When doctors discuss prognosis with advanced cancer patients, those patients have more realistic views of their life expectancy and don’t seem to experience a decrease in emotional wellbeing, according to a new study.
“That the vast majority of cancer patients who are dying say that they want to know their prognosis seems surprisingly courageous,” said senior author Holly G. Prigerson of Weill Cornell Medical College in New York City.
Every patient needs to know their prognosis, including life expectancy, and expected outcomes of treatment; for example, they should know that chemotherapy cannot cure incurable cancer, Prigerson said.
“Providers often are reluctant to communicate grim news, as anyone would be,” she said.
The study included 590 patients with advanced, metastatic cancer who had been treated with at least one round of palliative chemotherapy, which is meant to improve comfort rather than to cure.
Researchers asked the patients whether their oncologist had ever given them a prognosis with a life expectancy estimate, then asked the patients to estimate their own life expectancy and to complete assessments of emotional distress, whether they had advance directives and their end-of-life care preferences.
The patients also described their relationship with their doctors.
Half of the patients survived for less than six months after the study began.
About 70 percent wanted to be told their life expectancy, but only about 18 percent recalled having this discussion with their oncologist.
Half of the patients were willing to estimate their own life expectancy, and those who remembered having a prognosis conversation with their doctor estimated a life expectancy closer to their actual survival than those who did not.
Less than 10 percent of those who remembered having a conversation with their doctor made estimates that were more than five years longer than their actual survival. That compares with 35 percent of those who did not remember having the conversation who overestimated their life expectancy by more than five years.
Remembering a prognostic discussion with a doctor decreased patient estimated life expectancy by about 17 months, when the researchers accounted for other factors, according to the results in the Journal of Clinical Oncology.
Talking to a doctor about life expectancy was not tied to worse doctor-patient relationship, more sadness or higher anxiety, the surveys found.
“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 to want comfort care,” Prigerson said by email.
“There was no emotional fallout that damaged their relationship with their oncologist – as reported by the patient,” she said.
Often these conversations should happen, but they do not, for a multitude of reasons, she said. The patient may not be ready to hear bad news, some patients may reject information they are given because they believe a miracle may happen, and other reasons, she said.
“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 percent of patients benefit from prognostic disclosures and it is a minority of patients for religious or personal or social reasons that do not benefit.”