**5. Prognostic communication techniques**

While developing and communicating prognosis is critical for patient care, evidence-based recommendations for these processes are limited. In 2005, a Working Group of the Research Network of the European Association for Palliative Care found that prognostication is feasible with the use of certain clinical tools [55]. The working group found the strongest evidence of prognostic correlation with the use of clinical prediction of survival in conjunction with performance status, symptoms associated with cancer anorexia-cachexia syndrome (weight loss, anorexia, dysphagia, and xerostomia), dyspnea, delirium, and some biologic factors (leukocytosis, lymphocytopenia, and C-reactive protein) [55]. More recently in an opinion statement, similar factors were identified as key to more accurate prognostication [56]. In addition to using validated prognostic tools to complement clinical judgement, the authors recommended seeking multi-professional prognostic estimates, formulating and recording prognosis estimates in order to better cultivate prognostic skill, and receiving training in advanced communication skills to better deliver prognostic conversations [56].

Every cancer is a complex clinical phenomenon, whose outcome is influenced by many variables: the age, underlying health, and motivation of the patient; their social support system; the availability of advanced treatments, clinicians' ability to choose and manage these treatments, patient's ability to access and afford these treatments and tolerate their side effects; and critically, the biology of the cancer itself. Even in

#### *Prognostic Communication in the Era of Targeted Therapy and Immunotherapy DOI: http://dx.doi.org/10.5772/intechopen.105144*

an age of molecular and genetic tumor profiling and validated prognostic models, an estimate of prognosis is an educated guess. Clinicians must make this guess in the most accurate and objective way possible, and then use communication techniques that effectively convey the information to the patient and caregivers, while being sensitive to their receptiveness and ability to process this information.

Surveys have consistently shown that majorities of patients prefer to receive accurate and honest prognostic information, [33, 57] including average and best-case survival outcomes [58]. However, this is not universal: there is considerable variation in how much prognostic information patients and caregivers wish to receive [13, 59]. This can change over the course of illness: as the disease becomes more advanced, the patient may want less detailed prognostic information, while caregivers may need more. Therefore, prognostic discussion calls for an individualized approach, which elicits permission from patients and caregivers to discuss prognosis, and uses explicit questions and implicit cues to determine how much prognostic information to impart [3, 60, 61]. Information needs and preferences should be reassessed any time there is a significant change in the condition, prognosis, or living circumstances of the patient.

An effective discussion of prognosis is not limited to a prediction of medical outcomes, but should integrate affective communication including expressions of support and empathy, demonstration of expertise, reassurance of non-abandonment, and reinforcement of a collaborative relationship [60, 62]. Assuming permission has been given to offer predictions regarding outcome, it is important to utilize the opportunity to openly and directly discuss prognosis [61]. Clinicians should be as transparent as possible about the basis for the estimate – multiple studies, a single clinical trial, or simply an estimate based on personal clinical experience – and about the associated uncertainties.

Presenting a range of possible outcomes is a useful technique to convey the scope of uncertainty, and is preferred by patients over more narrow predictions [63]. Effort should be taken to counteract the tendency of both clinicians and patients to focus on the most favorable potential outcome. One way to frame this is surprise: describing a relatively favorable outcome but stating that it would be surprising, implying that it should not be assumed. The surprising outcome can then be contrasted against other outcomes which are expected or feared. This is one form of the best case/worst case framework, which invites hope for a favorable outcome, while encouraging preparation for a more adverse one. This approach was first studied in the context of high-risk surgery, [64, 65] but it is broadly applicable in any situation where plausible outcome scenarios differ widely. In addition to best and worst, a third scenario for the typical or average case, but it is important to emphasize that this is not a prediction, and that the best and worst outcomes remain possible.

There is no one-size-fits-all approach to improving communication skills. For delivering prognostic information, collaboration with other cancer clinicians, oncology nurses, and palliative care specialists is encouraged [66]. REMAP (Reframe, Expect emotions, Map out patient goals, Align with goals, and Propose a plan) has been suggested as a framework for goals of care conversations [67].

Indeed viewing communication interactions from a procedural lens (procedures require specialized skills, have component steps, are intentional in purpose, and have pause points and a known set of complications) may improve quality of prognostic communication [68]. In discussing the use of prognostic tools in communicating prognosis, it is useful to quote from a paper by Lakin et al., entitled, Timeout Before Talking: Communication as a medical procedure: "Skilled communication requires nuance, adjustments, and careful thought, in complex interpersonal

interactions. Just as surgery is a technical intervention and a practiced art form, communication procedures require both thoughtful structure and flexible skill. When a communication task is deconstructed, it can be better applied, taught, legislated, and researched, ultimately allowing for iterative improvement of this foundational medical practice" [68].
