Applied Evidence

Primary care for the declining cancer survivor

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Asking yourself 1 question can help you to estimate an advanced cancer patient’s prognosis and determine how best to help in setting end-of-life priorities.


› Implement palliative/ supportive care shortly after the diagnosis of an incurable cancer. A

› Candidly communicate prognoses to patients and help them adjust their goals of care. B

› Recommend hospice care for patients who likely have less than 6 months to live, especially with treatmentrelated complications or significant caregiver stress. B

› Delay opioid therapy— if possible—to better control symptoms near the end of life. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



As a family physician (FP), you are well positioned to optimize the quality of life of advanced cancer patients as they decline and approach death. You can help them understand their evolving prognosis so that treatment goals can be adjusted, and you can ensure that hospice is implemented early to improve the end-of-life experience. This practical review will help you to provide the best care possible for these patients.

Family physicians can fill a care gap

The term cancer survivor describes a patient who has completed initial cancer treatment. Within this population, many have declining health and ultimately succumb to their disease. There were 16.9 million cancer survivors in the United States as of January 1, 2019,1 with 53% likely to experience significant symptoms and disability.2 More than 600,000 American cancer survivors will die in 2019.3

In 2011, the Commission on Cancer mandated available outpatient palliative care services at certified cancer centers.4 Unfortunately, current palliative care resources fall far short of expected needs. A 2010 estimate of required hospice and palliative care physicians demonstrated a staffing gap of more than 50% among those providing outpatient services.5 The shortage continues,6 and many cancer patients will look to their FP for supportive care.

FPs, in addition to easing symptoms and adverse effects of medication, can educate patients and families about their disease and prognosis. By providing longitudinal care, FPs can identify critical health declines that oncologists, patients, and families often overlook. FPs can also readily appreciate decline, guide patients toward their care goals, and facilitate comfort care—including at the end of life.

Early outpatient palliative care improves quality of life and patient satisfaction. It also may improve survival time and ward off depression.7,8 Some patients and providers resist palliative care due to a misconception that it requires abandoning treatment.9 Actually, palliative care can be given in concert with all active treatments. Many experts recommend a name change from “palliative care” to “supportive care” to dispel this misconception.10

Estimate prognosis using the “surprise question”

Several algorithms are available—using between 2 and 13 patient parameters—to estimate advanced cancer survival. Most of these algorithms are designed to identify the last months or weeks of life, but their utility to predict death within these periods is limited.11

The “surprise question” may be the most valuable prognostic test for primary care. In this test, the physician asks him- or herself: Would I be surprised if this patient died in 1 year? Researchers found that when primary care physicians answered No, their patient was 4 times more likely to die within the year than when they answered Yes.12 This test has a positive predictive value of 20% and a negative predictive value of 95%, making it valuable in distinguishing patients with longer life expectancy.12 Although it overidentifies at-risk ­patients, the "surprise question" is a simple and sensitive tool for defining prognosis.

Continue to: Priorities for patients likely to live more than a year


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