Palliative Prognostic Score (PaP)

The PaP score explained

The Palliative Prognostic Score was originally developed for use in cases of solid tumors and has been validated in large prospective studies. It predicts 30-day survival based on the Karnofsky Performance Score (KPS) and five other criteria: dyspnea, anorexia, clinical prediction of survival in weeks, total WBC and lymphocyte percentage:

• Dyspnea: No (0), Yes (+1);
• Anorexia: No (0), Yes (+1.5);
• Karnofsky Performance Status: >30 (0), <20 (+2.5);
• Clinical Prediction of Survival (weeks): >12 (0), 11-12 (+2), 9-10 (+2.5), 7-8 (+2.5), 5-6 (+4.5), 3-4 (+6), 1-2 (+8.5);
• Total WBC: Normal (4.8-8.5) (0), High (8.5-11) (+0.5), Very High >11) (+1.5);
• Lymphocyte %: Normal (20-40) (0), Low (12-19.9) (+1), Very Low (<11.9) (+2.5).

The PaP score is particularly clinically useful in palliative care practice in oncologic illnesses that virtually always warrant a poor prognosis, such as pancreatic cancer, untreated small cell lung cancer, metastatic adenocarcinomas etc.

PaP cores range from 0 to 17.5 and patients are divided into three groups, based on survival prediction:

• 0 - 5.5: 30-day survival probability >70%;
• 6 - 11.0: 30-day survival probability 30-70%;
• 1 – 17.5: 30-day survival probability <30%.

About the original study

The score was constructed based on factors identified in a prospective multicenter study by Pirovano et al., of 519 terminally ill cancer patients with a median survival of 32 days.

An exponential multiple regression model was adopted to evaluate the joint effect of some clinico-biological 36 variables on survival.

A numerical score was given to each variable, based on the relative weight of the independent prognostic significance shown by each single category in the multivariate analysis.

The sum of the single scores was then used to subdivide the study population into three groups, each with a different probability of survival at 30 days.

• 178 (34.3%) patients were classified in risk group A (30-day survival probability >70%) with median survival of 64 days;
• 205 (39.5%) patients were in risk group B (30-day survival probability 30-70%) with median survival of 32 days;
• 136 (26.2%) patients were in risk group C (30-day survival probability <30%) with median survival of 11 days.

Validation study

The study by Glare and Virik, set out to validate the Palliative Prognostic Score in a population of 100 terminally ill hospitalized patients, consecutively referred to a palliative medicine consultation service.

The PaP score was found able to subdivide this heterogeneous patient population into three groups, the differences being highly statistically significant. Median survivals for the three groups were:

• 60 days (95% confidence interval 41-89 days);
• 34 days (25-40);
• 8 days (2-11).

The 30-days percentage survival for the three groups was found to be 66%, 54%, and 5% respectively.

References

Original reference

Pirovano M, Maltoni M, Nanni O. A new Palliative Prognostic Score: a first step for the staging of terminally ill Cancer patients. J Pain Symp Manage. 1999; 17(4):231-239.

Validation

Glare P, Virik K. Independent validation of Palliative Prognostic Score in terminally ill patients referred to a hospital-based palliative medicine consultation service. J Pain Symp Manage. 2001; 22(5):891–898.

Maltoni M, et al. Successful Validation of the Palliative Prognostic Score in Terminally Ill Cancer Patients. J Pain and Symptom Manage. 1999; 17:240-247.

Other references

Glare P, Eychmueller S, Virik K. The use of the palliative prognostic score in patients with diagnoses other than cancer. J Pain Symp Manage. 2003; 26(4):883-885.