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Adler et al. J Cancer Metastasis Treat 2019;5:45 I http://dx.doi.org/10.20517/2394-4722.2019.03 Page 3 of 12

Table 1. Molecular phenotypes of metastatic breast cancer with related survival times [26]
Molecular Phenotype Luminal A Luminal B HER2-enriched Triple-negative-status
ER and PR positive ER and/or PR positive HER2-positive ER and PR and HER2-negative
Low Proliferation Rate (Ki-67) High Proliferation Rate (Ki-67) (Basal-like)
Mean survival time 60 months 60 months 56.5 months 15-19 months

Table 2. Karnowsky Performance Scale from 1949 [34]
Score Parameter
100 Normal; no complaints; no evidence of disease
90 Able to carry on normal activity; minor signs or symptoms of disease
80 Normal activity with effort; some signs or symptoms of disease
70 Cares for self; unable to carry on normal activity or to do active work
60 Requires occasional assistance, but is able to care for most of their personal needs
50 Requires considerable assistance and frequent medical care
40 Disabled; requires special care and assistance
30 Severely disabled; hospital admission is indicated although death not imminent
20 Very sick; hospital admission necessary; active supportive treatment necessary
10 Moribund; fatal processes progressing rapidly
0 Dead

higher compared to hormone receptor positive (HR+) status . Biggest progress regarding survival times
[6]
and therapy options was achieved in HER-2 enriched phenotypes in the last decade. Until some years a HER-2
positive status was associated as a negative predictor with a mean survival time of 5-9 months. After the
introduction of new Anti-Her-2 therapeutics (Trastuzumab, Pertuzumab, T-DMI) the mean survival time is
reported with 56.5 months [2-4,10,34,36] .

Whereas triple negative phenotypes (ER-, PgR-, HER-2-) were reported with a mean survival time of 6-9 months
until the year 2015, actual data show a prolonged survival
time of 15-19 months [2-6,9,10,13-15,26-28,34,35,37,38] .

SCORE SYSTEMS
Life expectancy in metastasized tumor diseases is estimated with well known and evaluated score systems.
The Karnofsky-Index [Table 2] dating from 1948 describes patients´ general condition and physical
resilience [17,21,39] . Furthermore, the Karnofsky-Index is part of different score systems (Tokuhashi and
revised Tokuhashi score, Oswestry Disability Index, Van-der-Linden-Score) [18,20,21,39,40] . Patients describe
[41]
pain with the numeric or visual analogue scale (NAS/VAS) . Vertebral stability is estimated by the Spinal
Instability Neoplastic Score (SINS) [Tables 3 and 4] [21,42] , Harrington Score [21,43] or Taneichi score . The
[44]
[19]
revised Tokuhashi score [Tables 5 and 6] [18,34] and Tomita score [Tables 7 and 8] are worldwide accepted
to determine individual life expectancy in malignancy and to plan optimal treatment options. The modified
[20]
[16]
[39]
Bauer score , Van-der-Linden score and Oswestry-risk index are named for the sake of completeness.
[18]
[19]
The revised Tokuhashi and Tomita score merely discern tumor entities (breast, prostate, lung, thyroid)
and in both scores breast cancer is assessed with a favorable prognosis. The four different phenotypes
of breast cancer are not included. A life expectancy limited to 5 to 9 months was published until 2015
concerning HER-2 enriched and triple negative phenotypes [2-6,9,10,13-15,26-28,34,35,37,38,45] . Therefore, modifications
[19]
[2,3]
[18]
in the revised Tokuhashi and Tomita score were suggested and highly invasive anterior-posterior
spine surgery should be evaluated critically. Based on present-day knowledge we can no longer emphasize
these recommendations. Due to better oncologic treatment options actual studies estimate mean survival
times of 15-19 months with regard to the triple negative and 56.5 months concerning HER-2 enriched
phenotypes [4,6,7,10,15,26] . A mean survival time of 15-19 months implies that several patients live longer and