The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
E
P
E
C
O
EPEC - Oncology
Education in Palliative and End-of-life Care - Oncology
Module 8
Clarifying Diagnosis
and Prognosis
Objectives

Describe the difficulty with
prognostication

Discuss limitations of current
prognostic models

Apply the 6-step protocol to
communicate diagnosis and
prognosis
Video
Importance

Most people want to know

Strengthens physician-patient
relationship

Fosters collaboration

Permits patients, families to plan,
cope
Inaccuracy of prognostication9
Studies of Clinical Predictions of Survival vs Actual Survival
Study
# Patients
Median CPS (days)
Median AS (days)
Parkes et al1
71
28 (45-56)
21 (9-34)
Evans et al2
42
81 (28-182)
120 (43-180)
Heyse-Moore et al3
50
56 (33-84)
14 (7-28)
Maltoni et al4
100
42 (28-56)
32 (13-63)
Maltoni et al5
530
42 (28-70)
32 (13-62)
Oxenham et al6
21
21 (14-35)
15 (9-25)
Maltoni et al7
451
42 (21-70)
33 (14-62)
Christakis et al8
325
77 (28-133)
24 (12-58)
1,591
42 (28-84)
29 (13-62)
Overall
Clinical predictions vs.
actual survival

Over optimistic by factor of 3 - 5
Glare P. BMJ. 2003.
Clinical predictions vs.
actual survival

Relationships between predictions
and survival

Actual is 30% less than predicted

Survival = predicted  1 week for 25%

Predicted  survival + 4 weeks for
27%
Glare P. BMJ. 2003.
Sources of prognostic
information

Physician prediction

Stage-specific survival data

Performance status

Signs and symptoms

Integrated models
Sources of
survival data . . .

Stage specific survival curves

Natural history studies

Randomized trials with a ‘best
supportive care’ arm
Natural history studies
N
Median
survival
(Years)
Actuarial
5-year
survival %
Breast14
250
2.7
18.4
Breast14
1,022
2.3
19.8
808
0.32
0
Cancer type
Head and neck15
Performance status and
prognosis . . .

Independent prognostic factor

Karnofsky Performance Score <50:
survival <8 weeks
Mor V, et al. Cancer. 1984.
. . . Karnofsky Score as
predictor of survival
KPS
Survival in days
50
86.1
30-40
49.8
10-20
16.8
Reuben DB, Mor V, Hiris J. Arch Intern Med. 1988.
Clinical signs and symptoms as
prognostic indicators in patients
with advanced disease
Symptom
Median survival
Dyspnea5
<30 days
Dysphagia5
<30 days
Confusion/delirium23,24
<28 days
Xerostomia20
<50 days
Weight loss (10 kg)
<28 days
Prognostic impact
Index
Hypercalcemia
Median survival (Months)
1 - 4.5
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
Adapted from Robert Buckman
Communicating
prognosis . . .

Some patients want to plan

Others are seeking reassurance
. . . Communicating
prognosis . . .

Limits of prediction
Hope for the best, plan for the worst
Better sense over time
Can’t predict surprises, get affairs in
order

Reassure availability, whatever
happens
. . . Communicating
prognosis . . .

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
Adapted form Robert Buckman
. . . Communicating
prognosis

Patients vary
‘Planners’ want more details
Those seeking reassurance want less

Avoid precise answers
Hours to days. . .months to years
Average
Summary

Prognostication is inexact

Karnofsky performance status is an
important prognostic factor

In advanced (<3 months) disease,
symptoms predict prognosis

Prognosis is difficult to define for
patients with survival >6 months