Reply: Prediction of survival in terminally ill cancer patients: why we cannot avoid an evidence-based palliative medicine

D. Tassinari1, M. Maltoni2 and D. Amadori2

1 Department of Oncology, City Hospital, Rimini; 2 Department Oncology, Pierantoni Hospital, Forlì, Italy (E-mail: dtassinari@rimini.com)

We very much appreciated the reply of Tanneberger to our work [1], because it gives us the opportunity to focus attention on one of the main issues of palliative care. In recent years, many authors have investigated the problem of survival prediction in terminal cancer patients, underlining its role in planning either the optimal treatment or the most appropriate palliative services for different subgroups of patients. In a systematic review of 24 trials, Viganò et al. [2] identified the parameters that could represent independent survival predictors in terminal cancer patients, and drew attention to the methodological limits of existing trials, suggesting that further well-designed trials are needed to overcome the present uncertainty in this issue of palliative care. Moreover, analyzing the role of clinical prediction of survival, Viganò and colleagues observed that even though it can be considered an independent prognostic factor, the magnitude of its association with survival is small. It follows that it should be considered just one of the main criteria of prognostic evaluation, and not a soul criterion. The same opinion is supported by the findings of Christakis et al. [3], who reported an accuracy of ~20% in prediction of survival, as well as by the results of Tanneberger, who obtained an overall accuracy of 33% in prediction of survival, higher than that observed by Christakis but essentially comparable from a clinical point of view. Indeed, other factors can play a role in the prediction of survival; an attempt of classifying them on the basis of their levels of evidence is given in Table 1. In recent years, many efforts have been made by our group to identify a model to predict survival, which is either ‘evidence-based’ or easily assessed in a clinical setting [46]. Based on our investigations, we suggested the ‘Palliative Prognostic Score’ (PaP-Score), which has recently been validated by two different groups [67] and could represent a useful tool in the prognostic evaluation of terminally ill cancer patients. It facilitates the differentiation of three classes of patients with differing prognoses, with a methodological {alpha}-error <5%. The clinical prediction of survival represents one of the parameters contributing to the final score (Table 1). We are firmly convinced that we are still far from an ideal solution, nevertheless, we believe that no step forward can avoid ‘evidence-based’ models of working. We strongly agree with Viganò [2] that palliative medicine should be an ‘evidence-based palliative medicine’, and we hope that new simple ‘evidence-based’ tools can be identified and validated for the prognostic evaluation of terminally ill cancer patients.


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Table 1.  Parameters with prognostic value and their level of evidence
 
D. Tassinari1, M. Maltoni2 & D. Amadori2

1Department of Oncology, City Hospital, Rimini; 2Department of Oncology, Pierantoni Hospital, Forlì, Italy (E-mail: dtassinari@rimini.com)

Acknowledgements

Supported by Istituto Oncologico Romagnolo (IOR).

References

1. Maltoni M, Amadori D. Palliative medicine and medical oncology. Ann Oncol 2001; 12: 443–450.[Abstract]

2. Vigano A, Dorgan M, Buckingham J et al. Survival prediction in terminal cancer patients: a systematic review of the medical literature. Palliat Med 2000; 14: 363–374.[ISI][Medline]

3. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. Br Med J 2000; 320: 469–473.[Abstract/Free Full Text]

4. Maltoni M, Pirovano M, Scarpi E et al. Prediction of survival of patients terminally ill with cancer. Results of an Italian prospective multicentric study. Cancer 1995; 75: 2613–2622.[ISI][Medline]

5. Pirovano M, Maltoni M, Nanni O et al. A new Palliative Prognostic Score: a first step for the staging of terminally ill cancer patients. Italian Multicenter Study Group on Palliative Care. J Pain Symptom Manage 1999; 17: 231–239.[ISI][Medline]

6. Maltoni M, Nanni O, Pirovano M et al. Successfull validation of the Palliative Prognostic Score in terminally ill cancer patients. Italian Multicenter Study Group on Palliative Care. J Pain Symptom Manage 1999; 17: 240–247.[ISI][Medline]

7. Glare P, Virik K. Independent prospective validation of the PaP score in terminally ill patients referred to a hospital-based palliative medicine consultation services. J Pain Symptom Manage 2001; 22: 891–898.[ISI][Medline]





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