Integrated Models for Prognostication
Prognostication is both art and science, and is imperfect at best. Integration of data from multiple sources of prognostic information improves one's ability to predict outcome with accuracy.[38,39]The European Association for Palliative Care published evidence-based recommendations related to prognostication in advanced cancer patients, and reported that the strongest evidence supports use of CPS with prognostic scores in determining prognosis.[40]
Palliative Prognostic Score
The palliative prognostic score (PaP) is a validated model to predict prognosis for patients with advanced cancer.[18,41] This model incorporates performance status, CPS, and specific clinical symptoms and signs (Table 5). The model is able to predict 3- and 6-week survival in a cohort of advanced cancer patients, with a sensitivity and specificity of 83% and 85% at 3 weeks and 79% and 77% at 6 weeks.[29]
Table 5. PaP
| Prognostic Variable | Score | |
| Dyspnea | ||
| Absent | 0 | |
| Present | 1 | |
| Anorexia | ||
| Absent | 0 | |
| Present | 1.5 | |
| KPS | ||
| ≥ 50 | 0 | |
| 10-40 | 2.5 | |
| Clinician prediction of survival (weeks) | ||
| >12 | 0 | |
| 11-12 | 2 | |
| 7-10 | 2.5 | |
| 5-6 | 4.5 | |
| 3-4 | 6 | |
| 1-2 | 8.5 | |
| Total white blood cell count | ||
| Normal (4800-8500) cell/mm3 | 0 | |
| High (8501-11,000) cell/mm3 | 0.5 | |
| Very high (>11,000) cell/mm3 | 1.5 | |
| Lymphocyte percentage | ||
| Normal (20%-40%) | 0 | |
| Low (12%-19.9%) | 1 | |
| Very low (0%-11.9%) | 2.5 | |
| Interpretation of the PaP score | ||
| Risk group | 30-day survival probability | Total score |
| A | > 70% | 0-5.5 |
| B | 30%-70% | 5.6-11 |
| C | < 30% | 11.1-17.5 |
Palliative Prognostic Index
The palliative prognostic index (PPI) was developed by Morita and colleagues.[42] Five variables (performance status, oral intake, edema, dyspnea at rest, and delirium) were found to be independently predictive of survival. Each of the variables is used to produce a partial score, which are then summed (possible scores 0-15). A score of > 4 is predictive of 6-week survival (Table 6).
Table 6. PPI
| Variable | Partial Score Value | |
| Palliative performance scale (modified Karnofsky) | ||
| 10-20 | 4 | |
| 30-50 | 2.5 | |
| ≥ 60 | 0 | |
| Oral intake | ||
| Severely reduced | 2.5 | |
| Moderately reduced | 1.0 | |
| Normal | 0 | |
| Edema | ||
| Present | 1.0 | |
| Absent | 0.0 | |
| Dyspnea at rest | ||
| Present | 3.5 | |
| Absent | 0.0 | |
| Delirium | ||
| Present | 4.0 | |
| Absent | 0.0 | |
| Interpretation of the PPI score | ||
| Total Score | PPV for 6-week survival | NPV for 6-week survival |
| > 4 | 0.83 | 0.71 |
NPV = negative predictive value; PPV = positive predictive value
A prognostic model for patients continuing on treatment that includes integration of signs and symptoms is not available, and the PPI has not been evaluated in patients earlier in their disease course. Other prognostic scoring systems, such as the Terminal Cancer Prognostic Score[43]and Bruera's Poor Prognostic Indicator[38] have not been independently validated in large patient cohorts.
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Cite this: Linda Emanuel, Frank D. Ferris, Charles F. von Gunten, et. al. Communicating Diagnosis and Prognosis to Patients With Cancer: Guidance for Healthcare Professionals - Medscape - Jan 07, 2011.
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