The Author's Response: ASA Physical Status Classification in Surgical Oncology and the Importance of Improving Inter-Rater Reliability.

We appreciate for a valuable comment by Araujo and Theobald. Numerous studies have been supported the prognostic role of comorbidity/performance indices in many cancer including urological malignancies such as prostate, bladder, and renal cell carcinoma (123).

We also concede that other comorbidity indices such as Charlson comorbidity index (CCI), Adult Comorbidity Evaluation-27 (ACE-27), Eastern Cooperative Oncology Group performance status (ECOG-PS), and Karnofsky performance status (KPS) are more appropriate for decision of chemotherapy eligibility and prediction of cancer related survival than American Society of Anesthesiologists physical status (ASA-PS) (4).

Previous frontier study by Berod et al. (5) showed the correlation between ASA classification and cancer-specific survival (CSS) after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC) patients. Without doubt, the aim of our study is not to evaluate the application of ASA-PS in decision on chemotherapy eligibility, but to explore the background of prognostic value of ASA-PS in UTUC patients after RNU.

Although no significant survival impact of ASA-PS score on overall survival (OS) or CSS in patients with localized UTUC was observed in subgroup analysis, high ASA-PS groups with locally advanced disease probably reflects a worse physical status directly related to the cancer itself as your comment (6).

Unfortunately, our multi-institutional data did not include any information about PS and we could not adequately adjust for PS. Further co-operated study is needed to clarify the relationship among ASA-PS and cancer related survival in UTUC patients after RNU.