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TagedEnUrologic Oncology: Seminars and Original Investigations 41 (2023) 255.e1−255.e6

Clinical-Bladder cancer
TagedH1Preliminary results regarding automated identification of patients with a
limited six-month survival prognosis using nursing assessment in
uro-oncology patientsTagedEn
TagedPCarmen Roch, MDa,*, Julian Alexander Kielkopf, MDa, Ulrich Stefenelli, MDa,
ubler, MDb, Birgitt van Oorschot, MDa, Anna Katharina Seitz, MDbTagedEn
Hubert K€
a
Interdisciplinary Center for Palliative Medicine, University Hospital W€urzburg, W€urzburg, Germany
b
Department of Urology and Pediatric Urology, University Hospital W€ urzburg, W€urzburg, Germany
Received 16 May 2022; received in revised form 14 September 2022; accepted 9 January 2023

TagedPAbstract
Introduction: Contrary to current recommendations, palliative co-management of tumor patients often occurs late in daily clinical
practice. Palliative care specialist (PCS) co-management should be considered at the latest after a 6-month prognosis has been presumed.
Therefore, identifying patients with a limited prognosis is a reasonable measure.
Methods: Patients were identified using a screening tool for limited prognosis, which combined their tumor stage and data from the nurs-
ing anamnesis. In this retrospective study, a monocentric cohort of patients with urological malignancies−UICC (Union for International
Cancer Control) stages III and IV − were enrolled from March to December 2019, with a 6-month follow-up period ending in May 2020.
Results: Most patients were male and suffered from prostate cancer. Patients with uro-oncological tumors dying within 6 months
correlated significantly with the presence of repeated hospitalizations within three months, pain on admission, malnutrition, impaired
breathing and reduced mobility (P < 0.001). The test was fair in quality (AUC 0.727) at a cut-point of five; a sensitivity of 97% and a
specificity of 25% were obtained. The PPV was 0.64 and NPV was 0.82.
Discussion/Conclusion: We specifically identified the predictors of limited prognosis in urological cancer patients across several entities
using an automated scoring system based on tumor stage and data from the nursing anamnesis. Therefore, we recognized hospitalization as
an important transition point and determined nurses to be valuable partners in identifying unmet palliative care needs without additional
technical, personnel or financial effort. Ó 2023 Elsevier Inc. All rights reserved.

TagedEnTagedPKeywords: Automated screening; Prognosis; Palliative care needs; Specialized palliative careTagedEn

TagedH11. IntroductionTagedEn relevant facilitators that help to improve timely palliative

TagedPNeeds-based palliative care for cancer patients is recom-
mended by national and international guidelines regardless
of the tumor entity or therapeutic intention [1,2]. However,
its implementation in clinical practice is still hampered by a
lack of awareness of surgical disciplines [3,4] and a delayed
realization of the course of disease [4]. Consensus-based
referral criteria and systematic distress screenings are
TagedEn*Corresponding author. Tel.: +49 931-201-28849.
E-mail address: roch_c@ukw.de (C. Roch).
care [5].TagedEn
TagedPRegardless of the tumor stage, cancer patients often
describe a high symptom burden, even when undergoing
tumor-specific therapy with palliative intentions [6]. Refer-
ral to palliative care specialists (PCS) can help address
these symptoms early and capture additional unmet needs
[7].TagedEn
TagedPAccording to current recommendations, screening for
palliative care needs should be considered no later than
when the prognosis for survival is 6 months or less [2,8].
When conducting a PCS assessment, it is important to iden-
tify these patients using previously existing prognosis tools

https://doi.org/10.1016/j.urolonc.2023.01.002
1078-1439/Ó 2023 Elsevier Inc. All rights reserved.
TagedEn255.e2 C. Roch et al. / Urologic Oncology: Seminars and Original Investigations 41 (2023) 255.e1−255.e6

[9−13]. However, using these tools for prognosis screening TagedEnTable 1

usually involves additional bureaucracy for both the patient Items of interest.
and the treatment team, as well as the question of who Items Answer Points
should perform the screening. An automated prediction of
limited prognosis using precollected patient data could at hospital stays in the last no hospital stays 0 point
three months 2 hospital stays 1 point
least allow for a preselection of patients who may benefit
>2 hospital stays 2 points
from a PCS assessment and co-management. This could be breathing impaired breathing 1 point
particularly useful when hospital admissions are viewed as mobility Independent 0 point
a key transition point, in which nurses are important part- mobile with support 1 point
ners in identifying patients with potential palliative needs immobile / mainly 2 points
bedridden
by finding out symptoms and distress.TagedEn
Pain on admission yes 1 point
TagedPUsing our uro-oncological patient collective patients Nutritional risk screening/
were required to be in UICC stage III or IV, we investigated NRS2002
whether patients with a limited prognosis could be identi- unexpected loss of weight 1 point
fied using a screening tool that looks at any relevant clinical in previous months
decreased nutrition intake 1 point
parameters collected from the routine nursing anamnesis on
in the past week
admission.TagedEn sum score 0-8 points

TagedH12. Material and methodsTagedEn TagedH22.3. Missing dataTagedEn

TagedH22.1. Study designTagedEn
TagedPThis was a retrospective, monocentric cohort study. All
adult patients who were inpatients at the Department of
Urology at University Hospital W€ urzburg from March to
December 2019 and had one of the following UICC stage
III or IV diagnoses on admission were included: prostate
carcinoma (C61), renal cell carcinoma (C64), renal pelvic
carcinoma (C65), and urinary bladder carcinoma (C67). A
follow-up of 6-month survival ended in May 2020.TagedEn
TagedH22.2. Data recruitmentTagedEn
T total of 726 hospitalized patients with urologic malig-
agedPA
nancies were identified via the clinical patient information
system, including 292 patients with UICC stages III and IV
tumors. Of these, a complete data set was obtained for 243
patients.TagedEn
TagedPParameter collection from nursing assessment:TagedEn
TagedPNursing assessment performed at University Hospital
W€ urzburg routinely collect data on hospitalizations and
physical capabilities on admission. These include respira-
tory impairment, mobility, pain at the time of admission,
and nutritional status. Depending on the presence or
absence of limitations, points from 0 to 2 (0 = not applica-
ble, 1 = moderate impairment or applicable, 2 = severe
impairment) are assigned to the individual data points,
which are added up to calculate an overall score (see
Table 1). The development of this scoring system was based
on statistically validated prognostic tools, such as the pallia-
tive performance scale [14] and, as a result, has been
adapted to our routine nursing assessment. Our instrument
is therefore similar but not identical and for this reason not
yet validated.TagedEn
TagedPUpon analyzing the completeness of the screening data,
missing values regarding the number of hospitalizations in
the past three months were found in 32 patients (13.2%).
Regarding the data concerning NRS 2002 (decreased food
intake in the past week and weight loss in the past 3
months), missing values were found in 7 patients (2.9%)
each. Data points for breathing, mobility, and pain at the
time of admission were all fully completed. Patients with
missing data were excluded from statistical evaluation
(n = 39; 16.1%). No substitution was made because there
were no significant differences in age and diagnosis, for
example, and therefore no selection bias should be assumed.TagedEn
TagedH13. StatisticsTagedEn
T ll data collected was analyzed using IBMÒ SPSS
agedPA
(Statistical Package for the Social Sciences) 26.TagedEn
TagedPFirst, a descriptive examination of the socio-demo-
graphics was carried out. We examined the difference
between the score results and the 6-month survival of
patients using a Mann-Whitney U test. To investigate the
diagnostic quality of the score, we performed a receiver
operating characteristic (ROC) analysis. Statistical signifi-
cance was assumed from P ≤ 0.05.TagedEn
TagedH14. ResultsTagedEn
TagedH24.1. Socio-demographicsTagedEn
TagedPMost patients were male (222/243−91.4%) and suffered
from prostate cancer (149/243−61.3%). 21/243 patients
(8.6%) were female. The mean age was 70.1 years (SD
9.5); the range was 39 to 91 years. The most common rea-
sons for hospital admission were tumor-related symptoms
(70/243−28.8%) or tumor-specific therapy (117/243
 TagedEnC. Roch et al. / Urologic Oncology: Seminars and Original Investigations 41 (2023) 255.e1−255.e6 255.e3

TagedEnTable 2
Socio-demographics − n = counts, M = mean, SD = standard deviation, range in years.

Prostate carcinoma (C 61) Renal cell carcinoma (C 64) Carcinoma of the renal pelvis (C65)
n=149 n=52 or carcinoma of the urinary bladder (C67)
n=42

Age (M; SD; (Range)) 71.0; 9.2; (50-91) 69.0; 8.8; (51-86) (68.1; 11.1; 39−84)
Gender
male (%) 100 73.1 83.3
Duration of hospital stay in days 9.5; 6.8 (2−37) 10.7; 6.4 (1-27) 8.8; 8.1 (2−37)
(M; SD (Range))
Reason for admission n=149 (100 %) n=52 (100 %) n=42 (100%)
tumor-related symptoms 42 (28.2) 14 (26.9) 14 (33.3)
tumor-related diagnostic measures 2 (1.3) 7 (13.5) 2 (4.8)
tumor-specific therapy 83 (55.7) 20 (38.5) 14 (33.3)
tumor-related complications 6 (4.0) 4 (7.7) 3 (7.1)
Other 13 (8.7) 4 (7.7) 4 (9.5)
Missing data 3 (2.0) 3 (5.8) 5 (11.9)
Tumor stage UICC
III 37 (24.8) 9 (17.3) 7 (16.7)
IV 112 (75.2) 43 (82.7) 35 (83.3)
SPC co-management
Yes 9 (6.0) 5 (9.6) 6 (14.3)

TagedEn TagedFiur
−48.2%) like radiation therapy, chemotherapy or hormone
therapy. Most patients included in the study had UICC stage
III tumors (78.2%). 20/243 patients (8.2%) were admitted to
SPC, based on clinical judgment of the primary care team.
For further information, please refer to Table 2.TagedEn

TagedH24.2. Diagnostic qualityTagedEn

TagedPTo evaluate the diagnostic quality of the sum score, we

performed a ROC analysis. The score was found to be of
fair quality and had an AUC (area under the curve) value of
0.727 (95% confidence interval 0.64−0.82) (see Fig. 1).
Furthermore, a cutoff value was calculated. A sensitivity of
97% and a specificity of 25% were obtained above a thresh-
old value of 5. The positive predictive value (PPV) was
0.64 and the negative predictive value (NPV) was 0.86.TagedEn

TagedH24.3. Overall survivalTagedEn

TagedPTwo hundred thirty-four patients were still alive on the

closing date of the follow-up period. Nine patients could not
be determined as having survived or died. Fifty patients died Fig. 1. ROC analysis.TagedEn
during the observation period (range 3−173 days, Mean
70.2, Median 56, Standard deviation 50.6). One hundred TagedEnTable 3
eighty-four patients survived the 6-month observation period. Overall survival.
Table 3.TagedEn <6 months >6 months
survival n (%) survival n (%)
TagedH24.4. Correlation between 6-month survival and the sum
Prostate carcinoma (C61) 22 (9.4) 122 (52.1)
scoreTagedEn Renal cell carcinoma (C64) 14 (6.0) 34 (14.5)
Carcinoma of the renal 14 (6.0) 28 (71.8)
TagedPPatients with uro-oncological tumor disease dying within pelvis (C65) or
6 months correlates significantly with the sum score (Mann- carcinoma of the
urinary bladder (C67)
Whitney U test, P < 0.001, R = 0.311). A higher sum score
All 50 (21.4) 184 (78.6)
significantly indicates shorter survival.TagedEn
TagedEn255.e4 C. Roch et al. / Urologic Oncology: Seminars and Original Investigations 41 (2023) 255.e1−255.e6
TagedH15. DiscussionTagedEn
TagedPIn this retrospective study, we identified urological can-
cer patients with a limited prognosis across several entities
using an automated scoring system based on tumor stage
and data from the nursing assessment. This approach over-
comes barriers among patients, physicians, and caregivers
[15] and helps to implement palliative care in a timely man-
ner [1,16]. According to current guideline recommenda-
tions, a symptom assessment can be performed by a
palliative care specialist, who can then go on to evaluate a
patient’s needs based on the complexity of their symptoms
and burdens [16]. Not every patient with a limited prognosis
automatically has PCS co-management needs, even though
palliative care is at least recommended when a limited 6-
month prognosis is presumed [2]. Gensheimer 2019 et al.
combined over 4,000 digitally captured predictors taken
from a clinical information system and constructed a well-
functioning prediction model [17]. In terms of an automated
detection of a limited prognosis, this approach is very
promising; however, powerful information technology is
required for its implementation, which also means a power-
ful financial background may be necessary. In contrast, our
approach uses existing processes without any additional
examinations, is data efficient, and can be implemented in
everyday clinical practice without additional personnel and
financial efforts. Furthermore, automated screening may
prevent overly favorable physician assessments and offload
the responsibility of implementing palliative care in a
timely manner, which may relieve the burden of clinical
workload. The nursing service is valued and upgraded as
well. The patient thus benefits from a timely PCS co-man-
agement with distressing symptoms being recorded in a
structured manner [18].TagedEn
TagedPIn our study cohort, automated capture of the 6-month
prognosis identified a large proportion of patients as having
the need for a patient-reported outcome measurement
screening (PROM) and benefitting from a further PCS
assessment. Without this capture, only 26% of the patients
who died within 6 months would have been presented to
the PCS. As in other screenings, tumor stage and/or disease
activity were also taken into account [14,19]. The complex-
ity of treatment strategies has increased in recent years, and
well-tolerated cancer therapies are now being used, mean-
ing that patients with a poor clinical status can be treated
more effectively, in turn making their prognosis difficult to
predict [20]. However, there is evidence that certain thera-
pies are associated with a limited prognosis because they
are only used as the disease progresses [17]. With this in
mind, it is also important to consider that different entities
are associated with different forms of therapy and different
prognoses even at primary diagnosis [7]. For example,
patients with urothelial carcinoma often receive combina-
tion chemotherapy in first-line palliative therapy, whereas
for patients with metastatic prostate carcinoma, extended
hormonal therapy is predominantly used in primary
therapy, which is associated with significantly better tolera-
bility and quality-of-life preservation [21]. In contrast, tra-
ditional chemotherapy much more frequently leads to an
acute deterioration of the condition and therapy-related hos-
pitalization due to acute toxicity. In this case, patients do
not necessarily require PCS, but instead require care for
therapy-associated side effects. Therefore, identifying these
patients is not a priority of palliative care screening, even if
it is undoubtedly an important task concerning close coop-
eration between palliative care and urology.TagedEn
TagedPEven though automated screening detects patients with a
limited prognosis, the proportion of patients without a lim-
ited prognosis who are falsely detected is, in our opinion,
acceptable in the current approach. Here, we have particu-
larly focused on sensitivity, as patients who will die within
6 months should be reliably detected. In contrast to conven-
tional screening methods, our screening approach does not
examine healthy individuals who are then referred to
undergo further invasive diagnostics if the screening tests
positive [22]. Morbidity and mortality can no longer be
reduced by prevention in this patient group. Instead, with
this screening approach, a reminder could be provided so
that palliative care is implemented in a timely manner and
patients can participate in the well-known positive effects
of timely palliative co-management [23]. Falsely detected
patients would not be harmed as they could also benefit
from palliative co-management [18], and there is still an
ongoing discussion about the right time to integrate pallia-
tive care [5,24]. Using this sum score, the number of
patients presented to PCS may significantly increase, espe-
cially if a positive screening result automatically prompts a
PROM screening. This transparent patient allocation offers
clear areas of responsibility that refer to different hospital
facilities (e.g., social services) and enables patient care in a
timely manner [25]. Ideally, this could result in an earlier
discharge from hospital with optimized medical care [26].TagedEn
TagedH16. LimitationsTagedEn
TagedPOur evaluation was conducted purely retrospectively on
a small cohort. No patients with testicular or penile carcino-
mas were included in the study. Therefore, our results can
only be transferred to uro-oncologic patients in general to a
limited extent. To achieve more valid results, a prospective
evaluation and validation of the score using a larger number
of patients should be performed.TagedEn
TagedPThe sole use of an automated prognosis screening relies
on the completeness of the nursing assessment. If elements
are missing, the prognosis screening cannot be calculated
adequately and may give too low a score for these patients.
In our cohort, approximately 16% of patients could not be
identified using automated screening as the nursing anam-
nesis was incomplete. Here, education should be provided
for nursing staff on the importance of obtaining a complete
nursing assessment.TagedEn
 TagedEnC. Roch et al. / Urologic Oncology: Seminars and Original Investigations 41 (2023) 255.e1−255.e6 255.e5

TagedH17. ConclusionTagedEn TagedP [3] Karlekar M, Collier B, Parish A, Olson L, Elasy T.

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TagedH1Conflicts of interestTagedEn TagedP[10] Hui D, Paiva CE, Del Fabbro EG, Steer C, Naberhuis J, van de Weter-
ing M, et al. Prognostication in advanced cancer: update and directions
TagedPThe authors have nothing to disclose.TagedEn for future research. Support Care Cancer 2019;27:1973–84.TagedEn
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TagedPThis research did not receive any specific grant from ing unmet palliative care needs in patients with cancer. J Oncol Pract
funding agencies in the public, commercial, or not-for- 2015;11:e81–6.TagedEn
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