Article of the Month
Carla Ripamonti, MD
(Italy)
Prognostic factors in advanced cancer patients: evidence-based clinical recommendations- A study by the Steering Committee of the European Association for Palliative Care
Author(s): Maltoni M, Caraceni A, Brunelli C, Broeckaert B, Christakis N, Eychmueller S et al.
Journal: J Clinical Oncology 2005; 23:6240-48
In advanced/terminal cancer patients, the study of prognostic indicators of survival has become more and more frequent in the international literature. The aims of such studies are to 1. Identify the indicators of the patients’ length of survival in order to avoid over or under treatments 2. Plan specific care strategies as to the best caresettings and 3. Improve patient care from social, emotional and spiritual points of view.
A Working Group of the Research Network of the European Association for Palliative Care ( EAPC ) carried out a systematic literature search of the prognostic factors of patients with advanced cancer who had a survival ≤ 90 days. They identified four areas of interest: 1.Clinical prediction of survival (CPS), 2. Biologic factors, 3. Clinical signs and symptoms and psychosocial variables, and 4. Prognostic scores.
The aim of the study was to produce evidence-based clinical recommendations concerning the prognosis in patients with advanced cancer. The type and the quality of the studies were considered in order to classify their level of evidence. Thirty-eight studies fit the quality criteria for study evaluation – 1) there was a prospective study, 2) well-defined cohort of patients as well as well-defined and measured prognostic variables, 3) random patient selection, 4) ≤ 20% of the patients lost to follow-up, 5) the ratio between the number of deaths and the number of potential predictors ≥ 10, and 6) a reliable measurement of outcome.
The recommendations of the authors on evidenced-based prognostic factors in advanced cancer patients can be summarized by the following 6 points:
- The quality of life of the patients other then their life expectancy has to be considered in the decision making process
- Clinical judgment should be used not alone but together other prognostic factors or scores because, by itself, it overestimates the length of survival
- Some clinical signs and symptoms proved to be correlated with survival, they are, low performance status, signs and symptoms of the cancer anorexia-cachexia syndrome (anorexia, weight loss, dysphagia, xerostomia), cognitive failure (delirium) and dyspnea
- Biologic factors such as leukocytosis, lymphocytopenia, C-reactive protein have a prognostic value
- The prognostic scores/indices developed to estimate the life expectancy in a rapid and simple way were the Palliative Prognostic (PaP) Score and the Palliative Prognostic Index (PPI). Both have been validated and are useful in clinical practice. However, such scores have never been compared.
- The use and the communication of prognosis to patients should be considered within the context of listening to each patient regarding his/her needs for communication and information on prognosis within an ethically valid patient-physician relationship
Why I Chose this article
I have chosen this article because it is a contribution to the literature with evidence-based clinical recommendations on prognostic indicators of survival in advanced cancer patients.
The studies on prognostic indicators of survival should have the aim to help patients, families and caregivers in the decision-making process and in the improvement in patient care.
However, there are no studies showing that these objectives are reached through the knowledge of the prognostic factors. This should be the aim of the future research on this topic.
Happy New Year
Carla Ripamonti, MD
Member of the Board of Directors, IAHPC
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