Comparison of the accuracy and characteristics of the prognostic prediction of survival of identical terminally ill cancer patients by oncologists and palliative care physicians

Comparison of the accuracy and characteristics of the prognostic prediction of survival of... Abstract Most terminally ill cancer patients in our hospice ward are referred from hospitals for anticancer treatment. For identical terminally ill cancer patients referred from other hospitals, differences in the accuracy and characteristics of the prognostic prediction of survival by oncologists and palliative care physicians were examined. We investigated 101 patients and compared the prognostic value between the clinical prediction of survival with oncologists and prognostic tool-conducted prediction by palliative care physicians with the actual survival times; the results were then classified as accurate, pessimistic and optimistic. Prognostic prediction by palliative care physicians was closer to the actual survival time. The number of accurately predicted cases by palliative care physicians was more than that by oncologists, and the number of optimistically predicted cases by oncologists was more than that by palliative care physicians. The palliative care physicians’ prediction was more accurate, while the oncologists’ prediction was more optimistic. prognostic prediction of survival, identical patient, accuracy, oncologist, palliative care physician Introduction For terminally ill patients and their families, the prognostic prediction of survival is important for setting goals, determining treatment strategies or end-of-life care and identifying hospice care programs or medical support services at an appropriate time. Therefore, all physicians must accurately predict the patient’s prognosis (1). In Japan, the number of hospice palliative care beds and patients who spend the last days of their lives at hospice wards is increasing (2). Most patients admitted at the hospice wards have received anticancer therapies, such as surgical therapies, chemotherapies and radiation therapies, at other hospitals or wards, and these patients are referred if they do not have options for intensive anticancer therapies. Oncologists usually start their relationships with patients with cancer at the time of diagnoses or at the start of anticancer treatment, and these professionals observe changes in the patients’ condition over a long period of time. By contrast, palliative care physicians in hospice wards often start their relationships with patients during hospitalization for end-of-life care. Therefore, they often understand the current treatments and changes in the patients’ condition with the use of medical information from the previous doctors, even without direct observation. In terms of the prognostic prediction of survival, it is important to understand the progress and condition of patients (3), and hence, in relation to this, oncologists can more accurately predict prognosis than palliative care physicians who only observe a patient over a short period of time. However meanwhile, previous studies have revealed that a stronger doctor–patient relationship is associated with lower prognostic accuracy (4) and that the course of disability within the last year of life does not follow a predictable pattern based on the condition leading to death (5), in fact, numerous studies have revealed the inaccurate prediction of the prognostic survival by a physician (6–8). Palliative care physicians in our institution independently predicted prognosis when a patient is admitted to the hospice ward. However, if it significantly differed from the prediction of oncologists, palliative care physicians often struggle in interpreting the prognostic prediction that they themselves have made. Moreover, they find it challenging to explain the results to the patient or the patient’s family. Herein, we report the comparison of the prognostic value between the clinical prediction of survival with oncologist and the prognostic tool-conducted prediction by palliative care physician in terminally ill cancer patients who were referred by oncologists and admitted to our hospice ward. Patients and methods From 1 October 2014 to 30 November 2017, among the patients referred from hospitals that provide anticancer therapies, such as surgical therapy, chemotherapy and radiotherapy, we enrolled patients whose oncologists had predicted their prognoses. The palliative care physicians independently predicted the patient’s prognoses again after admission to our hospice ward for end-of-life care. This is a prospective observational study. We adopted the prognostic predictions of survival by oncologists that were disclosed at the time of admission to our hospice ward via a review of the patient’s referral documents or telephone surveys. We subtracted the number of days required from the creation date of the patient’s referral document or from the confirmation date via telephone survey to admission to our hospice ward from the predicted prognosis. The prognostic prediction of survival after admission at our hospice ward was estimated on the day of admission by a palliative care physician. When physicians predicted the prognosis in terms of range, the median was used as a prognostic predictor of survival. The actual survival time was examined using the medical records of the patients. In this study, palliative care physicians in our hospice ward predicted the prognosis of terminally ill cancer patients based on palliative prognostic score (PaP) (9) and palliative prognostic index (PPI) (10). A t-test was performed to evaluate the significant differences between the prognoses predicted by oncologists and palliative care physicians and the actual survival time. For comparison with previous studies (4,11,12), prognostic prediction was defined as follows: accurate if it was within 0.67–1.33 times the actual survival time, pessimistic if it was less than 0.67 times and optimistic if it was greater than 1.33 times. A number of patients who were predicted accurately, pessimistically and optimistically by both oncologists and palliative care physicians were identified, and to evaluate the significant differences in the number of each prediction by oncologists and palliative care physicians, a Chi-square test was performed. A P value of <0.05 was considered statistically significant. This study was not reviewed by the local institutional review board. However, it was conducted according to ethical standards, and patient anonymity was maintained throughout the study. Results This study included 101 patients referred from 21 hospitals. Table 1 shows the characteristics of patients: age, sex, site of primary cancer and actual survival time. The mean age was 76.6 (range: 50–96) years. The male-to-female ratio was 62:39 (61.4 and 38.6%, respectively). The lungs (20 patients) were the most common sites of primary cancer, followed by the esophagus/stomach (15 patients). The mean actual survival time was 28.4 (range: 1–167) days. Table 1. Characteristics of patients Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Table 1. Characteristics of patients Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Table 2 shows the accuracy and characteristics of the clinical prediction of survival with oncologist and the prognostic tool-conducted prediction by palliative care physician. The differences between the actual survival time and the prognostic prediction of survival by oncologists and palliative care physicians were 31.2 (95% confidence interval (CI): 26.7–35.6, range: 0–110) days and 15.6 (95% CI: 12.4–18.7, range: 0–107) days, respectively. Thus, the survival time predicted by oncologists was significantly longer than that predicted by palliative care physicians (P < 0.0001). Table 2. Accuracy and characteristics of prognostic prediction of survival Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 CI, confidence interval. Table 2. Accuracy and characteristics of prognostic prediction of survival Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 CI, confidence interval. Oncologists and palliative care physicians had an accurate prognostic prediction in 22 (21.8%) and 38 (37.6%) patients, respectively. Meanwhile, in 11 (10.9%) and 12 (11.9%) patients, the oncologists and palliative care physicians had a pessimistic prognostic prediction, respectively, and an optimistic prognostic prediction was made by the oncologists and palliative care physicians in 68 (67.3%) and 51 (50.5%) patients, respectively. The number of patients with accurate and optimistic prognostic predictions differed significantly (P = 0.014 and P = 0.015, respectively). However, no significant difference was observed in the number of patients with pessimistic prognostic prediction (P = 0.825). Prognostic predictions of survival by both physicians were optimistic. However, prognostic tool-conducted prediction by palliative care physicians was more accurate than the clinical prediction of survival with oncologists. Discussion There are several studies and reviews showing that the prognostic prediction of survival by physicians or oncologists was accurate or inaccurate (4,6–8,11,13) and that the proportion of patients with accurate prognostic prediction significantly varied at a rate of 23–78% (7). Amano et al. have already revealed that palliative care physicians provide more accurate predictions than other physicians (14); however, our study is considered important because it revealed the difference in the accuracy and characteristics of the prognostic prediction of survival by oncologists and palliative care physicians in identical terminally ill cancer patients. Several important findings were obtained. First, the accuracy of the clinical prediction of survival with oncologists and prognostic tool-conducted prediction by palliative care physicians differed significantly. Moreover, the differences between the prognoses and actual survival time predicted by oncologists and palliative care physicians were 31.2 days and 15.6 days, respectively. Thus, palliative care physicians were more accurate in their prediction. A previous study has revealed a significant association between doctor–patient relationship and lower prognostic accuracy (4), and this may explain the result of the present study. In addition, it is believed that oncologists have a few opportunities to confirm the death of their terminally ill cancer patients because these patients are often transferred to hospice wards (2) or facilities that offer palliative care services due to the increasing death rates at home (including nursing homes), that is, from 15.0% in 2005 to 22.2% in 2016 in Japan (15), and this may also explain the result of our study. Other possible reasons include palliative care physicians usually use prognostic tools, such as PaP, PPI and palliative performance scale (16) that provide physicians with accurate information on the prognosis of patients with advance cancer, and they predict prognosis more closely to the time of death than oncologists. However, a previous study has also shown that predicting prognosis more closely to the time of death was not associated with higher prognostic accuracy (6). As to whether backgrounds of physicians, e.g. years of experience, might impact on the accuracy of physicians’ clinical predictions of survival, previous study has already reported that the greater the experience of the doctor, the greater the accuracy of the prognosis (4). Second, the characteristics of prediction differed between the clinical prediction of survival with oncologists and prognostic tool-conducted prediction by palliative care physicians. Approximately 21.8 and 37.6% of patients had an accurate prognostic prediction by oncologists and palliative care physicians, respectively, and this result indicates that palliative care physicians have a more accurate prognosis than oncologists. The proportion of patients with an optimistic prediction by both physicians was the highest, of which 67.3% were by oncologists and 50.5% were by palliative care physicians; these results are similar to those of previous studies (4,8,17). In addition, previous studies have revealed that physicians refer patients to hospices evaluate the prognosis of survival optimistically (8). Moreover, oncologists assess the condition of the patients more optimistically than palliative care specialists (18). Our result also indicates a significantly higher proportion of individuals with an optimistic prognosis by oncologists than by palliative care physicians. The proportion of patients with a pessimistic prognostic prediction by both physicians was the lowest, and no significant difference was observed between the pessimistic prognostic predictions by palliative care specialists and oncologists. This study suggests that oncologists had better refer to prognostic tools. Furthermore, for both physicians, the prognostic prediction of survival must be evaluated, and whether the prediction was accurate, pessimistic or optimistic must be confirmed to improve the accuracy of the prognostic prediction. However, the generalizability of the results is limited because oncologists and palliative care physicians did not predict the prognosis on the same day, and therefore we have to select the method of subtracting the number of days required from the confirmation date to admission to our hospice ward from the predicted prognosis. Moreover, this study was conducted in a single institution. Hence, further multicenter studies in which both physicians predict the prognosis on the same day with a large sample size must be conducted. Conclusion The results of the present study revealed that the prognostic value of the prognostic tool-conducted prediction by palliative care physician was more accurate than the clinical prediction of survival with oncologist; moreover, the predictions of oncologists were more optimistic in identical terminally ill cancer patients. Conflict of interest statement None declared. References 1 Glare P , Sinclair CT , Stone P , et al. . Predicting survival in patients with advanced disease. In: Cherny NI , Fallon MT , Kaasa S , Portenoy RK , Currow DC , editors . Oxford Textbook of Palliative Medicine . 5th ed . Oxford : Oxford University Press , 2015 ; 65 – 76 . 2 Specified Nonprofit Corporation, Hospice Palliative Care Japan [Internet] . Kanagawa: Annual transition of the number of institutions and beds for which palliative care ward admission fee have been notified; c2010 [cited 2017 Nov 15] (in Japanese). Available from: https://www.hpcj.org/what/pcu_sii.html 3 Lunney JR , Lynn J , Foley DJ , et al. . Patterns of functional decline at the end of life . JAMA 2003 ; 289 : 2387 – 92 . Google Scholar CrossRef Search ADS PubMed 4 Christakis NA , Lamont EB . Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study . BMJ 2000 ; 320 : 469 – 72 . Google Scholar CrossRef Search ADS PubMed 5 Thomas MG , Evelyne AG , Ling H , et al. . Trajectories of disability in the last year of life . N Engl J Med 2010 ; 362 : 1173 – 80 . Google Scholar CrossRef Search ADS PubMed 6 Gripp S , Moeller S , Bölke E , et al. . Survival prediction in terminally ill cancer patients by clinical estimates, laboratory tests, and self-rated anxiety and depression . J Clin Oncol 2007 ; 25 : 3313 – 20 . Google Scholar CrossRef Search ADS PubMed 7 White N , Reid F , Harris A , et al. . A systematic review of predictions of survival in palliative care: how accurate are clinicians and who are the experts? PLoS One 2016 ; 11 : e0161407 doi:10.1371/journal.pone.0161407 . Google Scholar CrossRef Search ADS PubMed 8 Glare P , Virik K , Jones M , et al. . A systematic review of physicians’ survival predictions in terminally ill cancer patients . BMJ 2003 ; 327 : 195 – 8 . Google Scholar CrossRef Search ADS PubMed 9 Maltoni M , Nanni O , Pirovano M , et al. . Successful validation of the palliative prognostic score in terminally ill cancer patients. Italian Multicenter Study Group on Palliative Care . J Pain Symptom Manage 1999 ; 17 : 240 – 7 . Google Scholar CrossRef Search ADS PubMed 10 Morita T , Tsunoda J , Inoue S , et al. . The palliative prognostic index: a scoring system for survival prediction of terminally ill cancer patients . Support Care Cancer 1999 ; 7 : 128 – 33 . Google Scholar CrossRef Search ADS PubMed 11 Kiely BE , Martin AJ , Tattersall MH , et al. . The median informs the message: accuracy of individualized scenarios for survival time based on oncologists’ estimates . J Clin Oncol 2013 ; 31 : 3565 – 71 . Google Scholar CrossRef Search ADS PubMed 12 Stockler MR , Tattersall MH , Boyer MJ , et al. . Disarming the guarded prognosis: predicting survival in newly referred patients with incurable cancer . Br J Cancer 2006 ; 94 : 208 – 12 . Google Scholar CrossRef Search ADS PubMed 13 Taniyama TK , Hashimoto K , Katsumata N , et al. . Can oncologists predict survival for patients with progressive disease after standard chemotherapies? Curr Oncol 2014 ; 21 : 84 – 90 . Google Scholar CrossRef Search ADS PubMed 14 Amano K , Maeda I , Shimoyama S , et al. . The accuracy of physicians’ clinical predictions of survival in patients with advanced cancer . J Pain Symptom Manage 2015 ; 50 : 139 – 46 . Google Scholar CrossRef Search ADS PubMed 15 Portal Site of Official Statistics of Japan (e-Stat) [Internet] . Tokyo: National Statistics Center; c2009. Vital Statistics; [cited 2017 Sep 15] (in Japanese). Available from: https://www.e-stat.go.jp/stat-search/files?page=1&layout=datalist&toukei=00450011&tstat=000001028897&cycle=7&year=20160&month=0&tclass1=000001053058&tclass2=000001053061&tclass3=000001053065&result_back=1&second2=1 16 Anderson F , Downing GM , Hill J , et al. . Palliative Performance Scale (PPS): a new tool . J Palliat Care 1996 ; 12 : 5 – 11 . Google Scholar PubMed 17 Cheon S , Agarwal A , Popovic M , et al. . The accuracy of clinicians’ predictions of survival in advanced cancer: a review . Ann Palliat Med 2016 ; 5 : 22 – 9 . Google Scholar PubMed 18 Kim YJ , Hui D , Zhang Y , et al. . Differences in performance status assessment among palliative care specialists, nurses, and medical oncologists . J Pain Symptom Manage 2015 ; 49 : 1050 – 8 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Japanese Journal of Clinical Oncology Oxford University Press

Comparison of the accuracy and characteristics of the prognostic prediction of survival of identical terminally ill cancer patients by oncologists and palliative care physicians

Japanese Journal of Clinical Oncology , Volume Advance Article (7) – May 30, 2018

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Abstract

Abstract Most terminally ill cancer patients in our hospice ward are referred from hospitals for anticancer treatment. For identical terminally ill cancer patients referred from other hospitals, differences in the accuracy and characteristics of the prognostic prediction of survival by oncologists and palliative care physicians were examined. We investigated 101 patients and compared the prognostic value between the clinical prediction of survival with oncologists and prognostic tool-conducted prediction by palliative care physicians with the actual survival times; the results were then classified as accurate, pessimistic and optimistic. Prognostic prediction by palliative care physicians was closer to the actual survival time. The number of accurately predicted cases by palliative care physicians was more than that by oncologists, and the number of optimistically predicted cases by oncologists was more than that by palliative care physicians. The palliative care physicians’ prediction was more accurate, while the oncologists’ prediction was more optimistic. prognostic prediction of survival, identical patient, accuracy, oncologist, palliative care physician Introduction For terminally ill patients and their families, the prognostic prediction of survival is important for setting goals, determining treatment strategies or end-of-life care and identifying hospice care programs or medical support services at an appropriate time. Therefore, all physicians must accurately predict the patient’s prognosis (1). In Japan, the number of hospice palliative care beds and patients who spend the last days of their lives at hospice wards is increasing (2). Most patients admitted at the hospice wards have received anticancer therapies, such as surgical therapies, chemotherapies and radiation therapies, at other hospitals or wards, and these patients are referred if they do not have options for intensive anticancer therapies. Oncologists usually start their relationships with patients with cancer at the time of diagnoses or at the start of anticancer treatment, and these professionals observe changes in the patients’ condition over a long period of time. By contrast, palliative care physicians in hospice wards often start their relationships with patients during hospitalization for end-of-life care. Therefore, they often understand the current treatments and changes in the patients’ condition with the use of medical information from the previous doctors, even without direct observation. In terms of the prognostic prediction of survival, it is important to understand the progress and condition of patients (3), and hence, in relation to this, oncologists can more accurately predict prognosis than palliative care physicians who only observe a patient over a short period of time. However meanwhile, previous studies have revealed that a stronger doctor–patient relationship is associated with lower prognostic accuracy (4) and that the course of disability within the last year of life does not follow a predictable pattern based on the condition leading to death (5), in fact, numerous studies have revealed the inaccurate prediction of the prognostic survival by a physician (6–8). Palliative care physicians in our institution independently predicted prognosis when a patient is admitted to the hospice ward. However, if it significantly differed from the prediction of oncologists, palliative care physicians often struggle in interpreting the prognostic prediction that they themselves have made. Moreover, they find it challenging to explain the results to the patient or the patient’s family. Herein, we report the comparison of the prognostic value between the clinical prediction of survival with oncologist and the prognostic tool-conducted prediction by palliative care physician in terminally ill cancer patients who were referred by oncologists and admitted to our hospice ward. Patients and methods From 1 October 2014 to 30 November 2017, among the patients referred from hospitals that provide anticancer therapies, such as surgical therapy, chemotherapy and radiotherapy, we enrolled patients whose oncologists had predicted their prognoses. The palliative care physicians independently predicted the patient’s prognoses again after admission to our hospice ward for end-of-life care. This is a prospective observational study. We adopted the prognostic predictions of survival by oncologists that were disclosed at the time of admission to our hospice ward via a review of the patient’s referral documents or telephone surveys. We subtracted the number of days required from the creation date of the patient’s referral document or from the confirmation date via telephone survey to admission to our hospice ward from the predicted prognosis. The prognostic prediction of survival after admission at our hospice ward was estimated on the day of admission by a palliative care physician. When physicians predicted the prognosis in terms of range, the median was used as a prognostic predictor of survival. The actual survival time was examined using the medical records of the patients. In this study, palliative care physicians in our hospice ward predicted the prognosis of terminally ill cancer patients based on palliative prognostic score (PaP) (9) and palliative prognostic index (PPI) (10). A t-test was performed to evaluate the significant differences between the prognoses predicted by oncologists and palliative care physicians and the actual survival time. For comparison with previous studies (4,11,12), prognostic prediction was defined as follows: accurate if it was within 0.67–1.33 times the actual survival time, pessimistic if it was less than 0.67 times and optimistic if it was greater than 1.33 times. A number of patients who were predicted accurately, pessimistically and optimistically by both oncologists and palliative care physicians were identified, and to evaluate the significant differences in the number of each prediction by oncologists and palliative care physicians, a Chi-square test was performed. A P value of <0.05 was considered statistically significant. This study was not reviewed by the local institutional review board. However, it was conducted according to ethical standards, and patient anonymity was maintained throughout the study. Results This study included 101 patients referred from 21 hospitals. Table 1 shows the characteristics of patients: age, sex, site of primary cancer and actual survival time. The mean age was 76.6 (range: 50–96) years. The male-to-female ratio was 62:39 (61.4 and 38.6%, respectively). The lungs (20 patients) were the most common sites of primary cancer, followed by the esophagus/stomach (15 patients). The mean actual survival time was 28.4 (range: 1–167) days. Table 1. Characteristics of patients Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Table 1. Characteristics of patients Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Sex [n (%)]  Male/female 62 (61.4)/39 (38.6) Age [mean (range), years] 76.6 (50–96) Site of primary cancer [n (%)]  Lungs 20 (19.8)  Esophagus/stomach 15 (14.9)  Colon 11 (10.9)  Urinary tracts/bladder 9 (8.9)  Pancreas 8 (7.9)  Liver 6 (5.9)  Biliary tract/gall bladder 6 (5.9)  Hematological 6 (5.9)  Prostate 4 (4.0)  Ovaries/uterus 4 (4.0)  Neck 3 (3.0)  Sarcoma 3 (3.0)  Breasts 2 (2.0)  Others 4 (4.0) Actual survival time [mean (range), days] 28.4 (1–167) Table 2 shows the accuracy and characteristics of the clinical prediction of survival with oncologist and the prognostic tool-conducted prediction by palliative care physician. The differences between the actual survival time and the prognostic prediction of survival by oncologists and palliative care physicians were 31.2 (95% confidence interval (CI): 26.7–35.6, range: 0–110) days and 15.6 (95% CI: 12.4–18.7, range: 0–107) days, respectively. Thus, the survival time predicted by oncologists was significantly longer than that predicted by palliative care physicians (P < 0.0001). Table 2. Accuracy and characteristics of prognostic prediction of survival Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 CI, confidence interval. Table 2. Accuracy and characteristics of prognostic prediction of survival Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 Oncologists Palliative care physicians P value Difference between prognostic prediction and actual survival time (days)  Mean 31.2 15.6  95% CI 26.7–35.6 12.4–18.7 <0.0001  Range 0–110 0–107 Characteristics of prognostic prediction [n (%)]  Accurate 22 (21.8) 38 (37.6) 0.014  Pessimistic 11 (10.9) 12 (11.9) 0.825  Optimistic 68 (67.3) 51 (50.5) 0.015 CI, confidence interval. Oncologists and palliative care physicians had an accurate prognostic prediction in 22 (21.8%) and 38 (37.6%) patients, respectively. Meanwhile, in 11 (10.9%) and 12 (11.9%) patients, the oncologists and palliative care physicians had a pessimistic prognostic prediction, respectively, and an optimistic prognostic prediction was made by the oncologists and palliative care physicians in 68 (67.3%) and 51 (50.5%) patients, respectively. The number of patients with accurate and optimistic prognostic predictions differed significantly (P = 0.014 and P = 0.015, respectively). However, no significant difference was observed in the number of patients with pessimistic prognostic prediction (P = 0.825). Prognostic predictions of survival by both physicians were optimistic. However, prognostic tool-conducted prediction by palliative care physicians was more accurate than the clinical prediction of survival with oncologists. Discussion There are several studies and reviews showing that the prognostic prediction of survival by physicians or oncologists was accurate or inaccurate (4,6–8,11,13) and that the proportion of patients with accurate prognostic prediction significantly varied at a rate of 23–78% (7). Amano et al. have already revealed that palliative care physicians provide more accurate predictions than other physicians (14); however, our study is considered important because it revealed the difference in the accuracy and characteristics of the prognostic prediction of survival by oncologists and palliative care physicians in identical terminally ill cancer patients. Several important findings were obtained. First, the accuracy of the clinical prediction of survival with oncologists and prognostic tool-conducted prediction by palliative care physicians differed significantly. Moreover, the differences between the prognoses and actual survival time predicted by oncologists and palliative care physicians were 31.2 days and 15.6 days, respectively. Thus, palliative care physicians were more accurate in their prediction. A previous study has revealed a significant association between doctor–patient relationship and lower prognostic accuracy (4), and this may explain the result of the present study. In addition, it is believed that oncologists have a few opportunities to confirm the death of their terminally ill cancer patients because these patients are often transferred to hospice wards (2) or facilities that offer palliative care services due to the increasing death rates at home (including nursing homes), that is, from 15.0% in 2005 to 22.2% in 2016 in Japan (15), and this may also explain the result of our study. Other possible reasons include palliative care physicians usually use prognostic tools, such as PaP, PPI and palliative performance scale (16) that provide physicians with accurate information on the prognosis of patients with advance cancer, and they predict prognosis more closely to the time of death than oncologists. However, a previous study has also shown that predicting prognosis more closely to the time of death was not associated with higher prognostic accuracy (6). As to whether backgrounds of physicians, e.g. years of experience, might impact on the accuracy of physicians’ clinical predictions of survival, previous study has already reported that the greater the experience of the doctor, the greater the accuracy of the prognosis (4). Second, the characteristics of prediction differed between the clinical prediction of survival with oncologists and prognostic tool-conducted prediction by palliative care physicians. Approximately 21.8 and 37.6% of patients had an accurate prognostic prediction by oncologists and palliative care physicians, respectively, and this result indicates that palliative care physicians have a more accurate prognosis than oncologists. The proportion of patients with an optimistic prediction by both physicians was the highest, of which 67.3% were by oncologists and 50.5% were by palliative care physicians; these results are similar to those of previous studies (4,8,17). In addition, previous studies have revealed that physicians refer patients to hospices evaluate the prognosis of survival optimistically (8). Moreover, oncologists assess the condition of the patients more optimistically than palliative care specialists (18). Our result also indicates a significantly higher proportion of individuals with an optimistic prognosis by oncologists than by palliative care physicians. The proportion of patients with a pessimistic prognostic prediction by both physicians was the lowest, and no significant difference was observed between the pessimistic prognostic predictions by palliative care specialists and oncologists. This study suggests that oncologists had better refer to prognostic tools. Furthermore, for both physicians, the prognostic prediction of survival must be evaluated, and whether the prediction was accurate, pessimistic or optimistic must be confirmed to improve the accuracy of the prognostic prediction. However, the generalizability of the results is limited because oncologists and palliative care physicians did not predict the prognosis on the same day, and therefore we have to select the method of subtracting the number of days required from the confirmation date to admission to our hospice ward from the predicted prognosis. Moreover, this study was conducted in a single institution. Hence, further multicenter studies in which both physicians predict the prognosis on the same day with a large sample size must be conducted. Conclusion The results of the present study revealed that the prognostic value of the prognostic tool-conducted prediction by palliative care physician was more accurate than the clinical prediction of survival with oncologist; moreover, the predictions of oncologists were more optimistic in identical terminally ill cancer patients. Conflict of interest statement None declared. References 1 Glare P , Sinclair CT , Stone P , et al. . Predicting survival in patients with advanced disease. In: Cherny NI , Fallon MT , Kaasa S , Portenoy RK , Currow DC , editors . Oxford Textbook of Palliative Medicine . 5th ed . Oxford : Oxford University Press , 2015 ; 65 – 76 . 2 Specified Nonprofit Corporation, Hospice Palliative Care Japan [Internet] . Kanagawa: Annual transition of the number of institutions and beds for which palliative care ward admission fee have been notified; c2010 [cited 2017 Nov 15] (in Japanese). Available from: https://www.hpcj.org/what/pcu_sii.html 3 Lunney JR , Lynn J , Foley DJ , et al. . Patterns of functional decline at the end of life . JAMA 2003 ; 289 : 2387 – 92 . Google Scholar CrossRef Search ADS PubMed 4 Christakis NA , Lamont EB . Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study . BMJ 2000 ; 320 : 469 – 72 . Google Scholar CrossRef Search ADS PubMed 5 Thomas MG , Evelyne AG , Ling H , et al. . Trajectories of disability in the last year of life . N Engl J Med 2010 ; 362 : 1173 – 80 . Google Scholar CrossRef Search ADS PubMed 6 Gripp S , Moeller S , Bölke E , et al. . Survival prediction in terminally ill cancer patients by clinical estimates, laboratory tests, and self-rated anxiety and depression . J Clin Oncol 2007 ; 25 : 3313 – 20 . Google Scholar CrossRef Search ADS PubMed 7 White N , Reid F , Harris A , et al. . A systematic review of predictions of survival in palliative care: how accurate are clinicians and who are the experts? PLoS One 2016 ; 11 : e0161407 doi:10.1371/journal.pone.0161407 . Google Scholar CrossRef Search ADS PubMed 8 Glare P , Virik K , Jones M , et al. . A systematic review of physicians’ survival predictions in terminally ill cancer patients . BMJ 2003 ; 327 : 195 – 8 . Google Scholar CrossRef Search ADS PubMed 9 Maltoni M , Nanni O , Pirovano M , et al. . Successful validation of the palliative prognostic score in terminally ill cancer patients. Italian Multicenter Study Group on Palliative Care . J Pain Symptom Manage 1999 ; 17 : 240 – 7 . Google Scholar CrossRef Search ADS PubMed 10 Morita T , Tsunoda J , Inoue S , et al. . The palliative prognostic index: a scoring system for survival prediction of terminally ill cancer patients . Support Care Cancer 1999 ; 7 : 128 – 33 . Google Scholar CrossRef Search ADS PubMed 11 Kiely BE , Martin AJ , Tattersall MH , et al. . The median informs the message: accuracy of individualized scenarios for survival time based on oncologists’ estimates . J Clin Oncol 2013 ; 31 : 3565 – 71 . Google Scholar CrossRef Search ADS PubMed 12 Stockler MR , Tattersall MH , Boyer MJ , et al. . Disarming the guarded prognosis: predicting survival in newly referred patients with incurable cancer . Br J Cancer 2006 ; 94 : 208 – 12 . Google Scholar CrossRef Search ADS PubMed 13 Taniyama TK , Hashimoto K , Katsumata N , et al. . Can oncologists predict survival for patients with progressive disease after standard chemotherapies? Curr Oncol 2014 ; 21 : 84 – 90 . Google Scholar CrossRef Search ADS PubMed 14 Amano K , Maeda I , Shimoyama S , et al. . The accuracy of physicians’ clinical predictions of survival in patients with advanced cancer . J Pain Symptom Manage 2015 ; 50 : 139 – 46 . Google Scholar CrossRef Search ADS PubMed 15 Portal Site of Official Statistics of Japan (e-Stat) [Internet] . Tokyo: National Statistics Center; c2009. Vital Statistics; [cited 2017 Sep 15] (in Japanese). Available from: https://www.e-stat.go.jp/stat-search/files?page=1&layout=datalist&toukei=00450011&tstat=000001028897&cycle=7&year=20160&month=0&tclass1=000001053058&tclass2=000001053061&tclass3=000001053065&result_back=1&second2=1 16 Anderson F , Downing GM , Hill J , et al. . Palliative Performance Scale (PPS): a new tool . J Palliat Care 1996 ; 12 : 5 – 11 . Google Scholar PubMed 17 Cheon S , Agarwal A , Popovic M , et al. . The accuracy of clinicians’ predictions of survival in advanced cancer: a review . Ann Palliat Med 2016 ; 5 : 22 – 9 . Google Scholar PubMed 18 Kim YJ , Hui D , Zhang Y , et al. . Differences in performance status assessment among palliative care specialists, nurses, and medical oncologists . J Pain Symptom Manage 2015 ; 49 : 1050 – 8 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Japanese Journal of Clinical OncologyOxford University Press

Published: May 30, 2018

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