Prevalence of prognostic uncertainty and impact on prognostic discussions in thoracic oncology.

Abstract

33 Background: Recent advances for late-stage lung cancer may have led to a shift from therapeutic ‘nihilism’ to ‘optimism’ (Temel, JCO 2016). It is not known whether this shift has increased prognostic uncertainty nor whether oncologists’ tolerance of uncertainty affects their prognostic discussion practices. Methods: In October 2018, we sent a 34-item survey by FedEx to a random sample of thoracic oncologists (n=444) listed in the publicly-available ASCO directory. The survey assessed professional training, perceptions of prognostic uncertainty for advanced lung cancer, prognostic discussion practices, uncertainty tolerance using an adapted Physicians’ Reactions to Uncertainty (PRU) scale (Gerrity , Motivation and Emotion 1995), and presented a clinical vignette. Results: We received 178 completed surveys from thoracic oncologists in 36 states (response rate: 40.4%). Median duration of practice was 29 years, and 56.7% endorsed an academic affiliation. 52.3% agreed that “there is more prognostic uncertainty in the management of lung cancer now than there was 10 years ago,” and 36.4% noted difficulty “staying up-to-date on the most recent science” in lung cancer management. Surprisingly, only 78.4% reported discussing prognosis with the vast majority (>95%) of their patients. In univariable logistic regression analyses, respondents had lower odds of reporting discussing prognosis with >95% of their patients if they scored highly on the PRU ‘anxious due to uncertainty’ subscale (OR=0.39 [0.18,0.83]), the PRU’s ‘reluctant to disclose uncertainty’ subscale (OR=0.43 [0.20,0.93]) or were male (OR=0.28 [0.08,0.97). Those with higher reluctant to disclose uncertainty scores were also less likely to agree that they would discuss life expectancy when first meeting a patient with stage IV NSCLC presented in the vignette (p=0.014). Conclusions: Data from this geographically diverse cohort of lung cancer oncologists suggest there is increasing prognostic uncertainty within thoracic oncology, and that many find it challenging to stay current with practice changes. Moreover, oncologists’ personal characteristics including gender and uncertainty tolerance may affect their propensity to discuss prognosis.