It Is Not What You Think: Associations Between Perceived Cognitive and Physical Status and Prognostic Understanding in Patients With Advanced Cancer

Accurate prognostic awareness is associated with increased emotional distress in Latino patients with advanced cancer

OBJECTIVES

To describe the frequency of prognostic awareness (PA) in a population of advanced cancer patients in a Latino community and to explore the relationship between accurate PA with emotional distress and other covariates.

METHODS

In this cross-sectional study performed in Puente Alto, Chile, advanced cancer patients in palliative care completed a survey that included a single question to assess PA (Do you believe your cancer is curable? yes/no). Patients reporting that their cancer was not curable were considered as having accurate PA. Demographics, emotional distress, quality of life, and patient perception of treatment goals were also assessed. Analyses to explore associations between PA and patient variables were adjusted.

RESULTS

A total of 201 patients were included in the analysis. Mean age was 65, 50% female. One hundred and three patients (51%) reported an accurate PA. In the univariate analysis, accurate PA was associated with not having a partner (p = 0.012), increased emotional distress (p = 0.013), depression (p = 0.003), and were less likely to report that the goal of the treatment was to get rid of the cancer (p < 0.001). In the multivariate analysis, patients with accurate PA had higher emotional distress or depression, were less likely to have a partner, and to report that the goal of the treatment was to get rid of the cancer.

SIGNIFICANCE OF RESULTS

Half of a population of Latino advanced cancer patients reported an accurate PA. Accurate PA was associated with increased emotional distress, which is similar to what has been reported in other countries. Weaknesses in prognostic disclosure by clinicians, local cultural factors, or higher motivation to seek prognostic information among distressed cancer patients could explain this association. Strategies to emotionally support patients when discussing prognostic information should be implemented.

Prognostic understanding among patients with advanced cancer recently referred to an enhanced supportive care service: results from the cross-sectional ProgESC study

PURPOSE

Prognostic understanding among patients with life-limiting diseases may help patient to make informed decisions about their care. The aim of our study was to assess the level of prognostic understanding among patients recently referred to an enhanced supportive care (ESC) service, to explore the factors associated with prognostic understanding and its association with patient-relevant outcomes.

METHODS

Adult patients with metastatic cancer referred to the ESC service between November 13th, 2023, and August 31st, 2024, at the University College Hospital Macmillan Cancer Centre London were eligible and completed a structured online questionnaire. The primary endpoint was patients' prognostic understanding assessed with the Prognosis and Treatment Perception Questionnaire. Secondary endpoints included symptoms of anxiety and depression, measured with the General Anxiety Disorder 2-item (GAD-2) and Patient Health Questionnaire-2 (PHQ-2), respectively.

RESULTS

Out of 311 patients referred to the ESC, 91 were included in the study. Of these 91 patients, 34 (37.4%) were unaware of their incurable prognosis. In a regression model adjusted for age and gender, being in a relationship was significantly associated with good prognostic understanding (adjusted OR 2.75, 95% CI 1.11 to 6.8, p = 0.03). Patients who had a good prognostic understanding reported fewer symptoms of anxiety (16% vs. 36%; adjusted OR 0.32, 95% CI 0.12 to 0.88, p = 0.03) and depression (23% vs. 45%; adjusted OR 0.35, 95% CI 0.13 to 0.91, p = 0.03).

CONCLUSION

A significant proportion of patients with metastatic cancer were unaware that their cancer was not curable at referral to the ESC service. Improving prognostic understanding may help to reduce psychological distress and enhance emotional well-being, supporting better patient-centred ESC care.

Correlates of Perceived Illness Severity and Terminality in Advanced Lung and Prostate Cancer

CONTEXT

While prognostic awareness has been commonly assessed as perceived illness terminality in patients with advanced cancer, both perceptions of illness severity and terminality may be correlated with symptom burden and quality of life.

OBJECTIVES

The present study examined physical and psychological symptoms, quality of life, and smoking status in relation to perceived illness severity and terminality in patients with advanced, inoperable lung and prostate cancer.

METHODS

Patients (N=198) were recruited from hospitals in the midwestern U.S. to complete a one-time survey. Prognostic awareness was assessed in the following categories: "relatively healthy," "seriously ill but not terminally ill," or "seriously and terminally ill."

RESULTS

Only 12% reported an accurate prognostic awareness ("seriously and terminally ill") and 66% perceived themselves as "relatively healthy." Higher levels of anxiety, depressive symptoms, fatigue, and pain and worse quality of life were associated with a higher likelihood of reporting serious illness, irrespective of perceived illness terminality. Smoking status was unrelated to prognostic awareness. For patients with advanced lung cancer, greater breathlessness was associated with a higher likelihood of reporting serious or terminal illness.

CONCLUSION

Our findings suggest that perceiving cancer as serious, not just terminal, is related to symptom burden and quality of life. Results point to the need for interventions to improve prognostic understanding and coping with the disease.

Prognostic understanding among caregivers of persons with dementia: A scoping review

INTRODUCTION

Despite the influence of caregivers' prognostic understanding (PU) on the end-of-life care for persons with dementia (PwDs), the literature on PU of caregivers of PwDs is sparse. We conducted a scoping review to understand the variation in existing definitions and measurement of caregivers' PU for PwDs. We also aimed to synthesize the prevalence of caregivers' correct PU and the factors (caregiver, PwD and healthcare related) associated with it.

METHODS

We systematically searched four databases-MEDLINE/PubMed, EMBASE, SCOPUS, and CINAHL. We included studies where study participants were informal caregivers, their PU was assessed, and measurement tool was implicitly described. We excluded studies where study participants were paid caregivers.

RESULTS

Out of the 2160 studies screened, we included 15 published between 2009 and 2023. The included studies measured caregivers' PU as limited estimated life expectancy, understanding that dementia is incurable and life-limiting. Estimated life expectancy was the most common measure of PU among caregivers to PwDs. Across studies, around 90% of caregivers acknowledged dementia as incurable, while only about 40% acknowledged it as life-limiting. Caregivers of PwDs who were sicker (acute medical problems or functional dependence) and those who had discussed goals of care with healthcare providers were more likely to have more accurate PU for PwDs. Caregivers' with better PU were more likely to state a preference for comfort-focused care, and their PwDs were likely to receive fewer burdensome interventions and experience greater comfort during the dying process.

CONCLUSION

Our findings highlight the need for a comprehensive measure to assess the multifaceted nature of caregivers' PU, delve deeper into factors influencing caregivers' PU, and explore its impact on caregivers themselves.

To be aware or not to be aware of the prognosis in the terminal stage of cancer? A systematic review of the associations between prognostic awareness with anxiety, depression, and quality of life according to cancer stage

Prognostic awareness (PA) has an important role in promoting informed care planning in cancer patients. However, studies in the literature showed discordant results regarding the impact of PA on psychological and quality of life outcomes. The present systematic review aimed to investigate the associations between PA with anxiety, depression, and quality of life in oncological patients according to early, advanced, and terminal cancer stages. The review adhered to PRISMA guidelines and was registered on PROSPERO. The research identified 42.357 studies, of which 54 were included. The main result showed that the associations of PA with anxiety, depression, and quality of life varied according to the cancer stage. In studies with early and advanced cancer patients, 0 % and 9 %, respectively, showed favourable associations, while in those with terminal cancer patients, 53 % showed favourable associations. In terminal stage cancer, the associations were favourable when patients were enrolled in hospice, had a mean survival time shorter than 60 days, and a mean age older than 65 years. These findings suggest that it could be important within psychological interventions for patients to consider the impact of PA at different stages of cancer. While in the early and advanced stages of cancer, patients might benefit most from interventions focused on implementing psychological resources to face the illness and maintaining a hopeful outlook, in the terminal stage of cancer, it could be important to promote the process of becoming aware of their prognosis.

Prognostic understanding among advanced heart failure patients and their caregivers: A longitudinal dyadic study

OBJECTIVES

To examine heart failure patients' and caregivers' prognostic understanding (PU) over time, and patient and caregiver factors associated with their own and each other's PU.

METHODS

We used longitudinal dyadic data from Singapore, involving surveys with 95 heart failure patient-caregiver dyads every 4 months for up to 4 years. We assessed the association of PU with patient health status, caregiver psychological distress and caregiving hours using random effects multinomial logistic models, controlling for patient and caregiver characteristics.

RESULTS

At baseline, half of patients and caregivers reported correct PU. Patient and caregiver variables were associated with their own and each other's PU. Patients with poorer functional well-being were less likely to report correct PU [Average Marginal Effects (95 % CI) 0.008 (0.002, 0.015)] versus incorrect PU. Greater caregiver psychological distress was associated with a lower likelihood of caregivers reporting a correct PU [- 0.008 (-0.014, -0.002)]. Higher caregiving hours reduced the likelihood of patients reporting correct [- 0.002 (-0.003, -0.001)] and increased the likelihood of patients reporting uncertain [0.001 (0, 0.002)] PU.

CONCLUSIONS

We found PU among patients and caregivers was influenced by their own and each other's experience. Our findings highlight the importance of ongoing communication to enhance PU of patients and caregivers.

Instability in Caregivers' Perception of Dementia as a Terminal Disease

OBJECTIVES

Family caregivers' perception that dementia is a terminal disease influence end-of-life (EoL) care of persons with severe dementia (PwSDs). Yet, this perception and the extent to which it changes over time is underexplored. We assessed PwSD caregivers' perception of dementia as a terminal disease and changes in this perception over time.

DESIGN

Prospective cohort.

SETTING AND PARTICIPANTS

Two hundred fifteen primary informal caregivers of community-dwelling PWSDs in Singapore were surveyed every 4 months over a period of 16 months.

METHODS

We assessed the proportion of caregivers who perceived that dementia is a terminal disease and the extent to which it changed between the previous time points. Using mixed effects multinomial regression models, we assessed factors associated with caregivers' perception and changes in perception between consecutive time points.

RESULTS

At baseline, only 26% of the caregivers reported correctly that dementia is a terminal disease. This changed over time, not necessarily toward a correct perception. Caregivers of PwSDs with an acute medical condition in the last 4 months (risk ratio [RR] 2.19, 95% CI 1.21, 3.97) and those with higher functional dependence (RR 1.11, 95% CI 1.01,1.22) were more likely and those of older PwSDs were less likely (RR 0.87, 95% CI 0.81, 0.93) to perceive dementia as a terminal disease. Caregivers of PwSDs who had experienced an acute medical problem in the last 4 months (RR 1.58, 95% CI 1.00, 2.49) were also more likely to shift their perception toward being correct. Caregivers of PwSDs who had more agitation behaviors were more likely to shift their perception toward being incorrect (RR 1.04, 95% CI 1.00,1.07) CONCLUSIONS AND IMPLICATIONS: Few caregivers perceived dementia as terminal, and this perception changed over time and differed according to age and the health status of PwSD. Results have implications regarding the frequency of prognostic discussions.

The past and future of uncertainty in advanced illness: a systematic scoping review of underlying cognitive processes

BACKGROUND

To explain what cognitive capacity shapes uncertainty in advanced illness by identifying the types of evidence, mapping underlying cognitive processes to uncertainty, and outlining future directions for research and interventions.

DESIGN

A systematic scoping review of mixed study designs was carried out following the methodological framework of Arksey and O'Malley (2005) and using qualitative content analysis.

METHODS

PubMed, CINAHL, Embase, and PsycINFO were searched for original studies published in full and in English through December 2021 that reported on uncertainty in illness and related cognitions, cognitive science, or cognitive functions.

RESULTS

After screening 978, 18 articles met the inclusion criteria for review. We found the cognitive capacity of mental time travel - to relive the past or foresee life in the future - interacted with episodic memory retrieval to inform decision-making, and prospection to imagine, predict or prepare for future outcomes to determine lesser or greater uncertainty in advanced illness.

CONCLUSIONS

Mental time travel is a fundamental cognitive function when the future is limited by an advanced illness, to review life as a meaningful narrative. The role of mental time travel to construct or make sense of uncertain futures inherent in advanced illness can inform theory and targets for intervention.

Association between prognostic awareness and quality of life in patients with advanced cancer

PURPOSE

Despite the current guidelines supporting open communication about serious news, the evidence about the impact of prognostic awareness on the quality of life in cancer patients is not clear. The aim of this study was to assess the association between quality of life and prognostic awareness in patients with advanced cancer.

METHODS

This was a cross-sectional study which involved patients (n = 129) with incurable advanced cancer (estimated by oncologist using 12-month surprise question). Data were collected at oncology departments at 3 hospitals using structured interview in which patients were asked about their quality of life (using Integrated Palliative Outcome Scale-IPOS and a single-item global measure), prognostic awareness, information needs and demographics.

RESULTS

Only 16% of the sample was completely aware of prognosis and 57% was partially aware. Accurate prognostic awareness was significantly associated (p = 0.02) with lower level of quality of life between (when measured by both the IPOS and the single-item scale) patients with accurate prognostic awareness (M = 37.1; 10.4) and partially aware (M = 31.9; 9.1) and unaware patients (M = 30; 7.4). Detailed analysis showed that significant difference between groups was found only for physical symptoms subscales (p = 0.002), not for emotional and communication subscales.

CONCLUSION

Prognostic awareness was found to be negatively associated with physical domain of quality of life, but not with emotional and communication domains. More research is needed on personality factors that might influence the development of prognostic awareness and quality of life.

Factors associated with distinct prognostic-awareness-transition patterns over cancer patients' last 6 months of life

Background

Cancer patients may develop prognostic awareness (PA) heterogeneously, but predictors of PA‐transition patterns have never been studied. We aimed to identify transition patterns of PA and their associated factors during cancer patients’ last 6 months.

Methods

For this secondary‐analysis study, PA was assessed among 334 cancer patients when they were first diagnosed as terminally ill and monthly till they died. PA was categorized into four states: (a) unknown and not wanting to know; (b) unknown but wanting to know; (c) inaccurate awareness; and (d) accurate awareness. The first and last PA states estimated by hidden Markov modeling were examined to identify their change patterns. Factors associated with distinct PA‐transition patterns were determined by multinomial logistic regressions focused on modifiable time‐varying variables assessed in the wave before the last PA assessment to ensure a clear time sequence for associating with PA‐transition patterns.

Results

Four PA‐transition patterns were identified: maintaining accurate PA (56.3%), gaining accurate PA (20.4%), heterogeneous PA (7.8%), and still avoiding PA (15.6%). Reported physician‐prognostic disclosure increased the likelihood of belonging to the maintaining‐accurate‐PA group than to other groups. Greater symptom distress predisposed patients to be in the still‐avoiding‐PA than the heterogeneous PA group. Patients with higher functional dependence and more anxiety/depressive symptoms were more and less likely to be in the heterogeneous PA group and in the still‐avoiding‐PA group, respectively, than in the maintaining‐ and gaining‐accurate PA groups.

Conclusions

Cancer patients heterogeneously experienced PA‐transition patterns over their last 6 months. Physicians’ prognostic disclosure, and patients’ symptom distress, functional dependence, and anxiety/depressive symptoms, all modifiable by high‐quality end‐of‐life care, were associated with distinct PA‐transition patterns.

Patients with cancer may not develop accurate prognostic awareness (PA) at the same rate or to the same degree and factors associated with PA‐transition patterns are unknown. Here, we identified PA‐transition patterns and their associated factors during the last six months of life for patients with advanced cancer and found that they developed PA in different ways. Four PA‐transition patterns were identified: maintaining accurate PA, gaining accurate PA, heterogeneous PA, and still avoiding PA. Prognostic disclosure by physicians, patient symptom distress, functional dependence, and anxiety/depression symptoms are major factors associated with PA‐transition patterns and can be acted on during high‐quality end‐of‐life care.

Prognostic Awareness in Advanced Disease: A Review Update and Concept Analysis

Purpose

Although subjective knowledge about the prognosis of an advanced disease is extremely important for coping and treatment planning, the concept of prognostic awareness (PA) remains inconsistently defined. The aims of the scoping review were to synthesize a definition of PA from the most recent literature, describe preconditions, correlates and consequences, and suggest a conceptual model.

Methods

By using scoping review methodology, we searched the Web of Science and PubMed databases, and included publications, reviews, meta-analyses or guidelines on all physical diagnoses, as well as publications offering a conceptual or an operational definition of PA. The data were analyzed by means of content analysis techniques.

Results

Of the 24 included publications, 21 referred exclusively to cancer, one to patients with hip fractures and two to palliative care in general. The deduced definition of PA comprised the following facets: adequate estimation of chances for recovery, knowledge of limited time to live, adequate estimation of life expectancy, knowledge of therapy goals, and knowledge of the course of the disease. Further content analysis results were mapped graphically and in a detailed table.

Conclusion

There appears to be a lack of theoretical embedding of PA that in turn influences the methods used for empirical investigation. Drawing on a clear conceptual definition, longitudinal or experimental studies would be desirable.

Prognostic disclosure and quality of life in palliative care: a systematic review

INTRODUCTION

Prognostic disclosure is an important component of communication in palliative care. Disclosing information on poor prognosis may affect quality of life (QoL) of palliative care patients. However, the effects of prognostic disclosure on QoL across different cultures and countries are unclear.

OBJECTIVE

To review the effects of prognostic disclosure on QoL of palliative care patients.

METHODS

A systematic review was conducted across seven databases (AMED, CINAHL plus, Cochrane Library, Medline (via the PubMed interface), Embase, Scopus and Web of Science). All primary studies, of any design, that explored the effects of prognostic disclosure on QoL of adult palliative care patients were eligible.

RESULTS

A total of 1926 records were screened for eligibility. Twenty-five articles were included (11 cross-sectional, 10 cohort, 3 mixed methods and 1 qualitative study). Studies were conducted in 11 countries. Five studies reported the sources of prognostic disclosure, while 20 studies did not. Emotional QoL was the most reported domain among the studies. The effects of prognostic disclosure on emotional aspects, overall QoL and other domains, including symptoms, physical functions, role functions, social functions and cognitive functions, were inconsistent.

CONCLUSIONS

The effects of prognostic disclosure on QoL across cultures and countries are inconsistent. Cultural differences are not sufficient to explain the effects. Future research is needed to explore the association between prognostic disclosure and QoL, and develop tools to support clinicians to share prognostic information in the most sensitive and supportive way.

Prognostic Awareness in Caregivers of Patients with Incurable Cancer

Background: Little is known about how patients with incurable cancer and caregivers differ in their prognostic awareness, and the relationship between caregiver prognostic awareness and their psychological distress. Objective: To investigate prognostic awareness in caregivers of patients with incurable cancer and prognostic discordance in patient-caregiver dyads and its association with psychological distress. Design: This is a cross-sectional study. Setting/Subjects: In total, subjects were 390 caregivers of adults with incurable lung, gastrointestinal, and brain cancers at a cancer center in the northeastern United States. Measurements: The Prognosis and Treatment Perceptions Questionnaire was used to assess prognostic awareness and Hospital Anxiety and Depression Scale to assess psychological distress. Results: In total, 39.7% (n = 147/370) and 17.3% (n = 64/370) caregivers reported clinically significant anxiety and depression symptoms. And 53.7% of caregivers reported the patients' cancer as "curable" and 44.1% reported the cancer was "not terminal." Caregivers' report of curability was not associated with their anxiety (odds ratio [OR] = 0.99, p = 0.93) or depression (OR = 1.05, p = 0.32) symptoms. Among 42.5% (124/292) and 26.0% (76/292) of dyads (n = 292), both patients and their caregivers agreed in their perception of the cancer as curable and incurable, respectively. In 19.9% of dyads (n = 58), patients reported their cancer as curable, while their caregivers reported it as incurable. In 11.6% of dyads (n = 34), patients reported the cancer as incurable while caregivers reported it as curable. Conclusions: More than half of caregivers have misperceptions about the patients' likelihood of cure, and one-third of patient-caregiver dyads have discordant perceptions. Supportive care interventions may facilitate conversations and enhance prognostic understanding in patients with incurable cancer and their caregivers.

Understanding Hospice Patients' Beliefs About Their Life Expectancy: A Qualitative Interview Study

BACKGROUND

Patients with advanced disease often overestimate their life expectancy, which potentially impacts decision making.

OBJECTIVE

To examine the nature and source of hospice patients' life expectancy estimates, about which little is known.

DESIGN

Using semi-structured interviews, patients were asked to estimate their life expectancy and elaborate on their response.

SETTING/SUBJECTS

Participants were hospice patients (n = 20, 55% male; 60% cancer).

MEASUREMENT

We conducted thematic analysis using open and focused coding.

RESULTS

Many participants had difficulty answering the life expectancy question and expressed uncertainty about when they would die. One-third overestimated their length of life relative to actual survival. The most common source of patients' prognostic beliefs was knowledge about their body, including physical symptoms and change over time. Half of patients reported that a provider had given them a prognostic estimate, and one-third agreed with, or gave estimates consistent with, the provider's estimate. Some patients said providers do not know prognosis or that time of death was unknowable.

CONCLUSIONS

Key findings were that 1) many hospice patients had difficulty estimating life expectancy, and 2) hospice patients' life expectancy estimates were frequently based on their body and not on information from medical providers. These findings have implications for measuring prognostic awareness, as valid assessment is a necessary component of determining whether prognostic awareness is beneficial for patients. Future research should examine how life expectancy estimates are associated with well-being and whether results extend to larger samples of patients with advanced disease not in hospice.

Illness and prognostic understanding in patients with hematologic malignancies

It is critical for patients with hematologic malignancies to have an accurate understanding of their illness and prognosis to make informed treatment decisions. Illness and prognostic understanding have primarily been studied in patients with solid tumors, however, data in patients with hematologic malignancies are rapidly growing. Patients with hematologic malignancies often face a unique and unpredictable illness trajectory with the possibility of cure persisting even in relapsed and refractory settings. These patients often require intensive therapies such as high-dose chemotherapy, hematopoietic stem cell transplantation (HCT), or CAR T-cell therapy, which carry with them significant risk of morbidity, mortality, and prognostic uncertainty. In this review article, we first described the current literature on illness and prognostic understanding in patients with hematologic malignancies including 1) patients' varying desire for prognostic information; (2) patients' prognostic misperceptions, (3) the association between patients' prognostic understanding and their psychological outcomes; and (4) barriers to prognostic understanding. Next, we examined insights gained from the literature about illness and prognostic understanding in patients with solid tumors to guide our understanding of the research gaps in hematologic malignancies. Future studies are needed to better delineate the longitudinal relationship between prognostic understanding, psychological distress, and coping in patients with hematologic malignancies. Strategies such as communicating effectively about prognosis, cultivating adaptive coping in the face of a terminal prognosis, and integrating specialty palliative care for patients with hematologic malignancies have the potential to improve patients' prognostic understanding and their quality of life and care.

Illness Understanding and Advance Care Planning in Patients with Advanced Lymphoma

Background: The prognosis of an aggressive lymphoma can change dramatically following failure of first-line treatment. This sudden shift is challenging for the promotion of illness understanding and advance care planning (ACP). Yet, little is known about illness understanding and ACP in patients with aggressive lymphomas. Objective: To examine illness understanding, rates of engagement in ACP, and reasons for lack of ACP engagement in patients with advanced B cell lymphomas. Design: Cross-sectional observational study. Setting/Subjects: Patients (n = 27) with aggressive B cell lymphomas that relapsed after first- or second-line treatment treated at a single urban academic medical center. Measurements: Participants were administered structured surveys by trained staff to obtain self-report measures of illness understanding (i.e., aggressiveness, terminality, curability) and ACP (i.e., discussions of care preferences, completion of advance directives). Results: The majority of patients reported discussing curability (92.6%), prognosis (77.8%), and treatment goals (88.9%) with their medical team. Yet, less than one-third of patients reported being terminally ill (29.6%) and having incurable disease (22.2%). Most patients had a health care proxy (81.5%) and had decided about do-not-resuscitate status (63%), but the majority had not completed a living will (65.4%) or discussed their care preferences with others (55.6%). Conclusions: The accuracy of lymphoma patients' illness understanding following first-line treatment is difficult to determine due to the potential for cure following transplant. However, this study suggests that a large proportion of patients with advanced B cell lymphomas may underestimate the severity of their illness, despite discussing illness severity with their medical team. Providing patients with information on prognosis, and the ACP process may increase engagement in ACP.