Background   “How long do I have?” is a common question patients with cancer ask clinicians, especially when informed that there are no further effective anti-neoplastic treatment options.  Although prognostication is not an exact science, there are data to help clinicians provide useful information to patients and families – information critical to making realistic end-of-life decisions and timely hospice referrals (see Fast Fact #30). This Fast Fact aims to provide prognostic guidance applicable for patients with cancer who are not receiving systemic cancer treatments. Given the emerging therapies available for many cancers (targeted cancer treatments, immunotherapy, CAR-T cell therapy, etc.), prognosticating for patients receiving systemic cancer treatments is a moving target and should be done in direct collaboration with cancer specialists.

Performance Status    For most patients, there are clinically identifiable warning signs or trends in cancer which suggest a short prognosis. Patient factors such as functional capacity, the presence of distant metastases, and symptom burden generally have more prognostic value than the primary site or type of cancer.  The single most important prognostic predictive factor in patients with advance cancer who are not pursuing systemic cancer treatment is the patient’s performance status (‘functional ability,’ ‘functional status’): a measure of how much a patient can do for themselves and their activity and energy levels.  Patients with solid tumors typically lose ~ 70% of their functional ability in the last 3 months of life.  The most common scales used to measure functional ability are the Karnofsky Performance Status (KPS) (100 = normal; 0 = dead) and the ECOG scale (Eastern Cooperative Oncology Group), (0 = asymptomatic; 5 = dead).  A KPS <40 or ECOG > 3 roughly correlates to a 3-month median survival.  Newer prognostic scales have also been developed (See Fast Fact #124, Fast Fact #125, Fast Fact #416, Fast Fact #434, and Fast Fact #444).

The simplest method to assess functional ability is to ask: “How do you spend your time? How much time do you spend in a chair or lying down?”  If the response is >50% of the time, and is increasing, prognosis can be roughly estimated as 3 months or less.  Survival time tends to decrease further with increasing numbers of physical symptoms, especially cancer-related dyspnea. In fact, patients with cancer who present to the emergency room due to acute symptoms like pain or dyspnea and are found to have progressive malignancy are at significantly higher risk of overall 14-day mortality and in-hospital mortality.

Other factors   Several common cancer syndromes have well-documented short median survival times: 

• Malignant hypercalcemia: 2-6 months, except newly diagnosed breast cancer, prostate cancer, or multiple myeloma which typically have longer survival times (see Fast Fact #151).
• Neoplastic meningitis (or leptomeningeal carcinomatosis): 2-4 months if untreated (Fast Fact #135).
• Brain metastases: 1-2 months without radiation; 3-12 or more months with radiation therapy (poorer functional status correlates with shorter survival); 8.1% 2-year survival, 2.4% 5-year survival across all primary tumor types (see Fast Fact #459).
• Malignant ascites (see Fast Fact #176 and Fast Fact #177): 5-6 months.
• Malignant pleural effusion (#209): 3-12 months.
• Malignant bowel obstruction: 1-6 months.
• Malignant pericardial effusion: 7-15 weeks (see Fast Fact #209).
• Modified Glasgow Prognostic Score (mGPS): multiple studies have shown that an elevated serum c-reactive protein and a reduced serum albumin are associated with a reduced cancer-specific survival curve, irrespective of cancer type.

Other Comments   In general, a patient with metastatic solid cancer, acute leukemia or high-grade lymphoma who will not be receiving systemic chemotherapy (for whatever reason), has a prognosis of less than 6 months, which is the prognostic requirement for hospice eligibility in the United States.  Notable exceptions to this are patients with metastatic breast or prostate cancer with good performance status, as these cancers may have an indolent course.  In these patients, additional features suggesting short prognosis are needed to support medical eligibility for hospice, such as declining functional status and escalating symptom burden from dyspnea and/or malnutrition.

Discussing Prognosis   When discussing prognosis, the following four step approach is recommended: Preparation; Content; Patient’s Response; Close.  Remember to: 

1. Confirm that the patient/family are ready to hear prognostic information.
2. Present information using a range: a few days to weeks; 2-4 months, etc.
3. Allow silence after you provide information; respond to emotion (see Fast Fact #29).
4. Use prognostic information to guide the discussion on end-of-life goals (see Fast Fact #65). 

References 

1. Khosla AA, Saxena S, Ozair A, Venur VA, Peereboom DM, Ahluwalia MS. Novel therapeutic approaches in neoplastic meningitis. Cancers, 2023; 15(1): 119. 2023.
2. Lamont EB, Christakis NA. Complexities in prognostication in advanced cancer. JAMA, 2003; 290:98-104.
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4. Reuben DB, Mor V. Clinical symptoms and length of survival in patients with terminal cancer. Arch Int Med,1998; 148:1586-1591.
5. Asonitis N, Angelousi A, Zafeiris C, et al. Diagnosis, pathophysiology and management of hypercalcemia in malignancy: a review of the literature. Hormone and Metabolic Research, 2019; 51(12): 770-778. 2019.
6. Asonitis N, Angelousi A, Zafeiris C, et al. Diagnosis, pathophysiology and management of hypercalcemia in malignancy: a review of the literature. Hormone and Metabolic Research, 2019; 51(12): 770-778.
7. Achrol AS, Rennert RC, Anders C, et al. Brain metastases. Nature Reviews Disease Primers, 5(1): 5. January 17, 2019.
8. Cagney DN, Martin AM, Catalano PJ, et al. Incidence and prognosis of patients with brain metastases at diagnosis of systemic malignancy: a population-based study. Neuro-Oncology, 2017; 19(11): 1511-1521.
9. Yri, OE, Astrup GL, Karlsson AT, et al. Survival and quality of life after first-time diagnosis of brain metastases: a multicenter, prospective, observational study. The Lancet Regional Health – Europe, 2025; 49, 101181.
10. Hϋgel M, Stöhr J, Kuhnt T, et al. Long-term survival in patients with brain metastases – clinical characterization of a rare scenario. Strahlentherapie und Onkologie, 2023; 200(4): 335-345.
11. Gonnelli F, Hassan W, Bonifazi M, et al. Malignant pleural effusion: current understanding and therapeutic approach. Respiratory Research, 2024; 25(1): 47.
12. Demarest K, Lavu H, Collins E, et al. Comprehensive diagnosis and management of malignant bowel obstruction: a review. Journal of Pain & Palliative Care Pharmacotherapy, 2023; 37(1): 91-105. 2023.
13. Hodge C, Badgwell BD. Palliation of malignant ascites. Journal of Surgical Oncology,120(1): 67-73. July 1, 2019.
14. Reuben DB, Mor V. Clinical symptoms and length of survival in patients with terminal cancer. Arch Int Med,1998; 148:1586-1591.
15. Mudra SE, Rayes D, Kumar AK, et al. Malignant pericardial effusion: a systematic review. CJC Open, 2024; 6(8): 967-972.
16. Proctor MJ, Morrison DS, et al.  An inflammation based prognostic score (mGPS) predicts cancer survival independent of tumour site: a Glasgow inflammation outcome study.  British Journal of Cancer 2011; 104: 726-734.
17. Geraci JM, et al.  Progressive disease in patients with cancer presenting to an emergency room with acute symptoms predicts short-term mortality.  Supportive Care in Cancer, 2006; (10) 14 1038-45.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015. Re-copy-edited July 2019 and again in November 2025 by Amanda Sommerfeldt MD.
Conflicts of Interest: None.