Clinical predictors of survival in advanced cancer

Prognostication is one of the three cardinal clinical skills. Although it has been undervalued by modern medicine compared with diagnostics and therapeutics, poor prognostication can have dire consequences for the patient with advanced cancer, almost as serious as the wrong diagnosis or treatment. Oncologists relying on their subjective judgment for predicting survival often will be inaccurate, usually as too optimistic, which may result in overly aggressive cancer treatment. Actuarial judgment, based on assessment of statistically derived key factors, has the potential to improve prognostic accuracy. These factors in patients with advanced cancer differ from those in patients with newly diagnosed disease; they include performance status, symptoms of the cancer cachexia syndrome, and patient-rated quality of life, rather than tumor size, tumor grade, or extent of disease. Laboratory markers such as leukocytosis or lymphopenia also appear to be useful. Novel markers include acute phase reactants (C-reactive protein, vitamin B12) and cytokines that may provide more objective evidence of survival prospects. Prognostic indices, nomograms, and web-based tools are in development for the advanced cancer population. Identifying the clinical markers predicting for short-term survival in patients with advanced cancer is important to help form the basis for teaching prognostication skills to physicians.