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Jane C. Weeks, MD; E. Francis Cook, ScD; Steven J. O'Day, MD; Lynn M. Peterson, MD; Neil Wenger, MD; Douglas Reding, MD; Frank E. Harrell, PhD; Peter Kussin, MD; Neil V. Dawson, MD; Alfred F. Connors, Jr, MD; Joanne Lynn, MD; Russell S. Phillips, MD

JAMA. 1998;279:1709-1714.

Context.— Previous studies have documented that cancer patients tend to overestimate the probability of long-term survival. If patient preferences about the trade-offs between the risks and benefits associated with alternative treatment strategies are based on inaccurate perceptions of prognosis, then treatment choices may not reflect each patient's true values.

Objective.— To test the hypothesis that among terminally ill cancer patients an accurate understanding of prognosis is associated with a preference for therapy that focuses on comfort over attempts at life extension.

Design.— Prospective cohort study.

Setting.— Five teaching hospitals in the United States.

Patients.— A total of 917 adults hospitalized with stage III or IV non–small cell lung cancer or colon cancer metastatic to liver in phases 1 and 2 of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

Main Outcome Measures.— Proportion of patients favoring life-extending therapy over therapy focusing on relief of pain and discomfort, patient and physician estimates of the probability of 6-month survival, and actual 6-month survival.

Results.— Patients who thought they were going to live for at least 6 months were more likely (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.8-3.7) to favor life-extending therapy over comfort care compared with patients who thought there was at least a 10% chance that they would not live 6 months. This OR was highest (8.5; 95% CI, 3.0-24.0) among patients who estimated their 6-month survival probability at greater than 90% but whose physicians estimated it at 10% or less. Patients overestimated their chances of surviving 6 months, while physicians estimated prognosis quite accurately. Patients who preferred life-extending therapy were more likely to undergo aggressive treatment, but controlling for known prognostic factors, their 6-month survival was no better.

Conclusions.— Patients with metastatic colon and lung cancer overestimate their survival probabilities and these estimates may influence their preferences about medical therapies.

From the Department of Adult Oncology, Dana-Farber Cancer Institute, Boston, Mass (Drs Weeks and O'Day); Section of Clinical Epidemiology, Division of General Medicine (Dr Cook), and Department of Surgery (Dr Peterson), Brigham and Women's Hospital, Boston, Mass; Department of Medicine, University of California, Los Angeles Medical Center (Dr Wenger); the Marshfield Medical Research Foundation/Marshfield Clinic, Marshfield, Wis (Dr Reding); Division of Biostatistics and Epidemiology, Department of Health Evaulation Sciences, University of Virginia School of Medicine, Charlottesville (Dr Harrell); Department of Medicine, Duke University Medical Center, Durham, NC (Dr Kussin); Department of Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio (Drs Dawson and Connors); and Center to Improve Care of the Dying, George Washington University, Washington, DC (Dr Lynn); Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Hospital, Boston, Mass (Dr Phillips).

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