Author: David E. Weissman, MD
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 is 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).
The single most important predictive factor in cancer is Performance Status also known as Functional Ability; 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 Fact #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 bed or laying 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 when there are increasing number of physical symptoms, especially dyspnea, if secondary to the cancer.
Several common cancer syndromes have well-documented short median survival times:
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).
When discussing prognosis with patients/families, the following four step approach is recommended: Preparation; Content; Patient’s Response; Close. Remember to:
Fast Facts were edited by David Weissman MD,
Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE . Determining prognosis in advanced cancer. Fast Fact and Concept #13; 2 nd Edition, July 2005. End-of-Life Palliative Education Resource Center www.eperc.mcw.edu.
Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in 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.
Purpose: Instructional Aid, Teaching
Audience(s)
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Training: Fellows, 1st/2nd Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice |
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Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery |
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Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers |
ACGME Competencies: Medical Knowledge, Patient Care
Keyword(s): prognosis, cancer