More than two-thirds of patients with advanced cancer had survival expectations that did not match the prognostic estimates of their oncologists, with most patients being more optimistic than their physicians and only about 10% of patients being aware that their views differed, researchers have found. Yet, nearly all patients in the mismatched or
“discordant” patient-oncologist dyads expressed a desire to be actively engaged in treatment decision making and 70% wanted comfort care near the end of life.
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“The vast majority of prognostic discordance happened among patients who either reported a mistaken understanding of their oncologists’ opinions or were unable to guess what their oncologist thought,” write the authors of a report published in JAMA Oncology. However, “our findings identify that the most common form of patient-oncologist discordance in prognosis expectations involves patients being unknowingly discordant.”
“Known discordance,” i.e., when patients knowingly and deliberately hold opinions they realize are different from their physicians’ views, is to be expected, and can lead to further discussion and shared decision making, note the authors. In contrast, “unknown discordance” suggests a failure in communication.
For effective advance care planning discussion when physicians and patients do not know that their views of prognosis differ, “physicians might ask patients what they wish to know, provide clear, sensitive prognostic information, check their patients’ understanding and only then proceed to decision making,” advise the authors.
Investigators evaluated questionnaire responses of 236 patients with advanced cancer (mean age, 64.5 years; female, 54%) and their 38 oncologists from nine outpatient oncology practices located in two U.S. states (NY and CA). The sample was drawn from participants enrolled from 2012 to 2014 in a larger, randomized trial of an intervention to promote high-quality clinical communication between patients with advanced cancer and their oncologists. The expected median survival of the study population was 12 to 14 months.
Oncologists were asked to rate each patient’s two-year survival probability. Patients were asked independently to rate their opinion of their chances of surviving for two years or more, as well as what they believed was their oncologist’s opinion.
- 68% of patient-physician prognosis estimates were discordant.
- Discordance was found to be substantially more common among non-white patients compared with white patients (95% vs 65%).
- 89% of patients with discordant views did not know that their opinions differed from those of their oncologists.
- 96% of patients in discordant dyads rated their prognosis more optimistically than did their physicians.
- 99% of patients with discordant ratings said they wished to be actively involved in treatment decision making.
- 70% of patients in discordant pairs reported desiring to have palliative care near the end of life.
- In 52% of discordant dyads, the oncologists recalled having had a thorough discussion of prognosis with the patient.
The authors explain that prognosis communication is a complex, relational process, noting it “is not merely a straightforward exchange of information; it is affective and, when it happens, it occurs amid substantial uncertainty, confusion and often terror.” Despite many oncologists’ best efforts, too many patients seem not to accurately comprehend prognostic information relevant to their treatment decision making.
“Therefore, this study supports the urgent clinical and societal need to better understand what it means to communicate well about prognosis to achieve treatment that honors patients’ values, preferences and wishes.”
Source: “Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer,” JAMA Oncology, Epub ahead of print, July 14, 2016; DOI: 10.1001/jamaoncol.2016.1861. Gramling R, et al; School of Nursing, University of Rochester, Rochester, NY; Division of Palliative Medicine and Department of Family Medicine, University of Vermont, Burlington; Department of Public Health Sciences and Center for Communication Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY; Center for Healthcare Policy and Research, University of California, Davis; and Department of Psychology, Tulane University, New Orleans.