Centro Interdipartimentale di Ricerche sul Cancro «Giorgio Prodi»
Is the ‘surprise’ question a useful trigger to predict those advanced cancer patients who could benefit from early palliative care? A prospective study among general practitioners.
Giulia Galli
8th World Research Congress of the European Association for Palliative Care
Lleida, 5 – 7 June 2014
The Academy of Sciences of Palliative Medicine is coordinated by the Isabella Seràgnoli Foundation Bologna
The ‘Surprise’ Question In Advanced Cancer Patients
“WOULD YOU BE
TSURPRISED
HE ‘SURPRISE
IF THIS ’
“WOULD YOU BE
SURPRISED IF THIS
PATIENT DIED
WITHIN A YEAR?”
PATIENT
DIED WITHIN A
QUESTION
YEAR?”
Della Penna R. Asking the right question, J Pall Med
2001
GSF Prognostic Indicator Guidance, Version 4, 2011
The ‘Surprise’ Question In Advanced Cancer Patients
METHODS‐1
‐2
Design: Prospective cohort study
Aim of the study: assessment of the reliability of the fase 1: clinical assessment of patients and answer to the SQ
GP’s answer to the 1‐year ‘surprise’ question.
THE STUDY
fase 2: patients’ status at 12‐month interval
Statistical
Subjects analysis:
of the study: 50 randomly selected
general
practitionersETHODS
from
the Bologna area in
Comparison of variables in the two
groups: Fisher’s Test and t‐test;
Italy.
M
Sensitivity, specificity, PPV and NPV of the answer given to the SQ; MCC;
Patients’ 1‐year survival curves: Kaplan‐Meier method;
Patients who were cared by the GP
and who had
advanced
stage cancer (stage IV), excluding those
Determination of the prognostic factors influencing the risk of death at 1 withand multivariate Cox proportional hazard regression models; onco-haematological disorders.
year: univariate
Measurement of the risk of death at 1 year for the SQ’s answer: odds ratio (OR). The ‘Surprise’ Question In Advanced Cancer Patients
RESULTS‐1
DEMOGRAPHICS AND CANCER SITE OF PATIENTS
Patients
All
(N = 231)
Yes
(N = 105)
No
(N = 126)
P value
Mean age
(years±SE)
70.2 (0.9)
69.5 (1.3)
70.7 (1.2)
0.47
Men, n (%)
117 (50.6)
57 (54.3)
60 (47.6)
0.36
Lung
47 (20)
16 (15)
31 (25)
Breast
46 (20)
28 (27)
18 (14)
Colon
33 (14)
17 (16)
16 (13)
Prostate
18 (8)
13 (12)
5 (4)
Pancreas
15 (6)
2 (2)
13 (10)
Ovary‐Uterus
15 (6)
6 (6)
9 (7)
Other sites
57 (25)
23 (22)
34 (27)
Cancer, n (%)
THE STUDY
RESULTS
0.003
Moroni M et al, Palliat Med, March 2014 The ‘Surprise’ Question In Advanced Cancer Patients
RESULTS‐2
‐3
DAYS OF‘SURPRISE
SURVIVAL’ IN
1 YEAR FOR(231 evaluable
‘YES’ AND ‘N
O’ GROUPS
QUESTION
cases)
100
‘Yes’
Group
Alive
SURVIVAL %
75
Deceased
Log‐rank P < 0.0001
‘Yes’
88
17
50
Mean (+SE) Days Alive
‘No’
25
PREDICTIVE
VALUE
39
‘Yes’ = 346.9 + 5.9
87
PPV 83.8%
(C.I. 75.3 – 90.3)
‘No’
NPV 69.0%
(C.I. 60.2 – 77.0)
‘No’ = 214.8 + 14.2
Sensitivity = 69.3% (C.I. 60.5 – 77.2)
0 Specificity = 83.6% (C.I. 75.1 – 90.2)
0 2 4 6 8 10 12
MCC = 0.53
MONTHS FROM ‘SURPRISE ’ QUESTION
Moroni M et al, Palliat Med, March 2014 The ‘Surprise’ Question In Advanced Cancer Patients
RESULTS‐4
‐5
UNIVARIATE COX REGRESSION TO PREDICT STATUS AT 1 YEAR
Hazard Ratio
95% CI
p value
MULTIVARIATE COX REGRESSION
1.015
(0.994, 1.036)
0.169
Age (years)
TO PREDICT 0. 775
STATUS (0.484, 1.241)
AT 1 YEAR 0.288
Sex (reference=male)
Variable
Site of cancer
(reference=lung)
Variabile
(reference=breast)
(reference =colon)
(reference
=pancreas)
Site of cancer
(reference=prostate)
(pancreas)
(reference=ovary‐uterus)
‘surprise’ question Specialisation
(reference=yes)
(reference=yes)
‘surprise’ question
(reference=yes) Doctor’s experience
Hazard 0.663
1.983
Ratio
1.382
0.354
2.228
3.517
1.955
(0.392, 1.121)
95% CI
(0.986, 3.993)
(0.662, 2.884)
(0.176, 0.714)
(0.772, 6.432)
(0.862, 14.347)
(0.615, 6.216)
0.125
p value
0.055
0.389
0.004
0.139
0.080
0.256
1.254
6.978
(0.727, 2.162)
(2.418, 20.134)
0.417
0.000
6.987
(3.747, 13.029)
0.000
1.002
(0.963, 1.042)
0.925
Moroni M et al, Palliat Med, March 2014 The ‘Surprise’ Question In Advanced Cancer Patients
CONCLUSIONS‐1
The answer to the 1‐year ‘surprise’ question given by generalists is a fairly
accurate predictor of advanced cancer patients’ status at 12‐months.
THE STUDY
When the answer to the SQ was positive, physicians accurately predicted
survival in more than 4/5 of the patients.
CONCLUSIONS
At the univariate Cox analysis the hazard ratio (HR) of a negative response
to the surprise question was 6.99 (95% CI: 3.75‐13.03). Patients in the ‘No’ group had an odds ratio of 11.55 (95%CI: 5.83‐23.28) of
being dead within the year, when compared to those in the ‘Yes’ group
(p=0.000). The ‘Surprise’ Question In Advanced Cancer Patients
CONCLUSIONS‐2
The SQ’s PPV (83,8%) suggests that the ‘surprise’ question is a good screening test to identify patients with an increased risk
of death within the year, among a population affected by
advanced stage cancer (stage IV).
The study suggests that the GP’s have a tendency to
underestimate the prognosis of their patients with
advanced neoplastic disease.
39 patients out of the 126 (30.7%) assigned to the ‘No’ group resulted
to have lived beyond the 12‐month observation period
The ‘Surprise’ Question In Advanced Cancer Patients
The 'surprise' question in advanced cancer patients: A prospective study among general practitioners
Matteo Moroni, Donato Zocchi, Deborah Bolognesi, Amy Abernethy, Roberto Rondelli, Giandomenico Savorani, Marcello Salera, Filippo G. Dall’Olio, Giulia Galli, Guido Biasco on behalf of the SUQ‐P Group.
Published online 24 March 2014 Palliat Med; DOI: 10.1177/0269216314526273.
THE AUTHORS WOULD LIKE TO THANK…
Surprise Question Practitioners group (SUQ‐P group) of the Emilia‐Romagna Region, Italy:
Antonio Balduzzi, Giulio Bandi, Laura Baraldini, Salvatore Bauleo, Luigi Bertini, Paolo Borghi, Paolo
Calzoni, Maurizio Camanzi, Antonino Cammarata, Piero Casarini, Roberto Cau, Cecilia Deni, Shirley Ehrlich,
Giuliano Ermini, Livio Franco, Giancarlo Furlò, Marina Grandi, Antonio Luigi Lalli, Marco Maccaferri, Carla
Marzo, Angelo Masi, Annunzio Matrà, Piero Mazzetti Gaito, Federico Montanari, Massimo Oggianu,
Gianluca Ognibene, Maria Palasciano, Saida Palestini, Fernando Perrone, Stefano Quadrelli, Antonino
Rappacciolo, Stefano Rubini, Marcello Salera, Sandra Santi, Giandomenico Savorani, Alberto Serio, Anna
Maria Severino, Matteo Siena, Pietro Speziali, Luigi Spinnato, Cesare Tosetti, Pietro Velonà, Andrea Verri,
Donato Zocchi.
Contact author: [email protected]