Beyond Performance Status

Abstract

Oncologists should recognise the need to move beyond the Eastern Cooperative Oncology Group Performance Status (ECOG PS) score. ECOG PS is a longstanding and ubiquitous feature of oncology. It was evolved 40 years ago as an adaption of the 70-year-old Karnofsky performance score. It is short, easily understood and part of the global language of oncology. The wide prevalence of the ECOG PS attests to its proven utility and worth to help triage patient treatment. The ECOG PS is problematic. It is a unidimensional functional score. It is mostly physician assessed, subjective and therefore open to bias. It fails to account for multimorbidity, frailty or cognition. Too often the PS is recorded only once in wilful ignorance of a patient's changing physical state. As modern oncology offers an ever-widening array of therapies that are ‘personalised’ to tumour genotype, modern oncologists must strive to better define patient phenotype. Using a wider range of scoring and assessment tools, oncologists can identify deficits that may be reversed or steps taken to mitigate detrimental effects of treatment. These tools can function well to identify those patients who would benefit from comprehensive assessment. This overview identifies the strengths of ECOG PS but highlights the weaknesses and where these are supported by other measures. A strong recommendation is made here to move to routine use of the Clinical Frailty Score to start to triage patients and most appropriately design treatments and rehabilitation interventions.

Safety and efficacy of abemaciclib plus endocrine therapy in older patients with hormone receptor-positive/human epidermal growth factor receptor 2-negative advanced breast cancer: an age-specific subgroup analysis of MONARCH 2 and 3 trials

“…Patients in the 65–74 and ≥75 age groups were more likely to have had potentially confounding comorbidities including hypertension, gastrointestinal disorders, and metabolism/nutritional disorders. In addition, there were more patients with ECOG PS 1 in the two older subgroups; however, no other assessments were done to further characterize the fitness/frailty in the older patients, and we acknowledge that ECOG PS is not the best indicator of functional impairment in this population [ 26 , 27 ]. Patients in the 2 older subgroups required more dose adjustments to manage AEs, which is in line with a previously published analysis of CDK4 and 6 inhibitors [ 5 ].…”

Combined Longitudinal Clinical and Autopsy Phenomic Assessment in Lethal Metastatic Prostate Cancer: Recommendations for Advancing Precision Medicine

“… Performance status (PS) Worsened PS associated with worse OS in patients with mCRPC [32] , [47] , [57] and used as part of Halabi et al’s [86] prognostic model In the Advanced Prostate Cancer Consensus Conference 2017, 62% of panelists considered patients with metastatic disease not suitable for docetaxel treatment if PS was ≥2 for reasons other than cancer [87] . ECOG PS has been criticized, and the use of a wider range of scoring and assessment tools has been encouraged [88] . Physical activity Physical activity associated with better CSS and OS [89] Physical activity should be encouraged and tracked [90] using exercise trackers, and should be included in future trials as covariate.…”

Single modality radical radiotherapy is an acceptable alternative for the older patient with squamous cell carcinoma of the oesophagus

“…Geriatric assessment tools are an emerging field that will be important in determining objective rather than subjective assessment for suitability of concurrent treatment. 27 28 Similarly, future clinical trials should aim to include older patients with robust assessment tools particularly as this particular subgroup is often underrepresented but is increasing in clinical relevance. 29 This represents a larger discussion that remains ongoing in the oncology community when consider how to balance these issues where older patients have radically treatable cancers.…”

“…PS is a relatively limited descriptor and does not holistically represent true patient fitness. 27 Future prospective reviews should use comprehensive geriatric assessment tools which give fuller assessments of this population as these patients are often heterogeneous in fitness and comorbidity. 32 Similarly, toxicity data were not collected for these patients and can bring a well-rounded view on patient outcomes both on treatment and beyond.…”