Pancreatic cancer and predictors of survival: comparing the CA 19-9/bilirubin ratio with the McGill Brisbane Symptom Score

HPB (Oxford). 2013 Dec;15(12):1002-9. doi: 10.1111/hpb.12085. Epub 2013 Mar 22.


Introduction: Few tools predict survival from pancreatic cancer (PAC). The McGill Brisbane Symptom Score (MBSS) based on symptoms at presentation (weight loss, pain, jaundice and smoking) was recently validated. The present study compares the ability of four strategies to predict 9-month survival: MBSS, carbohydrate antigen 19-9 (CA 19-9) alone, CA19-9-to-bilirubin ratio and a combination of MBSS and the CA19-9-to-bilirubin ratio.

Methodology: A retrospective review of 133 patients diagnosed with PAC between 2005 and 2011 was performed. Survival was determined from the Quebec civil registry. Blood CA 19-9 and bilirubin values were collected (n = 52) at the time of diagnosis. Receiver-operating characteristic (ROC) curves were used to determine a cutoff for optimal test characteristics of CA 19-9 and CA19-9-to-total bilirubin ratio in predicting survival at 9 months. Predictive characteristics were then calculated for the four strategies.

Results: Of the four strategies, the one with the greatest negative predictive value was the MBSS: negative predictive value (NPV) was 90.2% (76.9-97.3%) and the positive likelihood ratio (LR) was the greatest. The ability of CA 19-9 levels alone, at baseline, to predict survival was low. For the CA19-9-to-bilirubin ratio, the test characteristics improved but remained non-significant. The best performing strategy according to likelihood ratios was the combined MBSS and CA19-9 to the bilirubin ratio.

Conclusion: CA19-9 levels and the CA19-9-to-bilirubin ratio are poor predictors of survival for PAC, whereas the MBSS is a far better predictor, confirming its clinical value. By adding the CA19-9-to-bilirubin ratio to the MBSS the predictive characteristics improved.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Area Under Curve
  • Bilirubin / blood*
  • CA-19-9 Antigen / blood*
  • Female
  • Humans
  • Jaundice / etiology
  • Jaundice / mortality
  • Kaplan-Meier Estimate
  • Likelihood Functions
  • Male
  • Middle Aged
  • Pain / etiology
  • Pain / mortality
  • Pancreatic Neoplasms / blood*
  • Pancreatic Neoplasms / complications
  • Pancreatic Neoplasms / mortality
  • Pancreatic Neoplasms / therapy
  • Prognosis
  • Proportional Hazards Models
  • Quebec
  • Registries
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Smoking / adverse effects
  • Smoking / mortality
  • Weight Loss


  • CA-19-9 Antigen
  • Bilirubin