By Lori Solomon, Medical Tribune News Service
Researchers at University of Alberta in Canada found that 52
percent of oncology physicians overestimate life expectancy in
terminally ill cancer patients. These overly optimistic survival
predictions may adversely impact patients' final days by denying
them access to hospice care and allowing them to postpone important
end-of-life decisions.
The study of 233 terminally ill cancer patients aimed to compare
clinical estimation of survival -- a doctor's best guess of survival
-- with how long patients actually survived.
``The problem is that there is not a single gold standard,''
said Dr. Eduardo Bruera, a co-author of the study published in the
July 1 issue of the journal Cancer. ``It is based on the feeling of
a doctor. Physicians use a combination of their experience, how
fast the patient's health status changed, a patient's history and
clinical examination.'' Dr. Bruera added that cancer specialists
are much better at predicting survival at the beginning of illness
than at the end-stage of the disease.
The researchers found that physicians correctly predicted life
expectancy to within one month in 25 percent of terminal patients.
However, 23 percent of patients lived longer than predicted and
physicians overestimated survival in 52 percent of cases.
Oncologists most often estimated patient survival to be between two
and six months, but one third of their patients survived less than
two months.
These findings are significant because of the importance placed
on the clinical estimation of survival even if it is inaccurate.
Survival predictions are used to counsel patients and their
families, to determine when aggressive cancer treatments should be
discontinued and when to enroll patients in palliative care
programs, such as hospices, that try to control pain. In most
instances patients cannot be referred to a hospice unless they have
less than six months to live. Overly optimistic survival estimates
may delay referral to hospice programs, denying patients the full
benefits of such programs.
``Patients may not be getting the information they need to plan
if they are given the hope for longer survival,'' said Dr. Bruera,
director of Palliative Medicine. ``Unreasonable hope can paralyze
planning.'' Dr. Bruera stressed the importance of planning and
making end-of-life decisions as soon as possible. Such decisions
include writing a will, reconciliation with family and where to
spend one's last days.
A survey conducted in April by the National Hospice Foundation,
Arlington, Va., found that patients are spending less time in
hospice care with a decline in median length of stay from 29 days
to 25 days.
``As more treatments and technologies become available, doctors
and patients want to try them,'' said Bob O'Connor, vice president
of Marketing and Communication, National Hospice Foundation,
accounting for the decline. ``We welcome research that allows for
better diagnosis of where patients are on the spectrum from
curative to palliative care.''
Dr. Bruera suggested that with additional research, clinical
estimation of survival may be improved if it is used in conjunction
with quantifiable indicators such as nutritional status, certain
bloodwork markers and assessment of brain function or the onset of
confusion.
The immediate lesson to be learned from this study, said Dr.
Bruera, is that patients must be informed immediately that survival
estimates may be inaccurate. Good advice for patients, he said, is
to ``Prepare for the worst, but hope for the best.''
