Spotlight Case September 2004

1. Spotlight Case September 2004 Poor Prognosis?

2. Source and Credits • This presentation is based on the September 2004 AHRQ WebM&M Spotlight Case in Surgery • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Elizabeth B. Lamont, MD, MS Harvard Medical School, Massachusetts General Hospital • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand the current limitations of physicians’ ability to provide prognoses • List the variables that can be used to guide treatment decisions and prognostication in elderly patients • Appreciate the cognitive steps to determine prognosis in elderly patients

4. Case: Poor Prognosis A 91-year-old woman presented with 2 days of nausea and vomiting. Physical examination revealed a palpable mass in the right groin without bowel sounds. A CT scan of the abdomen showed an incarcerated hernia with small bowel obstruction. The patient was taken to the operating room for resection under general anesthesia. After extubation, she developed stridor, requiring re-intubation.

5. Case (cont.): Poor Prognosis Otorhinolaryngology (ENT) evaluation revealed no evidence of laryngeal edema. However, there was evidence of significant extrinsic compression of the trachea. A CT scan revealed a thyroid mass. A fine needle aspiration (FNA) biopsy was performed but was inconclusive. A repeat FNA was performed.

6. Case (cont.): Poor Prognosis The attending physician met with the family to discuss the patient's prognosis and direction of care. He explained that the prognosis was likely very poor, as he suspected malignancy. Given this news, the family decided not to pursue surgical intervention (tracheostomy).

7. Predicting Prognosis • Physicians are often asked to estimate survival and provide treatment guidance • “How long do I have to live?” 10x/year • Withdrawal of life support 5x/year • Refer patients to hospice 5x/year Christakis NA, Iwashyna TJ. Arch Intern Med. 1998;158:2389-95.

8. Predicting Prognosis • 60% of physicians find prognostication stressful • Stress with prognostication highly associated with self-perceived prognostic inaccuracy • Physicians make inaccurate prognostic estimates • Direction of error usually optimistic Christakis NA, Iwashyna TJ. Arch Intern Med. 1998;158:2389-95; Christakis NA, Lamont EB. BMJ. 2000;320:469-72.

9. Physicians’ Prognostic Accuracy Christakis NA, Lamont EB. BMJ. 2000;320:469-72.

10. Case (cont.): Poor Prognosis After further discussion, the family decided to withdraw care, because the patient had stated previously that she did not want to be intubated for a long period. Shortly after extubation, the patient died.A few days after the patient's death, the results of the second FNA were obtained. The biopsy revealed a benign nodular goiter.

11. Estimating Prognosis in This Case • If neck mass was benign goiter, estimated survival 4 years (her actuarial survival; goiter would have no influence) • If neck mass was anaplastic thyroid cancer, estimated survival 4 months • However, only 5% to 6.5% of thyroid nodules cancerous In Harrison LB, et al, eds. Head and neck cancer. 2004; Walter LC, Covinsky KE. JAMA. 2001;285:2750-6; Belfiore A, et al. Acta Endocrinol (Copenh). 1989;121:197-202.

12. Analyzing the Diagnostic Approach • Given the wide prognostic range associated with the patient’s neck mass — 4 months vs. 4 years —tissue diagnosis would be helpful • An FNA was performed, but decisions made prior to obtaining the results

13. Analyzing the Diagnostic Approach • Did the patient's advanced age somehow influence decision to pursue a less complete diagnostic approach? • Were there other life-limiting co-morbidities? • Previously diagnosed advanced cancer • Severe dementia • Class IV congestive heart failure • Poor functional status

14. Prognosis and Treatment Decisions in Elderly Patients • A comprehensive geriatric assessment, with sex and age data, can be used to estimate expected survival • Compare expected survival to that from new illness • Here, benign goiter vs. thyroid cancer • If baseline life expectancy > than untreated illness, estimate ability to tolerate diagnostic procedure • If patient likely to tolerate procedure, then may benefit from work up and treatment In Balducci, et al, eds. Comprehensive geriatric oncology. 1998.

15. Algorithm for Treatment of Older Cancer Patients Adapted with permission from (see note): Comprehensive geriatric oncology. The Netherlands Harwood Academic Publishers. 1998:295; Figure 20.1.

16. Analyzing the Diagnostic Approach • Life tables for 90-year-old American woman • 50% survive at least 3.8 years • 25% survive less than 1.8 years • 25% survive at least 6.8 years • Basic exploration of neck mass would be unlikely to affect survival; biopsy would be recommended • However, if patient had a severely life-limiting illness already, the result of the biopsy would not affect decision-making

17. Summary of Considerations when Prognosticating in Elderly Patients • What is diagnosis/extent of any new disease? • What is baseline life expectancy related to age, comorbidity, and functional status? • Is expected survival from new disease shorter than baseline life expectancy? • Will treatment improve expected survival from the new disease? • Will treatment for new disease be tolerated?