She then gingerly asked me: “How long do I have to live, Dr Val?” This has clearly been weighing heavily on her mind. Mrs A had decided that she was finally ready to hear the answer.
I took her hand and thanked her for asking. It must not have been easy to speak those words. Tears were shed. We discussed her reasons for asking and her fears. We also discussed her own expectations, how the answer to this question should rightly be used, and how we will fully support her no matter the trajectory.
Often, I find that our patients are more concerned for their loved ones than for themselves. And she is no exception.
“I want to be sure my family is ready and fully supported when I die,” she said.
The question of how long one has left is never easy to ask, let alone answer. Uncertainty hangs over it, and for many, the thought alone feels too heavy to face. Yet, amid this unknown, honest and open conversations provide the chance to draw loved ones closer during this time of difficulty. They are also necessary to provide the patient the best care possible.
Why the need for a prognosis?
Prognostication in cancer isn’t just about predicting survival – it is a foundational tool that informs nearly every aspect of care, from treatment planning to psychological support. Despite how it can be inaccurate, it helps ensure that patients receive care that aligns with both their clinical situation and personal values.
In simple terms, to prognosticate is to estimate the likely course and outcome of a patient. It is critically important for guiding treatment decisions, informed collective decision-making, psychological preparedness and even for end-of-life planning.
Prognostic information helps doctors to work with their patients to tailor treatment plans based on how aggressive or advanced the cancer is, and how specific treatments could change that trajectory.
Some patients with a better prognosis might avoid unnecessary toxic therapies with long-term side effects, while those with a poorer prognosis may benefit from more aggressive approaches. Others with an extremely poor prognosis may even choose to avoid treatments which are highly unlikely to bring meaningful benefit.
During my conversation with Mrs A, she asked what her final days would be like. “Will there be pain? Will it be sudden or slow?” I addressed each of these questions in turn.
Informed decision-making can collectively be done between the patient, their loved ones and their doctor. Best choices can be made about care, quality of life and goals, based on realistic and aligned expectations. Knowing the likely course of the disease also helps all involved in the patient’s care to be prepared mentally and emotionally.
Additionally, prognostication is often used to determine whether one is eligible for specific clinical trials. In healthcare systems with limited resources, prognostic data may even be used to prioritise interventions for those most likely to benefit.
Oncologists use a combination of clinical judgment, diagnostic tools and validated models to prognosticate. Many patients are also discussed in multidisciplinary tumour boards for input from surgeons, pathologists, radiologists and radiation specialists.
It’s not a countdown
Prognostication in cancer has improved significantly, but again, it is not perfectly accurate.
This is because every patient and every tumour is unique. There is biological variability between patient tumours even with the same histology, or even in different locations within the same patient – every cell within a tumour is also different.
In addition to the cancer itself, dynamic changes in a patient’s physiology, including their performance status and immune status, may not always follow a gradual trajectory and can even change suddenly. Prognostic tools and models are also limited.
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Even the best models are probabilistic, not deterministic – they give ranges or chances, not certainties. Lastly, new therapies (for example, immunotherapy) may also shift outcomes, sometimes for the better, in unpredictable ways.
It is important to recognise that prognostication in cancer is reasonably accurate at a population level (that is, predicting outcomes across groups), but less precise at the individual level. This therefore provides useful guidance but should always be used alongside clinical judgment and ongoing reassessment for change.
Prognosis should therefore be used as a guide, not a guarantee. It offers a range of possible outcomes and while it can help guide decisions, it does not define one’s future.
Navigating the uncertainty
A first step for patients and family members would be to ask for honest but balanced information. Ask your doctor to explain typical outcomes, best-case and worst-case scenarios and the factors that may shift your personal outlook.
Understand that prognosis can change. It’s something we reassess over time. Prognosis evolves with how one responds to treatment and even advances in therapy. Stay open to updates, especially in fast-moving fields like immunotherapy and targeted therapy.
Balance hope with planning. Hope and realism can live side by side. It is possible to hope for the best while preparing for all possibilities. Consider discussing advance care planning – not as a sign of giving up, but as a way of maintaining control (even with unexpected and sudden changes) and dignity.
Preparation can come in the way of wills, bank accounts, lasting power of attorneys (LPAs), advance care plans (ACPs), memories or legacies for loved ones. We may prepare for the worst but we hope for the best. There is no harm in preparing.
Focus on what you can control. No one can fully control the biology of cancer, but we can control: how we live our days, how we make our decisions, how we express our values and goals, and how we express our love and connect with our loved ones. Prognosis may be about numbers – our life is about meaning.
Seek support – medical, emotional, practical. Navigating uncertainty is extremely tough. We can use our care team, supportive and palliative care team (not just for end-of-life), support groups, and counselling to stay grounded. One does not have to carry this alone.
Having frank conversations with loved ones is encouraged. Often in our Asian society, some consider it “pantang” or bad luck to broach this topic. In reality, talking about it does not curse or doom anyone. Addressing the elephant in the room will instead facilitate open conversations and bring about a closeness with loved ones.
Prognosis is a tool, not a verdict. It serves to inform, not limit, one’s choices. The goal isn’t just to survive – it’s to live meaningfully, regardless of the timeline.
To Mrs A, I explained how my answer is a mere estimate, how these are seldom accurate and that these estimates can also change over time. It should not be taken as a hard truth and certainly should not lead to a “doomsday calendar countdown”.
We then spoke about what brings her meaning in life and what she would want for her young daughter and husband.
“I want my daughter to remember her mother for her strength, so that she may remember this when she faces her own storms. I want my husband to remarry, to find a good woman and live a full life that I cannot give. In the meantime, I want to live the rest of my days with them to the fullest.”
Dr Valerie Shiwen Yang is a senior medical oncologist at OncoCare Cancer Centre and visiting consultant at the National Cancer Centre. She is also an adjunct assistant professor at Duke-NUS Medical School.
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