Communicating Diagnosis and Prognosis to Patients With Cancer: Guidance for Healthcare Professionals

Linda Emanuel, MD, PhD; Frank D. Ferris, MD, FAAPHM; Charles F. von Gunten, MD, PhD; Jaime H. Von Roenn, MD

Disclosures

January 07, 2011

In This Article

Other Factors that Influence Survival Prognosis

Data to provide accurate prognostic information for most patients with metastatic disease and months to years of projected survival are inadequate. However, when complications such as hypercalcemia or brain metastases occur, the prognosis can be more clearly defined and inform both treatment and personal decisions.

A review of the median survival for patients with advanced or metastatic solid tumors reported in published phase 3 treatment trials from 1998 through 2004 provides a broad view of the prognosis for patients receiving treatment for advanced or metastatic disease. A summary of the common tumors and their reported median survival is shown in Table 7.

For patients with an anticipated survival of 6 months or more, survival data from recent trials provide little more than general information about prognosis. What factors help refine prognosis for these patients? Prognostic modifiers for patients believed to have "chronic" metastatic disease include performance status, hypercalcemia, brain metastases, and pleural effusions.

Hypercalcemia

Hypercalcemia is one of the most common metabolic complications of cancer and usually occurs during the last weeks of life. A review of the effects of antihypercalcemic treatment on morbidity and mortality in cancer-associated hypercalcemia reported a median survival of 30 days.[44] In the subset of patients for whom specific therapeutic interventions were directed at the cancer, survival was improved to 135 days. These data predate the widespread use of bisphosphonates for patients with osteolytic bone metastases from solid tumors. The poor prognosis for hypercalcemia does not appear to have changed, although anecdotally, its incidence is lower. In other words, treating hypercalcemia with bisphosphonates does not change prognosis, it only changes the way the patient dies.

Table 7. Survival of Adult Patients Receiving Antineoplastic Therapy

Tumor Site Disease Status Median Survival (mo)
Bladder (transitional cell carcinoma) Advanced/metastatic 9-15
Brain -- glioblastoma multiforme Newly diagnosed 10-11
Breast Metastatic 15-22
Cervix -- squamous Recurrent 6-8
Colon/rectum Advanced/metastatic 12-22
Esophagus Advanced/metastatic 3-6
Gastric Advanced 7
Head and neck Advanced/recurrent 5-12
Kidney Metastatic 12-13
Liver Advanced 3-10
Non-small cell lung Advanced 6-11
Small cell lung Extensive 9-14
Melanoma Metastatic 5-12
Ovaries Advanced 10-36
Pancreas Advanced 5-6
Prostate Refractory 9-14
Sarcoma Advanced 12-14
Unknown primary Metastatic 8-13

Brain Metastases

The incidence of brain metastases has increased as treatment options for systemic disease have improved. In addition, a multimodal approach to brain metastases can prolong survival in some patients, although for most patients, brain involvement is the limiting factor in survival irrespective of the state of the cancer in other parts of the body.

Gaspar and colleagues analyzed 1200 patients enrolled in 3 consecutive Radiation Therapy Oncology Group (RTOG) brain metastases trials to identify prognostic factors for survival.[45]Using recursive partitioning analysis, best survival (median 7.1 months) was observed in patients younger than 65 years with a KPS ≥ 70 and controlled primary tumor; worst survival (median 2.3 months) was observed in patients with a KPS < 70 (Group 3). All other patients fell into an intermediate prognostic group with a median survival of 4.2 months (Group 2).

When a similar analysis was applied to patients who underwent surgical resection of brain metastases (with or without radiation therapy), overall survival was improved.[46]However, the survival varied on the basis of patient characteristics defined by the 3 groups, with a median survival of groups 1, 2, and 3 of, respectively, 14.8, 9.9, and 6 months. In a highly selected group of patients, those with a KPS > 70 and the absence of extracranial disease, prolonged survival (> 1 year) can be anticipated.

Malignant Pleural Effusions

Symptomatic malignant pleural effusions generally portend a poor prognosis, with a median survival of less than 4 months.[47,48] As with other manifestations of advanced disease, prognosis is modified by the KPS.[36] Patients with recurrent, symptomatic pleural effusions and a Karnofsky performance scale score of ≥ 70 have a median survival of 13 months, while those with a KPS ≤ 30 have a median survival of 1 month. Although some series have failed to identify primary tumor site as a significant prognostic variable, others report a markedly worse survival for patients with non-small cell lung cancer and malignant effusion (median survival 2.9 months) and a better outcome for those with breast cancer (median survival 10 months) or ovarian cancer (median survival 9 months).[31,36,49]

Concurrent Palliative Care

In defining palliative care, the Institute of Medicine states: "Palliative care seeks to prevent, relieve, reduce or soothe the symptoms of disease or disorder without effecting a cure...Palliative care in this broad sense is not restricted to those who are dying or those enrolled in hospice programs..."[1] The World Health Organization defines palliative care as: "An approach which improves quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."[50]Both of these bodies recommend incorporation of palliative care throughout the spectrum of chronic, life-threatening illness.

But how does incorporating palliative care into disease-modifying care influence prognosis?

A prospective randomized study performed at the Massachusetts General Hospital enrolled newly diagnosed patients with non-small cell lung cancer into 2 groups. An intervention group consisted of patients assigned to receive early, concurrent, palliative care integrated with standard oncologic care, whereas the control group received only standard oncologic care. The findings were dramatic. Patients who received early palliative care were shown to have a better quality of life and fewer depressive symptoms, were more likely to have their resuscitation preferences documented, had a longer median duration of hospice care at end of life, and, most impressively, had a median survival that was significantly longer than the patients who received standard oncologic care (11.6 vs 8.9 months) in spite of receiving less disease-modifying and life-prolonging treatment.[51]

A previous retrospective study, which analyzed of Medicare claims databases for selected cohorts of Medicare beneficiaries (n = 4493) for 5 types of cancer and congestive heart failure patients, found that mean survival was 29 days longer for patients enrolled in hospice than for non-hospice patients. In particular, the mean survival was significantly longer for hospice patients with congestive heart failure, lung cancer, pancreatic cancer, and marginally significantly longer for patients with colon cancer.[52]

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