Symptoms tell it all: A systematic review of the value of symptom assessment to predict survival in advanced cancer patients
Introduction
Predicting the life expectancy of patients with advanced cancer is one of the most difficult challenges in medical care. For patients and their families, being aware of the prognosis makes a difference in decision making and planning the remaining lifetime. Cancer patients tend to choose life-extending therapy if they believe their survival is more than 6 months [1], [2], [3], [4]. This indicates that patients’ autonomy can be supported by providing realistic prognostication.
A systematic review of physicians’ survival predictions in terminally ill cancer patients showed that survival of patients was 30% shorter than predicted [5]. Due to inaccurate prognosis patients may develop unrealistic expectations.
Assessment of prognostic indicators in cancer patients has been performed previously, but the focus was not set on palliative cancer patients [6], [7]. Cognitive failure, weight loss, dysphagia, anorexia and dyspnea appeared to be independent predictors of survival in a systematic review published by Vigano et al. [8] Subsequently, it was demonstrated that the anorexia–cachexia syndrome, dyspnea and pain were associated with shorter survival [9]. These systematic reviews included studies published up to the year 2003. Since then, many new studies on this topic have been published. Moreover, critical appraisal of the literature addressing prognostic symptoms, by using a standardized approach is mostly absent or unsatisfactory.
This systematic review focuses on cancer patients in the palliative phase. The palliative phase starts from the moment that cure is not or no longer possible and lasts until the moment of death.
In palliative care three stages are distinguished. In the first stage palliation is disease-directed with the aim of prolonging life and improving or maintaining the quality of life by means of treating the underlying malignancy.
The second stage (symptom-oriented palliation) starts when anti-tumor treatment is discontinued because of lack of effect and/or severe side-effects. The focus in this stage is quality of life and stabilization and prevention of symptoms.
The terminal stage refers to the point at which it becomes clear that the patient is in a progressive state of decline and that death is imminent. In this stage the emphasis is set on improving the quality of dying by constraining symptoms to minimize suffering with acceptance of a potential loss of cognitive, emotional and social functioning. Little is known about the prognostic meaning of symptoms in relation to these three stages although symptom burden becomes the most hampering issue in quality of life during the progression of the disease [10], [11], [12].
In light of the aforementioned, the first aim of this review is to analyze the available evidence in literature about symptoms that predict the life expectancy in people with advanced cancer. The second aim is to relate the prognostic value of these symptoms to the three stages of palliative care. The third and last aim is to evaluate the quality of reporting of observational studies according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
We suggest a set of prognostic symptoms for further research in daily practice of palliative care.
Section snippets
Methods
Medline, Embase, Cochrane and Cinahl searches were carried out for the period of 1966 to January 2012 to examine which symptoms are predictive for survival in patients with advanced malignancy.
The domain of the search included synonyms for ‘advanced’ and ‘neoplasm’. The determinant was split into ‘symptoms (including ‘quality of life’)’ and ‘prognosis’. The outcome key words were synonyms for ‘survival’. Database limits ‘humans’, ‘adults’, ‘English or Dutch’ were used. The full electronic
Published papers
There were 3176 potential studies identified by the search strategy. On the basis of title and abstract 2948 papers were excluded because inclusion criteria were not met. In most cases the papers were excluded because symptoms were evaluated, but not the effect of these symptoms on prognosis.
The full text of 248 articles was reviewed (including 29 articles extracted from reference lists). Finally, 44 articles were included in this review (Fig. 1) [13], [14], [15], [16], [21], [22], [23], [24],
Importance of and flaws in prognostication
A systematic review of eight studies investigating the accuracy of physicians’ survival predictions has documented the poor and often too optimistic prognostic ability of many physicians. Median clinical prediction of survival was 42 days, while the median actual survival was 29 days [61].
This optimism of prognostication as perceived by patients may lead to possible requests for treatments that would not be chosen if a more accurate prognosis had been communicated.
Prognostication is not
Conclusion and further research
The WHO accentuates the fact that the majority of cancer patients are in advanced stage of cancer when first seen by a medical professional, so palliative care is an essential part of cancer control. This challenges all professionals to further improve the availability and quality of palliative care. It is a misfortune that so far, symptom assessment and monitoring is not analyzed in a more qualitative and standardized manner.
This extensive review includes all significant research evidence
Conflicts of interest
The authors of the present paper have no conflict of interest to declare.
Reviewers
Fabio Efficace, Ph.D., Head, Health Outcomes Research Unit, Gimema, Via Benevento, 6, Rome, Italy.
Chantal Quinten, M.Sc., ECDC European Center for Disease Prevention and Control, Stockholm, Sweden.
Marija Trajkovic-Vidakovic completed her medical study cum laude at the University of Antwerp in 2005. During her medical study she received a grant for versatile personal development residency at the St George Hospital, Sydney, Australia. She initiated the residency program of Internal Medicine from 2005 to 2009 at the St. Antonius Hospital, Nieuwegein. In 2009 she continued her residency at the University Medical Center Utrecht. In 2010 she temporarily discontinued her residency to work full
References (87)
- et al.
Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies?
Eur J Cancer
(1998) - et al.
A predictive model for survival in metastatic cancer patients attending an outpatient palliative radiotherapy clinic
Int J Radiat Oncol Biol Phys
(2002) - et al.
Identification and interpretation of clinical and quality of life prognostic factors for survival and response to treatment in first-line chemotherapy in advanced breast cancer
Eur J Cancer
(2000) - et al.
Cachexia worsens prognosis in patients with resectable pancreatic cancer
J Gastrointest Surg
(2008) - et al.
Estimate of survival of patients admitted to a palliative care unit: a prospective study
J Pain Symptom Manage
(1992) - et al.
Prediction of survival in terminal cancer patients in Taiwan: constructing a prognostic scale
J Pain Symptom Manage
(2004) - et al.
Terminal cancer: duration and prediction of survival time
Eur J Cancer
(2000) - et al.
A new palliative prognostic score: a first step for the staging of terminally ill cancer patients Italian Multicenter and Study*Group on Palliative Care
J Pain Symptom Manage
(1999) - et al.
Prognostic significance of symptoms of hospitalised advanced cancer patients
Eur J Cancer
(2006) - et al.
Baseline quality of life predicts survival in patients with advanced colorectal cancer
Eur J Cancer
(2002)
The prognostic impact of quality of life assessed with the EORTC QLQ-C30 in inoperable non-small cell lung carcinoma treated with radiotherapy
Radiother Oncol
The use of discriminant analysis to guide palliative treatment for lung cancer patients
Clin Oncol (R Coll Radiol)
Prognostic value of quality of life scores in terminal cancer patients
J Pain Symptom Manage
Does a patient's self-reported health-related quality of life predict survival beyond key biomedical data in advanced colorectal cancer?
Eur J Cancer
Is a patient's self-reported health-related quality of life a prognostic factor for survival in non-small-cell lung cancer patients? A multivariate analysis of prognostic factors of EORTC study 08975
Ann Oncol
Quality of life is predictive of survival in patients with unresectable hepatocellular carcinoma
Ann Oncol
Baseline health-related quality-of-life data as prognostic factors in a phase III multicentre study of women with metastatic breast cancer
Eur J Cancer
Predicting survival in patients with advanced disease
Eur J Cancer
Predicting prognosis in patients with advanced cancer
Ann Oncol
Correlation of patient and caregiver ratings of cancer pain
J Pain Symptom Manage
Fatigue in cancer patients during and after treatment: prevalence, correlates and interventions
Eur J Cancer
Recursive partitioning analysis of prognostic factors for survival in patients with advanced cancer
Int J Radiat Oncol Biol Phys
Weight stabilisation is associated with improved survival duration and quality of life in unresectable pancreatic cancer
Clin Nutr
Weight change during chemotherapy as a potential prognostic factor for stage III epithelial ovarian carcinoma: a Gynecologic Oncology Group study
Gynecol Oncol
Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study
BMJ
Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The study to understand prognoses and preferences for outcomes and risks of treatments
J Am Geriatr Soc
Truth may hurt but deceit hurts more: communication in palliative care
Palliat Med
The SUPPORT prognostic model Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments
Ann Intern Med
Palliative medicine review: prognostication
J Palliat Med
Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008
Health Qual Life Outcomes
The prognostic significance of patient-reported outcomes in cancer clinical trials
J Clin Oncol
Survival prediction in terminal cancer patients: a systematic review of the medical literature
Palliat Med
Prognostic factors in patients with recently diagnosed incurable cancer: a systematic review
Support Care Cancer
Palliatieve zorg Richtlijnen voor de praktijk
Living well at the end of life. Adapting health care to serious chronic illness in old age
In palliative cancer care symptoms mean everything
Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration
Gac Sanit
The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies
Lancet
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
BMJ
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration
BMJ
Construction of a new, objective prognostic score for terminally ill cancer patients: a multicenter study
Support Care Cancer
Predictors of inpatient mortality in an acute palliative care unit at a comprehensive cancer center
Support. Care Cancer
Prognostic value of symptom burden for overall survival in patients receiving chemotherapy for advanced nonsmall cell lung cancer
Cancer
Cited by (88)
Sensory nerves: A driver of the vicious cycle in bone metastasis?
2021, Journal of Bone OncologyCitation Excerpt :To support the hypothesis that CAP/CABP promotes cancer progression in clinical settings, determination of survival of cancer patients with or without CAP/CABP is informative and can serve as a surrogate for the evaluation of the effects of SNs on cancer progression. Previous systematic reviews reported that survival is significantly shorter in advanced cancer patients with CAP than those without CAP [6,51–52]. In particular, CAP was found as an independent prognostic factor for overall survival in advanced prostate cancer patients [6], suggesting that CAP accelerates cancer progression leading to shorter survival.
What symptoms tell us: A multiple case study of oncology consultations
2021, Palliative and Supportive CareFactors Associated With Long Survival in Patients With Cancer Admitted to Palliative Care: An Exploratory Study
2024, Journal of Palliative CareXerostomia in patients with advanced cancer: a scoping review of clinical features and complications
2023, BMC Palliative Care
Marija Trajkovic-Vidakovic completed her medical study cum laude at the University of Antwerp in 2005. During her medical study she received a grant for versatile personal development residency at the St George Hospital, Sydney, Australia. She initiated the residency program of Internal Medicine from 2005 to 2009 at the St. Antonius Hospital, Nieuwegein. In 2009 she continued her residency at the University Medical Center Utrecht. In 2010 she temporarily discontinued her residency to work full time as a researcher at the Center for Development of Palliative Care Utrecht at the University Medical Center Utrecht. In 2011 she started the fellowship Medical Oncology Utrecht at the University Medical Center Utrecht.
Alexander de Graeff was registered as a medical doctor in 1981. He was board certified as an internist in 1987 and as a medical oncologist in 1990. Since 1989 he has been a staff member of the Department of Medical Oncology of the University Medical Center Utrecht, The Netherlands. Since 2007 he also works as a physician at the Academic Hospice Demeter in De Bilt. He is a member of both a hospital-based and a regional palliative care team. In 1999 he completed his Ph.D. program on quality of life in head and neck cancer patients. He has been a member of the Board of the EORTC Quality Of Life Study Group and of several scientific advisory boards (CKTO and WRSO) of the Dutch Cancer Society. Since 2003 is chairman of the Working Party on national guidelines for palliative medicine of the Vereniging voor Integrale Kankercentra (VIKC) and has published two sets of guidelines for palliative care in 2006 and 2010.
Emile Voest was registered as a medical doctor in 1985. He became board certified as an internist July 1993, and as a medical oncologist in January 1995. He completed his Ph.D. program on the enhancement of the efficacy of anthracyclines by modulation of iron metabolism in tumor cells June 1993 (cum laude). In 1994 and 1995 he was a postdoctoral fellow of the Dutch Cancer Society. January 1996 he became a staff member of the Department of Medical Oncology at the University Medical Center Utrecht. January 1997 he was appointed head of the Laboratory of Medical Oncology at the University Medical Center Utrecht. November 1999 he became a full professor in Medical Oncology and head of the department of Medical Oncology at the University Medical Center Utrecht. In addition, he was co-director of the Research Institute “Oncology and Developmental Biology” and board member of the graduate school of Developmental Biology of the Royal Dutch Academy of Sciences until 2006. He currently is chair of the Scientific Advisory Board of the Dutch Cancer Society and serves in a variety of scientific committees and advisory boards. He is author of 168 peer reviewed scientific papers, has 6 patents to his name in the field of angiogenesis and biomarkers and is co-founder of PIFA Therapeutics. He is also heading the phase I program at the UMC Utrecht with a devoted team of nurses, scientists, data managers and clinicians.
Saskia Teunissen, is registered as a oncology nurse specialist and she has completed divers specialist and management programs. She is co-initiator of innovative healthcare projects in the transmural oncological and palliative care. In 1998 she fulfilled the role of Program Coordinator at the Center for Development of Palliative Care Utrecht. She completed her Ph.D. program on the symptoms and symptom management in palliative care for cancer patients in 2007. She is associate professor at the department of Medical Oncology at the University Medical Center Utrecht. Since 2010 she is also the director of the Academic Hospice Demeter, Utrecht.