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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 Percent of patients surviving 5 years
survival from some point in the course of their
disease
Case fatality Percent of patients with a disease who
die of it
Disease- Number of people per 10,000 (or
specific 100,000) population dying of a specific
mortality disease
Response Percent of patients showing some
evidence of improvement following an
intervention
Remission Percent of patients entering a phase in
which
*Time under observation disease
is either isor
stated noassumed
longertodetectable
be sufficiently
long so that all events that will occur have been
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observed
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
Terima Kasih