말기 암 환자의 생존기간 예측: 혈액학 검사와 PPI에 대한 전향적 연구
Survival Prediction in Terminally Ill Cancer Patients: Laboratory Variables and Prospective Validation of The Palliative Prognostic Index
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목적: 말기 암 환자를 진료하는 데 있어서 환자의 생존기간을 예측하는 것은 중요한 문제로 Palliative Prognostic Index (PPI)는 임상적 증상을 이용하여 남은 여생기간을 예측할 수 있게 고안되었다. 본 연구에서는 말기 암 환자에서 조기 사망 위험도를 높이는 위험인자를 알아내고, PPI가 3주 생존기간 예측을 위한 예후인자로서 유용한가를 알아보고자 하였다. 방법: 2008년 6월부터 2010년 3월까지 말기 암 환자로 완화치료를 목적으로 완화병동에 입원한 222명의 환자를 대상으로 사망 시까지 조사하였다. PPI 점수는 수행능력, 식이섭취, 부종, 휴식 시 호흡곤란 그리고 섬망 다섯 가지로 구성되었다. PPI 점수에 의해 환자는 3 그룹으로(그룹 1: PPI ≤ 4, 그룹 2: 4 < PPI ≤ 6, 그룹 3: PPI > 6) 분류하였다. 이와 더불어 입원 당시 혈액 검사 소견(백혈구, 림프구, C-반응성 단백질, 빌리루빈, 알부민, 크레아티닌, LDH)을 조사하였다. 결과: 그룹 1은 46명으로 평균 생존기간이 50일, 그룹 2는 51명으로 생존기간이 22일, 그룹 3은 125명으로 14일이었다. 그룹 3인 경우 3주 이내 사망률에 대한 민감도는 76.5%, 특이도 65.4%, 양성예측도 70.4%, 음성예측도 72.2%의 소견을 보였다. 3주 생존율에 대한 유의한 영향을 미치는 인자는 PPI > 6, 빌리루빈 > 1.3 mg/dL 및 C-반응성 단백질 > 10.3 mg/dL이었다. PPI > 6 + C-반응성 단백질 > 10.3 mg/dL + 빌리루빈 > 1.3 mg/dL인 경우가 AUC 0.77로 가장 높았다. 결론: 임상적 증상으로 비교적 쉽고 빠르게 이용할 수 있는 PPI는 3주 생존기간 예측에 적용할 수 있었다. 고빌리루빈혈증과 C-반응성 단백질은 간암 및 담도췌장암과 소화기암에서는 3주 생존기간을 예측할 때 도움을 줄 수 있는 인자로 생각한다.
Abstract
Background/Aims: The palliative prognostic index (PPI) was designed to predict life expectancy based on clinical symptoms. In this study, a PPI was constructed and used with other biological parameters to predict 3-week survival in patients with advanced cancer. Methods: The study included 222 patients. The PPI was constructed with five variables (performance status, oral intake, edema, dyspnea at rest, and delirium). PPI scores were grouped as follows: 4 (group 1); > 4 and ≤ 6 (group 2); and > 6 (group 3). At admission, seven biological variables (white blood cell count, lymphocyte, C-reactive protein [CRP], bilirubin, albumin, creatinine, and lactate dehydrogenase) were measured. Results: The overall survival duration was 50 days in group 1, 22 days in group 2, and 14 days in groups 3. Using the PPI, a survival of < 3 weeks in group 3 was predicted with a sensitivity of 76.5% and a specificity of 65.4%. The important factors significantly affecting the 3-week survival rate were a PPI score > 6 and increases in serum bilirubin and CRP levels. Furthermore, the 3-week survival rate in patients with hepatopancreatobiliary cancer was more accurately predicted using a combination of the PPI, CRP, and serum bilirubin levels. Conclusions: Although a PPI has limitations, it can be quickly applied to determine survival duration in patients admitted to hospice and accurately predicts 3-week survival. Furthermore, bilirubin and CRP are useful factors for predicting 3-week survival in patients with gastrointestinal cancer, including hepatopancreatobiliary cancer. (Korean J Med 2011;81:359-365)
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