Hiroka Nagaoka

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.

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.

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.

Advance directives and do-not-resuscitate orders among patients with terminal cancer in palliative care units in Japan: a nationwide survey.

Objective: To examine the current status of advance directives (ADs) and do-not-resuscitate (DNR) orders among patients with terminal cancer in palliative care units (PCUs) in Japan. Methods: We conducted a retrospective chart review of the last 3 consecutive patients who died in 203 PCUs before November 30, 2010. Results: The percentages of patients who had ADs during the final hospitalization for cardiopulmonary resuscitation, mechanical ventilation, intravenous fluid administration, tube feeding, antibiotic administration, and who had appointed a health care proxy were 47%, 46%, 42%, 19%, 18%, and 48%, respectively. Seventy-six percent of the patients had a DNR order. Of the patients with decision-making capacity, 68% were involved in the DNR decision. Conclusions: These findings may reflect positive changes in patients’ attitudes toward ADs, in Japan.

Specialized Palliative Care Services in Japan A Nationwide Survey of Resources and Utilization by Patients With Cancer

Objective: The aim of this study was to investigate the availability and utilization of specialized palliative care services among patients with cancer in Japan. Methods: We conducted a nationwide cross-sectional survey of 828 institutions predicted to provide specialized palliative care services. Results: Responses were received from 751 institutions (response rate, 91%); of these, 541 had specialized palliative care services. Adding the census data of palliative care units, the total estimated number of institutions with specialized palliative care services was 659. Of all the patients with cancer who died in the period from April 2009 to May 2010 in Japan, the estimated proportion who utilized specialized palliative care services was 24%. Conclusions: Usage of specialized palliative care services in Japan have increased explosively in the past decade.

Prospective Clarification of the Utility of the Palliative Prognostic Index for Patients With Advanced Cancer in the Home Care Setting

Aims: This study aimed to prospectively clarify the accuracy of the Palliative Prognostic Index (PPI) for advanced cancer patients in home care settings. Method: The study included 66 advanced cancer patients who received home visiting services between April 2010 and June 2012, and who died at home or in the hospital. Using medical records from initial home visits, we prospectively calculated PPI scores along with sensitivity and specificity. Results: For 3- and 6-week survival, prognostic prediction showed respective sensitivities of 60% and 70.6%, and specificities of 87.0% and 71.9%. Conclusion: The sensitivity of the PPI for advanced cancer patients in home care settings was lower than that reported for patients in palliative care units. Development of prognostic tools suitable for home care settings is needed.

Hospital Formulations for Palliative Medicine

　Palliative care had a role in maintaining and improving the patients QOL. To optimize symptomatic management, that cannot be controlled using commercial formulations, in-house pharmaceutical preparations customized to meet an individuals clinical needs are sometimes administered. Despite a growing arsenal of oncology drugs, opioids, and other compounds, many elderly cancer patients have a wide spectrum of comorbid conditions that require the help of skilled pharmacists. Although drugs prepared in in-house pharmacies can be customized to the conditions of individual patients, their preparation is time- and resource-intensive, and their benefits sometimes do not outweigh the costs. In addition, it is often difficult to predict the required amount of a drug that will be dispensed to a very small number of patients via these custom formulations. However, we occasionally experience cases in which hospital formulations (HF) significantly alleviate symptoms and improve the QOL of patients with cancer. In fact, efforts to develop HF of palliative medications sometimes pave the way to new marketable products. In fact, collaborations between physicians and pharmacists have indeed produced new types of medications, which have been further developed into commercial painkillers by drug manufacturers. This article presents examples of HF used in clinical practice. It also discusses the future need for HF, taking note of the ongoing shift towards outpatient oncology care. Regarding the use of HF, we believe it is always important to ensure patient safety, to obtain informed consent, and to follow up.