Karnofsky Index
Leticia Troung
Members of a terminal care support team in a London health district recorded upper and lower estimates of prognosis on 42 patients during 149 visits. Just over half of the actual survivals were within the estimate limits, and the estimates tended to be overoptimistic. For the initial observations on each patient, a health status measure, the Karnofsky index, gave a closer correlation with the actual survival than the estimates. Better predictors of prognosis are needed by staff caring for terminally ill people.
The ECOG Performance Status Scale and the Karnofsky Performance Status Scale are two widely used methods to assess the functional status of a patient. Both scales are in the public domain to classify a patient according to their functional impairment, compare the effectiveness of therapies, and assess the prognosis of a patient. The Karnofsky index, between 100 and 0, was introduced in a textbook in 1949.* Key elements of the ECOG scale first appeared in the medical literature in 1960.**
The Karnofsky scale (sometimes called the Karnofsky index) was devised by two American physicians in the 1940s (David Karnofsky and Joseph Burchenal) as an attempt to measure the more 'subjective' side of the outcome of cancer treatment.
The information obtained from these questions, the assessment and other medical data should then be used as specific criteria listed on the KPS Index. Once the criteria have been identified and the index which most closely corresponds to the criteria has been chosen, the KPS is documented. Following the admission assessment, when possible, the same health care provider should administer the scale on subsequent evaluations.
Data from medical records were extracted to identify and tabulate comorbidity according to both the Charlson19 and the Hematopoietic Cell Transplantation (HCT)-specific Comorbidity Indices (HCT-CI).20 Comorbidity describes any distinct additional clinical entity that has existed or may occur during a patient's clinical course with an index disease (in this case, MDS/AML). The Charlson Comorbidity Index (CCI) is the most commonly used in oncology. Its main limitation is that the data address only the 19 conditions listed in the index. The HCT-CI presents a comorbidity score adapted to the HCT setting. It assigns points for 17 common medical conditions relevant in the transplant setting, resulting in a score ranging from 0 to 29.
The ADL or Barthel Index comprises 10 activities of daily living with different levels of dependency.16 It has been suggested that this is more sensitive than the Karnofsky Index for assessing physical functioning in some patient groups but it has not yet been investigated as a potential prognosticator in patients with hematologic neoplasias.41 As opposed to the performance indices that reflect the physicians' estimation, ADL requires detailed information in a standardized questionnaire. Interestingly, despite correlations between ADL and Karnofsky Index, ADL does provide additional information, as both parameters were retained in our multivariate analysis. This easily obtainable index, used frequently in daily practice to estimate and communicate degrees of dependence, emerges in this study as having additional value in objectifying decision-making processes. In agreement with this, a recent investigation on the impact of a geriatric assessment in treatment decision-making in elderly patients revealed that the ADL's value correlates with treatment allocation (non-intensive care vs. intensive treatment efforts).37
When comparing our score to established risk assessment scores (i.e. comorbidity score by Sorror, risk index by Wheatley), we found that, despite some associations, independent and complementary information could be obtained. We, therefore, suggest that the scores do actually measure different aspects of patient- and disease-specific factors. Possibly, the estimation of functionality might display an increasing relevance in patients treated non-intensively who are, on average, older, while parameters calculated in the established scores may be even more relevant in younger, intensively treated patients. Future studies may reveal whether the scores can complement each other.
Overaggressive patient selection for Y90 radioembolization of liver dominant chemorefractory mCRC is of questionable benefit. A scoring system comprising hepatic tumor load, CEA and CA19-9 serum levels and Karnofsky index (TuCK-score) may support an improved patient selection. In our cohort of liver only versus liver dominant disease, extrahepatic lung or lymphatic metastases did not significantly alter the prognosis.
A score based on Tumor load, CEA and/or CA19-9 serum level as well as the Karnofsky index demonstrated a close association with patient outcome after Y90 radioembolization in the salvage situation. Patients displaying more than 1 point may not benefit from liver directed Y90 radioembolization; in those patients alternative systemic treatments or best supportive care should be considered. In our population with severe liver dominant disease, lung, bone and lymph node metastases had no negative prognostic effect. The role of combined salvage Y90 radioembolization and systemic therapy remains unclear.
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Of these 225 survivors, 87% had a Karnofsky Index above 60, which corresponds to being able to live independently without assistance from others. Of the 144 patients without MOF, 94% had a Karnofsky Index above 60, and in the MOF group, 74% had a Karnofsky Index above 60. Using logistic regression with adjustment for age, sex, and severe head injury, organ failure was significantly related to this dichotomised Karnofsky index (p = 0.042). Patients with MOF had an odds ratio of 3.88 (95% CI 0.99 to 15.21) for requiring assistance from others in activities of daily living more than 2 years after the trauma compared with patients with no organ failure. There was no significant difference in Karnofsky Index score between the no organ failure group and the single organ failure group (p = 0.794).
Meike Terhorst, Martina Kleber, Gabriele Ihorst, David De Pasquale, Monika Engelhardt; Comparison of 4 Previously Established, but Highly Different Comorbidity Scores (Kaplan Feinstein Index [KF], Charlson-Comorbidity Index [CCI], Satariano Index [SI], Hematopoietic cell transplantation-specific comorbidity index [HCT-CI]) Identifies the KF and HCT-CI as Most Relevant, but Use of An Easily Applied 3-Risk-Factor (KLeber) -Score Suggests to Even More Effectively Predict Progression-Free- and Overall-Survival Differences in Multiple Myeloma (MM) Patients (pts).. Blood 2009; 114 (22): 1797. doi:
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