Talking about life expectancy and prognosis with patients with advanced cancer and their caregivers is difficult. But communicating accurate prognoses is essential to ensuring patients are choosing clinically appropriate treatments and making the decisions they ultimately want at end of life. New research suggests there's work to be done to accomplish that. A recent study analyzed data from 38 oncologists, 263 patients with advanced nonhematologic cancers, and 193 of those patients' caregivers. When it came to predictions about 2-year survival prognoses, the study found that 62 percent of oncologists had realistic views on those prognoses, compared with 38 percent of patients and 42 percent of caregivers (Cancer 2019; doi:10.1002/cncr.32127). Just 12 percent of oncologists' forecasts turned out to be unduly optimistic, compared with 50 percent of patients' forecasts and 46 percent of caregivers' forecasts.
Study co-author Kirti Malhotra, MD, a third-year internal medicine resident at University of California, Davis, said the good news is that these results suggest oncologists themselves are more realistic than has otherwise been reported in terms of their predictions of optimism towards patients' prognoses. But, she noted there's work to be done in terms of better communicating with patients and their caregivers so expectations are more realistic. Here's what Malhotra told Oncology Times.
1 Why look at these questions about prognostic accuracy now and how are the findings different from what has previously been studied?
"Good communication seems essential, especially now when biotechnology and medical treatments are growing at an ever faster rate. Clinical decisions regarding the appropriateness of disease-directed, life-extending, and comfort-oriented approaches to care in advanced cancer often rely on shared decision-making among the oncologists, patients, and caregivers. We wanted to study the understanding of prognosis by the oncologist, patient, and caregivers to further the efforts at improving end-of-life communication.
"We observed relatively poor prognostic estimation by patients, and a large difference between predictions by oncologists and those of caregivers and patients.
"Our study found that, while oncologists may be less certain, they have good discriminatory ability in their 2-year survival predictions and their predictions are well-calibrated. In contrast, patients and caregivers expressed greater certainty; however, their predictions had inferior discriminatory ability and poor calibration. Moreover, among patients and caregivers, optimistic predictions were common. More research is needed to elucidate the causes of errors in judgments about survival prognosis among patients, caregivers, and oncologists to further improve end-of-life communication.
"Their results agree with findings of prior studies regarding accurate estimation of survival probabilities by physicians. However, unlike our study, several prior studies have shown that when prognosticating about cancer, physicians tend towards optimism. Also, few studies have compared prognostic estimates (by patients, caregivers, and oncologists) with actual survival in patients with advanced cancer."
2 Is overoptimism on the part of patients and caregivers necessarily problematic?
"Undue prognostic optimism can have short-lived psychological benefits; however, it may be harmful in the long run. When patients overestimate their own prognosis, they may pursue aggressive or invasive treatments that detract from quality of life. Accurate perception of prognosis is essential for patient-centered end-of-life care planning and avoiding unnecessary suffering at the end of life. Our research and prior similar studies highlight the need for patients to understand their prognosis and prepare for the most likely outcome while still maintaining hope.
"Our findings highlight the importance of considering how contemplating the prognosis of a patient differs from predicting one's own prognosis or prognosis of a loved one. Optimistically certain predictions by patients and caregivers could be based more on emotion while the pessimistically certain predictions of oncologists could be based more on reason. Oncologists, as experts, have a greater appreciation for unexpected events affecting survival, so they are less likely to be optimistically certain.
"Prior studies have also noted other potential explanations for the optimistically certain predictions seen among patients and caregivers, including poor understanding and recall of a patient's prognosis, poor patient-oncologist communication, and cognitive rigidity or cultural beliefs that are based on avoiding predictions of death."
3 What is the bottom line that practice oncologists and cancer care providers should know about this research?
"Our findings imply that oncologists were capable of formulating relatively accurate 2-year survival probabilities, both in an absolute sense and in comparison with patients and caregivers. Our analysis suggests that future efforts to enhance patients' prognostic understanding should focus more on communicating oncologists' estimates rather than recalibrating them.
"While oncologists may be less certain, they have good discriminatory ability in their 2-year survival predictions and their predictions are well-calibrated. In contrast, patients and caregivers express greater certainty. However, they have somewhat inferior discriminatory ability, their predictions are poorly calibrated, and they tend toward over-optimism. More research is needed to elucidate the causes of errors in judgments about survival prognosis among patients, caregivers, and oncologists to further improve end-of-life communication."