Performance Status Scale Research Articles

How do patients interpret and respond to a novel patient-reported eastern cooperative oncology group performance status (ECOG)?

Performance status is an important concept in oncology, but is typically clinician-reported. Efforts are underway to include patient-reported measures in cancer care, which may improve patient symptoms, quality of life and overall survival. The purpose of this study was to gain a preliminary understanding of how patients determined their physical performance status based on a novel patient-reported version of the Eastern Cooperative Oncology Group Performance Status (ECOG) scale. We conducted qualitative interviews, including concept elicitation and cognitive interviewing as part of the Patient Reports of Physical Functioning Study (PROPS) to investigate how participants selected their answers to a novel patient-reported ECOG. Participants were administered the patient-reported ECOG and asked to describe devices and modifications used to keep up with daily activities. Participants generally understood the ECOG as intended. Participants with recent changes in status had some difficulty selecting an answer. Most participants used modifications and assistive devices in their daily lives but did not incorporate these into their rational for the ECOG. The potential benefits of a patient-reported ECOG are numerous and this study demonstrates that participants were able to understand and answer the patient-reported ECOG as intended. We recommend future evaluation for the most-appropriate recall period, whether to include modifications in the ECOG instructions, and if increasing the number of response options to the patient-reported ECOG may improve confidence when providing an answer.

Frailty and Duration of Maintenance Dialysis: A Japanese Nationwide Cross-Sectional Study

Rationale & ObjectiveProlonged end-stage kidney disease (ESKD) is a risk factor for frailty and the number of patients in Japan receiving maintenance dialysis for more than 20 years is large and growing. This study aimed to characterize the association of dialysis vintage and frailty among patients receiving dialysis in Japan. Study DesignCross-sectional study. Setting & ParticipantsPatients with ESKD aged over 50 years of age who received maintenance dialysis in 2018 as represented in the JSDT Renal Data Registry database (n=227,136). ExposuresDialysis vintage categorized as: 0–<5 years, 5–<10 years, 10–<20 years, 20–<30 years, and over 30 years. OutcomesThe frailty and bedridden status were defined as graded ≥2 and graded 4, respectively, according to the Eastern Cooperative Oncology Group Performance Status scale. Analytical ApproachPoisson regression models with robust error variance adjusted for potential covariates were used to estimate the adjusted prevalence ratios (aPRs) for frailty and bedridden status. Clinical characteristics of patients undergoing dialysis for ≥ 30 years were also described. ResultsAmong the study cohort, 5510 patients (2.4%) had been undergoing dialysis for 30 years or more. The prevalence of frailty in the group with over 30 years of dialysis history was 36.2%, while the rate of being bedridden was 6.4%. Compared to <5 years, dialysis vintages of 5–<10 years, 10–<20 years, 20–<30 years, and over 30 years were associated with frailty (aPRs [95% confidence intervals]: 1.06 [1.05-1.08], 1.10 [1.08-1.11], 1.14 [1.10-1.17], and 1.67 [1.60-1.73]), respectively. Compared to <5 years, dialysis vintages of 5–<10 years, 10–<20 years, 20–<30 years, and over 30 years were associated with being bedridden (aPRs [95% confidence intervals]: 1.17 [1.13-1.22], 1.26 [1.20-1.31], 1.17 [1.08-1.26], and 1.66 [1.49-1.86], respectively. LimitationsPatients receiving short-term dialysis may have more unmeasured comorbidities compared to patients receiving long-term dialysis. ConclusionsLong-term dialysis therapy, particularly exceeding 30 years, is associated with deterioration of physical function and frailty.

Revisiting the Association of ECOG Performance Status With Clinical Outcomes in Diverse Patients With Cancer.

The ECOG performance status (PS) scale was developed to support national clinical trials, but the degree to which ECOG PS predicts clinical outcomes in patient subgroups outside of clinical trials is relatively unknown. This study examined associations between ECOG PS and adverse outcomes in a diverse community oncology population. In this retrospective cohort study, demographic and clinical characteristics, including the most recent ECOG PS between January 1, 2017, and December 31, 2019, were examined for patients receiving cancer treatment within Kaiser Permanente Northern California (KPNC). Proportional hazard models were used to evaluate the effect of ECOG PS on adverse outcomes. A total of 21,730 patients were identified. Overall, most patients had an ECOG PS of 0 (42.5%) or 1 (42.5%). In multivariable analysis, an ECOG PS of 3 or 4 was associated with higher risk of 30-day emergency department visits (adjusted hazard ratio [aHR], 3.85; 95% CI, 3.47-4.26), 30-day hospitalizations (aHR, 4.70; 95% CI, 4.12-5.36), and 6-month mortality (aHR, 7.34; 95% CI, 6.64-8.11) compared with an ECOG PS of 0. Additionally, we found that upper gastrointestinal and stage IV cancers were associated with a higher risk of adverse outcomes compared with breast and stage I cancers, respectively. When adjusted for ECOG PS, African American race, Asian race, and female sex were associated with a lower risk of mortality than White race and male sex. An ECOG PS of 3 or 4 was more predictive of mortality in younger patients and those with breast cancer (P<.001). ECOG PS and upper gastrointestinal and stage IV cancers were independently associated with increased risk of emergency department visits, hospitalizations, and mortality, whereas African American and Asian race and female sex were associated with decreased risk of mortality. An ECOG PS of 3 or 4 was more predictive of an increased risk of mortality in younger patients and patients with breast cancer. These findings can enhance the use of ECOG PS for clinical decision-making and defining eligibility for clinical trials.

A Comparative Analysis of Vitamin D Status among Tuberculosis Patients and Healthy Household Contacts: A Case–Control Study from Central India

Background and Objectives: When it comes to the nature of the relationship between tuberculosis (TB) and Vitamin D, the available literature offers contradictory findings. The purpose of this study was to assess the relationship between Vitamin D and TB, as well as the relationship between Vitamin D and functional capacity in TB patients from Central India. Materials and Methods: This case–control study comprised 400 participants divided into two equal groups: cases (200 TB patients) and controls (200 healthy household contacts). The study involved subjecting participants to standard laboratory tests in accordance with the management guidelines implemented by the institute. Abbott Architect i1000SR PLUS was used to test the Vitamin D levels while the Karnofsky Performance Status Scale score was used for the functional capacity of cases. Vitamin D levels were categorized into deficient, insufficient, and sufficient for every participant. Information related to the study was noted down on a structured pro forma. Results: The difference in Vitamin D values between the two groups was statistically significant, with 62.5% of deficient patients in the case group compared to 15% in the control group (confidence interval = 95%, χ 2 = 173.97, P = 0.001). The relationship between Vitamin D concentration and Karnofsky scale categories was statistically significant ( r = 0.752, P = 0.01). Interpretation and Conclusions: Vitamin D deficiency is associated with TB and a decrease in functional capacity in the region of Bundelkhand, highlighting the vital role of Vitamin D for TB patients.

Temporal Muscle Thickness Compared to Functional Scales as a Prognostic Parameter in Patients with Brain Metastases.

Metastases are the most frequent intracranial malignant tumors in adults. While Karnofsky Performance Status (KPS) and Clinical Frailty Scale (CFS) are known to have significant impact on overall survival (OS), temporal muscle thickness (TMT) has been postulated to be a promising new parameter to estimate prognosis. Patients who received a resection of one to three brain metastases in our institution were included. Temporal muscle thickness was measured in preoperative MRI scans according to a standardized protocol. In 199 patients, the mean TMT was 7.5 mm (95CI 7.3-7.7) and the mean OS during follow-up was 31.3 months (95CI 24.2-38.3). There was no significant correlation of TMT and preoperative or follow-up CFS and KPS. While CFS and KPS did significantly correlate with OS (p < 0.001 for each), no correlation was demonstrated for TMT. CFS showed a superior prognostic value compared to KPS. TMT failed to show a significant impact on OS or patient performance, whereas the clinical scales (KPS and CFS) demonstrate a good correlation with OS. Due to its superiority over KPS, we strongly recommend the use of CFS to estimate OS in patients with brain metastases.

Burden of obstructive sleep apnea in patients with lung cancer and its effect on performance status.

The association between lung cancer and obstructive sleep apnea has remained a matter of debate for years. Obstructive sleep apnea is thought to increase the incidence of lung cancer due to intermittent hypoxaemia and sleep fragmentation. The aim of this study is to assess the prevalence of obstructive sleep apnea in patients with lung cancer and its effect on those patients' performance status. This is a prevalence study that was conducted at Chest Diseases Department, Alexandria Main University Hospitals. We enrolled 153 patients with lung cancer. All patients underwent cardiorespiratory monitoring using a home sleep-testing device. Performance status was assessed using Karnofsky performance status scale. The study included 120 (78.4%) males and 33 (21.6%) females newly diagnosed with lung cancer. The mean age was 59.98 ± 11.11 years. Obstructive sleep apnea (apnea-hypopnea index ≥ 5) was present in 134 (87.6%) patients. Eighty-five (63.4%) patients had mild obstructive sleep apnea, 39 (29.1%) patients had moderate obstructive sleep apnea, and 10 (7.46%) patients had severe obstructive sleep apnea. Prolonged nocturnal oxygen desaturation as demonstrated by time of oxygen saturation spent below 90% (T90%) during total sleep time > 30% was present in 25 (16.3%) patients. There was a significant difference in the median value of Karnofsky performance status scale between patients with lung cancer and associated obstructive sleep apnea and those without obstructive sleep apnea. In conclusion, obstructive sleep apnea is highly prevalent among patients with lung cancer. Performance status is worse among patients with lung cancer in the presence of obstructive sleep apnea. Screening patients with lung cancer for obstructive sleep apnea is important regardless of the presence of classical symptoms of obstructive sleep apnea.

Long-term treatment of hereditary transthyretin amyloidosis with patisiran: multicentre, real-world experience in Italy.

Hereditary transthyretin (ATTRv, v for variant) amyloidosis with polyneuropathy is a rare disease caused by mutations in the transthyretin gene. In ATTRv amyloidosis, multisystem extracellular deposits of amyloid cause tissue and organ dysfunction. Patisiran is a small interfering RNA molecule drug that reduces circulating levels of mutant and wild-type TTR proteins. Prior to its regulatory approval, patisiran was available in Italy through a compassionate use programme (CUP). The aim of this study was to analyse the long-term outcomes of patients who entered into the CUP. This was a multicentre, observational, retrospective study of patients with ATTRv amyloidosis treated with patisiran. The analysis included change from baseline to 12, 24, 36 and 48 months in familial amyloid polyneuropathy (FAP) stage, polyneuropathy disability (PND) class, neuropathy impairment score (NIS), modified body mass index (mBMI), Compound Autonomic Dysfunction Test (CADT), Karnofsky Performance Status (KPS) scale and Norfolk Quality of Life-Diabetic Neuropathy (QoL-DN) questionnaire. Safety data were also analysed. Forty patients from 11 Italian centres were enrolled: 23 in FAP 1 (6 in PND 1 and 17 in PND 2) and 17 in FAP 2 (8 in PND 3a and 9 in PND 3b) stage. In this population, the mean NIS at baseline was 71.4 (± 27.8); mBMI, 917.1 (± 207) kg/m2; KPS, 67.1 (± 14.0); Norfolk QoL-DN, 62.2 (± 25.2); and CADT, 13.2 (± 3.3). Statistical analysis showed few significant differences from baseline denoting disease stability. No new safety signals emerged. Patisiran largely stabilised disease in patients with ATTRv amyloidosis.

Anterior Cervical and Upper Thoracic Column Reconstruction Using an Expandable Poly-Ether-Ether-Ketone Vertebral Body Replacement: A Retrospective Single Center Cohort Analysis

This study aimed to evaluate the safety and efficacy of a novel Poly-Ether-Ether-Ketone (PEEK) expandable vertebral body replacement (VBR) for anterior cervico-thoracic vertebral column reconstruction in patients with metastatic, traumatic, or degenerative diseases. Radiographic and clinical outcomes, as well as complication rates, were analyzed in a retrospective analysis of 28 patients (61 ± 13 years; 64% female) who underwent an anterior cervical corpectomy and fusion (ACCF) with the Expandable Corpectomy Device (ECD) from DePuy/Synthes (2011–2020). Correction of the bisegmental kyphotic angle (BKA) was chosen as the primary outcome. Bony fusion, loss of device height, and implant subsidence were evaluated additionally. Clinical outcome was assessed using Odom’s criteria, the numerical pain rating scale (NRS), the American Spinal Injury Association Impairment Scale (AIS), and the Karnofsky Performance Status Scale (KPSS). Our study found a significant improvement in the BKA (12.3° ± 9.6°; p = 0.0002) at the last follow-up with no statistically relevant loss of device height (p = 0.96) or implant subsidence (p = 0.99). Successful bony fusion was observed in all patients. The KPSS significantly improved in patients with a tumorous disease at the time of discharge (p = 0.0009), and the sensation of pain showed significant improvement at six months post-operatively and at the final follow-up (p = 0.004; p = 0.021). However, four patients needed further secondary posterior stabilization, and one ECD was explanted due to a severe surgical site infection after an accidental esophageal lesion. In conclusion, the ECD proofed the radiographic stability for the anterior column reconstruction of the cervico-thoracic spine with significantly improved clinical outcome.

Adult Central Neurocytomas: Clinical Features and Long-Term Treatment Outcomes in Different Age Groups

Central neurocytomas (CNs) usually occur in young adults, and the clinical characteristics and surgical outcomes of patients in different age groups may be different. This study was undertaken to compare the clinical and long-term treatment outcomes of patients with CNs in younger and older adult age groups. Eighty consecutive adults with CNs were included, with a mean presentation age of 28.4 ± 7.6 years (range: 19-66 years). Thirty (37.5%) patients were <27 years old, and they tended to manifest with multiple symptoms (p=0.002), increased intracranial pressure (ICP) symptoms (p=0.036), an acute clinical course (p=0.037), worse preoperative neurological function (p=0.023), and a larger lesion size and volume (p=0.004 and 0.007, respectively) than their older age counterparts (≧27 years). An older onset age (p=0.005) or age ≧27 years (p=0.014) and worsened Karnofsky Performance Status (KPS) scale (p=0.040) immediately after microsurgery were associated with unimproved long-term outcomes. CNs in younger adult patients behave differently from those in the older age group. Surgery can halt neurological deterioration and ensure satisfactory outcomes.

Comparison of the Real-World Reporting of Symptoms and Well-Being for the HER2-Directed Trastuzumab Biosimilar Ogivri With Registry Data for Herceptin in the Treatment of Breast Cancer: Prospective Observational Study (OGIPRO) of Electronic Patient-Reported Outcomes.

Trastuzumab has had a major impact on the treatment of human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC). Anti-HER2 biosimilars such as Ogivri have demonstrated safety and clinical equivalence to trastuzumab (using Herceptin as the reference product) in clinical trials. To our knowledge, there has been no real-world report of the side effects and quality of life (QoL) in patients treated with biosimilars using electronic patient-reported outcomes (ePROs). The primary objective of this prospective observational study (OGIPRO study) was to compare the ePRO data related to treatment side effects collected with the medidux app in patients with HER2-positive BC treated with the trastuzumab biosimilar Ogivri (prospective cohort) to those obtained from historical cohorts treated with Herceptin alone or combined with pertuzumab and/or chemotherapy (ClinicalTrials.gov NCT02004496 and NCT03578731). Patients were treated with Ogivri alone or combined with pertuzumab and/or chemotherapy and hormone therapy in (neo)adjuvant and palliative settings. Patients used the medidux app to dynamically record symptoms (according to the Common Terminology Criteria for Adverse Events [CTCAE]), well-being (according to the Eastern Cooperative Oncology Group Performance Status scale), QoL (using the EQ-5D-5L questionnaire), cognitive capabilities, and vital parameters over 6 weeks. The primary endpoint was the mean CTCAE score. Key secondary endpoints included the mean well-being score. Data of this prospective cohort were compared with those of the historical cohorts (n=38 patients; median age 51, range 31-78 years). Overall, 53 female patients with a median age of 54 years (range 31-87 years) were enrolled in the OGIPRO study. The mean CTCAE score was analyzed in 50 patients with available data on symptoms, while the mean well-being score was evaluated in 52 patients with available data. The most common symptoms reported in both cohorts included fatigue, taste disorder, nausea, diarrhea, dry mucosa, joint discomfort, tingling, sleep disorder, headache, and appetite loss. Most patients experienced minimal (grade 0) or mild (grade 1) toxicities in both cohorts. The mean CTCAE score was comparable between the prospective and historical cohorts (29.0 and 30.3, respectively; mean difference -1.27, 95% CI -7.24 to 4.70; P=.68). Similarly, no significant difference was found for the mean well-being score between the groups treated with the trastuzumab biosimilar Ogivri and Herceptin (74.3 and 69.8, respectively; mean difference 4.45, 95% CI -3.53 to 12.44; P=.28). Treatment of patients with HER2-positive BC with the trastuzumab biosimilar Ogivri resulted in equivalent symptoms, adverse events, and well-being as found for patients treated with Herceptin as determined by ePRO data. Hence, integration of an ePRO system into research and clinical practice can provide reliable information when investigating the real-world tolerability and outcomes of similar therapeutic compounds. ClinicalTrials.gov NCT05234021; https://clinicaltrials.gov/study/NCT05234021.

Profiling of swallowing function in head and neck cancer patients prior to radiation therapy-Findings from a tertiary hospital in South India

PurposeHead and neck cancer (HNC) patients often face difficulties with swallowing, which can be due to the cancer itself or the treatment modalities like radiation therapy. The presentation of HNC can vary between developing and developed countries due to socioeconomic factors. The current study aimed to profile the swallowing function of HNC patients before starting radiation therapy in a tertiary hospital in India. MethodThis cross-sectional observational study examined patients with HNC who were scheduled for radiation therapy. The Functional Oral Intake Scale (FOIS) and Karnofsky Performance Status Scale were used to assess the patients’ swallowing status and functional abilities, respectively. The study also evaluated the relationship between swallowing function and clinical-demographic factors. ResultsOur assessment of 162 HNC patients found that the cancer site significantly affects swallowing. Although 92% of patients had an oral diet, 64% made dietary modifications. Patients with non-oral intake had either oral or pharyngeal cancer, and over 80% of oral cancer patients and 60% of those with pharyngeal cancer had already made changes to their diet. Patients with laryngeal cancer had a better oral intake, with 58% reporting no swallowing issues. ConclusionPatients with HNC scheduled for radiation therapy may experience varying degrees of swallowing difficulty. Early intervention and teaching of safe swallowing strategies are crucial to prepare for the potential worsening of swallowing difficulties resulting from the treatment. Advanced tumor stages and oral/pharyngeal cancers increase the risk of significant swallowing issues.

Experience of pediatric palliative care among children with cancer in a tertiary care hospital in Bangladesh

Background: Palliative care is a holistic approach which can improve patients and their family’s quality of life through the prevention and relief of physical symptoms as well as support for emotional, social and spiritual suffering. Despite the substantial need for palliative care there is very limited access in Bangladesh, with only a few palliative care services focused on children including several hospital-based services as well as home and hospice-based services, within the capital city of Dhaka. The aim of the study was to evaluate the effect of pediatric palliative care on quality of life in children with cancer. Methods: This was an institutional based descriptive study conducted in the department of pediatric hematology and oncology and pediatric palliative care unit, Dhaka medical college hospital, Dhaka, from May to August 2023. A total of thirty child and parent pairs were taken as the study population according to inclusion and exclusion criteria. Outcome was evaluated by the CPOS-2 questionnaires for symptom and Lanskys performance status scale for assessment of activity level. Results: The median age of the children were 5.7 years where 70.0% were male. The duration of disease of the patients was up to 6 months in 63.3% cases. One third of the patients had ALL, 13.3% had NHL, and 10.0% had Ewing sarcoma while another 10.0% having neuroblastoma. Conclusions: There is significant improvement in the quality of life of pediatric cancer patients and their parents, as well as the enhanced performance status of patients with cancer after receiving pediatric palliative care.

Optimizing Real-World Outcomes in High-Risk Relapsed/Refractory (r/r) FL with CAR-T Cell Therapy: A Vodcast and Case Example.

Follicular lymphoma (FL) is often considered a chronic disease with frequent relapses, shortening both response duration and survival after every relapse. Selecting the most appropriate therapy at the right time within the treatment timeline is key to optimize outcomes. The aim of this vodcast, featuring Dr. Kai Hübel, is to outline the severity of FL by referring to a patient case as well as highlight chimeric antigen receptor (CAR)-T cells as an effective therapy in relapsed/refractory (r/r) FL. The patient was in their early 50s, diagnosed with FL in the early 2010s and presented with a third relapse. The patient complained of night sweats and fatigue but was still capable of self-care (Eastern Cooperative Oncology Group Performance Status Scale 2). The patient received eight cycles of rituximab-cyclophosphamide-doxorubicin-vincristine-prednisolone (R-CHOP), followed by irradiation and rituximab maintenance (first-line) and then received rituximab 4 × weekly, followed by rituximab maintenance (second-line). The patient relapsed during rituximab maintenance; the patient was rituximab refractory. The patient received six cycles of bendamustine/obinutuzumab followed by obinutuzumab maintenance. The patient relapsed during obinutuzumab maintenance, achieved a partial remission after irradiation and was switched to R/lenalidomide. Due to several high-risk features, CAR-T cell therapy was initiated. Dr. Hubel underlines how earlier treatment with CAR-T cell therapy would have been beneficial for this patient. Results of the ELARA trial as well as comparative studies have shown tisagenlecleucel to be more effective than standard of care in extensively pretreated r/r FL, including high-risk patients. In conclusion, CAR-T cell therapy is a promising therapy option for patients with multiply r/r FL. A vodcast feature is available for this article.

Minimally invasive interventions on celiac plexus in patients with persistent abdominal pain caused by pancreatic cancer

Background. Chronic abdominal pain is common in 50 % of patients with intra-abdominal malignancies and has a huge impact on quality of their lives. As the number and doses of systemic analgesics increase, so does the frequency of side effects that can further worsen functional status, which is important for this cohort of patients who have a five-year survival rate of only 8 %. The purpose of the study: to assess the efficacy and safety of computed tomography-guided celiac plexus neurolysis as a method of reducing persistent, severe pain in patients with pancreatic cancer that affects their functional status. Materials and methods. The analysis of the results of 17 interventional procedures on the celiac plexus in 16 participants was conducted, sympatholysis was performed twice in one patient. Inclusion criteria: pancreatic cancer with persistent pharmacoresistant neuropathic abdominal pain for ≥ 3 months, which did not respond to medications, including opioids, anti-inflammatory drugs, and other conservative methods of treatment. Age of patients was 39 to 72 years (mean of 62.6 ± 8.2 years), 10 (62.5 %) research participants were male and 6 (37.5 %) were female. Results. Interventions were successfully performed for all patients on the first attempt. There were no cases of perforations of hollow organs, damage to blood vessels, pleural sinuses, or other structures of the abdominal and thoracic cavities. No neurological complications were recorded, and no one required blood transfusion. All study patients had a significant reduction in pain on the visual analogue scale compared to baseline, both one week after the procedure, from 9.7 ± 0.6 to 4.7 ± 1.4 (P &lt; 0.001), and in six months, from 9.7 ± 0.6 to 4.1 ± 1.4 (P &lt; 0.001). The average Karnofsky Performance Status Scale score compared to the data before the procedure, one week after increased from 64.7 ± 7.9 to 78.2 ± 6.4 (P &lt; 0.001). A significant improvement in functional status was maintained up to three months — 71.2 ± 6.9 (P &lt; 0.001). However, in six months, this indicator was 63.5 ± 6.0 (Р = 0.668), which may be related not only to the intensity of the pain syndrome, but also to other complications of the underlying disease (ascites, cachexia, tumor growth, palliative surgical interventions, etc.). Conclusions. Computed tomography-guided celiac plexus neurolysis is a safe and effective procedure for patients with abdominal pain caused by inoperable pancreatic cancer. Sympatholysis provides a long-term significant reduction in pain syndrome according to the visual analogue scale after 1, 3, 6 months (Р &lt; 0.001) and increases the functional status of patients according to the Karnofsky Performance Status Scale in 1 (Р &lt; 0.001), 3 months (Р = 0.023). Celiac plexus neurolysis should be considered as part of a multidisciplinary approach to the comprehensive treatment of upper abdominal pain associated with cancer in the early stages of the disease.

Single brain metastases - prognostic factors and impact of residual tumor burden on overall survival.

Brain metastases (BM) are a common and challenging issue, with their incidence on the rise due to advancements in systemic therapies and increased patient survival. Most patients present with single BM, some of them without any further extracranial metastasis (i.e., solitary BM). The significance of postoperative intracranial tumor volume in the treatment of singular and solitary BM is still debated. This study aimed to determine the impact of resection and postoperative tumor burden on overall survival (OS) in patients with single BM. Patients with surgically treated single BM between 04/2007-01/2020 were retrospectively included. Residual tumor burden (RTB) was determined by manual segmentation of early postoperative brain MRI (72 h). Survival analyses were performed using Kaplan-Meier estimates for univariate analysis and Cox regression proportional hazards model for multivariate analysis, using preoperative Karnofsky performance status scale (KPSS), age, sex, RTB, incomplete resection and singular/solitary BM as covariates. 340 patients were included, median age 64 years (54-71). 119 patients (35%) had solitary BM, 221 (65%) singular BM. Complete resection (RTB=0) was achieved in 73%, median preoperative tumor burden was 11.2 cm3 (5-25), and RTB 0 cm3 (0-0.2). Median OS of patients with singular BM was 13 months (4-33) vs 20 months (5-92) for solitary BM; p=0.062. Multivariate analysis revealed singular BM as independent risk factor for poorer OS: HR 1.840 (1.202-2.817), p=0.005. Complete vs. incomplete resection showed no significant OS difference (13 vs. 13 months, p=0.737). When focusing on solitary BM, complete resection led to a longer OS than incomplete resection (21 vs. 8 months), without statistical significance(p=0.250). Achieving RTB=0 resulted in higher OS for patients with solitary BM compared to singular BM (21 vs. 12 months, p=0.027). Patients who received postoperative radiotherapy (RT) had significantly longer OS compared to those without it (14 vs. 4 months, p<0.001), with favorable OS in those receiving stereotactic radiosurgery (SRS) (15 months (3-42), p<0.001) or hypofractionated stereotactic radiotherapy (HSRT). When complete intracranial tumor resection RTB=0 is achieved, patients with solitary BM have a favorable outcome compared to singular BM. Singular BM was confirmed as independent risk factor. There is a strong presumption that complete resection leads to an improved oncological prognosis. Patients with solitary BM tend to benefit with a favorable outcome following complete resection. Hence, surgical resection should be considered as a treatment option for patients presenting with either no or minimal extracranial disease. Furthermore, the highly favorable impact of postoperative RT on OS was demonstrated and confirmed, especially with SRS or HSRT.

The impact of Karnofsky performance status on prognosis of patients with hepatocellular carcinoma in liver transplantation

BackgroundFunctional performance as measured by the Karnofsky Performance Status (KPS) scale has been linked to the outcomes of liver transplant patients; however, the effect of KPS on the outcomes of the hepatocellular carcinoma (HCC) liver transplant population has not been fully elucidated. We aimed to investigate the association between pre-transplant KPS score and long-term outcomes in HCC patients listed for liver transplantation.MethodsAdult HCC candidates listed on the Scientific Registry of Transplant Recipients (SRTR) database from January 1, 2011 to December 31, 2017 were grouped into group I (KPS 80–100%, n = 8,379), group II (KPS 50–70%, n = 8,091), and group III (KPS 10–40%, n = 1,256) based on percentage KPS score at listing. Survival was compared and multivariable analysis was performed to identify independent predictors.ResultsPatients with low KPS score had a higher risk of removal from the waiting list. The 5-year intent-to-treat survival was 57.7% in group I, 53.2% in group II and 46.7% in group III (P < 0.001). The corresponding overall survival was 77.6%, 73.7% and 66.3% in three groups, respectively (P < 0.001). Multivariable analysis demonstrated that KPS was an independent predictor of intent-to-treat survival (P < 0.001, reference group I; HR 1.19 [95%CI 1.07–1.31] for group II, P = 0.001; HR 1.63 [95%CI 1.34–1.99] for group III, P < 0.001) and overall survival(P < 0.001, reference group I; HR 1.16 [95%CI 1.05–1.28] for group II, P = 0.004; HR 1.53 [95%CI 1.26–1.87] for group III, P < 0.001). The cumulative 5-year recurrence rates was higher in group III patients (7.4%), compared with 5.2% in group I and 5.5% in group II (P = 0.037). However, this was not significant in the competing regression analysis.ConclusionsLow pre-transplant KPS score is associated with inferior long-term survival in liver transplant HCC patients, but is not significantly associated with post-transplant tumor recurrence.

Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department

BackgroundPredicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired.MethodsWe advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year.ResultsA total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74–0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69–0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56–0.57) by using SQ (surprise question), 0.54 (0.54–0.54) by using qSOFA, and 0.59 (0.59–0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic.ConclusionsThe A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.

Revisiting Feeding Tube Utilization in Oropharynx Cancer: 6-Year Prospective Registry Analysis.

Patients treated for oropharyngeal cancer (OPC) have historically demonstrated high feeding tube rates for decreased oral intake and malnutrition. We re-examined feeding tube practices in these patients. Retrospective analysis of prospective cohort from 2015 to 2021. Single-institution NCI-Designated Comprehensive Cancer Center. With IRB approval, patients with new oropharyngeal squamous cell cancer or (unknown primary with neck metastasis) were enrolled. Baseline swallowing was assessed via videofluoroscopy and Performance Status Scale for Head and Neck Cancer (PSSHN). G-tubes or nasogastric tubes (NGT) were placed for weight loss before, during, or after treatment. Prophylactic NGT were placed during transoral robotic surgery (TORS). Tube duration was censored at last disease-free follow-up. Multivariate regression was performed for G-tube placement (odds ratio [OR] [95% confidence interval [CI]) and removal (Cox hazard ratio, hazard ratio [HR] [95% CI]). Of 924 patients, most had stage I to II (81%), p16+ (89%), node-positive (88%) disease. Median follow-up was 2.6 years (interquartile range 1.5-3.9). Most (91%) received radiation/chemoradiation, and 16% received TORS. G-tube rate was 27% (5% after TORS). G-tube risk was increased with chemoradiation (OR 2.78 [1.87-4.22]) and decreased with TORS (OR 0.31 [0.15-0.57]) and PSSHN-Diet score ≥60 (OR 0.26 [0.15-0.45]). G-tube removal probability over time was lower for T3 to T4 tumors (HR 0.52 [0.38-0.71]) and higher for PSSHN-Diet score ≥60 (HR 1.65 [1.03-2.66]). In this modern cohort of patients treated for OPC, 27% received G-tubes-50% less than institutional rates 10 years ago. Patients with preserved baseline swallowing and/or those eligible for TORS may have lower G-tube risk and duration.

Outcomes and influencing factors of dental implants in fibula, iliac crest, and scapula free flaps: a retrospective case–control study

PurposeReconstruction with vascularized bone grafts after ablative surgery and subsequent dental rehabilitation with implants is often challenging; however, it helps improve the patient’s quality of life. This retrospective case–control study aimed to determine the implant survival/success rates in different vascularized bone grafts and potential risk factors.MethodsOnly patients who received implants in free vascularized bone grafts between 2012 and 2020 were included. The free flap donor sites were the fibula, iliac crest, and scapula. The prosthetic restoration had to be completed, and the observation period had to be over one year after implantation. Implant success was defined according to the Health Scale for Dental Implants criteria.ResultsSixty-two patients with 227 implants were included. The implant survival rate was 86.3% after an average of 48.7 months. The causes of implant loss were peri-implantitis (n = 24), insufficient osseointegration (n = 1), removal due to tumor recurrence (n = 1), and osteoradionecrosis (n = 5). Of all implants, 52.4% were classified as successful, 19.8% as compromised, and 27.8% as failed. Removal of osteosynthesis material prior to or concurrent with implant placement resulted in significantly better implant success than material not removed (p = 0.035). Localization of the graft in the mandibular region was associated with a significantly better implant survival (p = 0.034) and success (p = 0.002), also a higher Karnofsky Performance Status Scale score with better implant survival (p = 0.014).ConclusionImplants placed in vascularized grafts showed acceptable survival rates despite the potential risk factors often present in these patient groups. However, peri-implantitis remains a challenge.Graphical abstract

Assessment of Mobility Trajectories Using Wearable Inertial Sensors During Autologous Hematopoietic Cell Transplant

ObjectiveThis study aimed to characterize mobility patterns using wearable inertial sensors and serial assessment across autologous hematopoietic cell transplant (autoHCT) and investigate the relation between mobility and perceived function in patients with hematologic cancer. DesignProspective longitudinal study. SettingHospital adult transplant clinic followed by discharge. Participants78 patients with hematological cancer receiving autoHCT. Main Outcome MeasuresMobility was measured across 3 clinical phases (pretransplant, pre-engraftment, and post-engraftment) in using inertial sensors worn during prescribed performance tests in the hospital. Perceived function was assessed using validated provider-reported (Eastern Cooperative Oncology Group [ECOG] Performance Status Scale) and patient-reported [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ-C30]) measures. Trajectories of 5 selected mobility characteristics (turn duration, gait speed, stride time variability, double support time, and heel strike angle) across the clinical phases were also evaluated using piecewise linear mixed-effects models. ResultsUsing Principal Components Analysis, 4 mobility patterns were identified pretransplant: Gait Limitation, Sagittal Sway, Coronal Sway, and Balance Control. Gait Limitation measured pretransplant was significantly inversely associated with perceived function reported by the provider- (β = -0.11; 95% CI: -0.19, -0.02) and patient- (β = -4.85; 95% CI: -7.72, -1.99) post-engraftment in age-adjusted linear regression models. Mobility characteristics demonstrated immediate declines early pre-engraftment with stabilization by late pre-engraftment. ConclusionPatients with hematological cancer experiencing gait limitations pretransplant are likely to have worse perceived function post-engraftment. Mobility declines in early phases post-transplant and may not fully recover, indicating an opportunity for timely rehabilitation referrals. Wearable inertial sensors can be used to identify early mobility problems and patients who may be at risk for future functional decline who may be candidates for early physical rehabilitation.