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Prognostic disclosures benefit patients with advanced cancer without harming emotional well-being
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Patients with advanced cancer who received prognostic disclosures from their physicians had a more realistic expectation of their life expectancy without negatively affecting their emotional well-being or patient–physician relationship, according to findings from a multicenter observational study.
“That the vast majority of patients with cancer who are dying say that they want to know their prognosis seems surprisingly courageous,” Holly G. Prigerson, PhD, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine, told HemOnc Today. “It is also disappointing that less than 18% of patients reported that their oncologist told them how long they had left to live.
Holly G. Prigerson
“It is encouraging that the patients who reported a prognostic disclosure by their oncologist were more realistic in their life-expectancy estimate, more likely to complete a do-not-resuscitate order and want comfort care,” Prigerson added. “There was no emotional fallout that damaged their relationship with their oncologist — as reported by the patient.”
Prigerson and colleagues evaluated data from 590 patients with metastatic solid malignancies whose disease progressed after one or more line of palliative chemotherapy who underwent follow-up to death.
The patients received a baseline interview. The investigators found that 71% of the 590 patients included in this study — who had a median survival of 5.4 months — wanted to know their life expectancy, however only 17.6% of them remembered being given such a prognosis by their physician.
Fifty-one percent (n = 299) of patients were willing to estimate their life expectancy. From that group, those who recalled having a prognostic disclosure from their physician were able to offer more realistic life expectancy estimates compared with patients who had not been given a disclosure (median 12 months; interquartile range [IQR], 6-36 months vs. 48 months; IQR, 12-180 months; P < .001).
Further, their estimates were less likely to be different from their actual survival by more than 2 years (30.2% vs. 49.2%; OR = 0.45; 95% CI, 0.14-0.82) or 5 years (9.5% vs. 35.5%; OR = 0.19; 95% CI, 0.08-0.47) than patients who had not received a prognostic disclosure.
Results of an adjusted analysis showed prognostic disclosure receipt was associated with a 17.2-month (95% CI, 6.2-28.2) decrease in their life expectancy estimates.
Those with longer self-reported life expectancy estimates also had a lower likelihood of completing a do-not-resuscitate order (adjusted OR = 0.44; 95% CI, 0.30-0.63 per estimated 12-month increase) and an increased likelihood to prefer life-prolonging vs. comfort-oriented care (adjusted OR = 1.49; 95% CI, 1.09-1.94).
The researchers observed no association between prognostic disclosure and worse patient–physician relationship, sadness or anxiety.
“Every patient needs to know: a) their prognosis, including life expectancy, and b) expected outcomes of treatment — for example, if they have an incurable cancer, that chemotherapy will not cure them,” Prigerson said. “Providers often are reluctant to communicate grim news, as anyone would be.”
Clinicians may not disclose a patient’s life expectancy for many reasons, Prigerson said.
“Patients may not be ready to hear bad news [or they] may actually be provided with information that they reject as not mattering because they consider their future to be in God’s hands — not their doctors’ — because of hope that a miracle might happen,” she said. “There are a variety of other related reasons, too.”
This study had several limitations, most notably that the prognostic disclosures were assessed based on a patient’s memory of a conversation with their physician. Further, many patients were not willing or were unable to estimate their own prognosis, which also could have biased the outcomes.
“Some patients are not able to hear and process poor prognoses and more harm than good can be done by forcing the situation,” Prigerson said. “However, we have found that over 90% of patients benefit from prognostic disclosures, and it is a minority of patients for religious, psychological or social reasons who do not benefit.” – by Anthony SanFilippo
Disclosure: Prigerson reports no relevant financial disclosures. Please see the full study for the other researchers’ relevant financial disclosures.
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