title: Validation and Development of a Modified Breast Graded Prognostic Assessment As a Tool for Survival in Patients With Breast Cancer and Brain Metastases.
abstract: OBJECTIVE
  Several indices have been developed to predict overall survival (OS) in patients with breast cancer with brain metastases, including the breast graded prognostic assessment (breast-GPA), comprising age, tumor subtype, and Karnofsky performance score. However, number of brain metastases-a highly relevant clinical variable-is less often incorporated into the final model. We sought to validate the existing breast-GPA in an independent larger cohort and refine it integrating number of brain metastases.
  
  
  METHODS
  Data were retrospectively gathered from a prospectively maintained institutional database. Patients with newly diagnosed brain metastases from 1996 to 2013 were identified. After validating the breast-GPA, multivariable Cox regression and recursive partitioning analysis led to the development of the modified breast-GPA. The performances of the breast-GPA and modified breast-GPA were compared using the concordance index.
  
  
  RESULTS
  In our cohort of 1,552 patients, the breast-GPA was validated as a prognostic tool for OS (P < .001). In multivariable analysis of the breast-GPA and number of brain metastases (> three v ≤ three), both were independent predictors of OS. We therefore developed the modified breast-GPA integrating a fourth clinical parameter. Recursive partitioning analysis reinforced the prognostic significance of these four factors. Concordance indices were 0.78 (95% CI, 0.77 to 0.80) and 0.84 (95% CI, 0.83 to 0.85) for the breast-GPA and modified breast-GPA, respectively (P < .001).
  
  
  CONCLUSIONS
  The modified breast-GPA incorporates four simple clinical parameters of high prognostic significance. This index has an immediate role in the clinic as a formative part of the clinician's discussion of prognosis and direction of care and as a potential patient selection tool for clinical trials.
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Ishwaria M
authors.initials: IM
authors.lastname: Subbiah
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Xiudong
authors.initials: X
authors.lastname: Lei
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Weinberg
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Erik P
authors.initials: EP
authors.lastname: Sulman
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Mariana
authors.initials: M
authors.lastname: Chavez-MacGregor
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX. dtripathy@mdanderson.org.
authors.forename: Debu
authors.initials: D
authors.lastname: Tripathy
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Rohan
authors.initials: R
authors.lastname: Gupta
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Ankur
authors.initials: A
authors.lastname: Varma
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jay
authors.initials: J
authors.lastname: Chouhan
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Guevarra
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Vicente
authors.initials: V
authors.lastname: Valero
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Gilbert
authors.affiliation: All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Ana M
authors.initials: AM
authors.lastname: Gonzalez-Angulo
mesh_terms: D000367:Age Factors; D001932:Brain Neoplasms / Q000401:mortality* / Q000556:secondary* / Q000628:therapy; D001943:Breast Neoplasms / Q000401:mortality* / Q000473:pathology* / Q000628:therapy; D018567:Breast Neoplasms, Male / Q000401:mortality / Q000473:pathology / Q000628:therapy; D016009:Chi-Square Distribution; D016208:Databases, Factual; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D017567:Karnofsky Performance Status; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D060787:Neoplasm Grading; D018579:Patient Selection; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors