Most patients with advanced cancer report far more optimistic expectations for survival prognosis than their oncologists because patients misunderstand their oncologists’ clinical judgment.1
“Previous research shows that patients, families, and clinicians tend to either avoid prognosis-related conversations altogether or discuss prognosis in unbalanced ways,” said Robert Gramling, MD, MSc, Holly and Bob Miller Chair in Palliative Medicine at the University of Vermont, Burlington, Vermont, and first author.
Clear communication between a doctor and patient is essential, especially when patients with advanced cancer wish to participate in decision-making about their medical treatment options. Then, trade-offs emerge between quality and quantity of life.
In this study, a multimodal intervention that supports communication in advanced cancer was tested. At enrollment, 236 patients and 38 oncologists were asked to rate their expectations for the patient’s 2-year survival probability. In addition, patients were asked to rate what they believed their oncologists thought about their prognosis.
Gramling’s team found that more than 2 out of 3 patients held substantially more optimistic ratings than their oncologist and that the vast majority of them did not know their rating differed from their oncologist’s.
In many fields of medicine, Gramling explained, patients, families, and their doctors often craft an unwritten social contract to maintain unbalanced positivism, sometimes making it difficult to conduct meaningful prognosis discussions as the illness progresses.
“Our study reinforces the importance of clear and compassionate prognosis communication in advanced illness, but we must be aware that our data do not speak to what actually happens in clinical encounters between patients and their oncologists that leads to our observed differences in perceptions of prognosis,” Gramling cautioned.
“We need to better understand where, when, and how to support high quality prognosis communication,” said Gramling.
The researchers also found that patients who self-identified as black or African American were at substantially higher risk of unknowingly holding optimistically discordant opinions about their prognosis.
“Evidence is mounting about racial disparities in end-of-life care; our findings might point to an important piece of that puzzle and a promising area of work to improve health care for everyone,” Gramling added.
The study’s authors concluded that their report “supports the urgent clinical and societal need to better understand what it means to communicate well about prognosis to achieve treatment that honors patients’ values, preferences, and wishes.”
1. Epstein RM, Fiscella K, Xing G, et al. Determinants of patient-oncologist prognostic discordance in advanced cancer. JAMA Oncology. 2016 Jul 14. doi: 10.1001/jamaoncol.2016.1861. [Epub ahead of print]