Clinical Implications of C-Reactive Protein as a Prognostic Marker in Advanced Cancer Patients in Palliative Care Settings

The roles of C-reactive protein-albumin ratio as a novel prognostic biomarker in heart failure patients: A systematic review

C-Reactive Protein (CRP)-albumin ratio (CAR) is a novel prognostic biomarker that is predicted to be a more reliable indicator than CRP or albumin alone. Therefore, this systematic review aimed to evaluate the role of CAR in predicting poor outcomes of heart failure (HF) patients. We conducted a literature search across ProQuest, PubMed, ScienceDirect, Web of Science, and Scopus. All related studies assessing CAR and reporting mortality outcomes or other adverse outcomes were assessed. A total of five studies with a total of 1821 patients were included in this review. CAR is significantly associated with all-causes in-hospital mortality and out-hospital mortality in patients with acute and chronic heart failure. CAR is associated with higher hospitalization rates, the number of hospitalizations, severe New York Heart Association (NYHA) classification, and the risk of advanced HF. In conclusion, CAR is significantly associated with poor HF outcomes including all-cause mortality (cardiac and non-cardiac death).

Novel ensemble feature selection techniques applied to high-grade gastroenteropancreatic neuroendocrine neoplasms for the prediction of survival

BACKGROUND AND OBJECTIVE

Determining the most informative features for predicting the overall survival of patients diagnosed with high-grade gastroenteropancreatic neuroendocrine neoplasms is crucial to improve individual treatment plans for patients, as well as the biological understanding of the disease. The main objective of this study is to evaluate the use of modern ensemble feature selection techniques for this purpose with respect to (a) quantitative performance measures such as predictive performance, (b) clinical interpretability, and (c) the effect of integrating prior expert knowledge.

METHODS

The Repeated Elastic Net Technique for Feature Selection (RENT) and the User-Guided Bayesian Framework for Feature Selection (UBayFS) are recently developed ensemble feature selectors investigated in this work. Both allow the user to identify informative features in datasets with low sample sizes and focus on model interpretability. While RENT is purely data-driven, UBayFS can integrate expert knowledge a priori in the feature selection process. In this work, we compare both feature selectors on a dataset comprising 63 patients and 110 features from multiple sources, including baseline patient characteristics, baseline blood values, tumor histology, imaging, and treatment information.

RESULTS

Our experiments involve data-driven and expert-driven setups, as well as combinations of both. In a five-fold cross-validated experiment without expert knowledge, our results demonstrate that both feature selectors allow accurate predictions: A reduction from 110 to approximately 20 features (around 82%) delivers near-optimal predictive performances with minor variations according to the choice of the feature selector, the predictive model, and the fold. Thereafter, we use findings from clinical literature as a source of expert knowledge. In addition, expert knowledge has a stabilizing effect on the feature set (an increase in stability of approximately 40%), while the impact on predictive performance is limited.

CONCLUSIONS

The features WHO Performance Status, Albumin, Platelets, Ki-67, Tumor Morphology, Total MTV, Total TLG, and SUVmax are the most stable and predictive features in our study. Overall, this study demonstrated the practical value of feature selection in medical applications not only to improve quantitative performance but also to deliver potentially new insights to experts.

Deliberation on debilitating condition of cancer cachexia: Skeletal muscle wasting

BACKGROUND

Cancer cachexia is a debilitating syndrome associated with marked body loss because of muscular atrophy and fat loss. There are several mechanisms contributing to the pathogenesis of cachexia. The presence of the tumor releases cytokines from inflammatory and immune cells, which play a significant role in activating and deactivating certain pathways associated with protein, carbohydrate, and lipid metabolism. This review focuses on various cascades involving an imbalance between protein synthesis and degradation in the skeletal muscles.

OBJECTIVES

This study aimed to elucidate the mechanisms involved in skeletal muscle wasting phenomenon over the last few years.

METHODS

This article briefly overviews different pathways responsible for muscle atrophy in cancer cachexia. Studies published up to April 2023 were included. Important findings and study contributions were chosen and compiled using several databases including PubMed, Google Scholar, Science Direct, and ClinicalTrials.gov using relevant keywords.

RESULTS

Cancer cachexia is a complex disease involving multiple factors resulting in atrophy of skeletal muscles. Systemic inflammation, altered energy balance and carbohydrate metabolism, altered lipid and protein metabolism, and adipose tissue browning are some of the major culprits in cancer cachexia. Increased protein degradation and decreased protein synthesis lead to muscle atrophy. Changes in signaling pathway like ubiquitin-proteasome, autophagy, mTOR, AMPK, and IGF-1 also lead to muscle wasting. Physical exercise, nutritional supplementation, steroids, myostatin inhibitors, and interventions targeting on inflammation have been investigated to treat cancer cachexia. Some therapy showed positive results in preclinical and clinical settings, although more research on the efficacy and safety of the treatment should be done.

CONCLUSION

Muscle atrophy in cancer cachexia is the result of multiple complex mechanisms; as a result, a lot more research has been done to describe the pathophysiology of the disease. Targeted therapy and multimodal interventions can improve clinical outcomes for patients.

Cancer Cachexia: Underlying Mechanisms and Potential Therapeutic Interventions

Cancer cachexia, a multifactorial metabolic syndrome developed during malignant tumor growth, is characterized by an accelerated loss of body weight accompanied by the depletion of skeletal muscle mass. This debilitating condition is associated with muscle degradation, impaired immune function, reduced functional capacity, compromised quality of life, and diminished survival in cancer patients. Despite the lack of the known capability of fully reversing or ameliorating this condition, ongoing research is shedding light on promising preclinical approaches that target the disrupted mechanisms in the pathophysiology of cancer cachexia. This comprehensive review delves into critical aspects of cancer cachexia, including its underlying pathophysiological mechanisms, preclinical models for studying the progression of cancer cachexia, methods for clinical assessment, relevant biomarkers, and potential therapeutic strategies. These discussions collectively aim to contribute to the evolving foundation for effective, multifaceted counteractive strategies against this challenging condition.

Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral

PURPOSE

Despite that early integration of palliative care is recommended in advanced cancer patients, referrals to outpatient specialised palliative care (SPC) frequently occur late. Well-defined referral criteria are still missing. We analysed indicators associated with early (ER) and late referral (LR) to SPC of an high volume outpatient unit of a comprehensive cancer center.

METHODS

Characteristics, laboratory parameters and symptom burden of 281 patients at first SPC referral were analysed. Timing of referral was categorized as early, intermediate and late (> 12, 3-12 and < 3 months before death). Ordinal logistic regression analysis was used to identify factors related to referral timing. Kruskal-Wallis test was used to determine symptom severity and laboratory parameter in each referral category.

RESULTS

LRs (50.7%) had worse scores of weakness, loss of appetite, drowsiness, assistance of daily living (all p < 0.001) and organisation of care (p < 0.01) in contrast to ERs. The mean symptom sum score was significantly higher in LRs than ERs (13.03 vs. 16.08; p < 0.01). Parameters indicative of poor prognosis, such as elevated LDH, CRP and neutrophil-to-lymphocyte ratio (NLR) (p < 0.01) as well as the presence of ascites (p < 0.05), were significantly higher (all p < 0.001) in LRs. In univariable analyses, psychological distress (p < 0.05) and female gender (p < 0.05) were independently associated with an ER.

CONCLUSION

A symptom sum score and parameters of poor prognosis like NLR or LDH might be useful to integrate into palliative care screening tools.

Regulation of Conformational Changes in C-reactive Protein Alters its Bioactivity

The acute phase C-reactive protein (CRP) is mainly synthesized and secreted by the liver in a cytokine-mediated response to infection or inflammation and circulates as a pentamer (pCRP) in plasma. Recent studies indicate that CRP is not only a marker but is directly involved in inflammation. CRP has a vital role in host defense and inflammation, metabolic function and scavenging through its ability for calcium depended binding to exogenous and endogenous molecules having phosphocholine followed by activation of the classical complement pathway. Accumulating evidence indicates that pCRP dissociates into monomeric CRP (mCRP) and most proinflammatory actions of CRP are only expressed following dissociation of its native pentameric assembly into mCRP. The dissociation of CRP into mCRP altogether promotes the ligand-binding capability. mCRP emerges to be the main conformation of CRP that participates in the regulation of local inflammation, however, little is identified concerning what triggers the significantly enhanced actions of mCRP and their binding to diverse ligands. The separation of mCRP from pCRP may be a direct relationship between CRP and inflammation. Here we review the current literature on CRP dissociation and its interaction with different ligands. The possibility to avoid the generation of the proinflammatory potential of mCRP has driven therapeutic approaches by targeting the dissociation mechanism of pCRP or inhibition of mCRP itself during inflammation.

Inflamasyon ilişkili indeksler, palyatif bakım hastalarında kötü prognozu tanımlayabilir mi?

Aim: Palliative medicine provides holistic care to increase the quality of life of patients. Predicting prognosis is critical for a personalized treatment plan. Therefore, we aimed to investigate the survival prediction properties of routine biochemistry tests, complete blood count (CBC) and neutrophil/lymphocyte ratios, in addition to biomarker-based indices (the mGPS, PI, and PNI). Materials and methods: The laboratory parameter values, prognostic factor scores, diagnoses and survival time of 139 palliative care patients in the last 5 weeks of their life were evaluated retrospectively. Results: Ninety-one (65.5%) patients were male and the average age was 65.9 years (28–91 years). Results of all three prognostic indices (the mGPS, PI, and PNI) investigated in this study were found to have a statistically significant relationship with the survival time of our patients. In addition, NLR, neutrophil percent, hemoglobin, serum albumin and CRP values were seen to have a statistically significant relationship with the scores of all three prognostic indices. Moreover, hand it is detected that WBC, NLR, albumin, and CRP values were associated with overall survival. Conclusion: The results of our study, which showed that these indices have prognostic markers in palliative care patients, will guide the management of the clinical process. We would like to emphasize the importance of palliative care clinicians in developing personalized treatment plans for patients using prognostic tools for survival prediction.

Survival analysis of a prospective multicenter observational study on surgical palliation among patients with malignant bowel obstruction caused by peritoneal dissemination of gastric cancer

BACKGROUND

Our previous report showed that surgical palliation maintained quality of life (QOL), improved solid food intake, and had an acceptable surgical safety among patients with malignant bowel obstruction (MBO) caused by advanced gastric cancer. This study performed a survival analysis stratified by the patients' QOL to elucidate its impact on survival.

METHODS

Patients who underwent resection or bypass of the small intestine/colon or ileostomy/colostomy for bowel obstruction caused by peritoneal dissemination of gastric cancer were included. Validated instruments (EuroQoL-5 Dimensions) were used to assess QOL at baseline and 2 weeks, 1 month, and 3 months following surgical palliation. Postoperative improvement in oral intake was also evaluated using the Gastric Outlet Obstruction Scoring System (GOOSS). Univariate and multivariate survival analyses were performed using baseline characteristics and changes in QOL and GOOSS scores 2 weeks after surgery to determine prognostic factors.

RESULTS

We enrolled 60 patients with a median survival time of 6.64 (95% CI 4.76-10.28) months. Patients who received postoperative chemotherapy and had lower baseline C-reactive protein (CRP) levels, higher baseline albumin levels, better baseline EuroQoL-5 Dimensions (EQ-5D) scores, and improved oral intake after palliative surgery exhibited significantly better survival. Multivariate analysis identified postoperative chemotherapy, lower baseline CRP levels, and improved oral intake as independent prognostic factors.

CONCLUSIONS

The current study revealed that baseline QOL and postoperative QOL changes did not affect survival. Moreover, improved oral intake, lower baseline CRP levels, and postoperative chemotherapy were significant prognostic factors in patients who underwent palliative surgery for advanced gastric cancer with MBO.

Preoperative C-reactive protein to prealbumin ratio is independently associated with prognosis in patients with resectable colorectal cancer

BACKGROUND

Increasing attention has been drawn the prognostic value of inflammatory indices for colorectal cancer (CRC). However, the prognostic value of the preoperative C-reactive protein to prealbumin ratio (CPAR) in CRC remains unclear.

METHODS

A retrospective study was conducted with 794 patients who had CRC and underwent radical surgical resection. The predictive performance of the inflammatory indices was analyzed and compared using the area under the time-dependent receiver operating characteristic curve. A competing risk regression model and Cox proportional hazard model were used to analyze the effects of CPAR on disease-free survival (DFS) and overall survival (OS), respectively.

RESULTS

Patients with high CPAR (>7.25) had poor survival outcome. The CPAR had the best predictive performance among all inflammatory indices, and was significantly associated with several characteristics of tumor invasion, including histological grade, tumor stage, and tumor size. Multivariate analysis showed that high CPAR was independently associated with poor DFS (subdistribution hazard ratio = 2.28, 95% confidence interval [CI]: 1.74-2.82) and OS (hazard ratio = 1.78, 95% CI: 1.60-1.96).

CONCLUSION

Preoperative CPAR assessment could serve as an effective and reliable tool for prognostic prediction in patients with resectable CRC.

Correlation of Patient Generated-subjective Global Assessment with Serum C-reactive Protein Level in Stage I–IV Head-and-neck Cancer

AIM: This study aims to identify the correlation between patient generated-subjective global assessment (PG-SGA) with serum C-reactive protein (CRP) to be used to predict inflammation and prevent cachexia in head-and-neck cancer patients. METHODS: This was a cross-sectional study using 51 patients with inclusion criteria of patients diagnosed with head-and-neck cancer irrespective of stage, age ≥18 years old, had not received treatments of radiotherapy, chemotherapy, and surgery. The statistical analysis performed was Kolmogorov–Smirnov normality test, bivariate analysis by Spearman test, and linear regression analysis. RESULTS: As many as 64.7% of the patients had PG-SGA score ≥9 (average PG-SGA score 11.7 ± 6.2). The CRP median value was 6.4 (0.4–170.4) mg/L. There was a statistically significant positive but weak correlation between PG-SGA score with serum CRP (r = 0.372 and p = 0.007) and a significant linear relationship (r2 = 0.201). CONCLUSIONS: Malnutrition risk assessment using PG-SGA showed a high prevalence of malnutrition risk in head-and-neck cancer patients. PG-SGA score is correlated with serum CRP level. Further studies are needed to confirm the result of this study.

Exploring and predicting mortality among patients with end-stage liver disease without cancer: a machine learning approach

OBJECTIVE

End-stage liver disease is a global public health problem with a high mortality rate. Early identification of people at risk of poor prognosis is fundamental for decision-making in clinical settings. This study created a machine learning prediction system that provides several related models with visualized graphs, including decision trees, ensemble learning and clustering, to predict mortality in patients with end-stage liver disease.

METHODS

A retrospective cohort study was conducted: the training data were from patients enrolled from January 2009 to December 2010 and followed up to December 2014; validation data were from patients enrolled from January 2015 to December 2016 and followed up to January 2019. Hospitalized patients with noncancer-related chronic liver disease were identified from the hospital's electrical medical records.

RESULTS

In traditional multivariable logistic regression and Cox proportional hazard model, prothrombin time of international normalized ratio, which was significant with P value = 0.002, odds ratio = 2.790 and hazard ratio 1.363. Besides, blood urea nitrogen and C-reactive protein were also significant, with P value <0.001 and 0.026. The area under the curve was 0.771 in the receiver operating characteristic curve. In machine learning, blood urea nitrogen and age were regarded as the primary factors for predicting mortality. Creatinine, prothrombin time of international normalized ratio and bilirubin were also significant mortality predictors. The area under the curve of the random forest and AdaBoost was 0.838 and 0.792.

CONCLUSION

The machine learning techniques provided a comprehensive assessment of patient conditions; it could help physicians make an accurate diagnosis of chronic liver disease and improve healthcare management.

Symptom clusters and their influence on prognosis using EORTC QLQ-C15-PAL scores in terminally ill patients with cancer

Purpose

The aims of the present study were to investigate the symptom clusters in terminally ill patients with cancer using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL), and to examine whether these symptom clusters influenced prognosis.

Methods

We analyzed data from 130 cancer patients hospitalized in the palliative care unit from June 2018 to December 2019 in an observational study. Principal component analysis was used to detect symptom clusters using the scored date of 14 items in the QLQ-C15-PAL, except for overall QOL, at the time of hospitalization. The influence of the existence of these symptom clusters and Palliative Performance Scale (PPS) on survival was analyzed by Cox proportional hazards regression analysis, and survival curves were compared between the groups with or without existing corresponding symptom clusters using the log-rank test.

Results

The following symptom clusters were identified: cluster 1 (pain, insomnia, emotional functioning), cluster 2 (dyspnea, appetite loss, fatigue, and nausea), and cluster 3 (physical functioning). Cronbach’s alpha values for the symptom clusters ranged from 0.72 to 0.82. An increased risk of death was significantly associated with the existence of cluster 2 and poor PPS (log-rank test, p = 0.016 and p < 0.001, respectively).

Conclusion

In terminally ill patients with cancer, three symptom clusters were detected based on QLQ-C15-PAL scores. Poor PPS and the presence of symptom cluster that includes dyspnea, appetite loss, fatigue, and nausea indicated poor prognosis.

C-Reactive Protein and Its Relationship with Pain in Patients with Advanced Cancer Cachexia: Secondary Cross-Sectional Analysis of a Multicenter Prospective Cohort Study

Background: Limited information is available on the relationship between C-reactive protein (CRP) levels and pain in advanced cancer.

Objectives: To investigate the relationship between serum levels of CRP and subtypes of pain.

Design: A secondary cross-sectional analysis of a prospective cohort study.

Setting/Subjects: Patients with advanced cancer admitted to 23 palliative care units in Japan.

Measurements: Patients rated the severity of pain on the numerical rating scale (NRS) and physicians evaluated pain on the integrated palliative care outcome scale (IPOS). Physicians assessed neuropathic pain and breakthrough pain based on their presence or absence. Patients were divided into four groups according to CRP levels. Comparisons were performed using the Kruskal–Wallis test or chi-squared test. To evaluate the relationship between CRP and subtypes of pain, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in logistic models were calculated.

Results: We divided 1513 patients into four groups: low CRP (n = 234), moderate CRP (n = 513), high CRP (n = 352), and very high CRP (n = 414). Spearman's correlation coefficient between CRP and pain NRS and that between CRP and pain IPOS were 0.15 (p < 0.001) and 0.16 (p < 0.001), respectively. In the models of pain NRS and pain IPOS, significantly higher adjusted ORs than in the low CRP group were observed in the very high CRP group (1.81 [95% CI 1.14–2.88], p = 0.01; 1.74 [95% CI 1.18–2.57], p = 0.005, respectively). Relationships were not observed between CRP, neuropathic pain, and breakthrough pain.

Conclusions: The results indicated direct relationships between CRP, pain NRS, and pain IPOS.

The role of EORTC QLQ-C15-PAL scores and inflammatory biomarkers in predicting survival in terminally ill patients with cancer

Background

The clinical use of patient-reported outcomes as compared to inflammatory biomarkers for predicting cancer survival remains a challenge in palliative care settings. We evaluated the role of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative scores (EORTC QLQ-C15-PAL) and the inflammatory biomarkers C-reactive protein (CRP), albumin (Alb), and neutrophil-lymphocyte ratio (NLR) for survival prediction in patients with advanced cancer.

Methods

This was an observational study in terminally ill patients with cancer hospitalized in a palliative care unit between June 2018 and December 2019. Patients’ data collected at the time of hospitalization were analyzed. Cox regression was performed to examine significant factors influencing survival. A receiver operating characteristic (ROC) analysis was performed to estimate cut-off values for predicting survival within 3 weeks, and a log-rank test was performed to compare survival curves between groups divided by the cut-off values.

Results

Totally, 130 patients participated in the study. Cox regression suggested that the QLQ-C15-PAL dyspnea and fatigue scores and levels of CRP, Alb, and NLR were significantly associated with survival time, and cut-off values were 66.67, 66.67, 3.0 mg/dL, 2.5 g/dL, and 8.2, respectively. The areas under ROC curves of these variables were 0.6–0.7. There were statistically significant differences in the survival curves between groups categorized using each of these cut-off values (p < .05 for all cases).

Conclusion

Our findings suggest that the assessment of not only objective indicators for the systemic inflammatory response but also patient-reported outcomes using EORTC QLQ-C15-PAL is beneficial for the prediction of short-term survival in terminally ill patients with cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08049-3.

Revisiting the clinical usefulness of C-reactive protein in the set of cancer cachexia

Cancer cachexia is a highly complex multifactorial disorder that is often misdiagnosed, leading to suboptimal health outcomes. Indeed, cachexia is a concern in cancer, typifying lower response to treatment and risk of death. Thus, efforts have been made to better understand the molecular basis of this syndrome, envisioning to improve its diagnosis and management.

C-reactive protein (CRP) has been reported to be consistently increased in the circulation of patients with body wasting associated to chronic diseases. However, the role of CRP in the pathogenesis of cachexia remains elusive. Several hypotheses have been advanced but most of experimental findings support an indirect effect on the activation of muscle proteolysis, mostly through its interplay with pro-inflammatory cytokines. Herein, we overview the contribution of CRP to body wasting and its putative biomarker value for the diagnosis and follow-up of the therapeutic management of cachexia.

Association of dental occlusal support with the Prognostic Nutritional Index in patients with esophageal cancer who underwent esophagectomy

BACKGROUND

The Prognostic Nutritional Index is useful for predicting surgical risk and overall survival based on preoperative immunological and nutritional status in patients undergoing digestive organ cancer surgery. The purpose of this study was to examine the association between the Prognostic Nutritional Index and dental status in patients with esophageal cancer who underwent esophagectomy.

METHODS

This retrospective case-control study included 73 patients who underwent resection of esophageal cancer (69 males, 4 females; age 36-83). General and dental status were evaluated. The Prognostic Nutritional Index was calculated based on the serum albumin concentration and the total lymphocyte count, and subjects were divided into two groups based on index scores: a higher group, characterized by scores ≥ 45 (n = 54); and a lower group, characterized by scores < 45 (n = 19). Univariate analysis and multiple logistic regression analyses were used to compare between groups.

RESULTS

Total protein, C-reactive protein, the number of sound and total decayed, missing and filled teeth, and the rate of patients with poor dental occlusal support showed significant differences between the lower and higher Prognostic Nutritional Index groups (p < 0.05). Stepwise logistic regression analysis by backward selection approach showed that low total protein, few sound teeth, and poor status of dental occlusal support were significantly associated with the lower Prognostic Nutritional Index (p = 0.007, 0.042, and 0.009, respectively).

CONCLUSION

Dental status, especially dental occlusal support and the number of sound teeth, showed a positive relationship with the Prognostic Nutritional Index in esophageal cancer patients who underwent esophagectomy.

Machine-Learning Monitoring System for Predicting Mortality Among Patients With Noncancer End-Stage Liver Disease: Retrospective Study

Background

Patients with end-stage liver disease (ESLD) have limited treatment options and have a deteriorated quality of life with an uncertain prognosis. Early identification of ESLD patients with a poor prognosis is valuable, especially for palliative care. However, it is difficult to predict ESLD patients that require either acute care or palliative care.

Objective

We sought to create a machine-learning monitoring system that can predict mortality or classify ESLD patients. Several machine-learning models with visualized graphs, decision trees, ensemble learning, and clustering were assessed.

Methods

A retrospective cohort study was conducted using electronic medical records of patients from Wan Fang Hospital and Taipei Medical University Hospital. A total of 1214 patients from Wan Fang Hospital were used to establish a dataset for training and 689 patients from Taipei Medical University Hospital were used as a validation set.

Results

The overall mortality rate of patients in the training set and validation set was 28.3% (257/907) and 22.6% (145/643), respectively. In traditional clinical scoring models, prothrombin time-international normalized ratio, which was significant in the Cox regression (P<.001, hazard ratio 1.288), had a prominent influence on predicting mortality, and the area under the receiver operating characteristic (ROC) curve reached approximately 0.75. In supervised machine-learning models, the concordance statistic of ROC curves reached 0.852 for the random forest model and reached 0.833 for the adaptive boosting model. Blood urea nitrogen, bilirubin, and sodium were regarded as critical factors for predicting mortality. Creatinine, hemoglobin, and albumin were also significant mortality predictors. In unsupervised learning models, hierarchical clustering analysis could accurately group acute death patients and palliative care patients into different clusters from patients in the survival group.

Conclusions

Medical artificial intelligence has become a cutting-edge tool in clinical medicine, as it has been found to have predictive ability in several diseases. The machine-learning monitoring system developed in this study involves multifaceted analyses, which include various aspects for evaluation and diagnosis. This strength makes the clinical results more objective and reliable. Moreover, the visualized interface in this system offers more intelligible outcomes. Therefore, this machine-learning monitoring system provides a comprehensive approach for assessing patient condition, and may help to classify acute death patients and palliative care patients. Upon further validation and improvement, the system may be used to help physicians in the management of ESLD patients.

Potential Measurement Properties of a Questionnaire for Eating-Related Distress Among Advanced Cancer Patients With Cachexia: Preliminary Findings of Reliability and Validity Analysis

BACKGROUND

There are no validated tools for measuring eating-related distress among patients with advanced cancer. The aim of the study was to investigate the potential measurement properties of a questionnaire for eating-related distress.

METHODS

This is a secondary analysis. We performed an exploratory factor analysis for factorial validity and calculated Cronbach's α for internal consistency. Patients were classified into the 2 groups categorized using the international cachexia criteria. The total scores of each factor and all items were calculated, and comparisons were performed for known-group validity. We performed statistical correlation analysis for concurrent validity, convergent validity, and discriminant validity using Pearson's product moment correlation coefficient.

RESULTS

A total of 140 patients responded. Three factors were identified. The values of Cronbach's α were 0.90, 0.89, and 0.86, respectively. Patients were classified into 2 groups: Non-cachexia/Pre-cachexia (n = 57) and Cachexia/Refractory cachexia (n = 83). Significant differences were observed in the total scores of each factor and all items: (factor 1) 7.5 vs. 11.0, p < 0.001; (factor 2) 8.0 vs. 13.0, p < 0.001; (factor 3) 5.0 vs. 10.0, p < 0.001; (all items) 20.0 vs. 35.0, p < 0.001, respectively. The total scores of each factor and all items significantly correlated with the Edmonton Symptom Assessment System-revised and the nutrition impact symptoms: 0.62 (p < 0.001) and 0.63 (p < 0.001), respectively. Scaling success rates were 100% in factor 1, 2, and 3.

CONCLUSION

The questionnaire appears to be useful. Eating-related distress in patients with advanced cancer had 3 factors.

Shock Index: A Simple and Effective Clinical Adjunct in Predicting 60-Day Mortality in Advanced Cancer Patients at the Emergency Department

Deciding between palliative and overly aggressive therapies for advanced cancer patients who present to the emergency department (ED) with acute issues requires a prediction of their short-term survival. Various scoring systems have previously been studied in hospices or intensive care units, though they are unsuitable for use in the ED. We aim to examine the use of a shock index (SI) in predicting the 60-day survival of advanced cancer patients presenting to the ED. Identified high-risk patients and their families can then be counseled accordingly. Three hundred and five advanced cancer patients who presented to the EDs of three tertiary hospitals were recruited, and their data retrospectively analyzed. Relevant data regarding medical history and clinical presentation were extracted, and respective shock indices calculated. Multivariate logistic regression analyses were performed. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of the SI. Nonsurvivors within 60 days had significantly lower body temperatures and blood pressure, as well as higher pulse rates, respiratory rates, and SI. Each 0.1 SI increment had an odds ratio of 1.39 with respect to 60-day mortality. The area under the ROC curve was 0.7511. At the optimal cut-off point of 0.94, the SI had 81.38% sensitivity and 73.11% accuracy. This makes the SI an ideal evaluation tool for rapidly predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. Identified patients can be counseled accordingly, and they can be assisted in making informed decisions on the appropriate treatment goals reflective of their prognoses.

Association between continuous deep sedation and survival time in terminally ill cancer patients

PURPOSE

Our study aimed to evaluate the association between CDS and survival time using the likelihood of receiving CDS to select a matched non-CDS group through an accurate measurement of survival time based on initiation of CDS.

METHODS

A retrospective cohort study was performed using an electronic database to collect data regarding terminally ill cancer patients admitted to a specialized palliative care unit from January 2012 to December 2016. We first used a Cox proportional hazard model with receiving CDS as the outcome to identify individuals with the highest plausibility of receiving CDS among the non-CDS group (n = 663). We then performed a multiple regression analysis comparing the CDS group (n = 311) and weighted non-CDS group (n = 311), using initiation of CDS (actual for the CDS group; estimated for the non-CDS group) as the starting time-point for measuring survival time.

RESULTS

Approximately 32% of participants received CDS. The most common indications were delirium or agitation (58.2%), intractable pain (28.9%), and dyspnea (10.6%). Final multiple regression analysis revealed that survival time was longer in the CDS group than in the non-CDS group (Exp(β), 1.41; P < 0.001). Longer survival with CDS was more prominent in females, patients with renal dysfunction, and individuals with low C-reactive protein (CRP) or ferritin, compared with their counterpart subgroup.

CONCLUSIONS

CDS was not associated with shortened survival; instead, it was associated with longer survival in our terminally ill cancer patients. Further studies in other populations are required to confirm or refute these findings.

A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes

BACKGROUND

Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis.

METHODS

A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others.

RESULTS

The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting.

CONCLUSION

There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.

High C-reactive protein to albumin ratio and the short-term survival prognosis within 30 days in terminal cancer patients receiving palliative care in a hospital setting: A retrospective analysis

Survival estimates are very important to patients with terminal cancer. The C-reactive protein (CRP)/albumin ratio is associated with cancer outcomes. However, few studies have investigated the dose-response association in terminal cancer patients. Therefore, we aimed to evaluate the association between the CRP/albumin ratio and mortality in terminal cancer patients using a longitudinal analysis. We retrospectively investigated the electronic medical records of 435 inpatients with terminal cancer admitted to the palliative care unit of Yeouido St. Mary's Hospital between October 8, 2015, and January 17, 2018. In total, 382 patients with terminal cancer were enrolled in the study. The serum CRP/albumin ratio measured at admission had a linear dose-response relationship with the risk of death among the terminal cancer patients (P for linearity = .011). The multivariate analyses showed that the CRP/albumin ratio was an independent prognostic factor (Model 1, CRP/albumin ratio >48.53 × 10: HR = 2.68, 95% CI = 1.82-3.93; Model 2, tertile 2: HR = 1.91, 95% CI = 1.31-2.82 and tertile 3: HR = 3.66, 95% CI = 2.24-5.97). The relationship between a high CRP/albumin ratio and poor survival was a flat L-shape for survival time with an inflection point at approximately 15 days, while the relationship was not significant in terminal cancer patients who survived beyond 30 days. This study demonstrated that high CRP/albumin ratios are significantly and independently associated with the short-term survival prognosis of terminal cancer patients within 30 days.

The relationship between pain, analgesics and survival in patients with advanced cancer; a secondary data analysis of the international European palliative care Cancer symptom study

PURPOSE

Opioids reduce cancer-related pain but an association with shorter survival is variably reported.

AIM

To investigate the relationship between pain, analgesics, cancer and survival within the European Palliative Care Cancer Symptom (EPCCS) study to help inform clinical decision making.

METHODS

Secondary analysis of the international prospective, longitudinal EPCCS study which included 1739 adults with advanced, incurable cancer receiving palliative care. In this secondary analysis, for all participants with date of death or last follow up, a multilevel Weibull survival analysis examined whether pain, analgesics, and other relevant variables are associated with time to death.

RESULTS

Date of death or last follow-up was available for 1404 patients (mean age 65.7 [SD:12.3];men 50%). Secondary analysis of this group showed the mean survival from baseline was 46.5 (SD:1.5) weeks (95% CI:43.6-49.3). Pain was reported by 76%; 60% were taking opioids, 51% non-opioid analgesics and 24% co-analgesics. Opioid-use was associated with decreased survival in the multivariable model (HR = 1.59 (95% CI:1.38-1.84), p < 0.001). An exploratory subgroup analysis of those with C-reactive protein (CRP) measures (n = 219) indicated higher CRP was associated with poorer survival (p = 0.001). In this model, the strength of relationship between survival and opioid-use weakened (p = 0.029).

CONCLUSION

Opioid-use and survival were associated; this relationship weakened in a small sensitivity-testing subgroup analysis adjusting for CRP. Thus, the observed relationship between survival and opioid-use may partly be due to tumour-related inflammation. Larger studies, measuring disease activity, are needed to confirm this finding to more accurately judge the benefits and risks of opioids in advanced progressive disease.

[Palliative surgery of malignant small bowel obstruction after colorectal cancer]

Although invasive surgical procedures in cancer patients can possibly cure malignancy, these strategies are potentially harmful by restricting quality of life and lifetime. Surgical therapies in palliative situations have to be carefully considered and well planned for every individual patient. The case report of the following patient suffering from malignant small bowel obstruction caused by local recurrence of colorectal cancer may make aware of difficulties and doubts in decision-making. After research oft the literature on this topic it is obvious that standards of therapy currently do not exist.

Collapse of Fluid Balance and Association with Survival in Patients with Advanced Cancer Admitted to a Palliative Care Unit: Preliminary Findings

Background: Few studies have investigated water balance as a predictor of survival in cancer patients in the last days of life. Objective: To examine the association between extracellular water (ECW), intracellular water (ICW), ratio of ECW to ICW (ECW/ICW), and survival in nonedematous and edematous patients with advanced cancer admitted to a palliative care unit. Design: A prospective observational study. Setting/Subjects: Patients with advanced cancer admitted to a palliative care unit. Measurements: Upon enrollment, bioelectrical impedance analysis was used to assess ECW, ICW, and body composition. We conducted time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses. Results: A total of 190 of 204 patients who participated in this study had ICW and ECW measures available for analysis. The median survival was 10 days (95% confidence interval [CI] 9-12) days. The median ECW, ICW, and ECW/ICW were 18.9 L, 19.1 L, and 1.0 for 72 nonedematous patients, and 21.9 L, 20.1 L, and 1.1 for 118 edematous patients, respectively. In univariate Cox regression analysis, ICW ≤20 L was associated with a shorter survival in the nonedematous patients (hazard ratio [HR] 1.92, 95% CI 1.10-3.34, p = 0.02) and a longer survival in the edematous patients (HR 0.61, 95% CI 0.41-0.90, p = 0.01). In multivariable analysis, ICW (≤20 L vs. >20 L) remained an independent prognostic factor in edematous patients (HR 0.64, 95% CI 0.43-0.95, p = 0.03). Conclusions: Greater ICW was an independent predictor of poorer survival in cancer patients with edema in the last days of life.

Serum C-reactive protein is an important and powerful prognostic biomarker in most adult solid tumors

INTRODUCTION

Prognostication in cancer is challenging and inaccurate. C-Reactive Protein (CRP), a cheap and sensitive marker of inflammation may help. This study investigated the relationship between CRP and prognosis in a large cohort of solid tumors with mixed cancer diagnoses and stages.

METHODS

Electronic medical records of 4931 adults with solid tumors who attended the Taussig Cancer Institute from 2006-2012 were reviewed. Demographic and clinical characteristics were recorded. Maximum CRP (mCRP) was identified for each individual. CRP was analysed as a time-dependent, continuous and categorical variable for association with survival.

RESULTS

Two thirds of patients had a high mCRP. This was consistently associated with shorter survival, even after correction for time from diagnosis, and when analysed as a continuous or a categorical variable. When mCRP values above 10 mg/L were subcategorized, a higher mCRP was always worse. Even among those with normal values, statistically and clinically significant shorter survival was noted at mCRP levels >5 mg/L.

CONCLUSIONS

In a large representative cohort of consecutive solid tumor patients the risk of death was clinically and statistically significantly greater with a high mCRP. This was independent of other variables and regardless of statistical method from both dates of diagnosis and test. CRP appeared to be underutilized. Our results support the routine use of CRP as a universal cost-effective independent prognostic indicator in most solid tumors.

C-reactive protein, symptoms and activity of daily living in patients with advanced cancer receiving palliative care

BACKGROUND

The association between C-reactive protein (CRP) level, symptoms, and activities of daily living (ADL) in advanced cancer patients is unclear.

METHODS

Secondary data analysis of a multicenter prospective cohort study consisted of 2426 advanced cancer patients referred to palliative care settings was conducted to examine the cross-sectional relationships between CRP level, symptoms, and ADL disabilities. Laboratory data, symptoms, ADL, and manual muscle testing (MMT) results were obtained at baseline. Participants were divided into four groups: low (CRP < 1 mg/dl), moderate (1 = < CRP <5 mg/dl), high (5 = < CRP < 10 mg/dl), and very high CRP (10 mg/dl = < CRP). The proportions of eight symptoms, five ADL disabilities, and three categories of MMT according to the CRP groups were tested by chi-square tests. Multiple-adjusted odd ratios (ORs) were calculated by using ordinal logistic regression after adjustment for age, gender, site of primary cancer, metastatic disease, performance status, chemotherapy, and setting of care.

RESULTS

A total of 1702 patients were analysed. Positive rates of symptoms and ADL disabilities increased with increasing CRP level. In the very high-CRP group, rates of positivity for anorexia, fatigue, and weight loss were 89.8%, 81.0%, and 79.2%, respectively, and over 70% of patients received assistance for bathing, dressing, going to the toilet, and transfer. The grade of MMT also deteriorated with increasing CRP level. Adjusted ORs for the accumulated symptoms significantly increased with increasing CRP level in the moderate-CRP, high-CRP, and very high-CRP groups [1.6 (95% confidence interval 1.2-2.0), P < 0.001; 2.5 (1.9-3.2), P < 0.001; 3.5 (2.7-4.6), P < 0.001, respectively]. Adjusted ORs for the accumulated ADL disabilities significantly increased in the very high-CRP groups [2.1 (1.5-2.9), P < 0.001].

CONCLUSIONS

Associations between CRP level, symptoms, and ADL were observed in advanced cancer patients receiving palliative care.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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