Prognostication in palliative radiotherapy—ProPaRT: Accuracy of prognostic scores

Abstract

BackgroundPrognostication can be used within a tailored decision-making process to achieve a more personalized approach to the care of patients with cancer. This prospective observational study evaluated the accuracy of the Palliative Prognostic score (PaP score) to predict survival in patients identified by oncologists as candidates for palliative radiotherapy (PRT). We also studied interrater variability for the clinical prediction of survival and PaP scores and assessed the accuracy of the Survival Prediction Score (SPS) and TEACHH score.Materials and methodsConsecutive patients were enrolled at first access to our Radiotherapy and Palliative Care Outpatient Clinic. The discriminating ability of the prognostic models was assessed using Harrell’s C index, and the corresponding 95% confidence intervals (95% CI) were obtained by bootstrapping.ResultsIn total, 255 patients with metastatic cancer were evaluated, and 123 (48.2%) were selected for PRT, all of whom completed treatment without interruption. Then, 10.6% of the irradiated patients who died underwent treatment within the last 30 days of life. The PaP score showed an accuracy of 74.8 (95% CI, 69.5–80.1) for radiation oncologist (RO) and 80.7 (95% CI, 75.9–85.5) for palliative care physician (PCP) in predicting 30-day survival. The accuracy of TEACHH was 76.1 (95% CI, 70.9–81.3) and 64.7 (95% CI, 58.8–70.6) for RO and PCP, respectively, and the accuracy of SPS was 70 (95% CI, 64.4–75.6) and 72.8 (95% CI, 67.3–78.3).ConclusionAccurate prognostication can identify candidates for low-fraction PRT during the last days of life who are more likely to complete the planned treatment without interruption.All the scores showed good discriminating capacity; the PaP had the higher accuracy, especially when used in a multidisciplinary way.

Survival prediction in advanced cancer patients – a narrative review

“…Overall, the performance of ‘clinical prediction of survival’ had a similar discriminative accuracy in predicting short-term survival (e.g. 30-day survival) compared with established scores such as palliative prognostic score 16▪–18 and palliative prognostic index 19 in various settings, including outpatient radiation therapy and palliative clinic 16▪, palliative care service 17,18, outpatient medical oncology 10, and patients with head and neck cancer at their end-of-life 19. The clinical survival prediction C-indices generally ranged from 0.7 to 0.8, demonstrating a reasonable correlation with the aforementioned predictive scores.…”

“…Five articles that assessed the performance of a clinical prediction of survival in advanced cancer have been published in the past 2 years 10,16▪–19. Overall, the performance of ‘clinical prediction of survival’ had a similar discriminative accuracy in predicting short-term survival (e.g.…”

“…Over the years, new prognostic scoring systems have been devised and/or validated (Table 2) 16▪,18,23,24,28,40–62. These models often incorporate additional symptoms or laboratory values, which may be independent prognostic factors, to enhance the predictive power of the existing scoring systems.…”

“…Of note, clinician prediction of survival has the highest weighting in the scoring system. Recent studies have found that both the total score and the component of clinician prediction in the Palliative Prognostic Score showed good predictive performance among patients with advanced cancer in the palliative care setting 17,18,23,27,28 and those who were referred for palliative radiotherapy 16▪.…”