Cases & Commentaries

Poor Prognosis

Spotlight Case
Commentary By Elizabeth B. Lamont, MD, MS

Case Objectives

  • Understand the current limitations of
    physicians' ability to provide prognoses.
  • List the variables that can be used to
    guide treatment decisions and prognostication in elderly
    patients.
  • Appreciate the cognitive steps to
    determine prognosis in elderly patients.

Case & Commentary: Part 1

A 91-year-old woman presented with 2 days of
nausea and vomiting. Physical examination revealed a palpable mass
in the right groin without bowel sounds. A CT scan of the abdomen
showed an incarcerated hernia complicated by small bowel
obstruction. The patient was taken to the operating room for
resection under general anesthesia. After extubation, she developed
stridor, requiring re-intubation.
Otorhinolaryngology (ENT) evaluation revealed no evidence of
laryngeal edema; however, there was evidence of significant
extrinsic compression of the trachea. A CT scan revealed a thyroid
mass. A fine needle aspiration (FNA) biopsy was performed but was
inconclusive. A repeat FNA was performed.

The attending physician held a family meeting
to discuss the patient's prognosis and direction of care. He told
the family the prognosis was likely very poor, as he suspected
malignancy. Given this news, the family decided not to pursue
surgical intervention (tracheostomy).

Physicians are frequently called upon to make
predictions about expected patient survival and to disclose those
predictions to patients. Research has also shown that both types of
prognostic tasks are extremely difficult for physicians.

Results of a survey of a random sample of 1,311
US internists suggest that the average internist addresses the
question "How long do I have to live?" ten times per year,
withdraws life support five times per year, and refers patients to
hospice-based palliative care five times per year.(1) Among these
physicians, 60% reported that they found prognostication
emotionally "stressful," and their stress with prognostication was
highly associated with self-perceived prognostic inaccuracy.

Data on physicians' prognostic accuracy primarily
comes from studies of physicians caring for patients already
enrolled in palliative care. These studies reveal that, on average,
physicians make inaccurate prognostic estimates; the direction of
their error, overwhelmingly, is optimistic, with physicians
overestimating survival by a factor of three.(2-8)
In one study, 343 physicians provided survival estimates for 468
terminally ill cancer and non-cancer patients at the time of
patient referral to hospice-based palliative care. These estimates
were then compared with patients' actual survival. Physicians were
accurate in their prognoses approximately 20% of the time,
overestimated survival more than three times as often (63%), and
underestimated survival in only a minority of instances
(17%).(8)

Research has queried whether such systematic
prognostic overestimation by physicians may in part explain the
unexpectedly "short" survivals observed in patients referred for
hospice-based palliative care. Results of the above-noted survey
suggest that physicians believe an optimal length of stay in
hospice is 3 months (9), yet the
observed median length of stay is only 3 weeks.(8) Perhaps some
of this observed inconsistency results from physicians' optimistic
bias in prognostication.

This particular patient differed from those
enrolled in the studies mentioned above in that she did not yet
have an established "terminal illness." Since the science of
prognosis is anchored in disease diagnosis and extent, this
patient's diagnostic ambiguity contributed to making
prognostication quite challenging. On one extreme, if the patient's
neck mass was a result of anaplastic thyroid cancer (ie, a rare and
rapidly fatal form of thyroid cancer), her estimated median
survival would be approximately 4 months (10), and
the immediate institution of supportive (and non-curative) care
would be an appropriate clinical approach to managing the airway
compromise. On the other hand, if her neck mass was the result of a
benign goiter, her estimated median survival would probably be
quite similar to her baseline age-related expected survival of
approximately 4 years (11), and the
institution of supportive care would not be a conventional approach
to management of the airway compromise. Depending on the
characteristics of the goiter (eg, diffuse, multinodular) and the
approach of the endocrinologist (eg, trial of T4-suppression
therapy, reductive surgery, and/or radioactive iodine), other
approaches would be more conventional.

Given the very wide prognostic range associated
with this patient's neck mass—4 months vs. 4 years—and
the associated wide range of clinical approaches, for this patient,
a tissue diagnosis would help to narrow this prognostic range and
thus better define the immediate clinical approach. Although a
clinician might be tempted to assume that a large mass is
cancerous, studies of consecutive thyroid aspirations in community
hospitals suggest that cancer explains only 5% to 6.5% (12,13) of
nodules.

Case & Commentary: Part 2

After further discussion, the family decided
to withdraw care, because the patient had stated previously that
she did not want to be intubated for a long period. Shortly after
extubation, the patient died. A few days after the patient's death,
the results of the second FNA were obtained. The biopsy revealed a
benign nodular goiter.

The patient, family, and physician in this
vignette experienced the uncommon situation of a pessimistic
prognostic error. The events described are surprising and raise an
important question: why was the FNA done if its results were not
going to influence care?

A natural concern in this case is whether the
patient's advanced age somehow influenced the decision to pursue a
less complete diagnostic approach. It is certainly hard to imagine
that a 37-year-old woman would have been managed this way. However,
it is possible that there were other life-limiting comorbidities
(eg, a previously diagnosed advanced cancer, severe dementia, class
IV congestive heart failure) and/or poor functional status that
influenced her underlying or baseline prognosis and thus might
explain the clinical approach.

A general clinical approach to this patient can
be borrowed from the field of oncology, which is currently
struggling to develop systematic approaches or algorithms that
acknowledge and integrate important prognostic variables (both
cancer-related and non-cancer-related) to guide cancer treatment
decisions in elderly patients.(14) For
example, a comprehensive geriatric assessment (CGA) can yield
information about functional status and comorbidities, which, along
with sex and chronological age, have prognostic relevance and can
be integrated to generate an estimate of baseline life
expectancy.(14) The
physician compares the expected survival from the untreated illness
or illnesses being considered (eg, anaplastic thyroid cancer vs.
benign goiter) to this estimate of baseline life expectancy. If the
baseline life expectancy is greater than that of the untreated
condition, the physician then needs to decide if the diagnostic
procedure and/or the disease-specific treatment would result in
excess morbidity and mortaility (ie, decide if the interventions
are "tolerable"). If diagnostic procedure tolerance and/or
treatment tolerance is deemed adequate, then the patient may
benefit from further work up and, ultimately, therapy directed at
the illness or the illness under consideration.

In this case, no comorbidity or functional status
information is provided, but we do know that the patient was a
91-year-old woman. Life-tables indicate that 50% of 90-year-old
American women will live at least an additional 3.8 years, with 25%
living less than 1.8 years and 25% living at least 6.8 years. Since
the expected survival from the most aggressive thyroid cancer (ie,
anaplastic histology) is only 4 months and the expected survival
from the most benign explanation for the neck mass (ie, benign
goiter) will be unlikely to impact life-expectancy meaningfully,
most algorithms would recommend biopsy. If on the other hand, the
patient had a severely life-limiting illness already (eg, stage IV
lung cancer), the results of the biopsy would not impact
decision-making and thus would not be needed. In this latter case,
supportive care for the lung cancer would be an appropriate
approach. The Figure outlines
an approach to such clinical decision-making for elderly patients
with cancer.

When making prognostic estimates in elderly
patients, it is important to consider the following issues:

  • What is the diagnosis and extent
    of the new disease?
  • What
    is the patient's baseline life expectancy related to age,
    comorbidity, and functional status?
  • Is the expected
    survival from the new disease shorter than the baseline life
    expectancy?
  • Will treatment improve expected survival from the
    new disease?
  • Will treatment for
    the new disease be
    tolerated?

Prognostication is a
difficult task. Most physicians are unable to accurately predict
survival and are uncomfortable with the process. An evidence-based
approach should be employed whenever possible, taking care to
remove the effect of biases from the algorithm, but further
research is needed to develop clinically useful predictive
algorithms.(16-20)

Elizabeth B. Lamont, MD,
MS
Assistant Professor of Medicine
Harvard Medical School
Massachusetts General Hospital Cancer Center and Institute of
Technology Assessment

Faculty
Disclosure: Dr. Lamont has declared that neither she, nor any
immediate member of her family, has a financial arrangement or
other relationship with the manufacturers of any commercial
products discussed in this continuing medical education activity.
In addition, her commentary does not include information regarding
investigational or off-label use of pharmaceutical products or
medical devices.

References

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2. Christakis NA,
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16. Lamont EB,
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Figure

Figure. An
Algorithm for the Treatment of Older Cancer Patients