The effect of palliative care team intervention and symptom improvement using patient-reported outcomes: a multicenter prospective observational study.

PURPOSE: Hospital-based palliative care teams (HPCTs) are widespread internationally, but multicenter studies about their effectiveness, using patient-reported outcomes (PROs), are limited to Australia and a few other countries. We conducted a multicenter, prospective observational study in Japan to explore the effectiveness of the HPCTs using PROs. METHODS: Nationwide, eight hospitals participated in the study. We included newly referred patients for one month in 2021 and followed them for one month. We asked the patients to complete the Integrated Palliative Care Outcome Scale or the Edmonton Symptom Assessment System as PROs at the time of the intervention, three days later, and weekly after the intervention. RESULTS: A total of 318 participants were enrolled, of whom 86% were patients with cancer, 56% were undergoing cancer treatment, and 20% received the Best Supportive Care. After one week, the following 12 symptoms showed more than a 60% improvement from severe to moderate or less: vomiting (100%), shortness of breath (86%), nausea (83%), practical problems (80%), drowsiness (76%), pain (72%), poor sharing of feelings with family or friends (72%), weakness (71%), constipation (69%), not feeling at peace (64%), lack of information (63%), and sore or dry mouth (61%). Symptoms with improvement from severe/moderate to mild or less were vomiting (71%) and practical problems (68%). CONCLUSION: This multicenter study showed that HPCTs effectively improved symptoms in several severe conditions, as assessed by PROs. This study also demonstrated the difficulty of relieving symptoms in patients in palliative care and the need for improved care.

Absence of a weekday effect on short- and long-term oncologic outcomes of gastrectomy for gastric cancer: a propensity score matching analysis.

BACKGROUND: Day of the week when elective gastrointestinal surgery is performed may be influenced by various background and tumor-related factors. Relationships between postoperative outcome and when in the week gastrectomy is performed remain controversial. We undertook this study to evaluate whether weekday of gastrectomy influenced outcomes of gastric cancer treatment ("weekday effect"). METHODS: Patients who underwent curative surgery for gastric cancer between 2004 and 2017 were included in this retrospective study. To obtain 2 cohorts well balanced for variables that might influence clinical outcomes, patients whose gastrectomy was performed early in the week (EW group) were matched 1:1 with others undergoing gastrectomy later in the week (LW group) by use of propensity scores. RESULTS: Among 554 patients, 216 were selected from each group by propensity score matching. Incidence of postoperative complications classified as Clavien-Dindo grade II or higher was similar between EW and LW groups (20.4% vs. 24.1%; P = 0.418). Five-year overall and recurrence-free survival were 86.0% and 81.9% in the EW group, and 86.2% and 81.1% in the LW group (P = 0.981 and P = 0.835, respectively). CONCLUSIONS: Short- and long-term outcomes were comparable between gastric cancer patients who underwent gastrectomy early and late in the week.

Benefit of laparoscopic compared to standard open gastric cancer surgery for sarcopenic patients: a propensity score-matching analysis.

BACKGROUND: Laparoscopic gastrectomy (LG) is performed widely, but whether LG is the optimal treatment for sarcopenic gastric cancer patients is unclear. This study aimed to determine whether LG is particularly beneficial for gastric cancer patients with sarcopenia. METHODS: We collected data concerning 604 consecutive patients who underwent gastrectomy for gastric cancer between January 2003 and December 2019. After adjustment using one-to-one propensity score matching, short-term and long-term outcomes were compared between LG and open gastrectomy (OG) groups among patients with sarcopenia and those without. RESULTS: Among patients with and without sarcopenia, the LG group had a significantly longer operative time but less blood loss than the OG group. The two groups showed no significant differences regarding complications. Although 5-year overall and disease-specific survival were similar between LG and OG groups among patients with and without sarcopenia, LG was associated with greater 5-year non-gastric cancer-related survival than OG among patients with sarcopenia (88.3% vs. 78.1%, P = 0.048), but not those without. CONCLUSION: LG for resectable gastric cancer was not inferior to OG regarding complications and outcomes in patients with or without sarcopenia. No difference in overall survival was evident between these approaches, but LG may lessen mortality from conditions unrelated to gastric cancer in sarcopenic patients.

Impact of body fat and muscle quantity on short- and long-term outcome after gastrectomy for cancer.

BACKGROUND & AIMS: Preoperative low skeletal muscle mass and obesity have been identified as poor prognostic factors after gastrectomy for cancer, but the predictive value of combined quantitation of skeletal muscle mass and obesity remains unclear. This study examined the impact of combined body compositions on outcomes after gastrectomy for cancer. METHODS: 518 patients who had undergone gastric resection for cancer between 2004 and 2017 were analyzed retrospectively. Skeletal muscle mass (skeletal muscle mass index (SMI)) and visceral obesity (visceral fat area) were measured in preoperative computed tomographic images to categorize patients as outlined below. Impacts of these body compositions on outcomes after gastrectomy were investigated. RESULTS: Body composition was classified as high SMI without obesity in 231 patients (45%), high SMI with obesity in 202 (39%), low SMI without obesity in 55 (11%), and low SMI with obesity in 30 (6%). Postoperative complications developed in 128 patients (25%). Multivariate analysis identified low SMI with obesity as an independent risk factor for postoperative complications (odds ratio, 3.27; P = 0.010). Moreover, patients with low SMI without obesity had lower 5-year overall survival rates than patients with high SMI without obesity (64.4% vs. 88.0%; P < 0.001) and worse 5-year relapse-free survival rates (61.3% vs. 81.3%; P = 0.002). Multivariate analysis identified low SMI without obesity as a significant risk factor for overall survival (hazard ratio, 3.033; P < 0.001) and relapse-free survival (hazard ratio, 2.144; P = 0.008) after gastrectomy. CONCLUSION: Preoperative low SMI with obesity was an independent risk factor for postoperative complications, while low SMI without obesity was an independent risk factor for overall and relapse-free survival following gastrectomy for cancer.

Superior mesenteric vein reconstruction during pancreatoduodenectomy using a dilated right ovarian vein in a patient at future risk for pelvic congestion syndrome: a case report.

BACKGROUND: Pancreatoduodenectomy including resection of the superior mesenteric vein (SMV) is increasingly performed for right-sided pancreatic ductal adenocarcinoma invading the wall of that vessel. Various venous grafts may be chosen for reconstruction. We present a woman with pancreatic cancer who underwent such a pancreatoduodenectomy with venous reconstruction using a dilated right ovarian vein. CASE PRESENTATION: A 71-year-old woman with cancer involving the pancreatic head, uncinate process, and SMV underwent pancreatoduodenectomy with SMV resection. Reconstruction used a portion of the right ovarian vein that was markedly dilated and had placed her at risk for pelvic congestion syndrome (PCS). Graft patency was confirmed 8 months after surgery. She now finished receiving adjuvant chemotherapy and has no symptoms of PCS. CONCLUSION: If an ovarian vein has sufficient diameter, it can be used to reconstruct the resected segment of the SMV during pancreatoduodenectomy in suitable patients.

Cancer Rehabilitation Provided by Designated Cancer Hospitals in Japan: The Current State of Outpatient Setting and Coordination after Discharge.

Objectives: The aim of the present study was to clarify the current state of outpatient cancer rehabilitation and coordination systems provided by designated cancer hospitals in Japan. Methods: A questionnaire was sent to 427 designated cancer hospitals in Japan to investigate the status of outpatient cancer rehabilitation and whether it was sufficiently conducted. The status of regional coordination with post-discharge rehabilitation facilities was surveyed. Results: Responses were received from 235/427 facilities (55.0%). Outpatient cancer rehabilitation was implemented in 92 (39.1% of responding facilities), and of these facilities, 83.7% answered that the provision of rehabilitation was insufficient. The reasons were ineligibility for reimbursement of medical fees, a lack of human resources, a lack of awareness of the need, and a lack of education. Regional coordination was conducted by 39.1% of responding facilities, yet a regional alliance path had been established in only 9.8% of centers. The absence of coordination was associated with large facility size, the absence of physiatrists, and few rehabilitation professionals who had completed the training program; an insufficient framework for regional coordination was also given as a reason. Conclusions: To provide adequate outpatient cancer rehabilitation, sufficient human resources, the reimbursement of medical fees in the outpatient setting, and education and a framework to promote regional coordination are necessary.

The current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan.

OBJECTIVE: This survey was conducted to clarify the current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan. METHODS: A survey questionnaire was sent to 427 designated cancer hospitals in Japan. Information was sought regarding whether inpatient cancer rehabilitation was provided by the center, and if so, whether respondents regarded such provision as satisfactory. RESULTS: Responses were obtained from 235/427 surveyed institutions (55.0%). Cancer rehabilitation was provided in inpatient settings by 97.4%. Two-thirds of respondents (67.7%) regarded inpatient cancer rehabilitation provision as still inadequate. The primary reasons claimed for this inadequacy were a lack of human resources, a lack of rehabilitation professionals with the requisite knowledge/skills and patients who would benefit from cancer rehabilitation present but not prescribed. The total number of rehabilitation staff was identified as associated factor of inadequate inpatient cancer rehabilitation in multivariate analysis (odds ratio = 0.979, 95% confidence interval = 0.96-1.00, P = 0.009). CONCLUSIONS: In order to provide adequate cancer rehabilitation, a sufficient supply of rehabilitation staff, education and recognition of the need for cancer rehabilitation within oncology units are necessary.

Association between low preoperative skeletal muscle quality and infectious complications following gastrectomy for gastric cancer.

PURPOSE: It is known that sarcopenia affects the overall short- and long-term outcomes of patients with gastric cancer (GC); however, the effect of muscle quality on infectious complications after gastrectomy for GC remains unclear. We investigated the associations between the preoperative quantity and quality of skeletal muscle on infectious complications following gastrectomy for GC. METHODS: The subjects of this retrospective study were 353 GC patients who underwent radical gastrectomy between 2009 and 2018. We examined the relationships between their clinical factors, including skeletal muscle mass index and intramuscular adipose tissue content (IMAC), and infectious complications after gastrectomy. RESULTS: Infectious complications developed in 59 patients (16.7%). The independent risk factors for infectious complications identified by multivariate analysis were male gender (P < 0.001), prognostic nutritional index below 45 (P = 0.006), and high IMAC (P = 0.011). Patients with a high IMAC were older and had a higher body mass index, as well as a greater age-adjusted Charlson comorbidity index, than those with low or normal IMAC. CONCLUSIONS: Low skeletal muscle quality defined by a high IMAC is a risk factor for infectious complications following gastrectomy. When feasible, preoperative nutritional intervention and rehabilitation aiming to improve muscle quality could reduce infectious complications after gastrectomy for GC.

Rehabilitation for Cancer Patients in Inpatient Hospices/Palliative Care Units and Achievement of a Good Death: Analyses of Combined Data From Nationwide Surveys Among Bereaved Family Members.

CONTEXT: In end-of-life care, rehabilitation for patients with cancer is considered to be an important means for improving patients' quality of death and dying. OBJECTIVES: To determine whether the provision of rehabilitation for patients with cancer in palliative care units is associated with the achievement of a good death. METHODS: This study involved a cross-sectional, anonymous, and self-report questionnaire survey of families of patients with cancer who died in palliative care units in Japan. We evaluated the short version of Good Death Inventory (GDI) on a seven-point scale. A logistic regression model was used to calculate the propensity score. Covariates included in this model were survey year, patients' characteristics, and families' characteristics. The associations between rehabilitation and GDI were tested using trend tests after propensity score matching adjustment. RESULTS: Of the 1965 family caregivers who received the questionnaires, available data were obtained from 1008 respondents (51.2%). Among them, 285 (28.2%) cases received rehabilitation in palliative care units. There was no difference in total GDI score between the groups with and without rehabilitation. In exploratory analyses, patients receiving rehabilitation were significantly more likely to feel maintaining hope and pleasure (mean 4.50 [SE 0.10] vs. 4.05 [0.11], respectively; effect size [ES] 0.31; P = 0.003), good relationships with medical staff (mean 5.67 [SE 0.07] vs. 5.43 [0.09], respectively; ES 0.22; P = 0.035), and being respected as an individual (mean 6.08 [SE 0.06] vs. 5.90 [0.07], respectively; ES 0.19; P = 0.049) compared with patients not receiving rehabilitation. CONCLUSION: Rehabilitation in palliative care units may contribute to several domains of quality of death and dying, particularly maintaining hope and pleasure. Further research is needed to investigate whether palliative rehabilitation contributes to the achievement of a good death.

Quality indicators of palliative care for acute cardiovascular diseases.

BACKGROUND: Although recent attention to palliative care for patients with cardiovascular diseases has been increasing, there are no specific recommendations on detailed palliative care practices. We proceed on a discussion of the appropriateness and applicability of potential quality indicators for acute cardiovascular diseases according to our previous systematic review. METHODS: We created a multidisciplinary panel of 20 team members and 7 external validation clinicians composed of clinical cardiologists, a nutritionist, a physiotherapist, a clinical psychologist, a critical and emergent care specialist, a catheterization specialist, a primary care specialist, a palliative care specialist, and nurses. After crafting potential indicators, we performed a Delphi rating, ranging from "1 = minimum" to "9 = maximum". The criterion for the adoption of candidate indicators was set at a total mean score of seven or more. Finally, we subcategorized these indicators into several domains by using exploratory factor analysis. RESULTS: Sixteen of the panel members (80%) were men (age, 49.5 ± 13.7 years old). Among the initial 32 indicators, consensus was initially reached on total 23 indicators (71.8%), which were then summarized into 21 measures by selecting relatively feasible time variations. The major domains were "symptom palliation" and "supporting the decision-making process". Factor analysis could not find optimal model. Narratively-developed seven sub-categories included "presence of palliative care team", "patient-family relationship", "multidisciplinary team approach", "policy of approaching patients", "symptom screening and management", "presence of ethical review board", "collecting and providing information for decision-maker", and "determination of treatment strategy and the sharing of the care team's decision". CONCLUSION: In this study we developed 21 quality indicators, which were categorized into 2 major domains and 7 sub-categories. These indicators might be useful for many healthcare providers in the initiation and enhancement of palliative care practices for acute cardiovascular diseases in Japan.

Association Between Heart Rate and Reversibility of the Symptom, Refractoriness to Palliative Treatment, and Survival in Dyspneic Cancer Patients.

CONTEXT: Dyspnea is one of the most distressing symptoms for terminally ill cancer patients and a predictor of poor prognosis. Identification of simple clinical signs, such as heart rate, indicating clinical course of each patient is of value. OBJECTIVES: To explore the potential association between heart rate and reversibility of the symptom, treatment response to palliative intervention, and survival in terminally ill cancer patients with dyspnea at rest. METHODS: This is a secondary analysis of a multicenter prospective cohort study of patients with advanced cancer to validate multiple prognostic tools. In the patients with dyspnea at rest at the baseline, we examined a potential association between heart rate and the reversibility of dyspnea and refractoriness to palliative treatment using logistic regression analysis. Survivals were compared using the Cox proportional hazards model among four groups with different levels of the heart rate (≤74, 75-84, 85-97, and ≥98). RESULTS: A total of 2298 patients were enrolled, and 418 patients (18%) had dyspnea at rest. Reversibility of dyspnea was significantly higher in the patients with lower heart rate (P for trend = 0.008), and the refractoriness to palliative treatment tended to be higher in the patients with higher heart rate (P for trend = 0.101). The median survival for each heart rate quartile groups was significantly higher in the lower heart rate group (24 vs. 21 vs. 14 vs. 9 days; heart rate ≤74, 75-84, 85-97, and ≥98, respectively; log-rank P < 0.001). CONCLUSION: Heart rate may help clinicians to make the prediction of the patient's clinical course more accurate.

All-in-one Raman spectroscopy approach to diagnosis of colorectal cancer: analysis of spectra in the fingerprint regions.

OBJECTIVES: Raman spectroscopy yields precise information, not only regarding the secondary structure of proteins but also regarding the discrimination between normal and malignant tissues. There is, however, no standard measurement method. We evaluated the use of a miniaturized, handheld, all-in-one Raman spectrometer with a 1064-nm laser excitation source for the diagnosis of colorectal cancer. The ultimate goal is real-time, in vivo diagnosis. METHODS: Tissue samples were obtained from 20 patients who underwent surgery for colorectal cancer. The samples were irradiated with the portable Progeny™ Raman spectrometer, with which the Raman spectra were also obtained. We searched for characteristic Raman shifts and examined whether these shifts could distinguish the cancer tissues. To improve accuracy, we divided the spectra into 100 cm-1 bands and applied principal component analysis (PCA) to each range. We evaluated the contribution of each range for cancer discrimination. RESULTS: Intensities at 1261 and 1427 cm-1 differed significantly between the normal tissues and cancer tissues, but these did not efficiently discriminate the cancer tissues. However, we were able to identify the characteristic spectral range in fingerprint regions; accuracy was 85.1%. CONCLUSIONS: Use of the all-in-one type Raman spectrometer can efficiently discriminate colorectal cancer, not on the basis of the intensities at 1261 and 1427 cm-1 but rather on the basis of PCA. Thus, Raman spectroscopy performed using a handheld device has potential to become a clinically powerful tool for producing high-quality data, obtaining highly reproducible measurements, and thus accurately diagnosing colorectal cancer.

Development of a Consensus Syllabus of Palliative Medicine for Physicians in Japan Using a Modified Delphi Method.

CONTEXT: Although palliative care is rapidly being disseminated throughout Japan as a result of government policy, a systematic syllabus of palliative medicine for physicians has not been developed. AIMS: This study aimed to develop a Japanese national consensus syllabus of palliative medicine for physicians. DESIGN: We used a modified Delphi method to develop the consensus syllabus. METHODS AND SETTING: We created a Delphi panel by selecting 20 expert eligible panelists consisting of Diplomate or Faculty of the Specialty Board of Palliative Medicine and certified by the Japanese Society for Palliative Medicine. We inducted external reviewers from 11 palliative care-related organizations. RESULTS: Among 20 experts surveyed, 20 (100%) responded over all rounds. Ten (50%) participated in a panel meeting. In the first round, 179 of 179 (100%) learning objectives were judged to be appropriate and 5 of 179 (3%) learning objectives were judged to be too difficult. In the panel meeting, 25 learning objectives were excluded, three new learning objectives were added, and 15 learning objectives were reworded. In the second round, 18 of 18 (100%) learning objectives were judged to be appropriate. The final version of the syllabus developed consists of 157 specific behavioural objectives and 22 general instructional objectives across 22 courses. CONCLUSIONS: We have developed the first national consensus syllabus of palliative medicine for physicians in Japan. Based on this syllabus, a training program on palliative medicine will be established by training facilities in Japan, and physicians will be able to practice specific palliative care.

Toward standardized patient positioning to avoid peripheral nerve injury during laparoscopic colorectal surgery: Application of a protocol and study of the resulting relationship between total rotation time and contact pressure at the shoulder.

INTRODUCTION: Generally, laparoscopic colorectal surgery is performed with the patient in the lithotomy and rotated positions. The lithotomy position, however, is associated with intraoperative peripheral nerve injury (IPNI). We studied the relationship between patient positioning during laparoscopic colorectal surgery, contact pressure at the shoulder, and the occurrence of IPNI and tested a positioning protocol aimed at surgical safety in addition to maintenance of a good surgical field. METHODS: We applied our positioning protocol in 44 cases and collected data that could be used to answer our study questions. We set limits for shoulder contact pressure and time in the rotation position. When the time limit was reached, we returned the patient to the supine position for 5 min. RESULTS: Patients' median age was 71 years; mean BMI was 22.4 kg/m2 . Median time in the rotation position was 126 min. For the 22 patients for whom validated data was obtained, mean lower shoulder pressure changed from 8.5 mmHg just after rotation to 11.4 mmHg 120 min after rotation (P = 0.013). Absence of IPNI in our patients confirmed the proposed relation between patient positioning and IPNI. Our data indicate that a prolonged period in the rotation position increases contact pressure at the shoulder, which can increase the risk of IPNI. CONCLUSION: Our patient positioning protocol appears to have prevented laparoscopic colectomy-related IPNI. Future studies are warranted to confirm the relationship between patient positioning and IPNI and, if necessary, to further refine the protocol to ensure prevention of IPNI during laparoscopic colorectal surgery.

A combination of routine laboratory findings and vital signs can predict survival of advanced cancer patients without physician evaluation: a fractional polynomial model.

INTRODUCTION: There have been no reports about predicting survival of patients with advanced cancer constructed entirely with objective variables. We aimed to develop a prognostic model based on laboratory findings and vital signs using a fractional polynomial (FP) model. METHODS: A multicentre prospective cohort study was conducted at 58 specialist palliative care services in Japan from September 2012 to April 2014. Eligible patients were older than 20 years and had advanced cancer. We developed models for predicting 7-day, 14-day, 30-day, 56-day and 90-day survival by using the FP modelling method. RESULTS: Data from 1039 patients were analysed to develop each prognostic model (Objective Prognostic Index for advanced cancer [OPI-AC]). All models included the heart rate, urea and albumin, while some models included the respiratory rate, creatinine, C-reactive protein, lymphocyte count, neutrophil count, total bilirubin, lactate dehydrogenase and platelet/lymphocyte ratio. The area under the curve was 0.77, 0.81, 0.90, 0.90 and 0.92 for the 7-day, 14-day, 30-day, 56-day and 90-day model, respectively. The accuracy of the OPI-AC predicting 30-day, 56-day and 90-day survival was significantly higher than that of the Palliative Prognostic Score or the Prognosis in Palliative Care Study model, which are based on a combination of symptoms and physician estimation. CONCLUSION: We developed highly accurate prognostic indexes for predicting the survival of patients with advanced cancer from objective variables alone, which may be useful for end-of-life management. The FP modelling method could be promising for developing other prognostic models in future research.

A prospective, multicenter cohort study to validate a simple performance status-based survival prediction system for oncologists.

BACKGROUND: Survival prediction systems such as the Palliative Prognostic Index (PPI), which includes the Palliative Performance Scale (PPS), are used to estimate survival for terminally ill patients. Oncologists are, however, less familiar with the PPS in comparison with the Eastern Cooperative Oncology Group (ECOG) performance status (PS). This study was designed to validate a simple survival prediction system for oncologists, the Performance Status-Based Palliative Prognostic Index (PS-PPI), which is a modified form of the PPI based on the ECOG PS. METHODS: This multicenter, prospective cohort study enrolled all consecutive patients who were referred to 58 palliative care services in Japan. The primary responsible physicians rated the variables required to calculate the PS-PPI and the PPI. Patient survival in these risk groups was compared, and the sensitivity and specificity of the PS-PPI and the PPI were evaluated. Patients were subclassified as patients receiving care from in-hospital palliative care teams, palliative care units, or home-based palliative care services. Subsets of patients receiving chemotherapy were also analyzed. RESULTS: This study included 2346 patients. Survival predictions based on the PPI and the PS-PPI differed significantly among the 3 risk groups (P < .001). The PS-PPI was more sensitive, whereas the PPI was more specific. All areas under the receiver operating characteristic curves of both indices were >0.78 for predicting survival at all times, from 3 weeks to 180 days. CONCLUSIONS: In predicting the prognosis of patients with advanced cancer, the PS-PPI was as accurate as the PPI. The PS-PPI was useful for short- and long-term survival prediction and for the prediction of survival for patients undergoing chemotherapy. Cancer 2017;123:1442-1452. © 2016 American Cancer Society.

Clinical Implications of C-Reactive Protein as a Prognostic Marker in Advanced Cancer Patients in Palliative Care Settings.

CONTEXT: Plasma C-reactive protein (CRP) levels are elevated in patients with advanced cancer. OBJECTIVES: To investigate CRP as a prognostic marker in palliative settings. METHODS: This multicenter prospective cohort study comprised 2426 patients. Laboratory data were obtained at baseline, and all patients were followed until death or six months after their enrollment. A total of 1511 patients were eligible for the analyses. They were divided into four groups: low-CRP (CRP < 1 mg/dL), moderate-CRP (1 ≤ CRP <5 mg/dL), high-CRP (5 ≤ CRP <10 mg/dL), and very high-CRP (10 mg/dL ≤ CRP) groups. Survival was investigated by the Kaplan-Meier method with the log-rank test. The 30-, 60-, and 90-day mortality rates were tested by Chi-squared tests. Univariate- and multivariate-adjusted hazard ratios (HRs) and 95% CIs in each group were calculated using Cox proportional hazard models. RESULTS: Survival rate decreased and mortality rate increased with increasing CRP level. The differences in survival and 30-, 60-, and 90-day mortality rates among the groups were statistically significant (P < 0.001). Baseline CRP level was significantly associated with a higher risk of mortality after adjustment for age, gender, primary tumor site, metastasis, chemotherapy, Eastern Cooperative Oncology Group Performance Status, and setting of care (moderate-CRP: HR 1.47 [95% CI 1.24-1.73], high-CRP: HR 2.09 [95% CI 1.74-2.50], and very high-CRP: HR 2.55 [95% CI 2.13-3.05] vs. low-CRP). CONCLUSION: Clear dose-effect relationships between elevated CRP levels and prognoses indicate that CRP could be useful in predicting prognoses in patients with advanced cancer.

Effect of continuous deep sedation on survival in patients with advanced cancer (J-Proval): a propensity score-weighted analysis of a prospective cohort study.

BACKGROUND: Continuous deep sedation (CDS) before death is a form of palliative sedation therapy that has become a focus of strong debate, especially with respect to whether it shortens survival. We aimed to examine whether CDS shortens patient survival using the propensity score-weighting method, and to explore the effect of artificial hydration during CDS on survival. METHODS: This study was a secondary analysis of a large multicentre prospective cohort study that recruited and followed up patients between Sept 3, 2012, and April 30, 2014, from 58 palliative care institutions across Japan, including hospital palliative care settings, inpatient palliative care units, and home-based palliative care services. Adult patients (aged ≥ 20 years) with advanced cancer who received care through the participating palliative care services were eligible for this secondary analysis. Patients with missing data for outcome variables or who lived for more than 180 days were excluded. We compared survival after enrolment between patients who did and did not receive CDS. We used a propensity score-weighting method to control for patient characteristics, disease status, and symptom burden at enrolment. FINDINGS: Of 2426 enrolled patients with advanced cancer, we excluded 289 (12%) for living longer than 180 days and 310 (13%) with missing data, leaving an analysis population of 1827 patients. 269 (15%) of 1827 patients received CDS. Unweighted median survival was 27 days (95% CI 22-30) in the CDS group and 26 days (24-27) in the no CDS group (median difference -1 day [95% CI -5 to 4]; HR 0·92 [95% CI 0·81-1·05]; log-rank p=0·20). After propensity-score weighting, these values were 22 days (95% CI 21-24) and 26 days (24-27), respectively (median difference -1 day [95% CI -6 to 4]; HR 1·01 [95% CI 0·87-1·17]; log-rank p=0·91). Age (p(interaction)=0·67), sex (p(interaction)=0·26), performance status (p(interaction)=0·90), and volume of artificial hydration (p(interaction)=0·14) did not have an effect modification on the association between sedation and survival, although care setting did have a significant effect modification (p(interaction)=0·021). INTERPRETATION: CDS does not seem to be associated with a measurable shortening of life in patients with advanced cancer cared for by specialised palliative care services, and could be considered a viable option for palliative care in this setting. FUNDING: Japanese National Cancer Center Research and Development Fund.

Survival prediction for advanced cancer patients in the real world: A comparison of the Palliative Prognostic Score, Delirium-Palliative Prognostic Score, Palliative Prognostic Index and modified Prognosis in Palliative Care Study predictor model.

PURPOSE: The aim of this study was to investigate the feasibility and accuracy of the Palliative Prognostic Score (PaP score), Delirium-Palliative Prognostic Score (D-PaP score), Palliative Prognostic Index (PPI) and modified Prognosis in Palliative Care Study predictor model (PiPS model). PATIENTS AND METHODS: This multicentre prospective cohort study involved 58 palliative care services, including 19 hospital palliative care teams, 16 palliative care units and 23 home palliative care services, in Japan from September 2012 to April 2014. Analyses were performed involving four patient groups: those treated by palliative care teams, those in palliative care units, those at home and those receiving chemotherapy. RESULTS: We recruited 2426 participants, and 2361 patients were finally analysed. Risk groups based on these instruments successfully identified patients with different survival profiles in all groups. The feasibility of PPI and modified PiPS-A was more than 90% in all groups, followed by PaP and D-PaP scores; modified PiPS-B had the lowest feasibility. The accuracy of prognostic scores was ⩾69% in all groups and the difference was within 13%, while c-statistics were significantly lower with the PPI than PaP and D-PaP scores. CONCLUSION: The PaP score, D-PaP score, PPI and modified PiPS model provided distinct survival groups for patients in the three palliative care settings and those receiving chemotherapy. The PPI seems to be suitable for routine clinical use for situations where rough estimates of prognosis are sufficient and/or patients do not want invasive procedure. If clinicians can address more items, the modified PiPS-A would be a non-invasive alternative. In cases where blood samples are available or those requiring more accurate prediction, the PaP and D-PaP scores and modified PiPS-B would be more appropriate.

Surprise Questions for Survival Prediction in Patients With Advanced Cancer: A Multicenter Prospective Cohort Study.

BACKGROUND: Predicting the short-term survival in cancer patients is an important issue for patients, family, and oncologists. Although the prognostic accuracy of the surprise question has value in 1-year mortality for cancer patients, the prognostic value for short-term survival has not been formally assessed. The primary aim of the present study was to assess the prognostic value of the surprise question for 7-day and 30-day survival in patients with advanced cancer. PATIENTS AND METHODS: The present multicenter prospective cohort study was conducted in Japan from September 2012 through April 2014, involving 16 palliative care units, 19 hospital-based palliative care teams, and 23 home-based palliative care services. RESULTS: We recruited 2,425 patients and included 2,361 for analysis: 912 from hospital-based palliative care teams, 895 from hospital palliative care units, and 554 from home-based palliative care services. The sensitivity, specificity, positive predictive value, and negative predictive value of the 7-day survival surprise question were 84.7% (95% confidence interval [CI], 80.7%-88.0%), 68.0% (95% CI, 67.3%-68.5%), 30.3% (95% CI, 28.9%-31.5%), and 96.4% (95% CI, 95.5%-97.2%), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the 30-day surprise question were 95.6% (95% CI, 94.4%-96.6%), 37.0% (95% CI, 35.9%-37.9%), 57.6% (95% CI, 56.8%-58.2%), and 90.4% (95% CI, 87.7%-92.6%), respectively. CONCLUSION: Surprise questions are useful for screening patients for short survival. However, the high false-positive rates do not allow clinicians to provide definitive prognosis prediction. IMPLICATIONS FOR PRACTICE: The findings of this study indicate that clinicians can screen patients for 7- or 30-day survival using surprise questions with 90% or more sensitivity. Clinicians cannot provide accurate prognosis estimation, and all patients will not always die within the defined periods. The screened patients can be regarded as the subjects to be prepared for approaching death, and proactive discussion would be useful for such patients.