The Surprise Question: a tool to estimate and identify factors associated with 12-month mortality for gynecological oncology patients in an outpatient setting

Objectives: Although prognostic accuracy is essential to timely initiation of end-of-life (EOL) planning, clinicians’ ability to predict prognosis is generally poor. The Surprise Question - ‘would you be surprised if this patient died in the next year’ - is a validated screening tool for use in oncology patients and highly predictive of 12-month mortality. Our primary objective was to determine the prognostic significance of the Surprise Question in patients with late stage or recurrent gynecologic malignancy. Our secondary objective was to identify potential risk factors associated with increased mortality during a 12-month interval. Methods: We performed an observational prospective cohort study assessing the prognostic significance of the Surprise Question in patients with late stage and/or recurrent gynecologic malignancy at Women and Infants Hospital in Providence, Rhode Island. All providers seeing patients with late stage gynecologic malignancies were consented and participated in the study. When a patient presented to the gynecologic oncology clinic, the attending physicians, fellows, and nurse practitioners answered the Surprise Question for each person on an iPad. Patient data was abstracted via chart review 12-months from Surprise Question answer with demographic, clinical, and EOL data being collected. Data analysis included log-rank, Fisher's exact, and Wilcoxon rank sum tests. Results: A total of 44 providers were consented to participate in the study. A set of 12-month follow-up data was evaluated for 299/299 participants, with providers using the Surprise Question to screen 37% “no” and 63% “yes”. At the 12-month mark, 39% of those screened “no” were deceased while 91% of those screened “yes” were alive. Kaplan-Meier curves show that survival proportions at 12-months were statistically significant between those screened “no” and “yes” (Log-rank test=p<0.0001). Those who were deceased at 12-months were more likely to have recent hospitalizations (p<0.02), recurrent disease (p<0.002), received radiation treatment (p<0.04), and worse performance status (p<0.001) compared to those still living. Additionally, of those deceased at 12-months, 75% had been enrolled in hospice for a median of 10 days (range 1-365 days); however, at least 60% were receiving treatment within the last 30 days, the most common being chemotherapy (71%), followed by palliative radiation (9%). Conclusions: Our results demonstrate that the Surprise Question can help identify patients at high-risk for mortality within the following 12-months when used in the outpatient setting for those with gynecologic malignancy. When patients screen ‘no’ to the Surprise Question, early emphasis on EOL planning may be deemed higher importance. Identification of risk factors associated with increased risk of mortality at 12-months (recurrent disease, hospitalization, radiation, poor performance status) can help guide treatment decisions and when to best initiate EOL conversations. Although prognostic accuracy is essential to timely initiation of end-of-life (EOL) planning, clinicians’ ability to predict prognosis is generally poor. The Surprise Question - ‘would you be surprised if this patient died in the next year’ - is a validated screening tool for use in oncology patients and highly predictive of 12-month mortality. Our primary objective was to determine the prognostic significance of the Surprise Question in patients with late stage or recurrent gynecologic malignancy. Our secondary objective was to identify potential risk factors associated with increased mortality during a 12-month interval. We performed an observational prospective cohort study assessing the prognostic significance of the Surprise Question in patients with late stage and/or recurrent gynecologic malignancy at Women and Infants Hospital in Providence, Rhode Island. All providers seeing patients with late stage gynecologic malignancies were consented and participated in the study. When a patient presented to the gynecologic oncology clinic, the attending physicians, fellows, and nurse practitioners answered the Surprise Question for each person on an iPad. Patient data was abstracted via chart review 12-months from Surprise Question answer with demographic, clinical, and EOL data being collected. Data analysis included log-rank, Fisher's exact, and Wilcoxon rank sum tests. A total of 44 providers were consented to participate in the study. A set of 12-month follow-up data was evaluated for 299/299 participants, with providers using the Surprise Question to screen 37% “no” and 63% “yes”. At the 12-month mark, 39% of those screened “no” were deceased while 91% of those screened “yes” were alive. Kaplan-Meier curves show that survival proportions at 12-months were statistically significant between those screened “no” and “yes” (Log-rank test=p<0.0001). Those who were deceased at 12-months were more likely to have recent hospitalizations (p<0.02), recurrent disease (p<0.002), received radiation treatment (p<0.04), and worse performance status (p<0.001) compared to those still living. Additionally, of those deceased at 12-months, 75% had been enrolled in hospice for a median of 10 days (range 1-365 days); however, at least 60% were receiving treatment within the last 30 days, the most common being chemotherapy (71%), followed by palliative radiation (9%). Our results demonstrate that the Surprise Question can help identify patients at high-risk for mortality within the following 12-months when used in the outpatient setting for those with gynecologic malignancy. When patients screen ‘no’ to the Surprise Question, early emphasis on EOL planning may be deemed higher importance. Identification of risk factors associated with increased risk of mortality at 12-months (recurrent disease, hospitalization, radiation, poor performance status) can help guide treatment decisions and when to best initiate EOL conversations.