title: A decision-analytic approach to define poor prognosis patients: a case study for non-seminomatous germ cell cancer patients.
abstract: BACKGROUND
  Classification systems may be useful to direct more aggressive treatment to cancer patients with a relatively poor prognosis. The definition of 'poor prognosis' often lacks a formal basis. We propose a decision analytic approach to weigh benefits and harms explicitly to define the treatment threshold for more aggressive treatment. This approach is illustrated by a case study in advanced testicular cancer, where patients with a high risk of mortality under standard treatment may be eligible for high-dose chemotherapy with stem cell support, which is currently defined by the IGCC classification.
  
  
  METHODS
  We used published literature to estimate the benefit and harm of high-dose chemotherapy (HD-CT) versus standard-dose chemotherapy (SD-CT) for patients with advanced non-seminomatous germ cell cancer. Benefit and harm were defined as the reduction and increase in absolute risk of mortality due to HD-CT respectively. Harm included early and late treatment related death, and treatment related morbidity (weighted by 'utility').
  
  
  RESULTS
  We considered a conservative and an optimistic benefit of 30 and 40% risk reduction respectively. We estimated the excess treatment related mortality at 2%. When treatment related morbidity was taken into account, the harm of HD-CT increased to 5%. With a relative benefit of 30% and harm of 2 or 5%, HD-CT might be beneficial for patients with over 7 or 17% risk of cancer specific mortality with SD chemotherapy, while with a relative benefit of 40% HD-CT was beneficial over 5 and 12.5% risk respectively. Compared to the IGCC classification 14% of the patients would receive more aggressive treatment, and 2% less intensive treatment.
  
  
  CONCLUSIONS
  Benefit and harm can be used to define 'poor prognosis' explicitly for non-seminomatous germ cell cancer patients who are considered for high-dose chemotherapy. This approach can readily be adapted to new results and extended to other cancers to define candidates for more aggressive treatments.
authors.affiliation: Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands. mr_vdijk@hotmail.com
authors.forename: Merel R
authors.initials: MR
authors.lastname: van Dijk
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: J Dik F
authors.initials: JD
authors.lastname: Habbema
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage* / Q000009:adverse effects; D003131:Combined Modality Therapy; D003661:Decision Support Techniques; D006801:Humans; D008297:Male; D008875:Middle Aged; D009373:Neoplasms, Germ Cell and Embryonal / Q000188:drug therapy* / Q000628:therapy; D011379:Prognosis; D033581:Stem Cell Transplantation; D013736:Testicular Neoplasms / Q000188:drug therapy* / Q000628:therapy