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Development of Prognosis in Palliative care Study (PiPS) predictor models to improve prognostication in advanced cancer: prospective cohort study

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4920 (Published 25 August 2011) Cite this as: BMJ 2011;343:d4920
  1. Bridget Gwilliam, clinical research fellow1,
  2. Vaughan Keeley, consultant in palliative medicine2,
  3. Chris Todd, professor of primary care and community health and director of research3,
  4. Matthew Gittins, statistician4,
  5. Chris Roberts, reader in biostatistics4,
  6. Laura Kelly, Macmillan consultant in palliative medicine5,
  7. Stephen Barclay, Macmillan post-doctoral research fellow6,
  8. Patrick C Stone, reader in palliative medicine1
  1. 1Division of Population, Health Sciences and Education, St George’s University of London, London SW17 0RE, UK
  2. 2Royal Derby Hospital, Derby, UK
  3. 3School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
  4. 4Health Sciences, School of Community Based Medicine, University of Manchester
  5. 5Macmillan Consultant in Palliative Care Team, East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, UK
  6. 6General Practice and Primary Care Research Unit, Department of Public Health and Primary Care, Institute of Public Health, Cambridge, UK
  1. Correspondence to: P C Stone pstone{at}sgul.ac.uk
  • Accepted 4 July 2011

Abstract

Objective To develop a novel prognostic indicator for use in patients with advanced cancer that is significantly better than clinicians’ estimates of survival.

Design Prospective multicentre observational cohort study.

Setting 18 palliative care services in the UK (including hospices, hospital support teams, and community teams).

Participants 1018 patients with locally advanced or metastatic cancer, no longer being treated for cancer, and recently referred to palliative care services.

Main outcome measures Performance of a composite model to predict whether patients were likely to survive for “days” (0-13 days), “weeks” (14-55 days), or “months+” (>55 days), compared with actual survival and clinicians’ predictions.

Results On multivariate analysis, 11 core variables (pulse rate, general health status, mental test score, performance status, presence of anorexia, presence of any site of metastatic disease, presence of liver metastases, C reactive protein, white blood count, platelet count, and urea) independently predicted both two week and two month survival. Four variables had prognostic significance only for two week survival (dyspnoea, dysphagia, bone metastases, and alanine transaminase), and eight variables had prognostic significance only for two month survival (primary breast cancer, male genital cancer, tiredness, loss of weight, lymphocyte count, neutrophil count, alkaline phosphatase, and albumin). Separate prognostic models were created for patients without (PiPS-A) or with (PiPS-B) blood results. The area under the curve for all models varied between 0.79 and 0.86. Absolute agreement between actual survival and PiPS predictions was 57.3% (after correction for over-optimism). The median survival across the PiPS-A categories was 5, 33, and 92 days and survival across PiPS-B categories was 7, 32, and 100.5 days. All models performed as well as, or better than, clinicians’ estimates of survival.

Conclusions In patients with advanced cancer no longer being treated, a combination of clinical and laboratory variables can reliably predict two week and two month survival.

Footnotes

  • We thank the following colleagues for their help with this study: Rehana Bakawala, Mike Bennett, Teresa Beynon, Cath Blinman, Patricia Brayden, Helen Brunskill, Kate Crossland, Alison Cubbitt, Rachel Glascott, Anita Griggs, Anne Harbison, Debra Hart, Philip Lomax, Caroline Lucas, Wendy Makin, Oliver Minton, Paul Perkins, Marek Plaskota, Dai Roberts, Katie Richies, Susan Salt, Ileana Samanidis, Margaret Saunders, Jennifer Todd, Catherine Waight, Nicola Wilderspin, Gail Wiley, and Julie Young. We also thank John Ellershaw for chairing the steering committee and Robert Godsill for providing a service user’s perspective. Thanks go to Rosie Head for administrative support and data management. Thanks also go to the following hospices and palliative care units for their participation in the study: Arthur Rank House (Cambridge), Worcestershire Royal Hospital, St John’s Hospice (Lancaster), Gloucestershire Hospitals NHS Foundation Trust, Pasque Hospice (Luton), Guy’s and St Thomas’ NHS Foundation Trust (London), Princess Alice Hospice (Esher), Bolton Hospice, St Catherine’s Hospice (Crawley), St George’s Hospital NHS Trust (London), Surrey and Sussex Healthcare NHS Trust, St Ann’s Hospice (Manchester), Christie Hospital NHS Foundation Trust (Manchester), Nightingale Macmillan Unit (Derby), Trinity Hospice (London), and Trinity Hospice (Blackpool).

  • Contributions: PCS, BG, VK, CT, CR, LK, and SB contributed to the conception and design of the study. CR, MG, and BG contributed to the analysis of data. All authors contributed to the interpretation of data, the drafting or revising of the manuscript, and final approval for publication. PCS is the guarantor.

  • Funding: This study was funded by Cancer Research UK (grant number C11075/A6126). SB is funded by Macmillan Cancer Support and the NIHR CLAHRC (Collaborations for Leadership in Applied Health Research and Care) for Cambridgeshire and Peterborough.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: support from Cancer Research UK (CRUK) for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the Wandsworth Multi-centre Research Ethics Committee. Site specific approval and research and development approval were obtained for participating units. Exemption from Section 60 of the Health and Social Care Act (2001) was obtained from the Patient Information Advisory Group (PIAG). This allows the records of incompetent patients to be accessed without explicit consent so that study variables can be recorded and patients “flagged” for mortality purposes with the NHS Information Centre. Consent was given by competent patients and assent by the relatives/carers of incompetent patients.

  • Data sharing: No additional data available.

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