June 2022 Communication Tip

Prognosis Communication

Today’s communication tip is the final one of the 2021-22 academic year and I want to focus-in on talking about prognosis in cancer care.

When considering prognosis, we often think about predicting life expectancy (“How long do I have, doc?”), but people typically care about the probabilities of other outcomes as well, including changes in function, independence, symptom burden, and quality of life.

The research on prognostic disclosure in oncology is clear.  Most (almost all) patients want to know their prognosis.  Knowing one’s prognosis leads people to make different medical decisions.  Patients’ “prognostic awareness” is associated with good outcomes (e.g. improved patient mental health, quality of life, and caregiver bereavement). 

And yet, only about one-half of patients with advanced cancer know their prognosis.

So, how to improve our skills in discussing prognosis with patients and their families?

A recent scoping review provides some direction (Bloom JR, Marshall DC, Rodriguez-Russo C, Martin E, Jones JA, Dharmarajan KV. Prognostic disclosure in oncology - current communication models: a scoping review. BMJ Support Palliat Care. 2022;12(2):167-177.) 

Starting with more than 1500 papers, the review summarizes the 5 evidence-based models for discussion of prognosis.  These include 2 models that I’ve featured or referenced in this series previously (the Serious Illness Conversation Guide from Ariadne Labs and the Vital Talk ADAPT model).

The study concludes with the 3 core communication tasks common across all the successful models:

1. exploring patients’ illness understanding

(“What have you been told to expect from this cancer”)

2. communicating prognosis

(using guidelines, calculators, personal experience; communicated simply and clearly; offering ranges of time [days-weeks, weeks-months, months-years])

3. responding to emotion

(with empathy and compassion)

Of course, thanks to amazing, nearly daily advancements in cancer treatments, the data to estimate prognosis is a moving target.  However, the need to discuss it remains unchanged.  With targeted treatments and immunotherapy, with CAR-T, with combination therapies, some people with even advanced cancer are being cured and many are living better and longer lives. But, people still want and need to know our best estimates of how things will go, what life will look like, and how much time they might have to live the lives they want to live. 

If you wouldn’t be surprised if you patient died in the next year, chances are your patient would want to know (and to hear the information delivered skillfully).

All My Best,

mike