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Clinical Stem 1
Non-smoking female with a new right upper lobe lung mass and three PET-positive mediastinal lymph nodes

Answer C
Estimated survival is an important factor for decision making in all disease processes. If this patient has primary lung cancer, she would likely be clinically staged IIIB because of the contralateral mediastinal lymph node at station 4L. In such cases of advanced cancer, prognostic considerations are important because treatment goals may change from prolonging life at any cost, to palliating symptoms, preserving quality of life, and maintaining dignity.

Estimating survival based on objective data is warranted because subjective assessments of predicted survival are often incorrect and overly optimistic. Patients usually want their doctors to be realistic yet hopeful prognosticators. While data are not always shared, physicians who address prognosis conduct meaningful and honest discussions with patients and their families.

Performance status, along with heart rate, blood pressure, temperature, respiratory rate and pain level, is an important vital sign in clinical oncology. Because performance status is the strongest prognostic indicator of survival in patients with cancer, it is frequently used as an entry criterion and adjustment factor in clinical trials. One commonly used measure of performance is the Karnofsky Performance Status score that uses a 0?100 range in ten point increments to measure functional impairment. Lower scores correlate with worsened survival for most serious illnesses.
Results from the analysis of 100 variables from several studies showed that dyspnea, dysphagia, weight loss, xerostomia, anorexia, and cognitive impairment were strongly and independently associated with survival of cancer patients. These signs and symptoms were outranked, however, by the assessment of performance status.
References:
  1. Lamont EB, Christakis NA. Survival estimates in advanced cancer. Available at www.UpToDate.com.
  2. Hollingsworth HM. Wheezing and stridor. Clin Chest Med 1987;8:231?240.
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