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Opinions on prognosis often discordant between patients and their oncologists
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Patients with advanced cancers frequently interpreted their prognoses differently from their oncologists, according to the results of a cross-sectional study published in JAMA Oncology.
Further, patients were rarely aware of these discordances.
Reshma Jagsi
“When people think they’ll live a very long time with cancer despite evidence to the contrary, they may end up taking more aggressive chemotherapy and agreeing to be placed on ventilators or dialysis — paradoxically reducing their quality of life, keeping them from enjoying time with family and sometimes even shortening their lives,” Ronald M. Epstein, MD, professor of family medicine, psychiatry and oncology at University of Rochester Medical Center, said in a press release. “So it is very important for doctors and patients to be on the same page.”
Epstein and colleagues identified 236 patients (mean age, 64.5 ± 11.4 years; 54% women) who participated in a randomized trial in an outpatient oncology setting.
These patients were treated by 38 oncologists practicing in Rochester, New York or Sacramento, California.
All participating patients had stage IV nonhematologic cancer or stage III cancer. Their oncologists reported that they “would not be surprised” if the patients died within 12 months.
Epstein and colleagues separately surveyed patients and oncologists, asking them to rate the likelihood of surviving 2 or more years. Response options included 100%, about 90%, about 75%, about 50%, about 25%, about 10% and 0%.
Patients were additionally asked what they thought their doctors believed their survival prognosis to be, and to what extent they had discussed prognosis with their doctors.
End-of-life treatment preferences were assessed by asking patients what they would choose if their doctor informed them that no helpful anticancer treatments remained. The patients rated their likelihood of accepting palliative care options — described as “comfort care with a focus on quality of life, but not a cure” — as definitely yes, possibly yes, unsure, possibly no and definitely no.
Oncologists received a 14-item survey asking them to quantify their perceived communications skills in several domains, including giving bad news and eliciting patient fears about the end of life. The doctors rated their skills on a 5-point scale, representing basic to advanced efficacy.
Participating oncologists were further asked to what extent they discussed prognosis with individual patients; answer options included completely, mostly, a little and not at all.
Sixty-eight percent of patients (n = 161) rated their survival prognosis differently from their oncologists. The majority of these patients (89%; n = 144) did not know that their views differed from their doctors.
Twenty-nine percent of this group (n = 42) indicated on their surveys that they did not know their oncologists’ opinions.
Ninety-six percent (n = 155) of discordant dyads involved patients who rated a more positive prognosis than their doctors.
Discordance did not differ significantly based on patient income level, education, sex, confidence in patient–physician communication, recalled extent of prognosis communication, oncologists’ perceived end-of-life communication skills or recalled extent of communication, or study site.
The researchers found that nonwhite patients (n = 22) were significantly more likely than non-Hispanic white patients (n = 214) to hold prognostic expectations that differed from their oncologists (95% vs. 65%; P = .03); this difference persisted even in patients unaware of their oncologists’ views (91% vs. 62%; P = .04).
Ninety-nine percent (n = 159) of patients in discordant dyads indicated a desire to be involved in treatment decision-making, with 70% (n = 113) answering “definitely yes” or “possibly yes” when asked if they wished to be involved in palliative care.
Oncologists reported “completely thorough discussions” on prognosis with 52% (n = 83) of these patients.
The researchers acknowledged study limitations, including their inability to determine why discordant patients did not know their oncologists’ opinions and the fairly small sample of nonwhite patients. The study also did not attempt to quantify prognostic accuracy.
“Of course, it is only possible for doctors to provide a ballpark estimate about life expectancy, and some people do beat the odds,” Epstein said. “Positive thinking by patients can improve quality of life. But when a patient with very advanced cancer says that he has a 90% to 100% chance of being alive in 2 years, and his oncologist believes that chance is more like 10%, there’s a problem.”
High levels of discordance suggest that patient–provider communications must be improved to best reflect patient-desired outcomes, Jeffrey D. Robinson, PhD, professor and chair of the department of communications at Portland State University, and Reshma Jagsi, MD, DPhil, associate professor and deputy chair for faculty and financial operations in the department of radiation oncology at University of Michigan Health System, wrote in an accompanying editorial.
“It is particularly sobering that most cases of prognostic discordance occurred despite oncologists recalling having ‘completely’ thorough discussions about prognosis with patients,” Robinson and Jagsi wrote. “That virtually all of the patients in the discordant dyads wished to be actively involved in treatment decision making, and 70% of such patients had prognosis-relevant care preferences, suggests that this discordance may have a meaningful impact in terms of causing decisions to diverge from patients’ true underlying values and preferences.”
Communication improvements may also lead to more effective medical practice, according to Robinson and Jagsi.
“The NCI, Institute of Medicine and ASCO all call for improved communication with patients with incurable, life-limiting illnesses,” Robinson and Jagsi wrote. “The study ... provides clear evidence of the ongoing need for improved communication in the context of advanced cancer. After all, promoting more realistic prognostic estimates is a critical step toward improving patients’ quality of life and preference-concordant illness management decisions, including the reduction of overly aggressive treatments that many patients will otherwise continue to receive.” – by Cameron Kelsall
Disclosure: The researchers, Robinson and Jagsi report no relevant financial disclosures.
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