title: Predicting serious complications in patients with cancer and pulmonary embolism using decision tree modelling: the EPIPHANY Index.
abstract: BACKGROUND
  Our objective was to develop a prognostic stratification tool that enables patients with cancer and pulmonary embolism (PE), whether incidental or symptomatic, to be classified according to the risk of serious complications within 15 days.
  
  
  METHODS
  The sample comprised cases from a national registry of pulmonary thromboembolism in patients with cancer (1075 patients from 14 Spanish centres). Diagnosis was incidental in 53.5% of the events in this registry. The Exhaustive CHAID analysis was applied with 10-fold cross-validation to predict development of serious complications following PE diagnosis.
  
  
  RESULTS
  About 208 patients (19.3%, 95% confidence interval (CI), 17.1-21.8%) developed a serious complication after PE diagnosis. The 15-day mortality rate was 10.1%, (95% CI, 8.4-12.1%). The decision tree detected six explanatory covariates: Hestia-like clinical decision rule (any risk criterion present vs none), Eastern Cooperative Group performance scale (ECOG-PS; <2 vs ⩾2), O2saturation (<90 vs ⩾90%), presence of PE-specific symptoms, tumour response (progression, unknown, or not evaluated vs others), and primary tumour resection. Three risk classes were created (low, intermediate, and high risk). The risk of serious complications within 15 days increases according to the group: 1.6, 9.4, 30.6%; P<0.0001. Fifteen-day mortality rates also rise progressively in low-, intermediate-, and high-risk patients: 0.3, 6.1, and 17.1%; P<0.0001. The cross-validated risk estimate is 0.191 (s.e.=0.012). The optimism-corrected area under the receiver operating characteristic curve is 0.779 (95% CI, 0.717-0.840).
  
  
  CONCLUSIONS
  We have developed and internally validated a prognostic index to predict serious complications with the potential to impact decision-making in patients with cancer and PE.
authors.affiliation: Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Carmona-Bayonas
authors.affiliation: Department of Medical Oncology, H. Universitario Central de Asturias, Oviedo, Spain.
authors.forename: P
authors.initials: P
authors.lastname: Jiménez-Fonseca
authors.affiliation: Department of Medical Oncology, H. Universitario Clinic, Barcelona, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Font
authors.affiliation: Department of Physiology, Facultad de Medicina, Universidad de Murcia, Murcia, Spain.
authors.forename: F
authors.initials: F
authors.lastname: Fenoy
authors.affiliation: Department of Pneumology, H. Universitario Virgen del Rocío, CIBER de Enfermedades Respiratorias, Seville, Spain.
authors.forename: R
authors.initials: R
authors.lastname: Otero
authors.affiliation: Department of Medical Oncology, Hospital Nisa-Aljarafe, Seville, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Beato
authors.affiliation: Department of Radiology, Hospital Universitario Morales Meseguer, Murcia, Spain.
authors.forename: J M
authors.initials: JM
authors.lastname: Plasencia
authors.affiliation: Department of Medical Oncology, H. Universitario Vall d' Hebron, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Biosca
authors.affiliation: Department of Radiology, H. Universitario Clinic, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Sánchez
authors.affiliation: Department of Radiology, H. Universitario Clinic, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Benegas
authors.affiliation: Department of Radiology, H. Universitario Central de Asturias, Oviedo, Spain.
authors.forename: D
authors.initials: D
authors.lastname: Calvo-Temprano
authors.affiliation: Department of Radiology, H. Universitario Vall D' Hebron, Barcelona, Spain.
authors.forename: D
authors.initials: D
authors.lastname: Varona
authors.affiliation: Department of Medical Oncology, H. Universitario Central de Asturias, Oviedo, Spain.
authors.forename: L
authors.initials: L
authors.lastname: Faez
authors.affiliation: Department of Internal Medicine, ICO Duran i Reynals, Barcelona, Spain.
authors.forename: I
authors.initials: I
authors.lastname: de la Haba
authors.affiliation: Department of Medical Oncology, ICO Duran i Reynals, Barcelona, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Antonio
authors.affiliation: Department of Internal Medicine, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain.
authors.forename: O
authors.initials: O
authors.lastname: Madridano
authors.affiliation: Department of Medical Oncology, H. Universitario Central de Asturias, Oviedo, Spain.
authors.forename: M P
authors.initials: MP
authors.lastname: Solis
authors.affiliation: Department of Medical Oncology, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Ramchandani
authors.affiliation: Department of Medical Oncology, Clínica Universidad de Navarra, Pamplona, Spain.
authors.forename: E
authors.initials: E
authors.lastname: Castañón
authors.affiliation: Department of Internal Medicine, Parc Sanitari Sant Joan of Déu, Esplugues de Llobregat, Barcelona, Spain.
authors.forename: P J
authors.initials: PJ
authors.lastname: Marchena
authors.affiliation: Department of Internal Medicine, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Martín
authors.affiliation: Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain.
authors.forename: F
authors.initials: F
authors.lastname: Ayala de la Peña
authors.affiliation: Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain.
authors.forename: V
authors.initials: V
authors.lastname: Vicente
mesh_terms: D019540:Area Under Curve; D003661:Decision Support Techniques; D003663:Decision Trees; D005260:Female; D005500:Follow-Up Studies; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009369:Neoplasms / Q000150:complications*; D011379:Prognosis; D011655:Pulmonary Embolism / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D012720:Severity of Illness Index; D015996:Survival Rate