When to start planning for end-of-life care and death from prostate cancer

Alas, as most of our readers are all too well aware, some 30,000 or more men in America will die from prostate cancer this year and next year and on into the future, unless and until we find some radically new types of treatment. However, the speed at which a particular patient

  • Becomes metastatic or otherwise exhibits the need for androgen deprivation therapy (ADT, also known as “hormone therapy”)
  • Has progressive disease while on ADT, and becomes castration-resistant
  • Shows clear indication of further progression and organ failure leading to an actual death from prostate cancer

can be extremely variable and can happen over a period of as little as 18 months or as long as 30+ years, depending on the precise nature of the cancer in an individual patient and how well his care is managed.

This can make it extremely difficult for a patient, his family, and his doctor(s) to know when it might be appropriate to open a discussion about issues affecting end-of-life care, the value of hospice and palliative care, and other related issues. But knowing when to start to have those conversations can be very important.

Results of a recent study, to be presented by Vick et al. tomorrow at the ASCO Palliative Care in Oncology Symposium, have indicated that the answer to a single, very simple question, asked of a patient’s clinical care-giver (usually his doctor), may actually be very helpful in thinking about when a man and his family need to start to consider these issues.

Here is the question, which the study’s authors have termed “the Surprise Question”:

Would you be surprised if this patient died within the next year?

Vick and her colleagues collected data on > 4,600 patients with cancer and — between July 2012 and October 2014 — they used these data to carry out a randomized, controlled study of the impact of a structured intervention on improvement of conversations about cancer patients end-of-life goals. (We should immediately point out that the study encompassed all sorts of cancer patients, not just prostate cancer patients.) As a part of this study, the Surprise Question was asked about each patient seen by each enrolled clinician, and here is what Vick et al. have shown:

  • A total of 81 oncology clinicians were enrolled in the study.
    • They all worked at the Dana-Farber Cancer Institute in Boston.
    • 59 were oncologists
    • 18 were oncology nurse practitioners
    • 4 were physician assistants
  • In giving answers to the Surprise Question for the 4,617 patients on whom appropriately complete data were available
    • 3,821 answers or 83 percent were “Yes” (i.e., the clinician expected the patient to live for at least another year)
    • 796 answers or 17 percent were “No” (i.e., the clinician did not really expect the patient to live for another year)

When Vick and her colleagues then looked at what happened to the actual patients they found that

  • For the 3,821 patients expected to live for another year, 93 percent did in fact live for another year.
  • For the 796 patients who were not really expected to live for another year, only 53 percent did in fact live for another year.
  • The Surprise Question was a better predictor of patient death than type of cancer, age, cancer stage, or time since diagnosis.
  • The specificity of the “No” response was actually 59 percent. (In other words, the answer “No” was correct about 60 percent of the time.)

Now clearly the Surprise Question was far from perfect in predicting risk of death within 12 months, but it is definitely interesting that the answer to this question was better than any of the clinical parameters available. And, as noted in a discussion of this presentation on The ASCO Post web site today, the Surprise Question is one that clinicians tend to ask themselves about individual patients on a regular basis.

The question that patients often want the answer to, of course, is “How long do you expect me to live?” with their prostate cancer (or other type of cancer). That is usually a much, much harder question to answer, and there are a lot of data to suggest that clinicians are actually no better at answering that question than the rest of us. But for men with castration-resistant prostate cancer, the Surprise Question may well be a relatively good question to think about asking their doctors (if the patient wants to).

Here in the USA, today (and in most other countries with high-quality medical systems), until one has castration-resistant disease it is highly unlikely that prostate cancer is going to cause one’s death within 12 months (although other things might). And often a patient will actually have a pretty accurate idea in his own mind about the probability that he will survive for at least another year. But once he starts to feel less certain about that, his doctor’s answer to the Surprise Question may help a patient and his family to start to think hard about what they really need to do and plan for over the next 12 months — even if it does extend to more like 2 years (or perhaps even longer). It may also help the patient’s doctor to start to talk with the patient and his family about planning for that eventuality.

7 Responses

  1. When I learn from a caregiver that their loved one has been moved to hospice care because his advanced cancer treatment has pretty much ran its course and the patient’s health is rapidly declining, I first ask if they would be interested in information regarding end-of-life considerations. If so, I provide this paper.

  2. Dear Chuck:

    I would respectfully suggest that initiation of discussions about end-of-life care after a patient has already been moved to hospice care is almost certainly leaving many of the relevant discussions rather late.

  3. Mike

    Thanks for posting this article. It does hit close to home for me. The uncertainty that surrounds a patient like me with late stage disease can cause a fair amount of consternation. I know that in my case I am struggling to understand my situation. I also struggle with when it will be appropriate for me to stop treatments. Personally, the staying alive another year question needs to be tempered with quality of life considerations.

    In my opinion, any patient with mCRPC should put in place plans that include a health care proxy, living will, and related power of attorney. It is not fair to leave those decisions to be made by relatives at a time when emotional stress will already be elevated. Hope for the best but plan for the worst.


  4. But still soon enough for the loved one(s) to be aware of many important considerations/answers that could still be supplied by the patient.

  5. Thanks for “chiming in” Bill. That is exactly the point that I was trying to suggest that this study was offering … that it would help patients and families to really understand when they needed to be ensuring that appropriate plans needed to be put in place. As I suggested to Chuck Maack in my earlier post, leaving these things until a patient is already in hospice care is not really an optimal strategy. The patient himself may, by then, be losing the capacity to ensure this his wishes are being taken into appropriate account.

  6. Dear Chuck:

    Respectfully, by the time many patients actually enter hospice care, they may already be receiving such high doses of pain medication that they are not, in fact, able to contribute well to many of the questions on which they might well have had strong opinions 6 months or more earlier. I am in complete agreement with Bill Manning about this: most men with mCRPC should be putting well thought out plans in place earlier rather than later. Such plans can always be modified later, but better to get them in place in case of the unexpected.

  7. I don’t think it matters if you have prostate cancer or not. All of us should have a living will and other things in place for when we eventually die … and yes, we all eventually will. … Don’t need a double-blinded clinical trial to know that fact.

    Life is short even if you’re able to get into your 80s, 90s and beyond. Live (and have your plans in place) like there is no tomorrow.

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