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Survival estimates in advanced terminal cancer

Sei Lee, MD
Alexander Smith, MD
Section Editor
R Sean Morrison, MD
Deputy Editor
Diane MF Savarese, MD


Survival estimates are critical factors in clinician and patient decision making in all phases of a serious and/or life-threatening illness. However, prognostic estimates in patients with advanced terminal cancer may have increased importance as they approach the end of life, since this is a natural time to formally reevaluate the goals of treatment, with palliative care becoming more prominent, and disease-directed therapy less so.

However, despite its importance, prognostication in advanced terminal cancer is imperfect. Clinicians are typically optimistic in their estimates of patient survival, and the prognostic estimates they communicate to patients may be even more optimistic. As an example, in a national study of 1193 patients with terminal stage IV lung or colorectal cancer receiving chemotherapy, 69 percent of those with lung cancer and 81 percent of those with colorectal cancer inaccurately believed that chemotherapy was potentially curative [1]. Some of this misinformation may also be attributed to a lack of communication between oncologists and their patients about estimated life expectancy. (See 'Accuracy of survival estimates' below and 'Communication of survival estimates' below.)

In an effort to improve these estimates, investigators are integrating previously established prognostic factors into easy-to-use models that clinicians can use in the clinical care of their patients with advanced terminal cancer. The goal of improved prognostication is to provide patients with a better understanding of their expected survival, thereby allowing them to make informed medical and social choices regarding their treatment path at the end of life, whether disease-directed, palliative, or a combination of both [2,3].

Here we discuss general aspects of estimating survival in patients with advanced terminal cancer. Prognostic estimates and the factors that influence outcome in specific cancers are discussed in separate topic reviews that cover individual tumors.


Survival estimates that clinicians make, guided only by their intuition and clinical experience, are usually incorrect, and the direction of the error is almost always optimistic [4-12]. That is, clinicians tend to believe that their patients have longer to live than they actually do. The disparity in actual versus estimated survival varies in different studies (table 1) [4-8,13-19]. In an illustrative study, 343 physicians referring 468 patients to one of five Chicago-area hospices were asked to provide an estimate of their patient’s prognosis (“What is your best estimate of how long this patient has to live?”), and they compared these prognostic estimates with actual survival [7]. The median observed patient survival was 24 days, but the mean ratio of predicted to observed survival was 5.3.

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Literature review current through: Sep 2017. | This topic last updated: Mar 06, 2017.
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