ArticleInternational journal of clinical oncology2026
Impact of ascites on the prognostic performance of the palliative prognostic index in terminally ill cancer patients: a multicenter secondary analysis of the EASED study.
Article in International journal of clinical oncology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundAscites is common in patients with advanced cancer and is associated with systemic inflammation, malnutrition, and organ dysfunction. Although the Palliative Prognostic Index (PPI) is widely used to predict short-term survival in terminally ill cancer patients, ascites is not included in its components. We investigated whether ascites influences survival and modifies the prognostic performance of the PPI in terminally ill cancer patients.
methodsThis was a secondary analysis of the multicenter prospective the East-Asian cross-cultural collaborative Study to Elucidate the Dying process (EASED) study conducted in 23 palliative care units in Japan. Patients were classified according to the presence of edema and ascites at admission into four groups: G1 (edema+/ascites+), G2 (edema+/ascites-), G3 (edema-/ascites+), and G4 (edema-/ascites-). The primary outcome was the distribution of PPI scores according to edema and ascites status. Secondary outcomes included overall survival (OS) and the predictive performance of PPI thresholds for survival prediction.
resultsAmong 1889 patients, the distribution of PPI scores differed across the four groups. Median OS was shortest in G1 (13 days), followed by G2 (15 days), G3 (17 days), and longest in G4 (28 days) (P < 0.001). Compared with G4, adjusted hazard ratios for mortality were 1.90 in G1, 1.50 in G2, and 1.58 in G3. For predicting 21-day mortality, PPI ≥ 6.5 showed high PPV (Positive Predictive Value) in patients with ascites (G1: 87.0%; G3: 80.0%), whereas NPV (Negative Predictive Value) was markedly reduced in G3 (47.0%), suggesting potential underestimation of short-term mortality when PPI < 6.5 in ascitic patients. For predicting 42-day survival, PPI ≤ 3.5 demonstrated limited PPV across groups, particularly in patients with ascites.
conclusionsAscites is associated with shorter survival and modifies the clinical interpretation of the PPI. In patients with ascites, reliance on PPI alone may underestimate short-term mortality. Incorporating ascites assessment into prognostic evaluation may improve clinical decision-making in end-of-life care.
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