Development and validation of a nomogram to predict survival in incurable cachectic cancer patients on home parenteral nutrition.
BACKGROUND
The use of home parenteral nutrition (HPN) in incurable cancer patients is extremely varied across different countries and institutions. In order to assess the clinical impact implied, we previously conducted a survey of incurable cancer patients receiving HPN, which shows that survival was markedly affected by Karnofsky performance status (KPS), tumor spread, Glasgow prognostic score (GPS) and tumor site. The aim of this study was to develop a nomogram incorporating the above factors for survival prediction.


METHODS
We gathered a series of 579 patients, all receiving HPN, which was randomly split into a training and a testing sample. Using Cox proportional hazard regression modeling, a nomogram was built in the training sample, in order to estimate median survival or survival probability at 3 and 6 months according to individual patient characteristics. The nomogram performance was then verified in the testing sample.


RESULTS
In the training sample, median survival was 3.2 (95% CI 3.0-3.7) months. GPS, KPS, tumor site and spread were confirmed to be significant prognostic factors. A significant interaction was also shown between the site and spread while weight loss (WL), adjusted for body mass index, failed to provide any substantial prognostic contribution. In the testing sample, nomogram performance was good in terms of calibration and discreet regarding discrimination.


CONCLUSIONS
With the growing availability of new oncological treatments and their tendency to transform the trajectory of the advanced cancer into a chronic condition characterized by progressive WL and poor nutrients intake, an increasing number of patients are expected to receive HPN. In such a setting, tools for predicting the survival outcome may play a role toward personalized medicine and for investigating novel experimental therapies. Our proposed nomogram is a step forward in this direction but needs to be made stronger in order to definitely have clinical utility.
Faculty of Medicine, University of Milan, Milan.
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Bozzetti
Anesthesiology and Intensive Care, Unit of Parenteral Nutrition in Oncology, S. Giovanni Battista Hospital, University of Turin, Turin.
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Cotogni
Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan.
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Lo Vullo
Department of Medical and Surgical Science, St Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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Pironi
Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan.
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Giardiello
Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan luigi.mariani@istitutotumori.mi.it.
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Mariani
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002100:Cachexia / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D049451:Nomograms; D016331:Parenteral Nutrition, Home / Q000401:mortality* / Q000639:trends; D011237:Predictive Value of Tests; D015996:Survival Rate / Q000639:trends; D055815:Young Adult
cancer cachexia; home parenteral nutrition; incurable cancer patient; malignant obstruction; nomogram; survival prediction