Article of the Month
Carla Ripamonti, MD
(Italy)
Prognostic significance of symptoms of hospitalised advanced cancer patients
Author(s): Teunissen SC, de Graeff A, de Haes HC, Voest EE
Journal: European Journal of Cancer 2006; 42: 2510-6
The studies on prognostic indicators of survival of advanced cancer patients have progressively increased over the last 10-15 years. In these studies, the patients were cared for at home or in hospices and therefore were a homogenous group of patients with short life expectancies.
Most of those studies found that Performance Status (PS) and symptoms such as dyspnoea, anorexia, dysphasia, and delirium are independent predictors of survival and can be considered symptoms of the “final common pathway” (Reuben, Arch Intern Med 1988). Often, physicians underestimated expected survival.
Teunissen et al. prospectively investigated 1. the role of symptoms of advanced cancer patients as independent prognostic factors for death in hospitalized patients on oncologic wards who were referred to the palliative care team (PCT) and 2. Clusters of proven predictive symptoms as a means to improve prognostication. 181 patients were among those considered for the study. They were interviewed by a specialized nurse and referred to the PCT between 1998 and 2004.
The following measures were assessed:
- symptoms, included on a list of 49 of the most frequent symptoms plus those reported voluntarily - each was assessed as present or absent;
- PS was measured by the KPS
- socio-demographic data was collected by physicians and nurses; and
- the length of survival was noted (the time elapsed between the date of the 1 st consultation of the PCT and the date of the patient’s death, or their last follow-up).
The relation between the sociodemographic variables, diagnosis, KPS and symptoms occurring in ≥ 10% of cases was analysed to define the prognostic indicators of survival. Using a Cox regression model, a predictive survival model was built.
Forty three per cent of patients died within 1 month and only 15% of the patients lived longer than 6 month as measured by the time elapsed from the 1 st PCT consultation. The median survival was 53 days (range 1-1915).
The patients reported a median of 4 symptoms (range 1-8). In more than 10% of the patients 20 symptoms were declared and in more than 50% of the patients pain, fatigue, anorexia and anxiety were the most frequent symptoms. Most patients (88%) were in pain.
The patients with gastro-intestinal cancer had poor survival (p<0.001).
Multivariate analysis showed nausea, dysphasia, dyspnoea, confusion and absence of a depressed mood were independent prognostic factors for survival (p<0.05). Patients with 2, 3 or all 4 of these symptoms at the same time had respectively an estimated, 2.7, 2.1 and 9.0 times higher risk of dying than patients without any of these symptoms. The presence of four of these significant symptoms resulted in an 83% mortality rate at 1 month and 100% mortality rate at 6 months compared to patients without these symptoms who had a 1-month mortality of 20% and a 6-month mortality of 48%.
Why I chose this article
This study adds clinical information to previous studies published in the literature that were carried out on patients cared for either at home or in a hospice setting. This article provides particular information regarding non-homogeneous behaviour of hospitalized advanced cancer patients admitted to oncologic wards. In these patients, a cluster of factors such as nausea, dysphasia, dyspnoea, confusion and the absence of a depressed mood may accurately predict survival.
Regards,
Carla Ripamonti, MD
Member of the Board of Directors, IAHPC
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