Prognositication

Question 1

Cancer patient

Answer 1

• Functional Status is the most important predictive factors

Tools:

• ECOG scale (0 = normal; 5 = dead)
• Karnofsky Index (100=normal;0 = dead)
• Palliative Performance Scale (PPS); a reliable and valid tool and correlates well with actual survival and median survival time for cancer patients admitted to inpatient palliative care.
• ambulation, activity, evidence of disease, self-care, intake, conciousness

Question 2

Chemotherapy: Response rate, median duration, median survival Data (FF99)

Answer 2

• Breast: 25-55%; 6-12mo; 24-36mo
• Colon: 25-35%; 6-8mo; 12-18mo
• Esop; 30-50%; 4-6mo; 6-9mo
• NSLCA: 20-30%; 4-6mo; 6-9mo
• Stomach; 20-50%; 4-6mo; 6-12mo
• Melanoma; 15-25%;4-6mo; 6-9mo
• Cholan; 15-25%; 2-4mo; 6-9mo
• Pancreas; 10-25% 3-5mo; 6-9mo
• Hepato: 5-15%; 2-4mo; 6-9mo

Note: Median survival data includes both responders and non-responders

Question 3

Who has less than 6months

Answer 3

• Metastatic solid cancer, acute leukemia or high-grade lymphoma, not receiving systemic chemotherapy
• Malignant ascites (see Fast Fact #176)
• Malignant pleural effusion (#209)
• Malignant bowel obstruction

Question 4

median survival of less than 3months

Answer 4

• Karnofsky score <40
• ECOG > 3
• spending >50% in a chair or lying down

Question 5

Cancer complication and prognostic value

Answer 5

• Hypercalcemia: 8weeks
• Malignant Pericardial effusion: 8weeks
• Carcinomatosis meningitis: 8-12weeks
• Brain mets 1-2mo w/o XRT; 3-6mo XRT
• Malignant ascites, pleural effusion, SBO: 6mo.

Question 6

Cancer and ICU

Answer 6

• 10% of ICU patients.
• surgical ICU mortality is 10%-18%
• medical ICU mortality is 40%
• hematologic malignancies and bone marrow transplant patients have the highest mortality
• multiorgan failure have 75% mortality

Question 7

HIV/ AIDS (post HAART era)

Answer 7

• CD4 counts >200 cells/mm3 are more likely to die from non-HIV-related illnesses than they are from complications of AIDS, at least over a time-frame of one decade.
• MAC: median survival is 10mo
• Progressive mulitfocal lekoencephalopathy 11mo on HAART and 4mo not on.
• AIDS dementia: 40-81mo, worse if CD45,000
• Wasting syndrome: 10% wt loss w chronic fever: BMI
  *

Question 8

CA in HIV and its prognosis

Question 9

COPD

Answer 9

• BODE (BMI, O2, Dyspnea, Exercise): 1yr, 2yr and 52mo motality
• ambulatory patients, age, degree of dyspnea, weight loss (BMI), functional status and FEV1 are relevant prognostic factors for predicting 1-3 year survival.
• Hospitalized patients, the same factors are relevant. In addition, the need for prolonged or recurrent mechanical ventilation is predictive of shorter prognosis.

Question 10

Heart Failure

Answer 10

NYHA classification

• Class II (mild symptoms): 5-10%.
• Class III (moderate symptoms): 10-15%.
• Class IV (severe symptoms): 30-40%.

Independent predictors of shorter prognosis

• Recent cardiac hospitalization (triples 1-year mortality).
• Elevated BUN and/or creatinine ≥1.4 mg/dl (120 μmol/l).
• Systolic blood pressure 100 bpm (each doubles 1-year mortality).
• LVEF ≤ 45%
• resistant Ventricular dysrhythmias.
• Anemia (each 1 g/dl reduction in hemoglobin is associated with a 16% increase in mortality).
• Hyponatremia (serum sodium ≤135-137 mEq/l).
• Cachexia.
• Reduced functional capacity.
• Co-morbidities: diabetes, depression, COPD, cirrhosis, cerebrovascular disease, cancer, and HIV-associated cardiomyopathy

Question 11

dialysis-dependent patients

Answer 11

• DM/HTN then GN
• 25% annual death rate
• 5Yr mortality: 25-60%

age of on set (65y/o), KPS <70 and albumin

• albumin and 1 and 2 year survival
• albumin >3.5 g/dL is 86% and 76% albumin < 3.5g/dL is 50% and 17%
• Modified Charlson Comorbidity Index
• Stroke, Dementia, Proteinuria

Question 12

Liver

Answer 12

• 10-15% die without transplant
• Prvelence 17,000 but 6000 get trans
• Decom cirrhosis 2yr: ascites, varices
• Hepato-pulmonary 10mo
• SBP 9mo
• Hepatorenal: 6mos (type 2) 6wk (T1)
• REFARCTORY ascites: 6mos
• Na<126 may reflect 3-6mos

Question 13

ESLD prognostic tools

Answer 13

Child-Pugh score

• Albumin, Ascites, bilirubin, PT, encephalopathy
• Child-C 1year prognosis.

MELD score: serum bilirubin, serum creatinine, INR

• >20 reflex: 3mos in hospitalized pt

Question 14

Neurological disease

Question 15

Anoxic-Encephalopathy

Question 16

amyotrophic lateral sclerosis

Answer 16

• Mean survival: 2.5-3 years
• Age of onset, duration of disease, diagnostic delay, weight loss, and respiratory symptoms predict survival.
• Noninvasive ventilation, percutaneous endoscopic gastrostomy tube feeding, and early use of riluzole improves by several months.
• Nocturnal desaturation (less than 90% for one cumulative minute) is more sensitive than the FVC in predicting shortened survival.
• bulbar involvement and difficulty in clearing secretions, cannot tolerate BiPAP.
• Oxygen alone is not sufficient

Question 17

Dementia

Answer 17

FAST scale

Mininal Data Set-12 (6mo prognosis)

• Age >83, ADL, Asleep>50%, BedFast, Continent, CA, CHF, SOB, Man, <25% meal, medical conditions unstable, Oxygen last 14days
• Score >9 57% 6mo motality

NHPCO

• Unable to ambulate
• unable to hold meaningful conversation
  *

Question 18

Dementia w acute condition

Answer 18

• Pneumonia: 53% 6-yr motality
• Hip fracture: 55% 6-yr motality

Question 19

General prognostic tools

Answer 19

• Karnofsky Performance scale
• ECOG
• PPS
• PPI
• PaP

Question 20

Karnofsky Performance scale

Answer 20

• derived and validated in cancer.
• broadened non-cancer
• Part of PPS

TIPS

80-100: no special care need

80-70 Unable to work

0-40 unable to care for self.; 3 mos indicator

Question 21

The Palliative Performance Scale (PPS)

Answer 21

• Reliable and valid tool and correlates well with actual survival and median survival time for cancer and non-cancer patients post-admission to an inpatient palliative unit.
• Ambulation, activity level and evidence of disease, self-care, Intake, conciousness
• 70 reflect less than 6mo prognosis
• 50-60 reflect 1mo prognosis;