Determining Prognosis: It’s Getting Really Difficult
When I finished medical school in the 1980s, it was often easy to determine prognosis:
- Metastatic cancer of most types: Less than a year
- Cardiac ejection fraction of 15%: Less than a year
- Critical aortic stenosis in someone older than 80 (making them poor operative candidates): Less than a year
Now, everything is so different.
Daily, I see patients in their tenth year of metastatic cancer who are still active and enjoying life. Their cancer is still present and they get treated intermittently. They have some difficult months, but they also have many good months.
Cardiomyopathy with an EF of 15% used to be a death sentence. Now, with drugs, pacemakers and ICD’s, we can actually “cure” this condition.
Patients in their 90s with critical aortic stenosis now get a TAVR and most do pretty well and feel many years younger.
These treatments are extending life and doing it with decent quality. People ask: “This looks serious. How long do I have?”
My response: “I have no idea!”
As I have gotten older and more cynical my answer to patients seeking to define from me their expiration date has become more and more pithy and blunt. I used to use the old “I dont have a crystal ball” retort. Then I moved on to ” if I had a crystal ball I’d be at the racetrack instead of here”. Now I tell patients that they have been dying since they were born, or some riff on that.
I was actually thinking about this the other day and I am having to change the way I look at things. I am seeing patients living longer, even those with severe metastatic cancer. And as you say it seems to be high quality life for the most part.
Somewhat related, I am running into pain control issues sometimes with these patients. A patient is diagnosed with metastatic CA and has severe pain – typically I have not hesitated to prescribe narcotics in this situation as traditionally they haven’t lived very long. Then, the patient gets better and as you say I have no idea what their life expectancy is, but they still have pain. So what do I do now. The oncologists generally are vague on the prognosis and I really can’t blame them. I have been keeping them on the narcotics and following closely, doing the PMP’s etc. I haven’t really seen that issue addressed.