# 013 Determining Prognosis in Advanced Cancer, 2nd ed

FAST FACTS AND CONCEPTS #013 PDF


Author(s): David E Weissman MD

Background How long do I have, Doc? is among the most common questions asked by cancer patients, especially when informed that there are no further effective anti-neoplastic treatment options. Although prognostication is not an exact science, there are data to help clinicians provide useful information to patients and families – information critical to making realistic end-of-life decisions and referrals for home hospice service (see Fast Fact #30).

Performance Status The single most important predictive factor in cancer is Performance Status (‘functional ability,’ ‘functional status’): a measure of how much a patient can do for themselves, their activity and energy level. Patients with solid tumors typically lose ~ 70% of their functional ability in the last 3 months of life. The most common scales used to measure functional ability are the Karnofsky Index (100 = normal; 0 = dead) and the ECOG scale (Eastern Cooperative Oncology Group), (0 = normal; 5 = dead). A median survival of 3 months roughly correlates with a Karnofsky score <40 or ECOG > 3. Newer prognostic scales have been developed to help provide prognostic information (See Fast Facts #124, 125).

The simplest method to assess functional ability is to ask patients: How do you spend your time? How much time do you spend in a chair or lying down? If the response is >50% of the time, and is increasing, you can roughly estimate the prognosis at 3 months or less. Survival time tends to decrease further with increasing numbers of physical symptoms, especially dyspnea, if secondary to the cancer.

Other Factors Several common cancer syndromes have well-documented short median survival times:

  • Malignant hypercalcemia: 8 weeks, except newly diagnosed breast cancer or myeloma (see Fast Fact #151)
  • Malignant pericardial effusion: 8 weeks (see Fast Fact #209)
  • Carcinomatous meningitis: 8-12 weeks (see Fast Fact #135)
  • Multiple brain metastases: 1-2 months without radiation; 3-6 months with radiation.
  • Malignant ascites (see Fast Fact #176), malignant pleural effusion, or malignant bowel obstruction: < 6 months.

Other Comments In general, a patient with metastatic solid cancer, acute leukemia or high-grade lymphoma, who will not be receiving systemic chemotherapy (for whatever reason), has a prognosis of less than 6 months. Notable exceptions to this are patients with metastatic breast or prostate cancer with good performance status, as these cancers may have an indolent course. In these patients additional features suggesting short prognosis are needed (declining functional status, dyspnea, weight loss).

Discussing Prognosis When discussing prognosis with patients/families, the following four step approach is recommended: Preparation; Content; Patient’s Response; Close. Remember to:

  • Confirm that the patient/family are ready to hear prognostic information.
  • Present information using a range: a few days to weeks; 2-4 months, etc.
  • Allow silence after you provide information; respond to emotion (see Fast Fact #29).
  • Use prognostic information as a starting point for eliciting end-of-life goals (see Fast Fact #65).

References

  1. Lamont EB, Christakis NA.. Complexities in prognostication in advanced cancer. JAMA. 2003; 290:98-104.
  2. den Daas, N. Estimating length of survival in end-stage cancer: a review of the literature. J Pain Symp Manage. 1995; 10:548-555.
  3. Lassauniere JM, Vinant P. Prognostic factors, survival and advanced cancer. J Pall Care. 1992; 8:52-54.
  4. Ralston SH, et al. Cancer associated hypercalcemia. Ann Int Med. 1990; 112:499:504.
  5. Reuben DB, Mor V. Clinical symptoms and length of survival in patients with terminal cancer. Arch Int Med. 1998;148:1586-1591.

Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2005. Current version re-copy-edited March 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE. Determining Prognosis in Advanced Cancer, 2nd Edition. Fast Facts and Concepts. July 2005; 13. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_013.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Prognosis