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UK audit shows need for greater caution with chemotherapy in very sick patients

BMJ 2008; 337 doi: (Published 12 November 2008) Cite this as: BMJ 2008;337:a2498

Chemotherapy in very sick patients. Results from NCEPOD audit.

Dear Editor,

Chemotherapy in very sick patients. Results from NCEPOD audit.

The UK National Confidential Enquiry into Patient Outcome and Death
(NCEPOD), has reported that chemotherapy has probably hastened or caused
death, in over a quarter of patients who died within 30 days of receiving
treatment. They suggest therefore, that greater caution be used in
prescribing chemotherapy in very sick patients. They do not suggest how
this problem might be avoided or how the very sick patients are to be

The reality is that patients receiving chemotherapy have been deemed
to be fit by their oncologist. Currently, this is assessed, in the main,
by performance status. However, although simple to use, it is recognised
to be subjective (1) and therefore determination of “fitness” and the
selection of patients for chemotherapy is sub-optimal.

There is increasing evidence that the presence of a systemic
inflammatory response, as evidenced by elevated concentrations of C-
reactive protein and hypoalbuminaemia, are useful prognostic factors in
patients with advanced cancer, independent of stage or treatment.
Recently, we have reported that an elevated C-reactive protein and
hypoalbuminaemia may be combined in a simple, objective scoring tool, the
Glasgow Prognostic score (GPS) (2).

We have reported that the GPS was superior to ECOG-ps in predicting
survival in patients receiving chemotherapy for non small cell lung cancer
(3) and gastro-oesophageal cancer (4). Moreover, an elevated GPS was not
only associated with decreased survival but also poorer clinical response
and an increased need for dose reduction. Therefore, we believe that the
use of simple objective prognostic tools, such as the GPS, will improve
the selection of patients for chemotherapy and reduce the number of
chemotherapy associated deaths.

Yours sincerely

Andrew BC Crumley
Donald C McMillan

1. Ando M. Prognostic value of performance status assessed by
patients themselves, nurses and oncologists in advanced non-small cell
lung cancer. British Journal of Cancer 2001;85:1634-9.

2. McMillan DC. An inflammation-based prognostic score and its role in
the nutrition-based management of patients with cancer. Proc Nutr Soc.

3. Forrest LM, McMillan DC, McArdle CS et al. Comparison of an
inflammation-based prognostic score (GPS) with performance status (ECOG)
in patients receiving platinum-based chemotherapy for inoperable non-small
-cell lung cancer. Br J Cancer 2004;90:1704-6.

4. Crumley AB, Stuart RC, McKernan M et al. Comparison of an inflammation
-based prognostic score (GPS) with performance status (ECOG) in patients
receiving palliative chemotherapy for gastro-oesophageal cancer. J
Gastroenterol. Hepatol. 2008;23:e325-9.

Competing interests:
None declared

Competing interests: No competing interests

27 November 2008
Andrew B Crumley
Specialty Registrar
Donald C McMillan
Glasgow Royal Infirmary G31 2ER