Survival Outcomes in Malignancy-related Hypercalcemia: A Tertiary Care Single-center Experience

Abstract

Introduction: Malignancy-related hypercalcemia is commonly observed in patients with advanced stages of cancer. It is intricately linked with an unfavorable prognosis among oncology patients. This study aimed to evaluate survival outcomes among individuals diagnosed with hypercalcemia associated with malignancy.

Materials and methods: This retrospective analysis of 173 cancer patients with hypercalcemia who sought treatment at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, between July 2019 and June 2020. This cohort of patients underwent a longitudinal follow-up for 2.5 years. To assess survival outcomes, the Kaplan-Meier tool was used to construct survival curves and estimate the survival probability over time. The significance of potential survival factors was evaluated using the log-rank test.

Results: All patients exhibited elevated levels of calcium. At admission, the cohort demonstrated varying degrees of hypercalcemia severity attributable to malignancy: Mild hypercalcemia was observed in approximately 61.3% of patients, moderate hypercalcemia in 23.7%, and severe hypercalcemia in 15% of cases. Among the total sample, most patients were female (54.9%), with a median age of 54. The primary tumor site most frequently observed was in cases of breast cancer (35.3%), wherein the prevalent histological subtype was lobular/ductal invasive carcinoma (34.1%). Most of the patients (93.6%) had an Eastern Cooperative Oncology Group (ECOG) performance status (ECOG) >1. In addition, the median overall survival for patients diagnosed with hypercalcemia was 51 days. Notably, there was a significant association between survival factors, including the primary site of malignancy (P = 0.001), bone metastasis (P = 0.04), severity and symptoms of hypercalcemia (P = 0.001), altered mental state (P = 0.001), albumin levels (P = 0.001), and ECOG (P = 0.001).

Conclusion: Malignancy-related hypercalcemia in patients with cancer is a significant predictor of an unfavorable prognosis. The aforementioned survival factors may have the potential to influence patient survival outcomes. Further studies on larger cohorts are warranted.

Keywords: Cancer; hematological malignancies; hypercalcemia; survival outcomes.

Figure 1

Radiological representative images of bone metastasis: Images of a 50-year-old female patient of breast cancer with extensive axial skeleton osseous metastasis. Magnetic resonance imaging whole spine (a) T2 weighted, (b) T1 weighted, (c) contrast-enhanced mid-sagittal slices, (d) computed tomography scan mid-sagittal slice, bone window settings, and (e and f) Bone scan, anterior and posterior planer images. Blue arrows are sites of axial skeleton osseous metastasis.

Figure 2

The median overall survival (OS) for the patients was found to be 51 days. X-axis: Cancer survival days. Y-axis: Cumulative survival proportion. The median OS curve represents the relationship between the onset of hypercalcemia and the proportion of patients who survive beyond that time. X-axis represents the time (number of days) from the onset of hypercalcemia till death. Y-axis represents the cumulative proportion of patients who survive beyond a certain time point. Curve starts at 1 (100 %) on Y-axis indicating that all patients are alive at the beginning of the study. As time progresses, the curve descends gradually, reflecting the decrease in the proportion of patients surviving as time goes on. Median OS represents the time at which 50 % of patients have survived beyond. Median OS was 51 days (95% confidence interval 31–70 days)

Figure 3

Impact of various factors on overall survival (OS) was determined: (a) Delineated significant variance in OS across distinct histopathologies (P < 0.001). Squamous cell carcinoma exhibited better long-term survival compared to adenocarcinoma, ductal/lobular invasive, lymphoma, multiple myeloma, and others. In (b), the illustration depicted a notable survival discrepancy between groups based on the presence or absence of bone metastasis (P < 0.04). (c) Elucidated the gradation of hypercalcemia severity (mild, moderate, and severe) with superior OS observed in patients with mild hypercalcemia (P < 0.001). (d) Clarified OS differences among various reported symptoms (P < 0.001). (e) Illustrates the contrast in OS based on the presence or absence of altered mental state (AMS) (P < 0.001). In addition, (f) depicted a significant survival discrepancy across different Eastern Cooperative Oncology Group (ECOG) statuses (P < 0.001), with better survival rates observed in patients with ECOG statuses of 0–2 compared to those with statuses below 2. (g and h) demonstrated OS variation between albumin categories (<2.5 vs. >2.5) (P < 0.001) and primary cancer sites (P < 0.001), with marginal survival differences between albumin categories and no disparity observed among primary cancer sites