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. 2022 Feb 1;5(2):e220018.
doi: 10.1001/jamanetworkopen.2022.0018.

Association of Prognostic Understanding With Health Care Use Among Older Adults With Advanced Cancer: A Secondary Analysis of a Cluster Randomized Clinical Trial

Kah Poh Loh  1 , Christopher L Seplaki  2 , Chandrika Sanapala  1 , Reza Yousefi-Nooraie  2 , Jennifer L Lund  3   4 , Ronald M Epstein  5   6 , Paul R Duberstein  7 , Marie Flannery  8 , Eva Culakova  9 , Huiwen Xu  10 , Colin McHugh  1 , Heidi D Klepin  11 , Po-Ju Lin  9 , Erin Watson  12 , Valerie Aarne Grossman  13 , Jane Jijun Liu  14 , Jodi Geer  15 , Mark A O'Rourke  16 , Karen Mustian  9 , Supriya G Mohile  17
Affiliations

Association of Prognostic Understanding With Health Care Use Among Older Adults With Advanced Cancer: A Secondary Analysis of a Cluster Randomized Clinical Trial

Kah Poh Loh et al. JAMA Netw Open. .

Abstract

Importance: A poor prognostic understanding regarding curability is associated with lower odds of hospice use among patients with cancer. However, the association between poor prognostic understanding or prognostic discordance and health care use among older adults with advanced incurable cancers is not well characterized.

Objective: To evaluate the association of poor prognostic understanding and patient-oncologist prognostic discordance with hospitalization and hospice use among older adults with advanced cancers.

Design, setting, and participants: This was a post hoc secondary analysis of a cluster randomized clinical trial that recruited patients from October 29, 2014, to April 28, 2017. Data were collected from community oncology practices affiliated with the University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program. The parent trial enrolled 541 patients who were aged 70 years or older and were receiving or considering any line of cancer treatment for incurable solid tumors or lymphomas; the patients' oncologists and caregivers (if available) were also enrolled. Patients were followed up for at least 1 year. Data were analyzed from January 3 to 16, 2021.

Main outcomes and measures: At enrollment, patients and oncologists were asked about their beliefs regarding cancer curability (100%, >50%, 50%, <50%, and 0%; answers other than 0% reflected poor prognostic understanding) and life expectancy (≤6 months, 7-12 months, 1-2 years, 2-5 years, and >5 years; answers of >5 years reflected poor prognostic understanding). Any difference between oncologist and patient in response options was considered discordant. Outcomes were any hospitalization and hospice use at 6 months captured by the clinical research associates.

Results: Among the 541 patients, the mean (SD) age was 76.6 (5.2) years, 264 of 540 (49%) were female, and 486 of 540 (90%) were White. Poor prognostic understanding regarding curability was reported for 59% (206 of 348) of patients, and poor prognostic understanding regarding life expectancy estimates was reported for 41% (205 of 496) of patients. Approximately 60% (202 of 336) of patient-oncologist dyads were discordant regarding curability, and 72% (356 of 492) of patient-oncologist dyads were discordant regarding life expectancy estimates. Poor prognostic understanding regarding life expectancy estimates was associated with lower odds of hospice use (adjusted odds ratio, 0.30; 95% CI, 0.16-0.59). Discordance regarding life expectancy estimates was associated with greater odds of hospitalization (adjusted odds ratio, 1.64; 95% CI, 1.01-2.66).

Conclusions and relevance: This study highlights different constructs of prognostic understanding and the need to better understand the association between prognostic understanding and health care use among older adult patients with advanced cancer.

Trial registration: ClinicalTrials.gov Identifier: NCT02107443.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Loh reported receiving a grant from the National Cancer Institute (NCI) during the conduct of the study and receiving consulting fees from Pfizer and Seattle Genetics and honoraria from Pfizer outside the submitted work. Dr Lund reported that her spouse was formerly employed by GlaxoSmithKline and owned stock in the company (which was sold in November 2021) outside the submitted work. Dr Epstein reported receiving grants from the NCI and American Cancer Society during the conduct of the study. Dr Flannery reported receiving a contract from the Patient-Centered Outcomes Research Institute (PCORI) and a grant from the NCI during the conduct of the study. Dr Culakova reported receiving a grant from the NCI and a contract from PCORI during the conduct of the study. Dr Mustian reported receiving a grant from the NCI and a contract from PCORI during the conduct of the study and receiving grants from the NCI outside the submitted work. Dr Mohile reported receiving a grant from the National Institute on Aging and the NCI and a contract from PCORI during the conduct of the study and receiving grants from Carevive outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Definitions of Poor Prognostic Understanding and Prognostic Discordance
Definitions of poor prognostic understanding and prognostic discordance regarding curability and life expectancy estimates, as well as prognostic discordance regarding curability and life expectancy estimates, are shown. For poor patient prognostic understanding regarding curability, note that patients with a response of uncertain were excluded. For prognostic discordance regarding curability, patients and oncologists with a response of uncertain were excluded.
Figure 2.
Figure 2.. Distribution of Prognostic Understanding Regarding Curability and Life Expectancy Estimates Reported by Patients and Oncologists
A, Patients and oncologists were asked about their beliefs about the curability of the cancer: “What do you believe are the chances the cancer will go away and never come back with treatment?” Any response other than 0% for curability was considered poor prognostic understanding regarding curability (59% [206 of 348]; responses of uncertain were excluded). B, Patients and oncologists were asked: “Considering your (the patient’s) health, and your (the patient’s) underlying medical conditions, what would you estimate your (the patient’s) overall life expectancy to be?” Response of life expectancy of more than 5 years was considered poor prognostic understanding regarding life expectancy estimates (41% [205 of 496]).
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