Prognostic evaluation in patients with advanced cancer in the last months of life: ESMO Clinical Practice Guideline

Stone, Patrick; Buckle, Peter; Dolan, Ross D.; Feliú, Jaime; Hui, David; Laird, Barry; Maltoni, Marco; Moine, Sébastien; Morita, Tatsuya; Nabal, María; Vickerstaff, Victoria; White, Nicola; Santini, Daniele; Ripamonti, Carla

doi:10.1016/j.esmoop.2023.101195

Cited by 20 publications

(9 citation statements)

References 99 publications

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“…The LMR prognostic score, based on the LMR level and tumor resection history, reliably identified high-risk patients. The accurate prediction of survival can help future care and provide opportunities for patients and their families to focus on what is relevant to them when time is limited 75 . Our model can help avoid harm and inappropriate therapies in vulnerable patients 76 and enhance patients’ autonomy 77 .…”

Section: Discussionmentioning

confidence: 99%

Lymphocyte-to-monocyte ratio as a prognostic and potential tumor microenvironment indicator in advanced soft tissue sarcoma treated with first-line doxorubicin therapy

Watanabe

Shimoi

Nishikawa

et al. 2023

Sci Rep

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Prognostic value of hematologic indices and their association with the tumor microenvironment (TME) remain unclear in advanced soft tissue sarcoma (STS). We aimed to evaluate their prognostic value and correlation with the TME status in advanced STS treated with first-line doxorubicin (DXR) therapy. Clinical data and three hematological indices, including lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio, and neutrophil-to-lymphocyte ratio, were collected from 149 patients with advanced STS. The TME status was pathologically examined by CD3, CD68, and CD20 staining of resected tumor slides. In a multivariate Cox analysis, low LMR and absence of primary tumor resection were independently associated with worse overall survival (OS) (HR 3.93, p = 0.001; HR 1.71, p = 0.03). A prognostic model using these variables predicted OS with greater area under curves than those obtained using Systemic Inflammatory Score and Glasgow Prognostic Score. The LMR significantly correlated with the tumoral CD3/CD68-positive cell ratio in surgical specimens (R = 0.959, p = 0.04). In conclusion, LMR was a prognostic factor in advanced STS treated with first-line DXR therapy. LMR could partially reflect anti-tumor immunity in the TME and have the prognostic value. The potential role of LMR as an indicator of TME status warrants further investigation.

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Section: Discussionmentioning

confidence: 99%

Lymphocyte-to-monocyte ratio as a prognostic and potential tumor microenvironment indicator in advanced soft tissue sarcoma treated with first-line doxorubicin therapy

Watanabe

Shimoi

Nishikawa

et al. 2023

Sci Rep

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“…Evidence shows that clinicians' estimates are often inaccurate and over-optimistic. [2][3][4][5] Recommendations and guidelines include involvement of the multidisciplinary team in prognostic decisions, [6][7][8][9] on the basis that it has been reported to improve prognostic accuracy. 3,10 Clinicians may seek prognostic advice for social reasons, including self-affirmation and sharing of responsibility, knowing the difficulties of prognostication and concerns regarding inaccurate predictions.…”

Section: Introductionmentioning

confidence: 99%

Time estimates in prognostic discussions: A conversation analytic study of hospice multidisciplinary team meetings

Bruun,

White,

Oostendorp

et al. 2024

Palliat Med

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Background: Recommendations state that multidisciplinary team expertise should be utilised for more accurate survival predictions. How the multidisciplinary team discusses prognoses during meetings and how they reference time, is yet to be explored. Aim: To explore how temporality is conveyed in relation to patients’ prognoses during hospice multidisciplinary team meetings. Design: Video-recordings of 24 hospice multidisciplinary team meetings were transcribed and analysed using Conversation Analysis. Setting/participants: A total of 65 staff participating in multidisciplinary team meetings in a UK hospice from May to December 2021. Results: Team members conveyed temporality in three different ways. (i) Staff stated that a patient was dying as part of the patient’s current health status. These formulations did not include a time reference per se but described the patient’s current situation (as dying) instead. (ii) Staff used specific time period references where another specific reference had been provided previously that somehow constrained the timeframe. In these cases, the prognosis would conflict with other proposed care plans. (iii) Staff members used unspecific time period references where the reference appeared vague and there was greater uncertainty about when the patient was expected to die. Conclusions: Unspecific time period references are sufficient for achieving meaningful prognostic talk in multidisciplinary teams. In-depth discussion and accurate prediction of patient prognoses are not deemed a priority nor a necessity of these meetings. Providing precise predictions may be too difficult due to uncertainty and accountability. The lack of staff pursuing more specific time references implies shared knowledge between staff and a context-specific use of prognostic estimates.

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“… 9 , 20 – 24 Other research compared survival time between cancer and non-cancer diagnosis, 21 , 25 including covariates such as gender 23 , 24 , 26 and age. 20 , 27 Researchers however acknowledge the lack of accuracy, 5 level of uncertainty and unreliability of prognostic tools 28 and the risk of overestimation 7 , 8 when clinicians predict time till death. Despite this work, none of these studies focussed solely on the unresponsive dying person to determine the time till death; and as such cannot be used to answer the ‘how long’ question at end-of-life with confidence.…”

Section: Introductionmentioning

confidence: 99%

‘How long do you think?’ Unresponsive dying patients in a specialist palliative care service: A consecutive cohort study

O’Connor,

Liu,

Samara

et al. 2024

Palliat Med

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Background: Predicting length of time to death once the person is unresponsive and deemed to be dying remains uncertain. Knowing approximately how many hours or days dying loved ones have left is crucial for families and clinicians to guide decision-making and plan end-of-life care. Aim: To determine the length of time between becoming unresponsive and death, and whether age, gender, diagnosis or location-of-care predicted length of time to death. Design: Retrospective cohort study. Time from allocation of an Australia-modified Karnofsky Performance Status (AKPS) 10 to death was analysed using descriptive narrative. Interval-censored survival analysis was used to determine the duration of patient’s final phase of life, taking into account variation across age, gender, diagnosis and location of death. Setting/participants: A total of 786 patients, 18 years of age or over, who received specialist palliative care: as hospice in-patients, in the community and in aged care homes, between January 1st and October 31st, 2022. Results: The time to death after a change to AKPS 10 is 2 days ( n = 382; mean = 2.1; median = 1). Having adjusted for age, cancer, gender, the standard deviation of AKPS for the 7-day period prior to death, the likelihood of death within 2 days is 47%, with 84% of patients dying within 4 days. Conclusion: This study provides valuable new knowledge to support clinicians’ confidence when responding to the ‘how long’ question and can inform decision-making at end-of-life. Further research using the AKPS could provide greater certainty for answering ‘how long’ questions across the illness trajectory.

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Prognostic evaluation in patients with advanced cancer in the last months of life: ESMO Clinical Practice Guideline

Cited by 20 publications

References 99 publications

Lymphocyte-to-monocyte ratio as a prognostic and potential tumor microenvironment indicator in advanced soft tissue sarcoma treated with first-line doxorubicin therapy

Lymphocyte-to-monocyte ratio as a prognostic and potential tumor microenvironment indicator in advanced soft tissue sarcoma treated with first-line doxorubicin therapy

Time estimates in prognostic discussions: A conversation analytic study of hospice multidisciplinary team meetings

‘How long do you think?’ Unresponsive dying patients in a specialist palliative care service: A consecutive cohort study

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