"Doc, how much longer you think I've got?"

One of the things I've been most struck by since I graduated fellowship has been the need for patients to hear their prognosis. Some beat around the bush, asking vague questions like, "So, doc, how'm I doing?" Some come out and say, "Level with me, doc, how much longer have I got to live?" It's a constant, even among people who have remarkably different life philosophies.
What's even more amazing is how poorly I can answer that question. I usually start by saying "I don't know, only God knows that." I really believe that. People usually think I'm hiding the truth from them when I say that, and it can undermine trust.
What amazes me is how poorly prepared people are when they start to confront their mortality.
I think I understand where this question comes from. It comes from a limited vocabulary for discussing mortality. People don't generally sit around thinking about the grim reaper, so when faced with a mortal challenge, they fall back on that constant language, TV and movies. They've seen these medical dramas, and recall fictional conversations between benevolent sandy-maned physicians and their helpless patients who die in the next reel.
Here's a thought I had today: if I tell you you'll be dead in six months, I'll be really embarrassed when you return on the seventh month. How does one recover from a wrong prediction of prognosis? We all have heard the old warhorse, "Dr. Blackcloud told me I only had two weeks to live, and that was eight years ago!"
So what are people really asking when they are asking "How much longer, doc?" I take encouragement from the article in the oncology newsletter that addressed the problem of patients saying they want to die. They concluded that these patients are really trying to bring up the subject of their own mortality and symptoms, and that's just the language some people use to do it. Parenthetically speaking, it's hard to operationalize that knowledge into effective communication.
Maybe it's just a manifestation of fear. People would think you were weird if you answered the question with, "Don't be afraid; I'm here to help!"
Maybe they want to hear some encouragement. It's hard to give hope without giving false hope. False hope creates unrealistic expectations, and can interfere with good decisionmaking. Statistically, the survival distribution has a definitive mean, but also has a very long tail. Someone could quantify that by comparing the mean to the median survival from time of diagnosis for different cancers--a long tail means a skewed mean vs. median. I try not to get too bogged down in statistics with patients--some patients don't handle that all that well.

Post WHI thoughts

1. Prempro is probably bad, shouldn't be used, probably the progestin contributes to breast cancer risk.

2. Premarin has not been shown to increase the risk of breast cancer, may be protective.

3. HRT probably causes strokes, venous thrombosis, and heart attacks.

4. HRT definitely contributes to breast density, which makes mammograms harder to interpret. The odds of a false negative (missing a breast cancer that's there) is 1.6. But as this abstract from 1998 points out, this may not be leading to increased breast cancer disease burden or death.

The problem is, folks, mammography ain't the greatest tool in the world for reducing the burden of breast cancer upon humanity. It's hard to prove a link between mammography and reduced death from breast cancer.

A large cohort to see if HRT affects mammography accuracy

1: Radiology. 1998 Nov;209(2):511-8. Related Articles,Links

Effects of age, breast density, ethnicity, and estrogen replacement therapy on screening mammographic sensitivity and cancer stage at diagnosis: review of 183,134 screening mammograms in Albuquerque, New Mexico.

Rosenberg RD, Hunt WC, Williamson MR, Gilliland FD, Wiest PW, Kelsey CA, Key CR, Linver MN.

New Mexico Tumor Registry, Albuquerque, USA.

PURPOSE: To examine how common patient factors affect screening mammographic sensitivity and cancer stage at diagnosis. MATERIALS AND METHODS: The authors used a population-based database of 183,134 screening mammograms and a statewide tumor registry to identify 807 breast cancers detected at screening mammography. RESULTS: Sensitivity varied significantly with ethnicity, use of estrogen replacement therapy, mammographic breast density, and age. Sensitivity was 54% (13 of 24) in women younger than 40 years, 77% (121 of 157) in women aged 40-49 years, 78% (224 of 286) in women aged 50-64 years, and 81% (277 of 340) in women older than 64 years. Sensitivity was 68% (162 of 237) for dense breasts and 85% (302 of 356) for nondense breasts and 74% (180 of 244) in estrogen replacement therapy users and 81% (417 of 513) in nonusers. Sensitivity was most markedly reduced with the combination of dense breasts and estrogen replacement therapy use; there was little difference when only one factor was present. Median cancer size and the percentage of early cancers showed little change with any factors. CONCLUSION: Age is a minor determinant of mammographic sensitivity in women aged 40 years or older. Sensitivity is substantially decreased with the combination of higher breast density and estrogen replacement therapy use. There was not a notable shift in cancer outcomes in the groups with lower mammographic sensitivity. These data do not support different screening recommendations in women aged 40-49 years or in estrogen replacement therapy users.

Diet and cancer

Has anyone come across serious science about what people should eat when they have cancer? So far, I've seen a lot of infomercials and ads in the back of magazines, but not a lot of positive results.

Patients ask me all the time what they should be eating, and besides the stock response, "any food's better than no food," I don't have too much to offer.