Prognostic factors in cancer

Diagnosis, prognosis, and treatment are the three core elements of the art of medicine. Modern medicine pays more attention to diagnosis and treatment but prognosis has been a part of the practice of medicine much longer than diagnosis. Cancer is a heterogeneous group of disease characterized by growth, invasion and metastasis. To plan the management of an individual cancer patient, the fundamental knowledge base includes the site of origin of the cancer, its morphologic type, and the prognostic factors specific to that particular patient and cancer. Most prognostic factors literature describes those factors that directly relate to the tumor itself. However, many other factors, not directly related to the tumor, also affect the outcome. To comprehensively represent these factors we propose three broad groupings of prognostic factors: 'tumor'-related prognostic factors, 'host'-related prognostic factors, and 'environment'-related prognostic factors. Some prognostic factors are essential to decisions about the goals and choice treatment, while others are less relevant for these purposes. To guide the use of various prognostic factors we have proposed a grouping of factors based on their relevance in everyday practice; these comprise 'essential,' 'additional,' and 'new and promising factors.' The availability of a comprehensive classification of prognostic factors assures an ordered and deliberate approach to the subject and provide safeguard against skewed approaches that may ignore large parts of the field. The current attention to tumor factors has diminished the importance of 'patient' (i.e., 'host'), and almost completely overshadows the importance of the 'environment'. This ignores the fact that the latter presents the greatest potential for immediate impact. The acceptance of a generic prognostic factor classification would facilitate communication and education about this most important subject in oncology.     

Prognostic factors in colorectal cancer

Factors which influence survival in patients with colorectal cancers were analyzed. From the anatomical and clinical points of view, large bowel cancer should be evaluated separately as colon and rectal cancer. The factors were stages of the disease, depth of tumor infiltration, morphological type of tumor appearance, histological type of tumor, venous invasion of cancer cell, lymphatic invasion of cancer cells, lymphnode metastasis, degree of tumor resection, distant metastasis and dissemination in abdominal cavity.     

Prognostic factors in breast cancer

There are several independent but interrelated prognostic factors predictive of recurrence and survival in breast cancer. These include axillary nodal status, histopathology, steroid receptors, proliferative rate, ploidy, and oncogene amplification. Axillary nodal status has been the traditional mainstay predictor for recurrence and survival in primary breast cancer. In addition, the presence of the estrogen and progesterone receptors has correlated with longer disease-free interval and overall survival in stage I and II breast cancer. Thymidine-labeling index and percent S-phase as measured by flow cytometry are indices of cell proliferation that correlate with relapse rate in pre- and postmenopausal women with breast cancer. Estrogen and progesterone receptor-negative tumors are more commonly aneuploid, and have higher percent S-phase, factors that predict for recurrence in Stage I breast cancer.     

Prognostic factors in cervical cancer

Prognosis of cancer of the uterine cervix is determined mainly by clinical stage, histological type and degree of invasion or metastasis. Clinical stage is highly correlated with the prognosis of cancer. With regard to histological type, prognosis of adenocarcinoma is poorer than that of squamous cell carcinoma. The depth of invasion of the tumor and metastasis to the lymph node are also poor prognostic factors.     

Prognostic factors in lung cancer

For 1,886 cases, out of total 1,982 lung cancer cases, which had been admitted to and undergone resection at National Cancer Center Hospital during the period between May, 1962 and December, 1987, excluding cases of multiple primaries and low grade malignancies, prognostic factors have been reviewed and examined. Prognosis does not depend on only one factor, but many complicated factors, however, 5 year survival rate was very good for stage I and stage II cases, for which curative resection could have been performed. There have been difference histologically in prognoses between cases of squamous cell carcinoma, adenocarcinoma, large cell carcinoma and small cell carcinoma, but prognoses of stage I and II cases were good in the group, for which curative resection was possible. Prognostic factors of lung cancer cases can be epitomized by staging of the disease and histological type and it is evident from the review on these cases that early detection, early treatment and indication of curative resection should be pursued as much as possible.     

Prognostic factors in breast cancer

A variety of tumor characteristics can provide prognostic information useful in managing the patient with primary breast cancer. Some of these characteristics are firmly established, whereas others are observer dependent or require prospective validation. No single characteristic, however, is likely to fully define which patient with primary breast cancer is destined to relapse. This clinical dilemma--recognition of the high-risk patient--is particularly important in the management of women with node-negative breast cancer. Because most women with this early stage of disease will be cured by surgery alone, the use of adjuvant chemotherapy must be limited to high-risk subsets. Tumor size and ER status are established prognostic factors. Histologic and nuclear grade may be important, but problems of interobserver variability remain. Some studies have shown that aneuploidy or a high S-phase fraction may be independent, high-risk characteristics. Flow cytometric DNA content analysis must be applied with caution, however, because the calculation of S-phase fraction has not been standardized and because the prognostic utility of this approach has not been prospectively confirmed. For now, a prudent approach might be to gather as much prognostic information about each patient's tumor as possible. Those with several of the high-risk characteristics listed in Table 2 should receive strongest consideration for adjuvant treatment. Some of these same prognostic factors, along with several others, can be used to characterize the high-risk node-positive patient. The number of involved axillary nodes is the most important established predictor. Progesterone-receptor status is associated with both disease-free and overall survival, whereas ER status is independently related only to overall survival. Histologic grade, DNA ploidy, and S-phase fraction can also be used to help define the high-risk patient. Finally, tumors that amplify or overexpress the HER-2 gene may have a higher risk of relapse, although this finding has been questioned. Management of patients with breast cancer requires an individualized approach that is based on a careful weighing of a variety of prognostic considerations. The relative importance of these factors will require further large-scale, prospective, multiparameter studies. Although results from such studies are awaited, an understanding of the clinical heterogeneity of breast cancer must be based on a multiplicity of observations, each of which characterizes, in a limited way, the biology of this disease.     

Prognostic factors in gastric cancer

A total of 5,480 cases of gastric cancer was subjected to the analysis of main prognostic factors in gastric cancer. The uppermost factor which affected the prognosis of gastric cancer patients was the curability of surgery. Five year survival rates were 72.7% for the absolute curative cases, 33.6% for relative curative cases, and 13.8% for relative non-curative cases. None of the patients, who had absolute non-curative surgery, survived more than five years. Curability of surgery depended on the extent of cancer spread such as liver metastasis, peritoneal dissemination, remote lymphatic spread and continuous infiltration of adjacent organs. Gross and histological tumor types were important for the destination of cancer spread: localized, and well differentiated types tended to hematogenous metastasis. Infiltrating, and undifferentiated typestended to peritoneal dissemination.     

Prognostic factors in colorectal cancer

Prognosis of patients after colorectal cancer resection is predominantly influenced by the extent of local tumour growth and the presence or absence of nodal or distant metastasis. However, many factors have been used to generate numerous classification systems, leading to some debate and confusion. The effects on survival of 7 clinical and pathological parameters were reviewed in 801 consecutive patients operated upon with locally curative intent for colorectal cancer over a ten-year period. Age less than 50 or more than 70 years, poor cellular differentiation, high mucous secretion by tumour cells and Dukes' staging were the parameters significantly correlated to poor overall survival (p<0.001 for each). The Cox's regression analysis identified the same parameters as independent prognostic factors. The value of age as a prognostic factor remains debatable, but the other three parameters must be considered when evaluating prognosis after curative surgery for colorectal cancer and when considering adjuvant therapy.     

Prognostic factors in genitourinary cancer

Prognostic factors in genitourinary cancers, renal cell carcinoma, bladder cancer, prostatic cancer, and testicular tumor, were discussed from several aspects on the basis of the analysis of own cases and reviews of literatures. The anatomical distribution of disease, particularly beyond the kidney, and degree of tumor differentiation were mostly related to prognosis in renal cell carcinoma. In bladder cancer, macroscopic growth pattern, histopathological intramural mode of spread, lymphatic and venous invasion, played an important role in prognosis, as do tumor grade and stage including metastasis. Hormone dependency and tumor markers were reconfirmed to be important and complementary as prognostic indicators as well as stage and grade in prostatic cancer. In testicular tumors, the most important factors for survival were extent of disease and tumor size, and histological cell type and determination of tumor markers, AFP and HCG, were also important and complementary as prognostic indicators.     

双侧乳腺癌的预后因素

目的：探讨影响双侧乳腺癌患者生存率的预后因素。方法：对21例经病理组织学证实的双侧原发性乳腺癌患者进行回顾性分析。其中，同时性双侧乳腺癌4例（19%），异时性双侧乳腺癌17例（81%），接受手术，放疗，化疗等单一或综合治疗，分析乳腺癌的多种预后因素与术后生存率的关系。结果：主要的预后因素与肿瘤振奋小，浸润淋巴结的数目，最初的正确治疗和两侧乳癌的间距时间等有关。二、五、十年的生存率各为90%（19/21），71.4%(15.21),66.7%(14.21)。结论：若双侧乳腺癌的治疗正确。仍有相当高的五年生存率，两侧乳腺癌之间的间距时间是最突出的预后因素。与生态2率呈正相关系。早期诊断，早期治疗第二原发癌仍是提高生存率的关键。     

Prognostic factors in ovarian cancer.

Epithelial ovarian cancers vary considerably in their biologic behavior and this is reflected in the variety of clinicopathologic factors that are used for predicting outcome. This article assesses the potential value of some of the newer prognostic factors and critically evaluates the more commonly used clinicopathologic variables.     

Prognostic factors in rectal cancer]

Morphologic type of growth of rectal adenocarcinoma was studied in 292 radically operated cases. Diffuse pattern of growth was established in 86.7% of patients. Mean five-year survival rate was 49.1 +/- 3.9%. Five-year survival rate was 88.2 +/- 9.1% in cases of tumor invading less than one-third of circumference of the intestinal wall, 45.1 +/- 4.0% in those with invasion of the total wall circumference, 83.3 +/- 6.1%--infiltration of all mucosa and submucosa, 39.4 +/- 4.8%--invasion of the entire wall thickness, 31.5 +/- 6.3%--in patients with histologically proven regional metastases, 58.1 +/- 4.8%--in metastasis-free cases, 70.9 +/- 8.1%--in patients with intermediate type of tumor growth with tissue stratification predominating and 43.8 +/- 4.4%--in those with diffusely growing tumors. In a correlation analysis, regional metastases (correlation coefficient K = 0.25), depth of invasion of the intestinal wall (K = 0.24), morphologic pattern of growth (K = 0.22) and length of the intestinal wall invaded (K = 0.20) were shown to influence prognosis most apparently (P < 0.01). Morphologic pattern of growth should, therefore, be considered a prognostic factor.     

Prognostic factors in early esophageal cancer

During the period from 1975 through 1988, 405 thoracic esophageal carcinoma were resected in our department. Among them, superficial carcinoma was proved in 50 cases. The prognosis of these 50 patients with superficial carcinoma has been analyzed in regard to the prognostic factors. As for the clinico-pathological findings, there were no evident differences in mean age, sex distribution and main location of the lesions between superficial cases and overall resected cases. The distribution of depth of invasion was as follows; ep 4 cases, mm 7 cases and sm 39 cases. The number of patients with invasion to submucosal layer had included the majority of the superficial cases. Lymph node metastasis was proved in 17 cases, and 16 of them had the invasion to the submucosal layer. On the other hand, neither patient with invasion to ep layer had lymph node metastasis, however, in one of seven cases with invasion to mm layer, lymph node metastasis to second group node was proved. The lesions have been resected through thoracotomy in 48 patients out of 50 cases. Blunt dissection has been carried out upon only two cases. The 5-year survival rate of superficial carcinoma was 61.7%, which was clearly better than that of all patients resected in the same period (31.6%). The prognosis distinctly correlated with the depth of invasion; 5-year survival rate of ep, mm and sm cases were 100%, 83.7% and 54.3%, respectively. We experienced no recurrence in case of ep or mm. As for sm cases, lymph node metastasis and/or vessel invasion were most dominant prognostic factors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prognostic factors in well-differentiated thyroid cancer

The differentiated thyroid carcinomas are malignant neoplasms most of them following an indolent course with infrequent metastases and long survival. However, a few cases behave in an aggressive fashion and, despite every attempt to treat, cause the death of the patient. Numerous investigations have been carried out to define the markers which affect the prognostic course of these tumors. There are three types of prognostic markers: clinicopathological, pathological (morphological) and biological. The first group include: age, sex, size of the tumor, multifocality, vascular and extrathyroidal invasion, grading and metastases. The second category collects some morphological features like tumor subtype, association with autoimmune thyroid diseases and ploidy. The last group features the oncogenes (RET and RET/PTC rearrangements). The accurate evaluation of all the previous prognostic markers is the basis of the treatment schemes discussed in the last section.     

Prognostic factors in operable breast cancer

A series of 743 consecutive cases of operable breast cancer, admitted and treated at the Istituto Nazionale Tumori of Milan from 1969 to 1970, was analyzed by a multivariate statistical method to evaluate a) the variables of the host and the primary tumor associated with the frequency of nodal metastases, b) the variables that significantly affect survival, and c) the identification of homogeneous risk groups. As regards the frequency of regional node metastases, they were more frequently observed in young than in old patients with large tumors (P values 10(-5) and 3 X 10(-5), respectively). Tumors that originated in the axillary tail, upper, outer and central quadrants were significantly associated with a higher rate of node metastases (P = 0.002). Each of these variables maintained its significant value when adjusted by the other two. Survival was affected at a statistically significant level by the age of the patients (P = 2 X 10(-4) ), the pathologic diameter of the primary tumor (P less than 10(-6) ), and the number of metastatic regional nodes (P less than 10(-6) ). The number of involved nodes appears to be the most relevant factor in the assessment of prognosis of patients with positive nodes, Age of the patients, size of the primary tumor, and number of involved nodes maintain their own statistical significance when each is adjusted by the remaining two. The site of origin of the primary tumor, even if associated with the frequency of regional node metastases, did not affect survival. Three groups with a significantly different risk of death were identified in patients with negative lymph nodes and three groups in patients with positive nodes. It is concluded that age, size of the primary, and number of involved lymph nodes are important pieces of information that clinicians should have at hand following radical surgery, not only to make a prognosis, but also to identify groups of patients with high risk of death on which the role of adjuvant treatment should be evaluated.