Communicating Diagnosis and Prognosis to Patients With Cancer: Guidance for Healthcare Professionals

Linda Emanuel, MD, PhD; Frank D. Ferris, MD, FAAPHM; Charles F. von Gunten, MD, PhD; Jaime H. Von Roenn, MD

Disclosures

January 07, 2011

In This Article

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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