Is spiritual well-being related to survival time of inpatients with advanced cancer? An East Asian cohort study.

OBJECTIVES: It has been suggested that psychosocial factors are related to survival time of inpatients with cancer. However, there are not many studies examining the relationship between spiritual well-being (SWB) and survival time among countries. This study investigated the relationship between SWB and survival time among three East Asian countries. METHODS: This international multicenter cohort study is a secondary analysis involving newly admitted inpatients with advanced cancer in palliative care units in Japan, South Korea, and Taiwan. SWB was measured using the Integrated Palliative Outcome Scale (IPOS) at admission. We performed multivariate analysis using the Cox proportional hazards model to identify independent prognostic factors. RESULTS: A total of 2,638 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. The median survival time was 18.0 days (95% confidence interval [CI] 16.5-19.5) in Japan, 23.0 days (95% CI 19.9-26.1) in Korea, and 15.0 days (95% CI 13.0-17.0) in Taiwan. SWB was a significant factor correlated with survival in Taiwan (hazard ratio [HR] 1.27; 95% CI 1.01-1.59; p = 0.04), while it was insignificant in Japan (HR 1.10; 95% CI 1.00-1.22; p = 0.06), and Korea (HR 1.02; 95% CI 0.77-1.35; p = 0.89). SIGNIFICANCE OF RESULTS: SWB on admission was associated with survival in patients with advanced cancer in Taiwan but not Japan or Korea. The findings suggest the possibility of a positive relationship between spiritual care and survival time in patients with far advanced cancer.

Prevalence and severity of symptoms and signs in patients with advanced cancer in the last days of life: the East Asian collaborative cross-cultural study to elucidate the dying process (EASED).

PURPOSE: Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of specific symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer. METHODS: In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients in the last 3 days of life according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer. RESULTS: We analyzed 2131 patients from Japan, Korea, and Taiwan. The prevalence of most symptoms and signs were relatively stable from 1 week after admission to the last 3 days of life. According to cancer type, edema of the lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/respiratory secretion were the most severe symptoms. CONCLUSION: We demonstrated the prevalence and severity of symptoms and signs associated with the impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the specific symptoms and signs at the very end of life.

Association between Percent Body Fat and Low High-Density Lipoproteinemia in Middle-Aged Men in Korea.

Background: Obesity is a significant health risk factor for cardiovascular diseases. Dyslipidemia, defined as a low high-density lipoprotein cholesterol (HDL-C) level, is associated with these risks. Recent bioelectrical impedance analysis (BIA) devices offer precise measurements of the percent body fat (PBF). We aimed to determine the association between PBF and HDL-C levels in middle-aged men in Korea. Methods: We conducted a cross-sectional sstudy of men aged 40-65 years who visited a health examination center. Body composition was analyzed using BIA. Health habits were assessed using a self-administered questionnaire. The participants were divided into four groups based on their PBF: group 1 (<21%), group 2 (21%-23.99%), group 3 (24%-28.99%), and group 4 (≥29%). Logistic regression was used to obtain the odds ratio (OR) between the PBF group and the low HDL-C level and adjusted for other variables. Results: In this study, 2,685 men were analyzed. The number of individuals diagnosed with low HDL-C levels increased significantly as the group-specific PBF increased. Group 4 showed a 5.5-fold greater association with low HDL-C compared to group 1 (P<0.01), whereas group 3 and group 2 showed an OR of 4.38 and 2.95 (P<0.01 and P<0.01), respectively. Conclusion: These results suggest that if middle-aged men are able to decrease their body fat by <5%, their HDL-C levels will increase. We suggest that 3%-5% PBF is a useful guideline for general body fat reduction in Korean middle- aged men in primary care.

Mid-upper Arm Circumference as an Indicator of Quality of Life of Patients with Advanced Cancer.

Objective: Mid-upper arm circumference (MUAC) has been used to assess malnutrition and health status across various disease groups. However, it is unclear whether MUAC is associated with quality of life (QOL) of patients with advanced cancer. Our goal was to investigate the relationship between MUAC and QOL in ambulatory out-patients with advanced cancer. Method: This was a cross-sectional study conducted in a tertiary cancer center in South Korea. A total of 200 patients with advanced cancer at oncology clinics of Seoul National University Bundang Hospital from March 2016 to January 2019 were enrolled. Out-patients with advanced cancer whose survival was expected to be less than one year by their oncologists were enrolled. QOL of patients was evaluated using the European Organization for Research and Treatment of Cancer quality of life questionnaire core 30 (EORTC QLQ-C30). Associations of QOL with MUAC and nutritional parameters were examined with generalized linear models. Results: The most common cancer sites were the lung, colon or rectum, and genitourinary tract. In univariate analyses, significant factors associated with higher summary score of EORTC QLQ-C30 were higher MUAC (≥ 26.5 cm, p < 0.001), higher body mass index (BMI) (≥ 22 kg/m2, p < 0.001), higher serum albumin (≥ 3.7 g/dL, p < 0.01), higher creatinine (≥ 0.8 mg/dL, p = 0.023), and higher uric acid (≥ 5 mg/dL, p < 0.01). In multivariate analysis, higher serum albumin (≥ 3.7 g/dL, p < 0.01) and higher MUAC (≥ 26.5 cm, p = 0.03) were independently associated with better summary score of EORTC QLQ-C-30. Conclusion: MUAC was highly associated with QOL in terms of summary score and overall health status. Thus, MUAC, with its simplicity, can be a useful tool to reflect QOL in patients with advanced cancer.

Clinicians' Prediction of Survival and Prognostic Confidence in Patients with Advanced Cancer in Three East Asian Countries.

Background: Little is known about accuracy and confidence of clinicians' prediction of survival (CPS) in East-Asian countries. Objective: We aimed to examine accuracy of CPS for 7-, 21-, and 42-day survival in palliative inpatients and its association with prognostic confidence. Design: An international prospective cohort study in Japan (JP), Korea (KR), and Taiwan (TW). Setting/Subjects: Subjects were inpatients with advanced cancer admitted to 37 palliative care units in three countries. Measurements: Discrimination of CPS was investigated through sensitivity, specificity, overall accuracy, and area under the receiver operating characteristics curves (AUROCs) according to 7-, 21-, and 42-day survival. The accuracies of CPS were compared with those of Performance Status-based Palliative Prognostic Index (PS-PPI). Clinicians were instructed to rate confidence level on a 0-10-point scale. Results: A total of 2571 patients were analyzed. The specificity was highest at 93.2-100.0% for the 7-day CPS, and sensitivity was highest at 71.5-86.8% for the 42-day CPS. The AUROCs of the seven-day CPS were 0.88, 0.94, and 0.89, while those of PS-PPI were 0.77, 0.69, and 0.69 for JP, KR, and TW, respectively. As for 42-day prediction, sensitivities of PS-PPI were higher than those of CPS. Clinicians' confidence was strongly associated with the accuracy of prediction in all three countries (all p-values <0.01). Conclusions: CPS accuracies were highest (0.88-0.94) for the seven-day survival prediction. CPS was more accurate than PS-PPI in all timeframe prediction except 42-day prediction in KR. Prognostic confidence was significantly associated with the accuracy of CPS.

Risk Factors Related to Serious Adverse Drug Reactions Reported through Electronic Submission during Hospitalization in Elderly Patients.

BACKGROUND: Many studies have assessed the risk factors for adverse drug reactions (ADRs) in elderly patients. However, most of these studies have focused on risk factors for ADRs, not serious ADRs (s-ADRs). s-ADRs are commonly found in hospitalized patients. s-ADRs warrant imminent but thorough investigations, given their critical impact on patient health. Therefore, this retrospective study aimed to assess the associated risk factors for s-ADRs in elderly hospitalized patients. METHODS: In-patients aged >65 years having ADRs during hospitalization at a university hospital in Korea between 2010 and 2012 were included. Medical professionals spontaneously reported ADRs using an electronic submission system at the study hospital. Further, all descriptions of ADRs were characterized and categorized through the screening of electronic medical records. We compared the characteristics of patients having s-ADRs with those of patients not having s-ADRs. RESULTS: There were 353 cases of ADRs, 67 of which were s-ADRs. Patients taking more than eight concomitant drugs showed the highest odds ratio (OR, 11.99; 95% confidence interval [CI], 3.42-42.03). The ratio of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) was also significantly related to s-ADRs (OR, 2.78; 95% CI, 1.33-5.81). The use of antibiotics (OR, 2.39; 95% CI, 1.13-5.02) and antineoplastics (OR, 4.17; 95% CI, 1.09-15.94) were significant risk factors. CONCLUSION: Our findings highlight the importance of polypharmacy. Liver function tests (AST/ALT ratio) must be monitored carefully within high-risk groups for ADRs.

Performance of mid-upper arm circumference and other prognostic indices based on inflammation and nutrition in oncology outpatients: a tertiary cancer center study.

BACKGROUND: We aimed to compare the performance of established inflammation and nutrition-based prognostic indices with a relatively novel index 'mid-upper arm circumference (MUAC)' in outpatients with advanced cancer. METHODS: This study was a secondary analysis of a prospective cohort study that enrolled 200 outpatients with advanced cancer visiting a medical oncology clinic at a tertiary hospital. All patients were followed until death, and the Glasgow Prognostic Score (GPS), modified GPS (mGPS), Prognostic Nutritional Index (PNI), neutrophil/lymphocyte ratio (NLR), C-reactive protein/albumin ratio (CAR), and MUAC were compared by calculating the area under the receiver operating characteristic curves (AUROCs). RESULTS: The mean age of the patients was 64.4 years, 64.0% were male, and the median overall survival was 32.4 weeks [95% confidence interval (CI): 5.6-142.7]. Overall, all indices showed similarly high AUROCs for estimating 12-week (0.68 to 0.75) and 24-week survival (0.67 to 0.74). When confined to the GPS, mGPS, and MUAC, the AUROCs for 12-week survival were 0.75 (95% CI: 0.66-0.82), 0.74 (95% CI: 0.65-0.82), and 0.72 (95% CI: 0.64-0.79), respectively. For 24-week survival, the AUROCs were 0.70 (95% CI: 0.62-0.76), 0.67 (95% CI: 0.60-0.74), and 0.72 (95% CI: 0.64-0.79), respectively. MUAC had the highest specificity for estimating 12-week survival (86.0%), while GPS showed the highest sensitivity for estimating 12-week survival (81.1%). CONCLUSIONS: Inflammation and nutrition-based prognostic indices showed similar acceptable accuracies in estimating the 12- and 24-week survival of oncology outpatients. Notably, a simple and non-invasive index MUAC, showed comparable performance with established indices including GPS and mGPS.

The association between changes in symptoms or quality of life and overall survival in outpatients with advanced cancer.

BACKGROUND: Several prognostic tools have been developed to aid clinicians in survival prediction. However, changes in symptoms are rarely included in established prognostic systems. We aimed to investigate the influence of changes in symptoms and quality of life (QOL) on survival time in outpatients with advanced cancer. METHODS: Study subjects included a subgroup of those with longitudinal symptom and QOL data within a larger, single-site parent study. We assessed patients' symptoms and QOL at enrollment and follow-up at an approximately 3-month interval. Patients' symptoms were evaluated by the Korean version of the Edmonton Symptom Assessment System (K-ESAS). QOL was checked by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Participants were categorized into three groups by changes in symptoms or QOL. These groups were: improved (having at least a one level of improvement in the response scale), stable (no change), or worsened (at least a one level of worsening in the scale). We compared survival time in the improved plus stable vs. worsened groups, using a log-rank test. RESULTS: We analyzed 60 patients, with a median survival time of 346 days. In the Worsened group, depression (P<0.01) and sleep disturbance (P<0.01) by K-ESAS, and dyspnea (P<0.03) per the EORTC QLQ-C30, were statistically significantly related to shorter survival time compared to 'improved and stable' group. There was no relationship between changes in other symptoms, overall QOL, and survival. CONCLUSIONS: Longitudinal assessment of depression, sleep disturbance and dyspnea may be useful in prognostication of patients with advanced cancer. Further studies are needed to confirm our findings with more consecutive assessments in diverse populations.

Assessment of Changes in Symptoms Is Feasible and Prognostic in the Last Weeks of Life: An International Multicenter Cohort Study.

Background: Symptoms are not typically part of established various prognostic factors and scoring systems but are among the most frequently assessed issues in patient care. Objectives: To evaluate that, changes in symptoms can provide additional useful prognostic information. Design: A secondary analysis of an international cohort study in Japan, Korea, and Taiwan. Setting/Subjects: Subjects were adult patients with advanced cancer (n = 2074) who were admitted to 37 palliative care units (PCUs) in 3 countries from January 2017 to September 2018. Measurements: Symptoms (dyspnea, fatigue, dry mouth, and drowsiness) were assessed at admission and one-week later. Dyspnea was assessed by the presence of resting and exertional dyspnea, whereas other symptoms were assessed using the Integrated Palliative care Outcome Scales (IPOS) (range 0-4). For analysis, we grouped patients by symptom change, as either Improved, Stable, or Worsened (by having at least a one increment decrease, no change, or at least a one increment increase, respectively). Results: Worsened groups had the shortest survival (median survival 15-21 days) compared with those with Improved (median survival 23-31 days) and Stable symptoms (median survival 27-29 days) across all four symptoms (dyspnea, fatigue, dry mouth, and drowsiness). Survival differences were statistically significantly different across all three groups for all symptoms (all p < 0.001). Interestingly, Improved symptoms were associated with similar survival compared with Stable groups, with no statistical differences. Conclusions: Worsened symptoms at one week after admission were useful predictors of survival for patients with advanced cancer in PCUs during the final weeks of life. Longitudinal assessments are needed to reflect passage of time as well as impact of treatments.