Assessment of performance status, such as ECOG performance status and Karnofsky performance status scale

What it is

A single ordinal measure of functional capacity - the most powerful and most used prognostic variable in oncology
Determines trial eligibility, treatment intensity, and whether systemic therapy is offered at all
*An objective statement of what the patient can do, not how they feel or how unwell they look*

ECOG (WHO/Zubrod) is the standard in Australian practice; Karnofsky used in transplant, radiation oncology and palliative care
Independently prognostic in essentially every tumour type, often outweighing stage
Poor performance status is the commonest reason patients are excluded from clinical trials - hence trial populations are fitter than clinic populations

Reflects the integrated burden of tumour, comorbidity, treatment toxicity, nutrition, sarcopenia and psychological state
Deterioration may be from:
- Progressive cancer (irreversible)
- Reversible causes - anaemia, hypercalcaemia, hypothyroidism, adrenal insufficiency, infection, pain, opioid excess, depression, deconditioning, malnutrition
*Always ask whether poor performance status is fixed or fixable before withholding treatment*

Grade	Definition
0	Fully active, no restriction
1	Restricted in strenuous activity; able to do light or sedentary work (housework, office work)
2	Ambulatory and capable of all self-care but unable to work; up and about >50% of waking hours
3	Capable of only limited self-care; confined to bed or chair >50% of waking hours
4	Completely disabled; no self-care; totally confined to bed or chair
5	Dead

90 normal activity, minor signs; 80 normal activity with effort; 70 cares for self, unable to work; 50 requires considerable assistance and frequent medical care; 30 severely disabled, hospitalisation indicated

ECOG 0-1 - eligible for most trials and full-intensity systemic therapy
ECOG 2 - the grey zone; single agent, dose reduction, or best supportive care depending on whether the cause is the cancer
- If ECOG 2 is driven by tumour burden in a treatment-sensitive cancer, treat; if by comorbidity and frailty, usually do not
ECOG 3-4 - *cytotoxic chemotherapy generally causes harm without benefit*
- Exceptions: highly chemosensitive disease (germ cell tumour, small cell lung cancer, lymphoma, acute leukaemia), or an actionable driver where an oral TKI can produce a rapid response
ECOG >=3 with progressive disease on prior lines - a strong signal to move to supportive care

Ask what the patient actually did yesterday, hour by hour - not "how are you coping?"
"How much of the day are you in bed or in a chair?" - the >50% threshold separates 2 from 3
Cross-check with the carer; patients over-report function and clinicians under-rate it
Reassess at every visit - performance status is dynamic and a fall between cycles is a red flag
Record it in the notes with the date - it is a longitudinal variable

Geriatric assessment in patients >=65-70 - the G8 screening tool, then comprehensive geriatric assessment
- *Performance status alone under-detects vulnerability in older adults* - it misses cognition, polypharmacy, falls, nutrition and social supports
- CGA-guided care reduces chemotherapy toxicity without compromising outcomes (GAP70+, GAIN)
Frailty indices, sarcopenia on CT (L3 muscle index)
Australia-modified Karnofsky (AKPS) and Palliative Performance Scale in palliative care
Patient-reported outcome measures

Independently prognostic in lung, colorectal, breast, prostate, ovarian cancer and lymphoma
Component of prognostic scores: IPI (lymphoma), IMDC (renal), IGCCCG (germ cell), MASCC (febrile neutropenia), Glasgow Prognostic Score
Correlates with sarcopenia, weight loss, inflammatory markers (CRP, albumin), symptom burden
Determines eligibility for cisplatin (ECOG >2 = ineligible), high-dose therapy and stem cell transplant, and most clinical trials
Falling performance status is a trigger for advance care planning and palliative care referral

Declining performance status is one of the most reliable predictors of short prognosis - a fall from ECOG 1 to 3 over weeks suggests a life expectancy measured in weeks to a few months
Median survival in advanced solid tumours roughly halves with each ECOG grade
Performance status may improve with effective treatment of a highly responsive cancer, or with correction of a reversible cause - do not treat it as immutable at a single time point
*Chemotherapy given in the last 30 days of life confers no benefit and increases the chance of dying in hospital* - performance status trajectory is the best available warning
Discuss goals of care once ECOG reaches 3, or when it falls by 2 grades between cycles

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