PROGNOSIS (KELOMPOK 3)

1. Zuhdina Kamaliah 8. Rifhani atthaya putri

2. Michelle Wiryadana 9. Yabestin alfrianus pakpahan
3. Sri nauli Dewi Lubis 10. dady chayadinata
4. Ade Gustina siahaan 11. Joshua princeman sinaga
5. Ifen ayu malinda 12. Nanda Soraya monica
6. Wahyu medsa Y.P 13. aulia taufik akbar
7. Rika karim chan 14. cita pujiaty sinulingga
 Definisi
• Sebuah prediksi dari perjalanan penyakit setelah timbulnya onset. Dapat
termasuk kematian, komplikasi, remisi / rekurensi, morbiditas, kecacatan dan
fungsi sosial atau pekerjaan.
• Pertanyaan yang mengarahkan ke prognosis:
- Apakah penyakit ini berbahaya?
- Apakah saya akan meninggal akibat penyakit ini?
- Apakah akan timbul nyeri?
- Berapa lama saya akan dapat melakukan kegiatan saya sehari-hari seperti
sekarang?
- Apakah penyakit yang saya derita dapat sembuh secara keseluruhan?
 Prognostic Factors
• Merupakan kondisi yang terkait dengan outcome / akibat dari
penyakit.
Perbedaan Faktor Risiko dan Faktor Prognostik

Faktor Risiko Faktor Prognostik

Patient Orang Sehat Orang Sakit
Outcome Timbulnya Kematian,
penyakit komplikasi,
disabilitas,
morbiditas
Rates Kejadian langka Kejadian yang
(<0,001 – 0,00001) sering
 Elemen dari Studi Prognostik
• Patient Sample (pada populasi dengan penyakit yang
ditanyakan dalam sebuah daerah geografis sehingga pasien
dapat digambarkan sebagai sampel yang tidak bias)
• Zero Time (waktu dimulainya penyakit)
• Follow Up (pasien harus diikuti dalam waktu yang cukup lama
untuk melihat outcome
• Outcomes of Disease  5D – Death, Disease, Discomfort,
Disability, Dissatisfaction
 Describing Prognosis
• Rates
- 5-year survival (Persentase pasien)
- Case fatality (Persentase pasien yang meninggal akibat penyakit tersebut)
- Disease-specific mortality (Jumlah orang per 10.000(atau 100.000) populasi yang
meninggal karena suatu penyakit.
- Response (Persentase pasien menunjukkan bukti perbaikan setelah pemberian
intervensi)
- Remission (Persentase pasien yang memasuki sebuah fase dimana penyakit tersebut
tidak lagi terdeteksi)
- Recurrence (Persentase pasien yang kembali mendapatkan penyakit yang sama
setelah sebuah fase bebas penyakit)
 Group’s Performance Scale
Performance Status Definition

0 Asymptomatic
1 Symptomatic, fully ambulatory
2 Symptomatic, in bed <50%
3 Symptomatic, in bed >50%
4 Bedridden
5 Dead
 Survival Analysis
• It is the probability of remaining alive for a specific length of time.
• point of interest : prognosis of disease e.g.
– 5 year survival
e.g. 5 year survival for AML is 0.19, indicate 19% of patients with AML will
survive for 5 years after diagnosis
• In simple terms survival (S) is mathematically given by the formula;
S = A-D/A
A = number of newly diagnosed patients under observation
D= number of deaths observed in a specified period
 Survival Analysis
• Subjects are said to be censored
– if they are lost to follow up – drop out of the study,
– if the study ends before they die or have an outcome of
interest.
• They are counted as alive or disease-free for the time they
were enrolled in the study.
• In simple words, some important information required to make
a calculation is not available to us. i.e. censored.
 Need for Survival Analysis
• Investigators frequently must analyze data before all patients have
died; otherwise, it may be many years before they know which
treatment is better.
• Survival analysis gives patients credit for how long they have been
in the study, even if the outcome has not yet occurred.
• The Kaplan–Meier procedure is the most commonly used method
to illustrate survival curves.
• Life table or actuarial methods were developed to show survival
curves; although surpassed by Kaplan–Meier curves
 What is Survival Analysis
• Statistical methods for analyzing longitudinal data on the
occurrence of events.
• Events may include death, injury, onset of illness, recovery from
illness (binary variables) or transition above or below the clinical
threshold of a meaningful continuous variable (e.g. CD4 counts).
• Accommodates data from randomized clinical trial or cohort
study design.
 Objectives of survival analysis
- Estimate time-to-event for a group of individuals, such as time
until second heart-attack for a group of MI patients.
- To compare time-to-event between two or more groups, such
as treated vs. placebo MI patients in a randomized controlled
trial.
- To assess the relationship of co-variables to time-to event,
such as: does weight, insulin resistance, or cholesterol
influence survival time of MI patients?
 Survival Curves
- Kaplan-Meir Analysis
- On vertical axis  estimated probability of survival
- Horizontal axis  period of time following the beginning of
observation
- No one die = probability of surviving = 1
- When a patient dies = probability of surviving <1
- When a patients are lost from the study at any time and for any
other reason other than outcome = Censored = no longer counted in
the denominatior
 Interpreting Survival Curves
- Vertical axis represents estimated probability of surviving for
member of a hypothetical cohort, not the percent surviving for
an actual cohort
- Points on a survival curve are the best estimate, for a given set
of data, of the probability of survival for members of a cohort.
However, the precision of these estimates depends, as do all
observations of samples, on the number of patients whom the
estimate is based.
 Kaplan-Meier Product limit
method

• Survival is estimated each time a patient has an event.

• Withdrawals are ignored
• It gives exact survival times in comparison to
actuarial because it does not group survival time into
intervals

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 Limitations of Kaplan-Meier

• Requires nominal predictors only

• Does not control for covariates

Cox progressive hazard model solves these problems

57
 What does cox model do

• It examines two pieces of information:

– The amount of time since the event first happened
to a person
– The person's observations on the independent
variables.
Kaplan meir survival curve with 95 % confidence limits for
patients on irinotecan & cisplatin
(Source: Source: Noda K, Nishiwaki Y, Kawahara M, Negoro S, Sugiura T, Yokoyama A, et al:
Irinotecan plus cisplatin compared with etoposide plus cisplatin for extensive small-cell lung
cancer. N Engl J Med 2002; 346: 85–91.)
 Comparison between 2 survival
curve

• Don’t make judgments simply on

the basis of the amount of
separation between two lines
 Comparison between 2 survival
curve
• For comparison if no censored observations
occur, the Wilcoxon rank sum test
introduced, is appropriate for comparing the
ranks of survival time.
• If some observations are censored,
methods may be used to compare survival
curves.
– the Logrank statistic
 False Cohort
- Patients are included because they have the disease in question and are
currently available  their clinical course is then described by going back
in time when they were first seen upt to the present  aka false cohorts,
survival cohorts, or available patient cohorts, although they are not really
cohorts at all
- Reports of survival cohort are misleading when they are presented as true
cohort because they represent a biased view of the course of disease
- Report of survival cohorts are relatively common  particularly in form of
case series  but they represent tentative, not conclusive, observation
 Identifying Prognostic Factors
- We want to compare prognosis in patients with different
characteristics – that is, potential prognostic factors
- Multiple survival curves, one for patients with each of the
characteristics, are represented on the same figure where they
can be visually (and statistically) compared.
- The effects of possible prognostic factors, relative to one
another  summarized by a hazard ratio
 Bias in Cohort Studies
- Susceptibility Bias ( groups of patients assembled for study differ in ways other
than the variables under study)
- Migration Bias (another form of selection bias, occur when patients in one
subgroup of a cohort leave their original group, dropping out of study
altogether, or moving to one of the other groups under study)
- Measurement Bias (patients in one subgroup of a cohort stand a better chance
of having their outcomes detected than those in another subgroup.)
- Generalization/Sampling Bias (Generalization Bias are due to the sample used
are not generalizable to most other patients with the condition or to your
paitent. Sampling bias occur when patients selected for study are systematically
different from those the results are generalized to)
Dealing with Selection Bias and Confounding