Individuals with advanced cancer who have accurate prognostic awareness are reported to make more informed decisions about their plan of care. Despite this, it is reported that individuals do not always have accurate prognostic awareness with the rationale for this discordance unclear. The primary aim of the integrative literature review was to identify if there is concordance between actual prognosis and accurate prognostic awareness in individuals with advanced cancer. The secondary aim was to identify the rationale for any discordance between actual prognosis and prognostic awareness in individuals with advanced cancer. This is an integrative literature review using a systematic approach. Literature searches were undertaken in March 2018 in four databases; CINAHL, MEDLINE, PsycINFO and Cochrane Library. Searches were limited to between 2008 and 2018 and those written in the English language. Database searches were supplemented with papers from reference lists of included papers and grey literature. Two reviewers independently completed the literature search and independently reviewed the papers. Fourteen eligible research papers were identified. The majority of individuals with advanced cancer in the included studies did not have accurate prognostic awareness. When identified, the rationale for discordance relates to the individual not being communicated accurate prognostic information, not being able to recall prognostic conversations or prognosis being discussed in vague terms. As individuals with advanced cancer with accurate prognostic awareness make more informed decisions at a crucial time in their life trajectory, it is imperative that healthcare professionals are equipped to effectively deliver accurate prognostic information, ensuring understanding is assessed.

Azathioprine is an established immunosuppressive drug following renal transplantation with well known haematological toxicity. We report a patient with a previously unrecorded combination of azathioprine-induced haematological abnormalities. Case historyFollowing 4 months regular haemodialysis for end-stage renal failure due to chronic pyelonephritis, a I 6-year-old girl received a cadaver renal allograft after bilateral nephrectomy and splenectomy. Creatinine clearance was stable (80 mljmin) 2 months later and the haemoglobin was normal after 6 months. Prednisolone was reduced from 150 mg to 15 mg per day and the mean daily dose of Azathioprine was 3 mg/kg body weight per day until 28 months post-transplant.Then she presented with symptomatic anaemia: haemoglobin 4.2 g/dl, MCV 124 fl, white blood count 4.4 x 109/l, platelet count 200 x 1o9/I, neutrophils always greater than 1.5 x ioY/1, reticulocytes less than 2'%,; blood film showed postsplenectomy changes and features of B, Jfolate deficiency. The bone marrow was hypocellular with scanty megaloblasts and occasional giant metamyelocytes and hypersegmented megakaryocyte nuclei. Whole blood folate was 108 ng/m I (normal range 100-600 mg/ml) and serum B , was 380 pg/ml (normal range 240-1000 pg/ml) by radio-assay. The following tests gave normal or negative results : direct Coonibs; Ham's; Paul Bunnel; marrow, urine and laryngeal swab culture for tubercle bacilli;