Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer

Abstract

IMPORTANCE Patients with advanced cancer often report expectations for survival that differ from their oncologists’ expectations. Whether patients know that their survival expectations differ from those of their oncologists remains unknown. This distinction is important because knowingly expressing differences of opinion is important for shared decision making, whereas patients not knowing that their understanding differs from that of their treating physician is a potential marker of inadequate communication. OBJECTIVE To describe the prevalence, distribution, and proportion of prognostic discordance that is due to patients’ knowingly vs unknowingly expressing an opinion that differs from that of their oncologist. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study conducted at academic and community oncology practices in Rochester, New York, and Sacramento, California. The sample comprises 236 patients with advanced cancer and their 38 oncologists who participated in a randomized trial of an intervention to improve clinical communication. Participants were enrolled from August 2012 to June 2014 and followed up until October 2015. MAIN OUTCOMES AND MEASURES We ascertained discordance by comparing patient and oncologist ratings of 2-year survival probability. For discordant pairs, we determined whether patients knew that their opinions differed from those of their oncologists by asking the patients to report how they believed their oncologists rated their 2-year survival. RESULTS Among the 236 patients (mean [SD] age, 64.5 [11.4] years; 54%female), 161 patient-oncologist survival prognosis ratings (68%; 95%CI, 62%–75%) were discordant. Discordance was substantially more common among nonwhite patients compared with white patients (95%[95%CI, 86%–100%] vs 65%[95%CI, 58%–73%], respectively; P = .03). Among 161 discordant patients, 144 (89%) did not know that their opinions differed from that of their oncologists and nearly all of them (155 of 161 [96%]) were more optimistic than their oncologists. CONCLUSIONS AND RELEVANCE In this study, patient-oncologist discordance about survival prognosis was common and patients rarely knew that their opinions differed from those of their oncologists.

Effect of a Patient-Centered Communication Intervention on Oncologist-Patient Communication, Quality of Life, and Health Care Utilization in Advanced Cancer

“…Many patients hold unrealistically optimistic prognostic estimates, 8,11,21,58,59 which they mistakenly believe their physicians share 60 ; future studies can unravel how to interrupt the temporarily adaptive but ultimately dysfunctional pas de deux, in which physicians, caregivers, and patients avoid, euphemize, or misinterpret these discussions. 61–64 Oncologists need better training in the provision of information to patients with varying levels of health numeracy and literacy as well as “terror management,” a defense mechanism that may prompt some patients (and physicians) to respond to fear of death through avoidance and selective attention. 65–67 Venues already exist for communication and awareness training during residency and fellowship, 25,68,69 and interventions such as ours are feasible for practicing oncologists.…”

Does educating patients about the Early Palliative Care Study increase preferences for outpatient palliative cancer care? Findings from Project EMPOWER.

“…As emphasized in new initiatives of the National Cancer Institute (NIH, 2016), other forms of technology (e.g., EHR, mobile apps, smartphone-compatible websites) could also be useful for disseminating medical evidence. In contrast to technology-mediated interventions, it is worth testing whether it is advantageous for clinicians to communicate the medical evidence for palliative care directly to patients, drawing on the therapeutic relationship to increase engagement, check understanding, and allay fears (Epstein et al, in press; Gramling et al, 2016; Hargraves, LeBlanc, Shah, & Montori, 2016; Rodenbach et al, in press). With these possibilities in mind, the key translational question is whether psychoeducational interventions can ultimately increase utilization of palliative care services that can enhance quality of life.…”

A stakeholder-driven approach to improve the informed consent process for palliative chemotherapy

“…[15] Our intervention has the advantage of providing balanced, comprehensive, and evidence-based information about treatment risks/benefits and prognosis. Patient coaching and/or question prompt-lists have been shown to help engage patients in care decisions, improve understanding [50–52] and potentially promote prognostic discussions. [53,54] If our intervention proves successful, combining IC video tools with question prompt lists or audio-recordings could be examined.…”