.

RESULTS

Median age was 65 years, and median survival was 15 days. Prevailing primary cancer types were lung (39%) and breast (18%). Metastases were present in 94% of patients, brain (36%), bone (24%) and lung (18%). In 91%, KPS was < 0%. KPS, lactate dehydrogenase, dyspnea, leucocytosis, and brain metastases conveyed a poor prognosis. From 85 survival estimates, only 16% were correct, but 21% expected more than 6 months. Radiotherapy was delivered to 91% of patients. In 90% of radiation treatments, regimens of at least 30 Gy with fractions of 2-3 Gy were applied. Half of the patients spent greater than 60% of their remaining lifespan on therapy. In only 58% of patients was radiotherapy completed. Progressive complaints were noted in 52% and palliation in 26%.

CONCLUSIONS

Radiotherapy was not appropriately customized to these patients considering the median treatment time, which resembles the median survival time. About half of the patients did not benefit despite spending most of their remaining lives on therapy. Prolonged irradiation schedules probably reflect overly optimistic prognoses and unrealistic concerns about late radiation damage. Single-fraction radiotherapy was too seldom used.