Prognostication in brain tumors

Despite the use of aggressive multimodality therapies, the prognosis of brain tumor patients remains poor. Tumors of glial origin typically have the worst prognosis, with a predicted median survival of 12-15months for glioblastoma multiforme (WHO grade IV) and 2-5years for anaplastic glioma (WHO grade III). Palliative care problems and needs in patients with primary and secondary brain tumors are significantly different, both due to different trajectory of disease and to variable prognosis which in metastatic brain tumors is related to the natural history of primary tumors. This chapter describes the complex interactions influencing communication and the treatment decision process in primary brain tumor patients. The whole trajectory of disease and particularly the end-of-life (EOL) phase of brain tumor (BT) patients are quite different in respect to the expected trajectory observed in the general cancer population. The need to improve the communication of prognosis in BT patients has been clearly reported in neuro-oncological literature, but several issues may hinder a good communication in these patients. Adequate prognostic awareness (PA) is important for several reasons: to respect patient autonomy, to obtain her/his preferences about treatments and goal of care, and to share EOL treatment decisions. The high incidence of cognitive deficits in BT patients is one of the most challenging issues influencing the quality of communication and the participation of patients in the process of treatment decisions. Impaired neurocognitive functions may impact capacities of understanding, appreciation, reasoning, and expression of choice, reducing Medical Decisions Capacity (MDC). The lack of capacity to express preferences about EOL treatment decisions represents an important ethical issue, with a great impact on both the patient's family and healthcare professionals involved in the decision processes. Also, patients' coping styles may have an important influence in critical aspects of care such as communication of diagnosis and prognosis, discussion with patients and their caregivers about goal of treatments, early introduction of PC, and advanced planning of patients' preferences concerning EOL treatment and issues. Several barriers hinder good communication in BT patients. This chapter analyzes emerging literature data and possible strategies to improve communication about prognosis and goals of care and to promote patients' involvement in the treatment decision process particularly in the palliative care setting.