The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 8 Clarifying Diagnosis and Prognosis Module 8 Clarifying Diagnosis and Prognosis EPEC - Oncology Education in Palliative and End-of-life Care - Oncology

Objectives l Describe the difficulty with prognostication l Discuss limitations of current prognostic models l Apply the 6-step protocol to communicate diagnosis and prognosis l Describe the difficulty with prognostication l Discuss limitations of current prognostic models l Apply the 6-step protocol to communicate diagnosis and prognosis

Video

Importance l Most people want to know l Strengthens physician-patient relationship l Fosters collaboration l Permits patients, families to plan, cope l Most people want to know l Strengthens physician-patient relationship l Fosters collaboration l Permits patients, families to plan, cope

Inaccuracy of prognostication 9 Studies of Clinical Predictions of Survival vs Actual Survival Study # Patients Median CPS (days) Median AS (days) Parkes et al (45-56) 21 (9-34) Evans et al (28-182) 120 (43-180) Heyse-Moore et al (33-84) 14 (7-28) Maltoni et al (28-56) 32 (13-63) Maltoni et al (28-70) 32 (13-62) Oxenham et al (14-35) 15 (9-25) Maltoni et al (21-70) 33 (14-62) Christakis et al (28-133) 24 (12-58) Overall1, (28-84) 29 (13-62)

Clinical predictions vs. actual survival l Over optimistic by factor of Glare P. BMJ

Clinical predictions vs. actual survival l Relationships between predictions and survival l Actual is 30% less than predicted l Survival = predicted  1 week for 25% l Predicted  survival + 4 weeks for 27% l Relationships between predictions and survival l Actual is 30% less than predicted l Survival = predicted  1 week for 25% l Predicted  survival + 4 weeks for 27% Glare P. BMJ

Sources of prognostic information l Physician prediction l Stage-specific survival data l Performance status l Signs and symptoms l Integrated models l Physician prediction l Stage-specific survival data l Performance status l Signs and symptoms l Integrated models

Sources of survival data... l Stage specific survival curves l Natural history studies l Randomized trials with a ‘best supportive care’ arm l Stage specific survival curves l Natural history studies l Randomized trials with a ‘best supportive care’ arm

Natural history studies Cancer type N Median survival (Years) Actuarial 5-year survival % Breast , Head and neck

Performance status and prognosis... l Independent prognostic factor l Karnofsky Performance Score <50: survival <8 weeks l Independent prognostic factor l Karnofsky Performance Score <50: survival <8 weeks Mor V, et al. Cancer

... Karnofsky Score as predictor of survival KPS Survival in days  Reuben DB, Mor V, Hiris J. Arch Intern Med

Symptom Median survival Dyspnea 5 <30 days Dysphagia 5 <30 days Confusion/delirium 23,24 <28 days Xerostomia 20 <50 days Weight loss (  10 kg) <28 days Clinical signs and symptoms as prognostic indicators in patients with advanced disease

Prognostic impact Index Median survival (Months) Hypercalcemia Brain metastases plus surgery 9.5 Brain metastases without surgery 4 Pleural effusion 3

6-step protocol... 1.Getting started 2.Find out what the patient knows 3.Find out how much the patient wants to know 1.Getting started 2.Find out what the patient knows 3.Find out how much the patient wants to know Adapted from Robert Buckman

Communicating prognosis... l Some patients want to plan l Others are seeking reassurance l Some patients want to plan l Others are seeking reassurance

... Communicating prognosis... l Limits of prediction Hope for the best, plan for the worst Better sense over time Can’t predict surprises, get affairs in order l Reassure availability, whatever happens l Limits of prediction Hope for the best, plan for the worst Better sense over time Can’t predict surprises, get affairs in order l Reassure availability, whatever happens

... Communicating prognosis... l Inquire about reasons for asking “What are you expecting to happen?” “How specific do you want me to be?” “What experiences have you had with: others with same illness?” others who have died?” l Inquire about reasons for asking “What are you expecting to happen?” “How specific do you want me to be?” “What experiences have you had with: others with same illness?” others who have died?”

... 6-step protocol 4.Share the information 5.Respond to patient, family feelings 6.Plan, follow-up 4.Share the information 5.Respond to patient, family feelings 6.Plan, follow-up Adapted form Robert Buckman

... Communicating prognosis l Patients vary ‘Planners’ want more details Those seeking reassurance want less l Avoid precise answers Hours to days...months to years Average l Patients vary ‘Planners’ want more details Those seeking reassurance want less l Avoid precise answers Hours to days...months to years Average

Summary l Prognostication is inexact l Karnofsky performance status is an important prognostic factor l In advanced (<3 months) disease, symptoms predict prognosis l Prognosis is difficult to define for patients with survival >6 months l Prognostication is inexact l Karnofsky performance status is an important prognostic factor l In advanced (<3 months) disease, symptoms predict prognosis l Prognosis is difficult to define for patients with survival >6 months