Reviewed by Dr. Jasmine Singh
Fenton J, et al. J Clin Oncol. 2017 Nov 17:JCO2017756288

SUMMARY
In advanced cancer, clinicians often emphasize treatment choices without enough discussion about end of life planning and prognostic awareness, often out of fear this will negatively impact the doctor-patient relationship. In this prospective cohort study, 265 adults with advanced cancer (Stage IV non-hematologic or stage III with prediction of death within 12 months) who visited 38 oncologists from community and hospital-based cancer centers in New York and California were enrolled. The oncologists’ discussion of prognosis was assessed by trained coders from audio-recorded visits using the Prognostic and Treatment Choices scale (PTCC). The coders assessed domains including cancer prognosis, curability, the likelihood of effective treatment and the transition from active to palliative treatment using a point-based scale. Patients rated the strength of the patient-physician relationship using two scales, The Human Connection (THC) and the Perceived Efficacy in Patient-Physician Interactions (PEPPI), at baseline, 2 to 7 days, and 3 months after the discussion.

Discussion of prognosis by the oncologist was not associated with a decline in either patient measure. A one-unit increase in PTCC was associated with improvement in THC at 2 to 7 days (parameter estimate, 0.10; 95% CI, -0.02 to 0.23) after the visit but this was not statistically significant (p=0.09). There was also an improvement at 3 months (parameter estimate, 0.18; 95% CI, 0.02 to 0.35) which was statistically significant (p=0.029). A one-unit increase in PTCC was not associated with improvement in PEPPI at either time interval. Standardized effect sizes (SES) associated with an increase of two standard deviations in PTCC at each time interval indicated small beneficial effects (SES, 0.14 [95% CI, -0.02 to 0.29] at 2 to 7 days; SES, 0.24 [95% CI, 0.02 to 0.45] at 3 months).

COMMENTARY
Western medicine has transitioned from a paternalistic model to one of shared decision making, by which there is a bidirectional exchange with collaboration between patient and provider1. However, patients are still too often making decisions with inaccurate perception of prognosis. For example, in a study of 1193 patients with metastatic lung and colorectal cancer, 69% with lung cancer and 81% with colorectal cancer did not report understanding that chemotherapy was not likely to cure their cancer2. Clinicians are often reluctant to discuss prognostic information out of concern this may negatively impact the therapeutic alliance. However, prognosis is an integral part of health decisions, as those with an accurate understanding of prognosis make different decisions compared to patients who are less informed. This impacts patient

choices regarding aggressive care which can affect the quality of the last years of life3. This study illustrates that open prognostic discussion was not associated with a decline in the strength of the doctor-patient relationship and may strengthen the therapeutic alliance. An important observation is that although an increase in the PTCC score was associated with a statistically significant improvement in the rating of the doctor-patient relationship, this only applied to the THC scale at 3 months. This may not be clinically significant given the very small absolute value of change in scoring scales. A major limitation is that the measure of doctor-patient relationship may not be an appropriate metric to assess for the impact of conversations regarding prognosis. It may be more appropriate to ask patients and caregivers later in their disease trajectory whether these early prognostic conversations helped them prepare for the end of life. Lastly, while the PTCC scoring system evaluated domains of end of life and prognosis that were addressed, it provides limited information on the quality or depth of these conversations. This study could thus be strengthened in both the method used to assess prognostic discussion as well as overall outcomes measured.

REFERENCES
1. King JS, Moulton BW. “Rethinking informed consent: the case for shared medical decision-making. Am J Law Med 2006; 32: 429.
2. Weeks JC, Catalano PJ, Cronin A, et al. “Patients’ expectations about effects of chemotherapy for advanced cancer. NEJM 2012; 367: 1616.
3. Weeks JC, Cook EF, O’day SJ, et al. “Relationship between cancer patients’ predictions of prognosis and theire treatment preferences. JAMA 1998; 279: 1709.

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