Prognostication Remains More an Art Than a Science

Article Outline

• Copyright

Prognosis in Advanced Cancer is a multiauthored volume, edited by Drs. Paul Glare and Nicholas Christakis, divided into three sections. The first section, “The Science of Prognostication,” consists of eight chapters that serve as part critique of the current prognostic activities of physicians and part primer to improve prognostication. The goal of the first section is a renaissance in the science of prognostication. The second and third sections are entitled “Prognostication in Specific Cancers” and “Prognosis in Palliative Care” and consist of 12 and 14 chapters, respectively. The apparent purpose of these chapters is to provide a brief summary of selected information about survival based on the specific type of cancer or a sentinel finding, such as spinal cord compression or hypercalcemia. The goals of the latter two sections are to provide information that may be useful in prognostication in specific situations. The overall goal of the book is “…to help physicians and other clinicians to improve their skills of prognostication near the end of life in patient [sic] with cancer…” And therein lies the potential relevance of this volume to the readership of this journal. However, I believe that the relevance of this volume is seriously diminished by several shortcomings. Thus, having completed my review of the book, I suspect I will neither consult it again nor recommend it to colleagues or students.

The first major shortcoming of the volume is the complete absence of any substantial and well-informed discussion of what we know about the decision-making processes of people with advanced cancer and the physicians who recommend continued disease-directed interventions near the end of life. This is all the more striking because the editors explicitly recognize that accurate prognostication is “a technical prerequisite for rational clinical decision making about therapeutics and other aspects of clinical care.” And that the “[r]estoration of a high level of skill in prognostication will be an inevitable part of improving [end of life] care.” How so without integrating the more accurate prognostic estimates within the context of decision making?

The second shortcoming is the way in which prognosis is framed. The challenge in prognostication near the end of life is not answering the question (“Doctor, how long do I have?”) cited at least four times in the first section as pivotal. The relevant question is “Doctor, would I live longer if I elect to receive therapy?” The challenge of prognostication is recognizing when oncologists and other clinicians might justifiably conclude that that there are no anticancer interventions of reasonable benefit relative to the likely risk or burden of the anticancer therapy. At that point, we should engage in earnest discussions with the person affected by cancer about how he or she wishes to be cared for as life ends. This leads to the third shortcoming (in the disease-specific chapters): I did not find the information useful. A more simple and useful organization of the chapters might have been to have the authors define when they—as disease experts—perceive the cancer as advanced, and what options currently exist for such an affected individual, and when they find end-of-life care to be equal to or more reasonable than disease-specific interventions. This is done every day in clinical medicine, for example, eligibility criteria for Phase I clinical trials. We as cancer clinicians routinely identify a group of people for whom reasonable options do not exist and, therefore, are justified in offering treatments of unknown benefit or risk. Surely we could do the same for end-of-life care.

The fourth shortcoming is the avoidance of what I will call forestalling (building off of the brilliant exposition of the concepts of foreseeing and foretelling in Dr. Christakis's truly remarkable book Death Foretold: Prophecy and Prognosis in Medical Care). Oncologists—like most physicians—are trained to modify the future. Our diagnostic and therapeutic activities are organized around the possibility of a better or longer life with accurate diagnosis and effective treatment. We are invested in forestalling death. In close to 20 years of advising people about the merits of aggressive disease-directed interventions relative to more palliative symptom-directed interventions, I have rarely if ever felt the impediment was a lack of accurate information about likely outcomes. Not infrequently, however, a colleague and I will agree completely on the statistics but disagree in what we counsel the patient as his or her better choice.

The point is that the decision to prescribe or receive chemotherapy is far more a personal and emotional decision than an intellectual one. And from that perspective, the chapter “Ethical Perspectives” is especially disappointing (although I was thrilled to see at least an attempt). The discussion is pedestrian. Do we really need to be reminded of the ethics of clinical trials? Where is the consideration of alternative models of informed decision making, such as entrustment? What about truth telling, of which a fair amount has been written? In the overview, several substantial ethical questions are posed. Why are they ignored in this chapter? How would a virtuous physician behave?

Finally, who will find the book useful? When will the information be of use? This shortcoming is manifest in the title. To accurately conclude that a person has “advanced cancer,” one must have already done a fair bit of prognosticating! In the overview, prognosis is defined as “…an epidemiological term defined as the relative probabilities of the various outcomes in the natural history of the disease.” What is the threshold probability for the outcome of death that distinguishes advanced from nonadvanced cancer? The best but entirely unsatisfactory definition of advanced cancer is captured in the phrase, “…in whom the options for active treatment have been exhausted.” As a physician trained in medical oncology, the last two sections lack the necessary sophistication, timeliness, or specificity I would require to counsel a patient with advanced cancer.

Perhaps a palliative care clinician will find the information useful. It certainly confirms that the diagnosis of advanced cancer is associated with a poor prognosis. And it is convenient to have a single volume on the bookshelf. However, in my opinion, improving end-of-life care will ultimately require improving the quality of conversations about care toward the end of life. Those conversations—between physician and patient or between physicians—do not suffer because of a lack of information or greater certainty. They suffer because many lack the compassion and humility necessary to recognize the need to proceed deliberately, and with virtue, at times of uncertainty, at times of the most profound decisions we can make as human beings, to accept our mortality and to seek comfort as we die. This book will contribute little to those necessary conversations.