Fast Fact and Concept #13: Determining Prognosis in Advanced Cancer

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Title: Fast Fact and Concept #13: Determining Prognosis in Advanced Cancer

Author(s): Weissman, D.

This Fast Fact and Concept reviews prognostic indicators and performance status scales for cancer patients. The information is suitable for rounds discussion or as a handout at a teaching conference.

Educational Objective(s)
Learn the key prognostic factors for cancer. Understand how to use performance status scales. Review importance of determining prognosis to the Medicare Hospice Benefit.
"How long do I have, doc?" is among the most common questions asked by cancer patients, especially when informed that there are no further effective anti-neoplastic treatment options. Although prognostication is not an exact science, there is abundant data to help clinicians provide useful information to patients and families, information critical to making realistic end-of-life decisions and referrals for home hospice service.

The single most important predictive factor is Functional Ability; a measure of how much a patient can do for themselves, of their activity and energy level. Note: patients with solid tumors typically lose 70-80% of their functional ability in the last 3 months of life. The two scales used to measure functional ability are the Karnofsky Index (100 = normal; 0 = dead) and the ECOG (Eastern Cooperative Oncology Group) scale, (0 = normal; 5 = dead). A median survival of 3 months correlates with a Karnofsky score < 50 or ECOG < 3. The question to ask patients is: "How much time do you spend in bed or laying down?" If the response is > 50% of the time and is progressively increasing, this correlates to a median survival of approximately 3 months. Survival time decreases for added physical symptoms, especially dyspnea, if secondary to the cancer.

Several common cancer syndromes have well-documented short median survival times:

In general, a patient with metastatic solid cancer, acute leukemia or high-grade lymphoma, who will not be receiving systemic chemotherapy (for whatever reason), has a prognosis of less than 6 months**. Notable exceptions to this are patients with breast or prostate cancer with good performance status as these cancers may be indolent. In these patients additional features suggesting short prognosis are needed (declining functional status, dyspnea, weight loss). Other indicators of less than 6 months prognosis include malignant ascites, malignant pleural effusion or malignant bowel obstruction that cannot be surgically bypassed.

**Remember, referral for care under the Medicare Hospice Benefit requires certification that the prognosis is less than 6 months if the disease follows a usual course.

den Daas, N. Estimating length of survival in end-stage cancer: a review of the literature. J Pain Symp Manage 10:548-555, 1995; Lassauniere JM and Vinant P. Prognostic factors , survival and advanced cancer. J Pall Med 8:52-54, 1992; Miller RJ. Predicting survival in the advanced cancer patient. Henry Ford Hosp Med J 39:81-84, 1991; Ralston SH, et al. Cancer associated hypercalcemia. Ann Int Med 112:499:504, 1990; Reuben DB and Mor V. Clinical symptoms and length of survival in patients with terminal cancer. Arch Int Med 148:1586-1591, 1988.

Fast Facts and Concepts are developed and distributed as part of the National Internal Medicine Residency End-of-Life Education project, funded by the Robert Wood Johnson Foundation.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #13: Determining Prognosis in Advanced Cancer. June, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 5/2000

Format: Handouts

Purpose: Instructional Aid, Teaching

Training: Fellows, 1st/2nd Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Cancer, Medicare hospice benefit, Prognosis

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).