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

January 07, 2011

Summary: Determining Prognosis and Communicating Effectively

The 6-step protocol for communicating effectively provides a tool to guide the communication and confirmation of diagnosis and prognosis. Prognostication is an inexact science, and physicians are often overly optimistic with their survival estimates. Multiple sources of prognostic information (eg, clinician estimates of survival, signs and symptoms, the Karnofsky performance scale, stage-specific survival data, and integrated models) are available. Patient performance status, as measured by the KPS, the PPS, and the ECOG, is an independent prognostic factor that is highly predictive of survival, especially when scores are low. For patients with very advanced disease and an anticipated survival of less than 3 months, some symptoms (eg, dyspnea) are highly predictive of survival less than 1 month.

Prognosis is more difficult to predict for patients with advanced disease and a longer anticipated survival. Some cancer complications redefine prognosis for this group. For many of these patients, prognostic information is inadequate, and further research is needed.

Key Take-Home Points

Physicians are often overly optimistic with their survival estimates;
Inquire why the patient and family are asking about prognosis to have a sense of their context for the question;
Give as accurate an estimate of prognosis as you can, when requested; and
The 6-step protocol for communicating effectively provides a tool for clarification of diagnosis and prognosis.

Pearls

The shorter the anticipated survival, the more accurate physician predictions of survival;
Hypercalcemia, pleural effusion, and brain metastasis portend a poor prognosis; and
Make a partnership with your patient and the family caregiver; draw them into the interdisciplinary team and foster their active participation in the care plan.

Pitfalls

Trying to "soften the blow" -- the patient and family may not understand the significance of the message; and
Failing to clarify terms: be sure patients and families understand how response does and does not relate to cure.

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Cite this: Linda Emanuel, Frank D. Ferris, Charles F. von Gunten, et. al. Communicating Diagnosis and Prognosis to Patients With Cancer: Guidance for Healthcare Professionals - Medscape - Jan 07, 2011.

Case Study: RS, a 68-Year-Old Farmer
Determining the Prognosis
Integrated Models for Prognostication
Other Factors that Influence Survival Prognosis
Six Steps for Clarifying Diagnosis and Prognosis
Summary: Determining Prognosis and Communicating Effectively
References

Authors and Disclosures

Author(s)

Linda Emanuel, MD, PhD

Author, researcher, educator, previously practicing clinician; Principal, The EPEC Project; Director, Buehler Center on Aging, Heath and Society (where the EPEC Project and its derivatives are housed), Northwestern University Feinberg School of Medicine, Chicago, Illinois

Disclosure: Linda Emanuel, MD, PhD, has disclosed no relevant financial relationships.

Dr. Emanuel does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the US Food and Drug Administration (FDA) for use in the United States.

Dr. Emanuel does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Frank D. Ferris, MD, FAAPHM

Director, International Programs, Institute for Palliative Medicine at San Diego Hospice, San Diego, California; Professor, Department of Family and Preventative Medicine, University of California School of Medicine, San Diego, California; Co-principal, The EPEC Project

Disclosure: Frank D. Ferris, MD, FAAPHM, has disclosed no relevant financial relationships.

Dr. Ferris does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.

Dr. Ferris does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Charles F. von Gunten, MD, PhD

Medical Director, Center for Palliative Studies, San Diego Hospice & Palliative Care, San Diego, California; Associate Clinical Professor, University of California, San Diego, School of Medicine; Co-principal, The EPEC Project; Past Chairman, The American Board of Hospice and Palliative Medicine

Disclosure: Charles F. von Gunten, MD, PhD, has disclosed no relevant financial relationships.

Dr. von Gunten does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the US Food and Drug Administration (FDA) for use in the United States.

Dr. von Gunten does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Jaime H. Von Roenn, MD

Medical Director, Palliative Care and Home Hospice Program, Northwestern Memorial Hospital, Chicago, Illinois; Professor of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Co-Principal, The EPEC Project; Editor, EPEC-O Curriculum; Editor-in-Chief, The Journal of Supportive Oncology

Disclosure: Jamie H. Von Roenn, MD, has disclosed the following relevant financial relationships:
Serves as a consultant for: GX International Inc.

Dr. Von Roenn does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the US Food and Drug Administration (FDA) for use in the United States.

Dr. Von Roenn does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editor(s)

Cheryl Arenella, MD, MPH

Cancer Education Program Specialist, Contractor, National Cancer Institute, Office of Education and Special Initiatives, Rockville, Maryland

Disclosure: Cheryl Arenella, MD, MPH, has disclosed no relevant financial relationships.

Laura Stokowski, RN MS

Clinical Nurse, Inova Fairfax Hospital for Children, Falls Church, Virginia; Editor, Medscape Ask the Experts Advanced Practice Nurses

Disclosure: Laura Stokowski, RN, MS, has disclosed no relevant financial relationships.

Susan Yox, RN, EdD

Director, Editorial Content, Medscape from WebMD

Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.

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

Summary: Determining Prognosis and Communicating Effectively

Key Take-Home Points

Tables

References

Authors and Disclosures

Authors and Disclosures

Author(s)

Linda Emanuel, MD, PhD

Frank D. Ferris, MD, FAAPHM

Charles F. von Gunten, MD, PhD

Jaime H. Von Roenn, MD

Editor(s)

Cheryl Arenella, MD, MPH

Laura Stokowski, RN MS

Susan Yox, RN, EdD

Comments

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