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Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer– A Paper Posted Online by JAMA Oncology

2016-07-17

 

Here is a paper, posted for free by JAMA Oncology online, which explores the difference between doctor’s expectations about prognosis and patient’s beliefs.  It seems that the majority of patients disagree with their doctors about how long they have to live, they do not realize that their doctors differ, and the doctors are substantially more pessimistic about their chances than the patients are.  In addition, nonwhite patients tend to be more discordant from their doctors about their prognoses.

In summary, patients are usually more optimistic than their doctors about their chances, and do not realize that their doctors differ; this problem is especially acute for nonwhite patients.  This could be ameliorated by better communication between doctor and patient, but there is a chance that even good communication will not put the patients straight.  It is possible that patients are just more optimistic than their doctors are, for reasons that bear some speculation.

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.

Authors:

Robert Gramling, MD, DSc1,2,3,4,5,6,7; Kevin Fiscella, MD, MPH4,5,6,8; Guibo Xing, PhD9; Michael Hoerger, PhD10,11,12; Paul Duberstein, PhD5,6,12; Sandy Plumb, BS5; Supriya Mohile, MD, MS13,14; Joshua J. Fenton, MD, MPH9,15,16; Daniel J. Tancredi, PhD9,17; Richard L. Kravitz, MD, MSPH9,16,18; Ronald M. Epstein, MD5,6,7,12,14

Affiliations:

1School of Nursing, University of Rochester, Rochester, New York
2Division of Palliative Medicine, University of Vermont, Burlington
3Department of Family Medicine, University of Vermont, Burlington
4Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
5Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York
6Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
7Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York
8Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York
9Center for Healthcare Policy and Research, University of California, Davis, Sacramento
10Department of Psychology, Tulane University, New Orleans, Louisiana
11Tulane Cancer Center, Tulane University, New Orleans, Louisiana
12Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
13Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
14James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York
15Department of Family and Community Medicine, University of California, Davis, Sacramento
16UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento
17Department of Pediatrics, University of California, Davis, Sacramento
18Division of General Medicine, University of California, Davis, Sacramento

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