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Background Recently, the palliative appropriateness criteria (PAC) score, a novel metric to aid clinical decision-making between different palliative radiotherapy fractionation regimens, has been developed. It includes baseline parameters including but not limited to performance status. The researchers behind the PAC score analyzed the percent of remaining life (PRL) on treatment. The latter was accomplished by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. The purpose of the present study was to validate this novel metric. Patients and methods The retrospective validation study included 219 patients (287 courses of palliative radiotherapy). The methods were identical to those employed in the score development study. The score was calculated by assigning 1 point each to several factors identified in the original study and using the online calculator provided by the PAC developers. Results Median survival was 6 months and death within 30 days from start of radiotherapy was recorded in 13% of courses. PRL on treatment ranged from 1 to 23%, median 8%. Significant associations were confirmed between online-calculated PAC score, observed survival, and risk of death within 30 days from the start of radiotherapy. Patients with score 0 had distinctly better survival than all other groups. The score-predicted median risk of death within 30 days from start of radiotherapy was 22% in our cohort. A statistically significant correlation was found between predicted and observed risk (p Conclusion This study supports the dual strategy of PRL and risk of early death calculation, with results stratified for fractionation regimen, in line with the original PAC score study. When considering multifraction regimens, the PAC score identifies patients who may benefit from shorter courses. Additional work is needed to answer open questions surrounding the underlying components of the score, because the original and validation study were only partially aligned.

Aim: The aim of this study was to evaluate the feasibility and efficacy, in terms of overall survival, of sequential systemic therapy in patients with metastatic castration-resistant prostate cance...

Aim/Background - The aim of this study was to evaluate the feasibility and efficacy, in terms of overall survival, of intensified upfront systemic therapy in patients with metastatic hormone-sensitive prostate cancer who lived in rural Nordland County, Norway. Patients and methods - Overall 117 patients were included in this retrospective study. Three cohorts were created: early docetaxel and androgen deprivation therapy (ADT; the CHAARTED regimen; n = 37), ADT only during the same time period (2014–2020; n = 33), and ADT only in the years 2009–2014 (n = 47). Results - Four patients (11%) did not complete 6 cycles of docetaxel, one of these due to early progression of cancer. During follow-up, 8 patients (22%) progressed to castration-resistant disease (mCRPC), compared to 24 (73%) with ADT only and 35 (75%) in the historical cohort, p = 0.000001. Such progression occurred within 12 months in 3 patients (8%) treated with docetaxel and 9 patients (27%) treated with ADT only during the same time period, p = 0.05. Median survival was 56 months (95% CI: 40–72 months), compared to 30 months in both other cohorts. 3-year survival rates were 79%, 38% and 37%, respectively (p = 0.016). In multivariate analysis, the CHAARTED regimen was associated with significantly improved survival. Conclusion - In this rural health care setting, early docetaxel was feasible and effective in reducing progression to mCRPC and prolonging survival. Median survival was very close to the 58 months reported in the CHAARTED trial.

Ipilimumab was the first treatment that improved survival in advanced melanoma. Efficacy and toxicity in a real-world setting may differ from clinical trials, due to more liberal eligibility criteria and less intensive monitoring. Moreover, high costs and lack of biomarkers have raised cost-benefit concerns about ipilimumab in national healthcare systems and limited its use. Here, we report the prospective, interventional study, Ipi4 (NCT02068196), which aimed to investigate the toxicity and efficacy of ipilimumab in a real-world population with advanced melanoma. This national, multicentre, phase IV trial included 151 patients. Patients received ipilimumab 3 mg/kg intravenously and were followed for at least five years or until death. Treatment interruption or cessation occurred in 38%, most frequently due to disease progression (19%). Treatment-associated grade 3-4 toxicity was observed in 29% of patients, and immune-related toxicity in 56%. The overall response rate was 9%. Median overall survival was 12.1 months (95% CI: 8.3-15.9); and progression-free survival 2.7 months (95% CI: 2.6-2.8). After five years, 20% of patients were alive. In a landmark analysis from six months, improved survival was associated with objective response (HR 0.16, p = 0.001) and stable disease (HR 0.49, p = 0.005) compared to progressive disease. Poor performance status, elevated lactate dehydrogenase and C-reactive protein were identified as biomarkers. This prospective trial represents the longest reported follow-up of a real-world melanoma population treated with ipilimumab. Results indicate safety and efficacy comparable to phase III trials and suggest that the use of ipilimumab can be based on current cost-benefit estimates. This article is protected by copyright. All rights reserved.

Background/Aim: This study was designed to evaluate the prognostic impact of the previously validated LabBM score (serum lactate dehydrogenase, C-reactive protein, albumin, hemoglobin, platelets) in a new setting, namely patients with a limited number of brain metastases, arbitrarily defined as max. 4 brain lesions, from common tumor types such as lung and breast cancer. A total of 5 metastatic lesions overall were allowed to comply with current definitions of oligometastatic cancer. Patients and Methods: For this retrospective single-institution analysis, 101 patients were identified from a previously described, prospectively maintained database. Results: Twenty-one patients (21%) had extracranial metastases. Non-small cell and small cell lung cancer were the prevailing tumor types (78%). Forty-nine patients (49%) had normal blood test results (LabBM score 0 points). Their median survival (23 months) was significantly longer than that of patients with higher LabBM score. In multivariate analysis, LabBM score, performance status and single brain metastasis were associated with significantly better survival. Limited extracranial metastases did not impair prognosis. Patients with LabBM score 0 had a 5-year survival rate of 27% after surgery (n=24) and 39% after stereotactic radiotherapy (n=13), respectively (p=0.3). Conclusion: Blood biomarkers can be regarded as surrogate of the metastatic burden in the body, which is not always detectable by imaging methods. In contrast to circulating tumor cells and other emerging markers, the LabBM score is inexpensive. Patients with LabBM score >0 had a 2.8-fold increased risk of death. The score might be helpful in predicting survival improvement provided by ablative local treatment of oligometastases.

Background: Recently a prognostic score that predicts 12-month survival in patients treated with fractionated radiotherapy for painful bone metastases has been developed. Fractionated radiotherapy might cause unnecessary burden for patients with limited survival, thus estimation of survival is clinically relevant. The purpose of the present study was independent external validation of the new score and, in addition, its application in patients who received single fraction irradiation, a convenient option currently endorsed in several guidelines. Methods: We conducted a retrospective analysis of 270 patients, including 24% who had received single fraction irradiation. The three-tiered score was assigned as described in the development study, and included age, performance status and primary tumor type. Additional prognostic factors not studied in the development cohort, such as the Glasgow prognostic score (GPS) and presence of liver metastases, were included in this validation study. Results: The three-tiered score was valid in this independent cohort (12-month survival rates were 7%, 30% and 71%, respectively, P = 0.0001). Its performance and validity were also confirmed in the single fraction radiotherapy group. Three additional prognostic factors were significant in the multivariate analysis and may therefore contribute to decision making. Conclusions: Irrespective of fractionation, the score based on age, performance status and primary tumor type provides a readily available estimate of 12-month survival. J Clin Med Res. 2020;12(2):90-99 doi: https://doi.org/10.14740/jocmr4060

This is the accepted manuscript version of an article published by S. Karger AG in Oncology Research and Treatment. 2021;44(3):86-92, available at https://doi.org/10.1159/000513975. Purpose: The purpose of this study was to identify factors associated with the initiation or continuation of systemic treatment after brain irradiation. The outcome of interest was a utilization rate of at least 75%, given that active extracranial disease is common in patients with brain metastases. If left untreated, extracranial disease limits survival, regardless of successful local treatment of the brain metastases. In this context, systemic therapy has been shown to improve survival, e.g., after whole-brain radiotherapy. Patients and Methods: The study included 185 patients with active extracranial disease, 60% of whom received systemic therapy. Results: Survival from the start of brain irradiation was longest in patients who received additional immune checkpoint inhibitors, endocrine treatment, or anti-HER-2 drugs. After uni- and multivariate analyses, Eastern Cooperative Oncology Group performance status (PS) was selected as the first prediction criterion in the recursive partitioning analysis (RPA) decision tree analysis. RPA was successful for patients with PS 0–1, but patients with PS 2 had lower treatment utilization rates (maximum 60–70%, with a disease-dependent impact of age and LabBM score [blood test results]). The highest utilization rates were observed in (1) patients with PS 0 and (2) those with breast cancer, small-cell lung cancer, or lung adenocarcinoma with PS 1. Conclusions: These results inform the multidisciplinary discussion and treatment planning for the common scenario of simultaneous intra- and extracranial metastases.

Background: The aim of this study was to validate the prognostic impact of the recently introduced three-tiered LabBM score in patients with brain metastases. In contrast to the previous development and validation cohorts, the present cohort did not include patients treated with primary surgery and/or radiosurgery. The score is based on hemoglobin, platelet counts, albumin, C-reactive protein and lactate dehydrogenase. Methods: This was a retrospective single institution analysis. Overall, 167 patients managed with first-line whole-brain radiotherapy (WBRT) were identified from a prospectively maintained database. Results: The LabBM score significantly predicted overall survival (median 4.0, 2.9 and 1.5 months, respectively). Conclusions: The LabBM score is also valid in a patient population that differs from the previously studied cohorts, that is patients who were judged to be better candidates for WBRT than surgery or radiosurgery. As these patients in general represent a less favorable subset, their median survival was shorter than reported in the development cohort (11, 7 and 3 months, respectively). Future studies should examine whether or not combinations of the LabBM and other scores, for example, lung-molGPA and melanoma-molGPA, improve the clinical value of single scores. J Clin Med Res. 2019;11(5):321-325 doi: https://doi.org/10.14740/jocmr3746

The winter darkness or polar night induces endocrine and metabolic mechanisms, which might reduce the efficacy of cancer treatment and thus contribute to shorter survival. Moreover, season-and weather-related treatment delays and irregularities might also cause reduced efficacy of anti-cancer drugs. Therefore, this study evaluated the prognostic impact of timing of chemotherapy (start during winter darkness or outside of this season), in terms of overall survival, in patients with metastatic castration-resistant prostate cancer (MCRPC) who received oncology care at the Nordland hospital Bodø. The study included 111 patients treated with first-line docetaxel chemotherapy for MCRPC. Twenty patients (18%) started their treatment during winter darkness (arbitrarily defined as ±4 weeks around 21 December). In unadjusted univariate analysis, survival was shorter in this group (median 10.2 vs. 18.9 months, p = 0.055). However, not all baseline parameters were equally distributed between the two groups. In multivariable-adjusted Cox regression analysis accounting for several confounding variables, only one factor was statistically significant: pre-chemotherapy serum lactate dehydrogenase level (a surrogate marker of disease burden). Thus, the present results suggest that seasonal variation is not a major contributor to the diverging survival outcomes observed after docetaxel chemotherapy.

Background/aim Previous research has suggested that patients with metastatic renal cell cancer (mRCC) and bone metastases have a poorer prognosis compared to their counterparts with no skeletal involvement. Therefore, we analyzed the management and outcomes of such patients in our center. Patients and methods We performed a retrospective study of 35 consecutive patients who received systemic treatment, largely targeted therapy, for mRCC with bone metastases. Results The median overall survival was 25 months from the time of diagnosis of mRCC. The 5-year survival rate was 16%. Survival from diagnosis of mRCC was significantly worse in patients with bone metastases present at the start of first-line systemic therapy (median 13 months) compared to delayed metastases diagnosed later during the course of disease (46 months, p=0.01). Few patients (29%) were able to receive more than two lines of systemic therapy. Bone-only metastases were uncommon (11%). Conclusion Most patients with mRCC and bone metastases have limited overall survival.

Background/Aim: The aim of this study was to analyze the survival of patients with brain metastases treated with best supportive care or additional whole-brain radiotherapy (WBRT), in order to confirm results from the prospective randomized QUARTZ study, which suggested prolonged survival after WBRT (5 fractions of 4 Gy) if favorable prognostic factors were present (age younger than 60 years, graded prognostic assessment score 2.5-3 points). Patients and Methods: We performed a retrospective single institution analysis of 76 patients with favorable prognosis. In contrast to the QUARTZ trial, inclusion was not limited to patients with non-small cell lung cancer (NSCLC). Furthermore, a cohort treated with higher total doses of WBRT was included (10 fractions of 3 Gy). Results: All patients were younger than 60 years or had a graded prognostic assessment score of 2.5-3. The median survival was significantly shorter after best supportive care (1.2 months; 3.2 months after WBRT with 5 fractions of 4 Gy and 3.9 months after 10 fractions of 3 Gy). Also, in multivariate analyses, survival was significantly better after WBRT. Further favorable prognostic factors included better performance status, no or limited extracranial metastases and primary tumor other than gastrointestinal. Conclusion: In line with the QUARTZ trial results, WBRT prolonged survival in patients with favorable prognostic features.

Widely used prognostic scores, e. g., for brain or bone metastases, are based on disease- and patient-related factors such as extent of metastases, age and performance status, which were available in the databases used to develop the scores. Few groups were able to include patient-reported symptoms. In our department, all patients were assessed with the Edmonton Symptom Assessment System (ESAS, a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0–10) at the time of treatment planning since 2012. Therefore, we analyzed the prognostic impact of baseline ESAS symptom severity. Retrospective review of 102 patients treated with palliative radiotherapy (PRT) between 2012 and 2015. All ESAS items were dichotomized (below/above median). Uni- and multivariate analyses were performed to identify prognostic factors for survival. The most common tumor types were prostate, breast and non-small cell lung cancer, predominantly with distant metastases. Median survival was 6 months. Multivariate analysis resulted in six significant prognostic factors. These were ESAS pain while not moving (median 3), ESAS appetite (median 5), Eastern Cooperative Oncology Group (ECOG) performance status, pleural effusion/metastases, intravenous antibiotics at start or within 2 weeks before PRT and no systemic cancer treatment. Stronger pain while not moving and reduced appetite (below/above median) predicted significantly shorter survival. Development of new prognostic scores should include patient-reported symptoms and other innovative parameters because they were more important than primary tumor type, age and other traditional baseline parameters.

Palliative radiotherapy improves lung cancer related symptoms. Prognosis should be taken into account when deciding about fractionation. In this study, prognostic factors derived from multivariate analysis were used to assign a point sum reflecting 6-month survival. Four prognostic groups were compared. Performance status, lactate dehydrogenase, C-reactive protein, liver/adrenal gland metastases, and extrathoracic disease status significantly predicted survival and formed the basis of the score. The four groups had a median survival of 0.8, 1.6, 3.3, and 10.5 months (6-month survival 0, 10, 30, 70%; 12-month survival 0, 0, 12, 40%; p = 0.0001), respectively. In the unfavorable group best supportive care might be preferable.

Background Palliative thoracic radiotherapy is a common treatment for patients with incurable lung cancer. A recent study suggested that a prognostic score based on performance status and N and M stage predicts survival and might support decision-making (eg, when deciding about fractionation). Our aim was to perform a validation study in an independent, larger dataset. Patients and Methods This was a retrospective single-institution study of 232 patients with small- or non–small-cell lung cancer, with methodology comparable with that of the original study. Three subgroups were created, based on the point sum resulting from assessment of performance status and N and M stage (10-11, 12-14, 15-17 points). Results Performance status and N and M stage were significantly associated with overall survival after palliative radiotherapy in uni- and multivariate analyses. An unfavorable prognosis (10-11 points) was predicted in 56 patients (24%). Their median survival was 1.2 months. The intermediate group consisted of 137 patients (59%) with a median survival of 5.3 months. A favorable prognosis (15-17 points) was predicted in 39 patients (17%), whose median survival was 8.2 months. The difference between the intermediate and favorable subgroups did not reach statistical significance ( P = .1, as compared with P = .0001 for the remaining 2 comparisons). Conclusion In the original study, the median survival of patients in the 3 different prognostic strata was 2, 6, and 38 months. Except for the favorable subgroup, the validation study confirmed these results. Given the large, clinically highly relevant discrepancy (8 vs. 38 months), additional studies are needed in order to inform therapeutic decisions in patients with favorable point sum of 15 to 17.

Objective To describe the characteristics of patients who present with brain metastases already at first diagnosis of cancer and to evaluate overall survival (OS) and long-term survival. Methods Retrospective uni- and multivariate analyses in a group of 84 patients treated with different approaches. Results With respect to primary cancer type, the largest entities were adenocarcinoma non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) (34.5 and 21.4%, respectively). The most common diagnostic setting was symptomatic brain metastases (64 patients, 76.2%). Median OS was 7.2 months (one-year survival rate 31%). Four patients survived for at least three years, all had solitary metastases. The best survival was observed in the group managed with neurosurgical resection, median 17.7 months. Systemic treatment was also associated with better survival (median 9.7 vs. 2.8 months, p = 0.0001). Multivariate analysis revealed two prognostic baseline factors for OS, Karnofsky performance status (KPS) and number of brain metastases. Neurologic cause of death was uncommon (n = 14, 17%). Conclusion Long-term survival was limited and observed exclusively in the setting of a solitary brain metastasis. In patients with good KPS and limited number of brain metastases, systemic treatment as well as effective local treatment, such as resection and/or radiotherapy with sufficiently high equivalent dose, is warranted.

Background/Aim: The aim of this study was to analyze the prognostic impact of biomarkers, such as serum lactate dehydrogenase (LDH), in patients with oligometastatic castration-resistant prostate cancer, arbitrarily defined as a maximum of five metastatic lesions. Patients and Methods: This was a retrospective single-institution analysis. Overall 34 patients were included, all of whom received first-line docetaxel without ablative local treatment. Results: Twelve patients (35%) had elevated LDH (≥255 U/l). Their median survival was significantly shorter than that of patients with normal LDH. Due to an interaction with other biomarkers, multivariate Cox regression analysis was performed. The latter showed that serum hemoglobin was the only significant predictor of survival. Conclusion: Correct diagnosis of oligometastatic disease is not trivial, because all radiological modalities are limited by certain thresholds for detection of small metastases. Serum biomarkers may reflect the total burden of malignant disease. However, this relatively small study did not clearly demonstrate that elevation of LDH may be useful for clinical decision-making, e.g. in terms of adding local treatment for all sites of metastatic spread.

Source at https://doi.org/10.1080/22423982.2019.1620086. The goal of the Norwegian Ministry of Health and Care Services is to offer an equal health-care service with the same outcomes wherever people are living within the country. The aim of this study was to evaluate whether this was true for patients diagnosed with metastatic prostate cancer (mPC) and living in Nordland County, a region with a challenging geography and climate and having, several small and remote communities and only 1 department of oncology. The latter is located in the main city, Bodø. We also compared a subgroup living in communities having lower average annual income (less than NOK 240,000 (equivalent to USD 28,600)) with patients living in Bodø (NOK 285,000 (USD 33,900)). Overall 288 patients were included and stratified into 3 subgroups (favourable distance and income, unfavourable distance and income, and unfavourable distance and favourable income). No statistically significant differences were observed regarding patient characteristics. There was no indication towards under-treatment among patients from the distant regions or the lower income region. Given that disparities were not observed, it was not surprising to see comparable survival outcomes (p=0.35). In conclusion, these results suggest that the health-care system in Nordland County successfully delivers state-of-the-art oncology care to patients with mPC.

Background/Aim - The aim of this study was to analyze the prognostic impact of serum lactate dehydrogenase (LDH) in patients with oligometastatic brain metastases, arbitrarily defined as max. Four brain lesions and 5 metastatic lesions overall. Patients and Methods - This was a retrospective single institution analysis. Overall, 42 patients were identified from a prospectively maintained database. Results - Seventeen patients (40%) had extracranial metastases. Twelve patients (29%) had elevated LDH (≥255 U/l). Their median survival was significantly shorter than that of patients with normal LDH. Due to an interaction with performance status, this result was separately confirmed in patients with performance status ≥70. Conclusion - Oligometastatic disease is not always correctly diagnosed, because all radiological modalities are limited by certain thresholds for detection of small metastases. We hypothesize that LDH is associated with survival, because this biomarker may reflect the total burden of malignant disease. Future studies should examine whether or not ablative local treatment of oligometastases is warranted in patients with elevated LDH.

Background/aim The aim of this study was to analyze differences in symptom burden, baseline and outcome parameters, including completion of palliative radiotherapy and 30-day mortality, between patients treated with palliative radiotherapy (RT) who were managed exclusively by regular oncology staff or a multidisciplinary palliative care team (MPCT) in addition. Patients and methods This was a retrospective single-institution analysis. Comparison of two groups of patients: MPCT versus none (n=36 and 65, respectively). All patients provided Edmonton symptom assessment system (ESAS) data before RT. Results The MPCT group included significantly more patients with reduced performance status. Furthermore, these patients had higher ESAS symptom scores, except for two items (dyspnea, sleep). The largest differences were observed for pain, fatigue, anxiety and depression. The significant difference in pain scores was also reflected in different opioid medication rates. Failure to complete radiotherapy was more common in the MPCT group (11 and 2%, respectively, p=0.05). Thirty-day mortality was different, too (28 and 2%, respectively, p=0.0001). The Kaplan-Meier survival curves were not significantly different (1-year survival rates 21 and 25%, respectively, p=0.27). Conclusion The MPCT group was characterized by a higher symptom burden. Prognostic factors such as performance status were not balanced between the two groups. Despite this fact, actuarial overall survival was comparable. Given the high rate of 30-day mortality in the MPCT group, efforts to optimize criteria for initiation of radiotherapy are warranted.

Oncologists commonly overestimate the survival time of patients receiving palliative therapy, which may result in the administration of treatments that are too aggressive for patients near the end of their lives. Previous studies have discussed the negative implications of palliative radiotherapy if administered during the last month of life. Models predicting a limited survival time may improve the ability of the oncologists to tailor the treatment according to the needs of each individual patient. In the present study, prognostic factors for survival time, and the use of palliative radiotherapy during the last month of life, were analyzed in 873 patients. Models predicting the likelihood of administering such therapy were examined, and the risk of receiving radiotherapy during the last month of life was observed to be lower in patients with non-metastatic cancer than in those with metastatic cancer (7 vs. 13%, respectively; P=0.12). On multivariate analysis, 11 factors that significantly influenced the survival time were identified. These findings emphasize the complexity of potential prediction models. The most important risk factor regarding the prediction of extremely short survival times was observed to be an Eastern Cooperative Oncology Group performance status (ECOG PS) of 4, followed by an ECOG PS of 3 (median survival times, 14 and 64 days, respectively). A limited number of patients who received palliative radiotherapy during their last month of life died unexpectedly. Disease-specific prediction models were developed; however, the small number of events available for analysis limited their immediate clinical impact. Furthermore, these prediction models identified a minority of patients who received radiotherapy during the last month of life. In conclusion, the majority of the palliative radiotherapy courses administered to patients with advanced cancer during their last month of life may be preventable if accurate decision models for the clinic are developed. However, due to the complexity associated with the prediction of survival times in patients receiving palliative radiotherapy, large databases are required to allow accurate models to be established. The present study also discusses the recommendations of the Department of Oncology and Palliative Medicine of Nordland Hospital (Bodø, Nordland, Norway) with regard to the use of palliative radiotherapy during the last month of life of patients with terminal cancer.

Purpose To analyze indications for early palliative radiation therapy (RT) (ie, start within 1 month from cancer diagnosis), regimens used in clinical practice, rate of treatment completion and treatment in the last 30 days of life, and overall survival. Methods and materials Retrospective uni- and multivariate analyses covering a 4.5-year inclusion period. Results Seventeen percent of all palliative RT courses were administered in the specified time frame (n = 100 patients, 30 Gy in 10 fractions in 49%). Common indications were bone and brain metastases, whereas metastatic spinal cord compression or other emergencies comprised a minority. Only 14% of patients had no distant metastases. Most patients had non-small cell lung cancer (51%), whereas other high-incidence primary tumors such as breast, prostate, and colorectal cancer combined comprised 10%. Failure to complete RT occurred in 6%. Median survival was 3.6 months. A startling high rate of RT in the last 30 days of life was observed (19%). Risk correlated significantly with performance status and extent of metastatic disease. Conclusions The study population of patients who received early palliative RT is not identical to the general population described in previous studies, which covered the entire disease trajectory. Median survival was relatively short and rate of RT in the last 30 days of life higher than expected. Need for early palliative RT might be caused by large symptom burden and/or contraindication(s) for other management options, and might in many cases also be associated with adverse prognostic features and aggressive disease.

This study aims to explore patterns of practice of tumor marker analyses and potential prognostic impact of abnormal markers in patients with brain metastases from solid tumors. Previously, lactate dehydrogenase (LDH) and albumin were identified as relevant biomarkers. We performed a retrospective analysis of 120 patients with known LDH and albumin treated with whole-brain radiotherapy (WBRT) in two different situations: (1) brain metastases detected at initial cancer diagnosis (n = 46) and (2) brain metastases at later time points (n = 74, median interval 13 months). Twenty-six patients (57 %) from group 1 had at least one tumor marker analyzed, and 11 patients (24 %) had abnormal results. Twenty-two patients (30 %) from group 2 had at least one tumor marker analyzed, and 16 patients (22 %) had abnormal results. When assuming that LDH and albumin would be standard tests before WBRT, additional potential biomarkers were found in 36 % of patients with normal LDH and albumin. Marker positivity rates were for example 80 % for carcinoembryonic antigen (CEA) in colorectal cancer and 79 % for CA 15-3 in breast cancer. Abnormal markers were associated with presence of liver metastases. CA 15-3 values above median predicted shorter survival in patients with breast cancer (median 1.9 vs. 13.8 months, p = 0.1). Comparable trends were not observed for various markers in other tumor types. In conclusion, only a minority of patients had undergone tumor marker analyses. Final group sizes were too small to perform multivariate analyses or draw definitive conclusions. We hypothesize that CA 15-3 could be a promising biomarker that should be studied further.

Previous research has identified disparities between urban and rural cancer care, including clinical trial access. Therefore, we addressed three different questions in patients with metastatic renal cell cancer managed according to national guidelines in a rural Norwegian standard practice setting. (1) How many patients would have been eligible for three recent landmark randomized clinical trials? (2) Is survival different between eligible and non-eligible patients receiving first-line systemic therapy? (3) Is survival different between eligible patients and published trial results? We performed a retrospective analysis of 101 consecutive patients (2006-2016). Only 52% of the patients were eligible for the first-line study of pazopanib versus sunitinib. The main reasons for violating inclusion or exclusion criteria were presence of brain metastases, absence of clear cell histology, and poor performance status. Even fewer patients were eligible for trials of nivolumab and cabozantinib in pre-treated patients. Eligible patients had significantly better survival than non-eligible patients, median 29.2 versus 8.5 months (p = 0.0001). These results confirm that many patients from rural practices do not fulfill all mandatory trial eligibility criteria. However, eligible patients managed according to national guidelines had survival outcomes in line with published first-line trial results.

The following article: Nieder, C., Mannsåker, B., Dalhaug, A., Pawinski, A. & Haukland, E. (2017). The Glasgow prognostic score: Useful information when prescribing palliative radiotherapy. Molecular and clinical oncology, 6, 811-816. https://doi.org/10.3892/mco.2017.1228 was published 26 April 2017 in Molecular and clinical oncology. Source at https://doi.org/10.3892/mco.2017.1228. The purpose of the present retrospective study was to investigate whether a score reflecting systemic inflammatory processes [the Glasgow Prognostic Score (GPS)] provides relevant information for radiation oncologists. GPS is a three‑tiered score [0: normal C-reactive protein (CRP) and albumin; 1: one abnormal result; 2: increased CRP and low albumin]. Correlations between disease type and extent, resource utilization, survival and GPS were analyzed in 703 patients. In the subgroup with GPS 2, significantly higher rates of lung, adrenal gland and liver metastases were observed. An increasing GPS score was associated with a higher likelihood of anemia, leukocytosis and thrombocytosis. Comparable findings were made regarding utilization of palliative care resources, need for blood transfusion and intravenous administration of antibiotics. Compared with GPS 0 or 1, more patients with GPS 2 did not complete their prescribed course of radiotherapy. One-third of patients with GPS 2 received treatment during the final month of life. Multivariate analysis demonstrated that GPS was a significant prognostic factor for overall survival (median, 479, 136, and 61 days, for GPS 0, 1 and 2, respectively). In patients with GPS 2 and additional leukocytosis, the median survival was 38 days. In conclusion, GPS provides important prognostic information. This biomarker-based score may be considered for deciding fractionation, and should be validated further.

Aims To explore the role of expanded assessment of metastatic extracranial organ involvement, as well as albumin and lactate dehydrogenase (LDH), i.e. surrogates of disease extent, in survival prediction models for patients with brain metastases. Materials and methods A retrospective analysis of 189 patients treated with whole brain radiotherapy was carried out. Uni- and multivariate analyses included recursive partitioning analysis classes, basic score for brain metastases and diagnosis-specific graded prognostic assessment (DS-GPA). Results Elevated LDH correlated significantly with extracranial organ involvement, low albumin with primary tumour type and primary tumour control. Elevated LDH, low albumin and a combination of both correlated significantly with overall survival. LDH, albumin and the number of extracranial organs involved (none, one, two or more harbouring metastases) were independent prognostic factors in multivariate analyses (if added to the three established scores mentioned above and also if added to individual parameters such as age, performance status, etc.). A combination of these three new prognostic factors predicted very short survival (median 0.7 months if all three were present). Conclusion We have previously defined patient groups in whom foregoing radiotherapy was unlikely to compromise survival. These were patients with a DS-GPA score of 0–1.5 points and age ≥75 years or Karnofsky performance status ≤50 or uncontrolled primary tumour with extracranial metastases to at least two organs. Patients with a combination of three new adverse features (elevated LDH plus low albumin plus extracranial metastases to at least two organs) might also be considered for best supportive care. Furthermore, it appears warranted to study whether scores such as DS-GPA can be optimised by integrating information on these three parameters.

Purpose. Validation of a Canadian three-tiered prognostic model (survival prediction score, SPS) in Norwegian cancer patients referred for palliative radiotherapy (PRT), and evaluation of age-dependent performance of the model. Patients and Methods. We analyzed all 579 PRT courses administered at a dedicated PRT facility between 20.06.07 and 31.12.2009. SPS was assigned as originally described, That is, by taking into consideration three variables: primary cancer type, site of metastases, and performance status. Results. Patients with poor prognosis (non-breast cancer, metastases other than bone, and Karnofsky performance status (KPS) ≤ 60) had median survival of 13 weeks. Those with intermediate prognosis (two of these parameters) survived for a median of 29 weeks, and patients with good prognosis for a median of 114 weeks, P<0.001. While this model performed well in patients who were 60 years or older, it was less satisfactory in younger patients (no significant difference between the good and intermediate prognosis groups). Conclusion. SPS should mainly be used to predict survival of elderly cancer patients. However, even in this group accuracy is limited because the good prognosis group contained patients with short survival, while the poor prognosis group contained long-term survivors. Thus, improved models should be developed.

This study aimed to develop a survival prediction model that might aid decision making when choosing between best supportive care (BSC) and brain radiotherapy (RT) for patients with brain metastases and limited survival expectation.A retrospective analysis of 124 patients treated with BSC, whole brain radiotherapy (WBRT), or radiosurgery was conducted. All patients had adverse prognostic features defined as 0-1.5 points according to the diagnosis-specific graded prognostic assessment score (DS-GPA) or GPA if primary tumor type was not among those represented in DS-GPA. Kaplan-Meier survival curves were compared between patients treated with BSC or RT in different scenarios, reflecting more or less rigorous definitions of poor prognosis. If survival was indistinguishable and this result could be confirmed in multivariate analysis, BSC was considered appropriate.Irrespective of point sum examined, DS-GPA by itself was not a satisfactory selection parameter. However, we defined a subgroup of 63 patients (51 %) with short survival irrespective of management approach (only 5 % of irradiated patients survived beyond 6 months; they had newly diagnosed, treatment-naïve lung cancer), i.e., patients in whom foregoing RT was unlikely to compromise survival. These were patients with 0-1.5 points and aged ≥ 75 years, had Karnofsky performance status ≤ 50, or had uncontrolled primary tumor with extracranial metastases to at least two organs.BSC is a reasonable choice in patients with limited life expectancy. After successful external validation of the selection criteria developed in this analysis, identification of patients who are unlikely to benefit from WBRT might be improved.

Source at https://doi.org/10.1080/22423982.2016.1270080 . The aim of this study was to reduce barriers that prevent implementation of evidence-based recommendations about single-fraction palliative radiotherapy (PRT) and to demonstrate that single-fraction PRT yields similar outcomes as long-course treatment (≥10 fractions) in patients with bone metastases from breast cancer. This retrospective study (2007–2014) included 118 Norwegian female patients. All patients received guideline-conform systemic therapy including bone-targeting agents. Median survival was 12.7 months. Long-course PRT was prescribed in 60% of patients, while 21% had PRT with a single fraction of 8 Gy to at least one target. Reirradiation rate was not significantly higher after 8 Gy (9%, compared to 5% after long-course PRT and 6% after 4 Gy x5). Patients with favorable baseline characteristics such as younger age and good performance status (PS) were significantly more likely to receive long-course PRT. Biological subtype and comorbidity did not correlate with fractionation. Prognosis was influenced by biological subtype, extra-skeletal disease extent, severe anemia and abnormal CRP. The limited need for reirradiation after single fraction PRT might encourage physicians to prescribe this convenient regimen, which would improve resource utilization. Even patients with PS3 had a median survival of 3 months, which indicates that they could experience worthwhile clinical benefit.

Source at https://doi.org/10.14740/jocmr2653w. Accepted manuscript version, licensed CC BY-NC-ND 4.0. Background: The aim of the study was to explore the prognostic impact of different abnormal blood tests and the tumor marker CA 15-3 as well as established parameters such as disease extent and receptor status in patients with bone metastases from breast cancer who received palliative radiotherapy in addition to contemporary systemic treatment. Methods: This was a retrospective uni- and multivariate analysis of 118 female patients treated in the time period from 2007 to 2014 (median follow-up 28 months). Results: The median age was 61 years and the median time interval from the initial diagnosis of breast cancer was 57 months (median time interval from metastatic disease to radiotherapy was 7 months). Only 16% of patients had normal serum CA 15-3. HER2 receptor status correlated with CA 15-3. The median survival was 17.6 months (lowest CA 15-3 quartile), 14.7 months (intermediate), and 6.9 months (highest quartile) (P = 0.002). However, multivariate analysis showed that survival was influenced by extent of extra-skeletal metastases, pleural metastases/effusion, lung metastases, estrogen receptor status, serum C-reactive protein, and anemia with need for blood transfusion (all P < 0.05) rather than CA 15-3. Conclusions: Survival was highly variable. The tumor marker CA 15-3 did not provide independent prognostic information. Nevertheless, the results of simple blood tests contributed to the multivariate prognostic model.

BACKGROUND/AIM Patients with bone-only metastases survive longer than patients with widespread visceral disease. We analyzed the prognostic impact of different baseline parameters, such as abnormal blood tests and receptor status in patients who received local radiotherapy, in addition to contemporary systemic treatment, according to national guidelines. PATIENTS AND METHODS Retrospective uni- and multivariate analyses of 57 consecutive female patients treated in the time period 2007-2014 (median follow-up=29 months). RESULTS The median age was 59 years and the median time interval from the initial diagnosis of breast cancer was 57 months. The median survival was 23 months from radiotherapy and 32 months from initial diagnosis of metastatic disease. Five-year survival rates were 13 and 21%, respectively. Survival after radiotherapy was significantly longer in patients who were prescribed higher radiation doses; 29 months after ≥30 Gy and 10 months after

Connections exist between inflammation and cancer, for example with regard to disease progression and prognosis. Therefore, we investigated whether systemic inflammatory processes indicated by increased serum C-reactive protein (CRP) provide prognostic information for physicians prescribing palliative radiotherapy.We analyzed data from 781 patients and evaluated prognostic factors for survival.Only 277 patients (35%) had CRP8 mg/l before radiotherapy. No significant association was observed between CRP level and steroid treatment. In patients with the highest CRP level (60 mg/l, 20% of patients), intravenous therapy with antibiotics was more common. CRP significantly influenced survival and contributed prognostic information together with established parameters, such as performance status (PS). In the multivariate model, white blood cell count did not provide relevant additional information. A simple four-tiered prognostic score solely based on CRP showed promising results.Most patients treated with palliative radiotherapy had increased CRP. This widely available biomarker might improve decision-making and should be further validated.

Objective To evaluate disease pattern, patient characteristics, and survival in patients treated for brain metastases from renal cell carcinoma. Methods Retrospective analysis of all patients with brain metastases from renal cell carcinoma treated between 1983 and 2009 in northern Norway. Results The time interval between first cancer diagnosis and brain metastases was dependent on initial TNM stage (median 42 months in stage II vs. 10 months in both stage III and stage IV). Only few patients did not harbor extracranial metastases. Systemic therapy after diagnosis of brain metastases has been used in only three patients. Surgical resection and/or radiosurgery have been administered in 34% of patients, but whole-brain radiotherapy (WBRT) alone remained the cornerstone. Median survival was 4.1 months (3.7 months in the WBRT alone group, 10.1 months in the surgery and/or radiosurgery group). Two factors were significantly associated with better survival: solitary brain metastasis and age ≤64 years. The prognostic impact of the recursive partitioning analysis classes was not confirmed, while the new graded prognostic assessment index performed better. Conclusions Surgical resection and/or radiosurgery contribute to prolonged survival. As most patients harbor extracranial metastases that threaten their lives, systemic treatment theoretically might play a role in the management of these patients, but more data need to be collected to confirm the clinical impact of immunotherapy, angiogenesis inhibition, and other signal transduction inhibitor approaches.