PROGNOSIS

Dr. dr. Juliandi Harahap, MA

PROGNOSIS
 Clinicians help patients by

Diagnosing what is wrong with them

Administering treatment that does more
good than harm
Giving them an indication of what the
future is likely to hold (prognosis)
QUESTION RELATED TO PROGNOSIS IN
THE PRACTICE OF MEDICINE:
What are the consequences of
having the disease?
 Is it dangerous ?
 Could I die of it ?
 How long will I be able to continue my
present activities ?
 Will it ever go away altogether ?

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PROGNOSIS
 Possible outcomes of a disease and
the frequency with which they can
be expected to occur.

Natural history: the evolution of

disease without medical intervention.

Clinical course: the evolution of disease
in response to medical intervention.
NATURAL HISTORY AND CLINICAL COURSES

Natural history of diseases

(no medical intervention)

Recovery
Biologic Clinical
Diagnosis Outcome Disability
onset Death
etc

Clinical courses
(medical intervention)
 RISK FACTORS AND PROGNOSTIC FACTORS

Risk factors

Recovery
Biologic Clinical Outcome Disability
onset Diagnosis Death
Etc

Demographic variables
Prognostic factors Disease specific variables
Comorbid factors

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 RISK FACTORS Vs PROGNOSTIC FACTORS

Risk factor: Prognostic factors:

The condition that can The conditions that, when

be identified in well present in persons
persons and, when already known to have
present, are associated disease, are associated
with an increased risk of with an outcome of the
acquiring disease disease

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 RISK Vs PROGNOSIS

Risk Prognosis

Low probability events Relatively frequent events

The event: Death,

The event: Onset of disease complications, disability,
suffering, etc.

Risk factors are not Prognostic factors are not

necessarily the same as necessarily the same as
prognostic factors for a risk factors for a given
given disease disease
 Onset
Onset of
of acute
acute
myocardial
myocardial Outcome:
Well infarction Death, reinfarction
infarction

RISK PROGNOSIS
1. Age >> 1. Age >>
2. Male 2. Male
3. LDL>/ HDL< 3. Anterior infarction
4. Cigarette 4. Hypotension
smoking 5. Congestive heart
5. Hypertension failure
6. Inactivity 6. Ventricular arrythmia

Differences between risk and prognostic factors for acute

myocardial infarction 9
THE STRATEGY FOR MAKING A PROGNOSIS

 Expert opinion
 consulting the appropriate specialist
 looking it up in a textbook

 Clinical experience

 Read-up
THE PROGNOSIS QUESTIONS
 A qualitative aspect:
 which outcomes could happen?
cure, death, survive, etc
 A quantitative aspect
 how likely are they to happen?
relative risk, hazard ratio, etc
 A temporal aspect
 over what time period?
5 years, 10 years, etc
RESEARCH DESAIN

Early Recovery
Biologic Clinical Outcome Disability
onset diagnosis Diagnosis
possible Death
Etc

Cohort study
Survival analysis
Case Control study
 COHORT STUDY

a) No inception cohort b) Inception cohort

5 cases identifed at different points in time 5 cases identifed at the same point in time

0 1 2 3 4 5 0 1 2 3 4 5
Years Years
Start cohort Pre-clinical phase Start cohort Pre-clinical phase
Clinical phase Clinical phase

Av. duration of survival= 14.5/5 = 2.9 yrs Av. duration of survival= 11/5 = 2.2 yrs
 COHORT STUDY
 Ideal follow-up period
 Until every patient recovers or has one of the
other outcomes of interest,
 Until the elapsed time of observation is of clinical
interest to clinicians or patients.

 Short follow up time  too few study

patients with outcome of interest  little
information of use to a patient.
DESCRIBING OUTCOMES OF DISEASE: 5DS

Should include the full range of manifestations

that would be considered important to patients
(5Ds):
Death

Disease
Disability
Discomfort

Dissatisfaction

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RATES COMMONLY USED TO DESCRIBE PROGNOSIS
Rate Definition*
5-year survival Percent of patients surviving 5 years from some
point in the course of their disease
Case fatality Percent of patients with a disease who die of it
Disease-specific Number of people per 10,000 (or 100,000)
mortality population dying of a specific disease
Response Percent of patients showing some evidence of
improvement following an intervention
Remission Percent of patients entering a phase in which
disease is no longer detectable
Recurrence Percent of patients who have return of disease
after a disease-free interval

*Time under observation is either stated or assumed to be sufficiently

long so that all events that will occur have been observed 16
 COMPONENTS OF RATES

 Zero time
 People at risk
 Definition of events
 Time to follow-up

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 ZERO TIME
 A point in time when cohorts are started to
be observed
 Should be specified clearly and be the same

 Inception cohort:
 A group of people who are assembled near the
onset of disease

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 SURVIVAL ANALYSIS
 Presents information about average time-to-
event for any time in the course of disease
 Censoring: patients are lost from the study at
any point in time
 drop out
 lost to follow-up
 have outcome
 Survival curves

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 SURVIVAL ANALYSIS
 % of outcome of interest at a particular
point in time (1 or 5 year survival rates),
 Median time to the outcome (e.g. the
length of follow-up by which 50% of
patients have died)
 Event curves (e.g. survival curves) that
illustrate, at each point in time, the
proportion of the original study sample
who have not yet had a specified
outcome.  Kaplan Meier curves.
 Overall survival is a term that denotes the
chances of staying alive for a group of
individuals suffering from a cancer. It denotes
the percentage of individuals in the group who
are likely to be alive after a particular duration
of time. At a basic level, the overall survival is
representative of cure rates.
 DFS = disease-free survival:
In cancer, the length of time after primary
treatment for a cancer ends that the patient
survives without any signs or symptoms of that
cancer. In a clinical trial, measuring the
disease-free survival is one way to see how
well a new treatment works. Also called
relapse-free survival (RFS).
Prognosis shown as
survival curves (dashed
line indicates median
survival).

A: Good prognosis (or

too short a study).
B: Poor prognosis early,
then slower increase
in mortality, with
median survival of 3
months.
C: Good prognosis early,
then worsening, with
median survival of 9
months.
D: Steady prognosis.
INTERPRETING SURVIVAL CURVES:

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POTENTIAL BIAS
Prognostic factor Outcomes
Yes

Population Present No
of people
Sample TIME
with the
disease Yes

Absent No
Selection
Potential Sampling Measurement
biases

Location of potential bias in cohort studies

 BIAS IN COHORT STUDIES
 Assembly bias: groups of patients are assembled
for study that differ in ways other than the factors
under study

 Migration bias: patients in one cohort leave their

original cohort, either moving to one of the other
cohorts under study or dropping out of the study
altogether

 Measurement bias: patients in one of the cohorts

stand a better chance of having their outcome
detected 26
 PROGNOSIS IS USEFUL FOR

Initiating or not therapy,

monitoring therapy that has been initiated,
deciding which diagnostic tests to order.
providing patients and families with the
information they want about what the
future is likely to hold for them and their
illness.
Communicating to patients their likely fate
Guiding treatment decisions
Comparing outcomes to make inferences
about quality of care