UPDATED: May 17, 2025
Welcome to the Healthy Living Is Good Medicine Newsletter, a totally free, health education publication covering a wide variety of topics, with original articles intended to help people lead healthier and more fulfilling lives.
Let me begin by honoring all the well-meaning physicians engaged in the practice of oncology. Nobody in their right mind would want to become an oncology patient, and the dedicated professionals who work in that field have an especially stressful job.
Oncologists are often the bearers of very bad news, and a much higher percentage of their patients will be lost to death, compared to other specialties. The resulting emotional toll upon those working on the front lines of patient care in oncology can be huge.
When death wins, despite a doctor’s best efforts to prolong their patient’s life while relieving their suffering, it can be hard not to take it personally. We can experience a nagging sense of failure, even while knowing it is unwarranted. Viewed from an emotionally detached and strictly rational perspective, life itself is a terminal condition for all of us. But, human aren’t Vulcans, and our losses hurt.
Philosophically understanding the inevitability of death didn’t insulate me from the heart-wrenching anguish of delivering a stillborn infant on my very first day as a PGY-1 resident. As social primates, the ripple effects of a single human death, with its accompanying pain of loss and the grief that follows, deeply touch many of us in the health professions, much more so than most lay people realize.
How a grim medical prognosis is delivered and received can affect the course of a terminal illness. To illustrate that, I will present for your consideration fictional examples of two different oncologists informing the same patient about their prognosis. The two scenarios are for educational purposes only, and any similarities to actual patients, living or dead, are purely coincidental.
Case Background
Mr. X, a heavy smoker for his entire adult life, was diagnosed with inoperable lung cancer at the age of 67. Based upon the mortality statistics for patients in his age group, the type of cancer he has, and its current stage of progression, the predicted life expectancy following his diagnosis is 2-5 years, with standard chemotherapy.
Scenario 1
Mr. X was seen by a pessimistic (“glass half empty”) oncologist, who told him to get his affairs in order, because, given his current state of health and lifestyle, he likely would have no more than two years to live, even with the recommended chemotherapy.
Scenario 2
Mr. X was seen by an optimistic (“glass half full”) oncologist, who told him it was possible that he could live five more years with standard chemotherapy, and that there were also some exciting new treatment protocols in clinical trials that were currently accepting patients.
What You Probably Want to Know
Which oncologist had the more accurate prognosis?
And the correct answer is (drum-roll, please):
Neither!
Scenario 1, Post-Mortem
Mr. X, told that he might only have a couple of years to live even with the best available treatment, decided to do everything in his power to beat the odds. He quit smoking, stopped drinking, went on a plant-based diet, took up meditation, changed his attitudes, and reduced the amount of stress in his life. He lived for another six and a half years. During most of that time he felt his life was of a high quality. Passing peacefully at home, his last words were, “Damn doctor... two years? He didn't know what the hell he was talking about.”
Scenario 2, Post-Mortem
Mr. X did not qualify for any clinical trials and received the standard chemotherapy. He prayed for a miracle, but his cancer continued to advance. He became sullen and angry, continued smoking, drank more, binged on junk food, and argued incessantly with his spouse and children over his unhealthy lifestyle. In a little over a year, after spending the last six months of his life in and out of the hospital, his last words were, “Damn doctor... five years? She didn't know what the hell she was talking about.”
Analysis
A life-expectancy prognosis is a statistic that applies to a population of similar patients, with the time-distributed number of people plotted as a “normal” or bell-shaped curve (called a univariate probability distribution). Using that simplified statistical model, most of a studied population can be expected to neatly fall within a range that's centered around an average number of years (aka an arithmetic “mean”). In reality, things are never that simple or clear-cut, but most patients seem to want a straightforward answer to their question: “How long do I have?”
In our simplistic, hypothetical case, the mean life expectancy for similar patients is 3.5 years, with a standard deviation of plus or minus 1.5 years. That translates to about 68 percent of this particular patient population dying somewhere within a range of 2 to 5 years. However, there will always be outliers in both directions, with around 16 percent of the population living longer than 5 years, and another 16 percent living less than 2 years. Around 95 percent of the affected population can be expected to fall within two standard deviations of the mean, a range of 0.5 to 6.5 years. The remaining 5 percent could fall outside even that broad a range.
The Moral of This Story
Better communication skills can be taught as part of medical education. A clinical trial found that the quality of conversations between oncology clinicians and patients with advanced cancer could be improved through interventions that provide both clinician training and system changes.
Doctors don't have crystal balls that enable them to predict how individual patients will do, until the time of their departure draws near. Here are some great insights from Dr. Stacy Wentworth, and oncologist:
Some patients who are given a poor prognosis will passively await what they believe to be their inevitable fate. Others will decide to live as meaningfully and joyously as they can in the time that remains. Some patients will do whatever they can to improve their odds, and embark upon a healthier lifestyle that may or may not pay off, but at least they won’t be feeling as helpless when facing a poor prognosis. Other patients will carry on with their habitual patterns and leave it entirely up to their doctors to save them. Some patients might simply give up, and behave as if they already have one foot in their grave.
Let’s face it: We’re all going to die, so we might as well think about making the universal end-of-life experience as comfortable as possible. An advance healthcare directive is a necessity, along with other legal documents such as a will, possibly a living trust, financial and healthcare powers of attorney, and beneficiary designations.
A 2024 study examined the symptom burdens experienced at the end-stage of life. Adequately addressing these symptoms is crucial in improving the quality of care for terminally-ill patients. Individualized support through hospice and palliative care should be implemented early on.
There are likely a multitude of factors that can potentially influence how quickly a terminal illness will progress, and very few of these factors have been identified and quantified. Consequently, much research in this area remains to be done. What seems to be true is that, regardless of their prognosis, patients often experience a unique form of pleasure when they can prove that their doctor’s prognosis was wrong.
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