Wen-Chi Chou

Combined hepatocellular cholangiocarcinoma : prognostic factors investigated by computed tomography/magnetic resonance imaging

This study was designed to assess the clinical usefulness of imaging for predicting the prognosis of patients with combined hepatocellular cholangiocarcinoma (cHCC‐CC). Between 1999 and 2004, 30 patients with histopathologically proven cHCC‐CC underwent computed tomography (CT) or magnetic resonance imaging (MRI). The imaging data and survival were analysed. Univariate log‐rank analysis of imaging findings revealed that tumour necrosis, bile duct invasion, major vascular branch invasion, multiplicity, bilobar distribution, regional lymph node involvement, regional organ invasion, distant metastasis and ascites had adverse influences on overall survival. Multivariate Cox proportional hazard analysis demonstrated that major vascular branch invasion, regional organ invasion, nodal and distant metastases were independent prognostic factors that adversely affected overall survival rates. Overall cumulative survival rates at 1, 3 and 5 years were 53%, 26% and 12%, respectively. Analysing the survival of our patients by using clinical stages of the newly updated American Joint Committee on Cancer (AJCC) classification for liver neoplasm based on the imaging findings, we found significant differences between stages I/II and III (p < 0.001) and between stages III and IV (p = 0.040). We conclude CT or MRI can be used to identify the prognostic factors and to estimate the outcomes of patients with cHCC‐CC.

Chromogranin A is a reliable biomarker for gastroenteropancreatic neuroendocrine tumors in an Asian population of patients.

Purpose: To evaluate the significance of plasma chromogranin A (CgA) levels in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NET) in terms of disease status and treatment responses. Materials and Methods: Forty-four GEP-NET patients comprising 15 disease-free patients and 29 patients with active disease, as well as 26 healthy participants were enrolled in this study between April 2010 and April 2011. Clinicopathological factors were collected and serial plasma CgA levels were measured. Results: Plasma CgA levels were significantly higher in GEP-NET patients with active disease than in disease-free patients (p = 0.011) or healthy participants (p = 0.001). No difference in CgA levels was observed in terms of primary tumor location, tumor grade, and functional status in patients with active disease. CgA values at 94 U/l distinguished healthy individuals or disease-free patients from patients with active disease. Sensitivity and specificity rates were 86 and 88%, respectively. CgA levels at 110 U/l differentiated patients without recurrence from those with recurrence, with a sensitivity rate of 100% and a specificity rate of 80%. Patients (5/5, 100%) with stable disease and who showed partial response after treatment had a more than 20% decrease in CgA levels compared with the baseline values. Patients (6/6, 100%) with progressive disease showed a less than 20% decrease or increase in CgA levels. Conclusion: The plasma CgA level is a reliable biomarker for GEP-NET. We conclude that changes in CgA levels are associated with disease status and treatment responses.

Analysis of the Effect of Serum Interleukin-6 (IL-6) and Soluble IL-6 Receptor Levels on Survival of Patients with Colorectal Cancer

OBJECTIVE The correlations of serum interleukin-6 and soluble interleukin-6 receptor concentrations with clinicopathological features and survival of patients with colorectal cancer were studied. METHODS We measured the serum levels of interleukin-6 and soluble interleukin-6 receptor in 99 colorectal cancer patients at the Chang Gung Memorial Hospital, Taiwan. The interleukin-6 and soluble interleukin-6 receptor levels were tested for their association with each other, and with the clinical parameters and outcomes. RESULTS Both interleukin-6 and soluble interleukin-6 receptor concentrations were significantly higher in colorectal cancer patients than in normal individuals. Unlike patients with serum interleukin-6 levels >10 pg/ml, who have increased carcinoembryonic antigen levels and shorter survival, serum soluble interleukin-6 receptor levels >800 pg/ml were found in patients with stages I-II and no regional lymph nodal invasion and appeared to be a positive prognostic factor for improved survival. Especially, patients with serum interleukin-6 <10 pg/ml and soluble interleukin-6 receptor >800 pg/ml lived significantly longer. Nonetheless, the multivariate analysis showed that only tumor-node metastasis stage, metastatic status and serum interleukin-6 level were independent prognostic factors, whereas the serum soluble interleukin-6 receptor level became marginally important for survival. CONCLUSIONS We suggest the clinical relevance of interleukin-6 and soluble interleukin-6 receptor for the survival of colorectal cancer patients. From a practical point of view, detection of the serum interleukin-6 level alone, rather than combined measurement of interleukin-6 and soluble interleukin-6 receptor, may be sufficient to independently predict survival in colorectal cancer patients.

Combination of Initial Palliative Prognostic Index and Score Change Provides a Better Prognostic Value for Terminally Ill Cancer Patients: A Six-Year Observational Cohort Study

CONTEXT The Palliative Prognostic Index (PPI) is among the most popular scores used to predict life expectancy in terminally ill patients worldwide. PPI assessed on the first day of palliative care might be inappropriate because the contribution from subsequent changes in a patients condition are not taken into account. OBJECTIVES The aim of this study is to determine the utility of sequential PPI assessments as a better prognostic tool for patients with terminal cancer. METHODS In total, 2392 terminally ill cancer patients with initial and one-week PPI assessments under the palliative care consultation service between January 2006 and December 2011 at a single medical center in Taiwan were selected. Patients were categorized into initial PPI, Week 1 PPI, score change (initial PPI - Week 1 PPI; Δscore), and combined initial PPI and Δscore subgroups for survival analysis. RESULTS Overall median survival was 32 days (range eight to 180 days), and 2183 patients (91.3%) died within 180 days of palliative care consultation service care. A significant difference in survival was observed among patient subgroups (P < 0.001). Subgroup survival analysis showed significant difference in patients with Δscores >0, 0, and <0 in each prognostic group categorized by initial PPI. The c-statistic for predicting life expectancy <30 days was significantly higher with the combined initial PPI and Δscore (c-statistic, 0.71; 95% CI, 0.694-0.731) than with the initial PPI (c-statistic, 0.63; 95% CI, 0.61-0.65), Week 1 PPI (c-statistic, 0.67; 95% CI, 0.652-0.690), or Δscore (c-statistic, 0.64; 95% CI, 0.62-0.66). CONCLUSION Combination of initial PPI and score change is more useful than initial PPI for identifying patients with poor outcomes in good prognostic groups and patients with better outcomes in poor prognostic groups.

Longitudinal changes and predictors of prolonged grief for bereaved family caregivers over the first 2 years after the terminally ill cancer patient’s death

Background: A significant minority of bereaved caregivers experience prolonged grief. However, few longitudinal studies have examined prolonged grief, especially in an Asian context. Aim: We explored longitudinal changes and factors predicting prolonged grief in bereaved caregivers of terminally ill Taiwanese cancer patients. Design: Observational, prospective, and longitudinal. Prolonged grief symptoms were measured with the PG-13 at 6, 13, 18, and 24 months postloss. Setting/participants: A convenience sample of 493 caregivers (83.3% participation rate) of terminally ill cancer patients was recruited from a medical center in Taiwan. Results: The prevalence of prolonged grief decreased significantly over time from the patient’s death (7.73%, 1.80%, 2.49%, and 1.85% at 6, 13, 18, and 24 months postloss, respectively, p < 0.05 at all times in reference to 6 months postloss). Caregivers’ likelihood of prolonged grief was significantly higher if they had severe preloss depressive symptoms, negatively perceived their relative’s dying situation, and were poorly prepared for the patient’s death. However, the likelihood of prolonged grief decreased significantly with greater perceived concurrent social support and subjective caregiving burden right before the patient’s death. Conclusion: Prolonged grief in bereavement diminished over time and was predicted by modifiable factors before, during, and after bereavement. To facilitate bereavement adjustment and avoid prolonged grief, healthcare professionals should develop and provide at-risk caregivers with effective interventions starting when patients are still alive to improve their dying experience, to facilitate preparedness for the patient’s forthcoming death, to alleviate caregivers’ preloss depressive symptoms, and to enhance their perceived postloss social support.

Pretreatment serum interleukin‐1β, interleukin‐6, and tumor necrosis factor‐α levels predict the progression of colorectal cancer

The correlations of pretreatment serum concentrations of proinflammatory cytokines such as interleukin (IL)‐1β, IL‐6, and tumor necrosis factor‐α (TNFα) with the clinicopathologic features and progression of colorectal cancer (CRC) were investigated. The pretreatment serum levels of IL‐1β, IL‐6, and TNFα were measured in 164 CRC patients before treatment. The relationships between changes in proinflammatory cytokine and C‐reactive protein (CRP) levels and both clinicopathologic variables and disease progression were examined by univariate and multivariate analysis. Advanced tumor stage was associated with a poorer histologic differentiation, higher CRP level, lower albumin level, and inferior progression‐free survival rate (PFSR). Furthermore, high levels of CRP (>5 mg/L) were associated with proinflammatory cytokine intensity, defined according to the number of proinflammatory cytokines with levels above the median level (IL‐1β ≥10 pg/mL; IL‐6 ≥ 10 pg/mL; and TNFα ≥55 pg/mL). Under different inflammation states, proinflammatory cytokine intensity, in addition to tumor stage, independently predicted PFSR in patients with CRP <5 mg/L, whereas tumor stage was the only independent predictor of PFSR in patients with CRP ≥5 mg/L. Proinflammatory cytokine intensity and the CRP level are clinically relevant for CRC progression. Measurement of IL‐1β, IL‐6, and TNFα serum levels may help identify early cancer progression among patients with CRP <5 mg/L in routine practice.

Characteristics of patients with hematologic malignancies who received palliative care consultation services in a medical center.

This study aimed to compare the characteristics of patients with hematologic malignancies and solid cancers who received palliative care. A total of 124 patients with hematologic malignancy and 3032 patients with solid cancer, who received palliative care consultation services between 2006 and 2010 in a medical center in Taiwan, were retrospectively analyzed. Higher prevalence of oral stomatitis, diarrhea, and hematologic symptoms including infection, fever, severe anemia, and bleeding, and lower prevalence of constipation, abdominal distension, and pain were observed in patients with hematologic malignancies compared to that in patients with solid cancer. The interval from hospital admission to palliative care referral was longer for patients with hematologic malignancy than that for patients with solid cancer. Hematologists should refer patients earlier, and palliative care specialists should understand the specific needs of patients with hematologic malignancy.

Trajectory and predictors of quality of life during the dying process: roles of perceived sense of burden to others and posttraumatic growth

PurposeQuality of life (QOL) at end of life (EOL) is related to important themes, e.g., “sense of burden to others” and “perceived posttraumatic growth,” which have never been investigated concurrently. The purposes of this study were: (1) to describe the trajectory of QOL during the dying process and (2) to identify determinants of QOL, including the roles of perceived sense of burden to others and posttraumatic growth.MethodsA convenience sample of 313 terminally ill cancer patients was surveyed and longitudinally followed until death. QOL was measured by a modified McGill quality of life scale, and determinants were evaluated by a multiple linear regression model with the generalized estimating equation.ResultsTerminally ill Taiwanese cancer patients’ QOL decreased substantially as their death approached. However, after controlling for confounders, patients’ QOL did not change significantly in the last months of their life. QOL was significantly better for female and non-middle-aged patients with a religious affiliation of Buddhism/Taoism. Poorer QOL tended to be experienced by patients with greater physical symptom distress, anxiety, and depression. Patient QOL increased with greater tangible support, but decreased with greater emotional and affectionate social support. QOL was diminished by a greater degree of perceived burden to others but improved with greater perceived posttraumatic growth.ConclusionsDeteriorating QOL as death approaches may not be inevitable. Optimal QOL at EOL may be achieved by interventions designed to adequately manage physical and psychological symptoms, enhance social support, lighten perceived sense of burden to others, and facilitate experiences of posttraumatic growth.

Impact of high self‐perceived burden to others with preferences for end‐of‐life care and its determinants for terminally ill cancer patients: a prospective cohort study

Self‐perceived burden to others (SPB) is a major concern of terminally ill cancer patients and is frequently factored into end‐of‐life (EOL) care decision‐making. However, changes in and determinants of SPB and its longitudinal impact on preferences for EOL care over the dying process have not been investigated. Our study was aimed at filling this gap in knowledge.

Prevalence of severe depressive symptoms increases as death approaches and is associated with disease burden, tangible social support, and high self-perceived burden to others

PurposeTerminally ill cancer patients experience progressive functional decline, accelerating symptom severity, deteriorating social support, and self-perceived burden to others (SPB), predisposing them to depressive symptoms. However, changes in the prevalence of severe depressive symptoms as death approaches and the unique roles of these four variables have not been adequately studied. This study explored longitudinal changes in and associations of symptom distress, functional dependence, social support, and SPB with prevalence of severe depressive symptoms in the last year of life.MethodsA convenience sample of 325 cancer patients was longitudinally followed until death. Prevalence of severe depressive symptoms (score ≥11 on the depression subscale of the Hospital Anxiety and Depression Scale) was examined by multivariate logistic regression modeling with the generalized estimating equation.ResultsThe prevalence of severe depressive symptoms increased as death approached. The likelihood of severe depressive symptoms was significantly higher in patients who had higher levels of symptom distress and functional dependence, received greater tangible support, and reported high SPB, but lower for patients reporting a higher level of affectionate support and positive social interactions with their supportive network.ConclusionPrevalence of severe depressive symptoms increased as death approached and was associated with several modifiable factors. Healthcare professionals should become familiar with these factors to identify vulnerable patients. To decrease the likelihood of terminally ill cancer patients’ severe depressive symptoms, they should receive effective interventions to manage their symptoms, appropriately foster social support to restore their fragile self-esteem due to depending on others, and lighten their SPB.