Medical Manuscript
Sequential Assessments of the Eastern Cooperative Oncology Group Performance Scale Enhance Prognostic Value in Patients With Terminally Ill Cancer Receiving Palliative Care
American Journal of Hospice & Palliative Medicine® 1-6 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114566226 ajhpm.sagepub.com
Meng-Ting Peng, MD1, Chien-Ting Liu, MD2, Yu-Shin Hung, MD1, Chen-Yi Kao, MD1, Pei-Hung Chang, MD3, Kun-Yun Yeh, MD3, Hung-Ming Wang, MD1, Yung-Chang Lin, MD1, and Wen-Chi Chou, MD1
Abstract This study aimed to assess the utility of the Eastern Cooperative Oncology Group (ECOG) performance scale assessments on days 1 and 8 of palliative care, as well as scale change between these assessments, as prognostic tools for patients with terminally ill cancer. A total of 2392 patients with terminally ill cancer who received palliative care between January 2006 and December 2011 at a single medical center were analyzed. Our study showed that the ECOG scale is a useful prognostic tool to predict life expectancy in patients with terminally ill cancer. The ECOG scale assessments at different time points under palliative care were independent predictors for overall survival. The combined ECOG scale assessments on days 1 and 8 predicted survival more precisely than using day 1 ECOG scale assessment alone. Keywords performance scale, terminally ill, end of life, cancer, prognostication, life expectancy
Introduction Performance statuses represent general well-being of patients with cancer and quantify patients’ activity during daily life. In addition to assessing daily living abilities of the patients in oncologic practice, performance scales are widely used to determine appropriate antitumor therapy, to measure quality of life, to predict treatment-related toxicity, and to estimate prognosis, as well as being used as eligibility criteria for enrollment in clinical trials.1-4 Prediction of life expectancy in patients with terminally ill cancer is an important end-of-life care issue.5,6 The accurate prognostication of patients with terminally ill cancer helps medical personnel to discuss end-of-life issues with patients and families and provide appropriate end-of-life care.7 Awareness of the estimated life expectancy helps patients to prepare for death and select end-of-life care, as well as select the place of death.8-10 Performance status is commonly used as a prognostic tool when the patient enters palliative care.4 The Karnofsky performance status (KPS), palliative performance scale (PPS), and Eastern Cooperative Oncology Group (ECOG) scale are the 3 most commonly used scales for performance status assessment
in patients with cancer. The KPS, developed in 1948, is an 11-point scale that runs from 100 (normally activity) to 0 (death), at intervals of 10.2 The PPS, developed in 1996, is a modification of the KPS, and it integrates oral intake and level of consciousness into an 11-point scale that is used in palliative care setting.11 The ECOG scale, developed in 1982, ranks patients from 0 to 5, with 0 denoting fully active without restriction and 5 denoting death.1 The KPS and ECOG are extensively used at various points during cancer patient care, 1
Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital Linkou Branch, School of Medicine, Chang Gung University, Taoyuan, Taiwan 2 Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan 3 Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital Keelung Branch, Keelung, Taiwan Corresponding Author: Wen-Chi Chou, MD, Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, School of Medicine, Chang Gung University, No. 5 Fuxing Street, Guishan Township, Taoyuan County 333, Taiwan. Email: [email protected]
Downloaded from ajh.sagepub.com at Monash University on November 14, 2015
American Journal of Hospice & Palliative Medicine®
2 while PPS is used specifically in the palliative care setting. A highly significant linear correlation, as well as similar ability to prognosticate in patients with advanced cancer, has been reported for the KPS, PPS, and ECOG scales in the palliative care setting.12 In the acute care and community setting, the ECOG scale is interchangeable with the KPS and the PPS as a functional and prognostic tool.13 In a direct comparison, the ECOG scale and KPS were both reported to have good interobserver reliability, but the interobserved variability was lower for the ECOG scale.14 Compared to KPS and PPS, the ECOG scale is relatively simple and easy to employ in practice. We hypothesize that sequential assessments of the ECOG scale would enhance prognostic information in patients with terminally ill cancer under palliative care. The aim of our study was to assess the utility of the ECOG scale assessments at days 1 and 8, as well as the change in the ECOG scale between the 2 assessments, as prognostic tools for patients with terminal cancer in a palliative care consultation service (PCCS).
Methods
Figure 1. Study flow chart.
Patient Selection A total of 2392 patients with terminally ill cancer who received PCCS care between January 2006 and December 2011 at a single medical center in Taiwan (Chang Gung Memorial Hospital, Linkou) were selected for analysis in this study. All patients had pathologically or radiographically verified malignancies and were referred to PCCS based on their clinicians’ judgment that they would benefit from palliative care and were unlikely to survive for >6 months. All patients completed ECOG scale assessments on days 1 and 8 of PCCS care. Patients were stratified by ECOG scale at days 1 and 8 for survival analysis. Patients stratified into different ECOG scales at day 1 were further categorized into ECOG scale change (day 8 ECOG to day 1 ECOG scale, Dscale) as ‘‘deteriorated,’’ ‘‘no change,’’ and ‘‘improved’’ group for survival analysis. The change in ECOG scales in 1-week interval was calculated because palliative care was provided to patients on a weekly basis. The study design is presented in Figure 1. The study protocol was approved by the institutional review board of the hospital.
hospice ward or home hospice care, or discharge from the hospital under stable condition.
Data Collection Patient demographics, including age, sex, referring medical department, and primary cancer origin, were recorded at the first consultation by a nurse specialist with a formulated ‘‘patient record form,’’ developed by the Bureau of Health Promotion in Taiwan.15 The patient record form included the ECOG scale and 29 patient-assessed distress symptoms. The ‘‘patient record form’’ was recorded at each visit by a palliative care physician or nurse specialist. The survival time was defined from the first day of ECOG assessment to the day of death. For outpatients, the date of death was obtained from the cancer registration center in our institute or from the National Register of Death Database in Taiwan. All patients were censored until death or, if alive, 180 days. For all patients, the overall median survival was 32.0 days (range, 8-180 days). The survival and death rates based on ECOG scale assessment at days 1 and 8 under care of PCCS are shown in Table 2. The day 1 performance status assessment assigned 4.5%, 11.3%, 32.4%, and 51.8% of the patients to the ECOG scale 1, 2, 3, and 4, respectively. For patients with initial ECOG scale 1, 2, 3, and 4, the death rates were 74.8%, 84.4%, 91.9%, and 93.8%, respectively, and the median survival durations were 82, 49, 34, and 24 days, respectively. The day 8 ECOG performance status assessment assigned 4.4%, 9.1%, 27.4%, and 59.1% of the patients to the ECOG scale 1, 2, 3, and 4, respectively. For patients with day 8 ECOG scale 1, 2, 3, and 4, the death rate was 69.8%, 80.3%, 90.2%, and 95%, respectively, and the median survival durations were 92, 58, 32, and 16 days, respectively. The adjusted HRs were significantly different when comparing ECOG scale day 1 (Figure 2) and day 8 (Figure 3) assessments. A subgroup survival analysis according to Dscale in the patient groups stratified by day 1 ECOG scale is shown in
Table 3 and Figure 4. For ECOG scale, 1 patient categorized as Dscale ‘‘no change’’ group and ‘‘deteriorated’’ group, the death rates were 68.5% and 88.2%, respectively and the median survival durations were 96 and 53 days, respectively. For ECOG scale, 2 patients categorized as Dscale ‘‘improved’’ group, no change group, and deteriorated group, the death rates were 70.4%, 79.7%, and 93.6%, respectively, and the median survival durations were 114, 65, and 30 days, respectively. For ECOG scale, 3 patients categorized as Dscale improved group, no change group, and deteriorated group, the death rates were 86.3%, 90.3%, and 96.5%, respectively, and the median survival durations were 63, 38, and 23 days, respectively. For ECOG scale, 4 patients categorized as Dscale improved group and no change group, the death rates were 81.6% and 94.8% respectively, and the median survival durations were 49 and 23 days respectively. The median survival calculated according to Dscale stratification showed significant in-group difference in each ECOG scale group (all P value
Sequential Assessments of the Eastern Cooperative Oncology Group Performance Scale Enhance Prognostic Value in Patients With Terminally Ill Cancer Receiving Palliative Care
American Journal of Hospice & Palliative Medicine® 1-6 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114566226 ajhpm.sagepub.com
Meng-Ting Peng, MD1, Chien-Ting Liu, MD2, Yu-Shin Hung, MD1, Chen-Yi Kao, MD1, Pei-Hung Chang, MD3, Kun-Yun Yeh, MD3, Hung-Ming Wang, MD1, Yung-Chang Lin, MD1, and Wen-Chi Chou, MD1
Abstract This study aimed to assess the utility of the Eastern Cooperative Oncology Group (ECOG) performance scale assessments on days 1 and 8 of palliative care, as well as scale change between these assessments, as prognostic tools for patients with terminally ill cancer. A total of 2392 patients with terminally ill cancer who received palliative care between January 2006 and December 2011 at a single medical center were analyzed. Our study showed that the ECOG scale is a useful prognostic tool to predict life expectancy in patients with terminally ill cancer. The ECOG scale assessments at different time points under palliative care were independent predictors for overall survival. The combined ECOG scale assessments on days 1 and 8 predicted survival more precisely than using day 1 ECOG scale assessment alone. Keywords performance scale, terminally ill, end of life, cancer, prognostication, life expectancy
Introduction Performance statuses represent general well-being of patients with cancer and quantify patients’ activity during daily life. In addition to assessing daily living abilities of the patients in oncologic practice, performance scales are widely used to determine appropriate antitumor therapy, to measure quality of life, to predict treatment-related toxicity, and to estimate prognosis, as well as being used as eligibility criteria for enrollment in clinical trials.1-4 Prediction of life expectancy in patients with terminally ill cancer is an important end-of-life care issue.5,6 The accurate prognostication of patients with terminally ill cancer helps medical personnel to discuss end-of-life issues with patients and families and provide appropriate end-of-life care.7 Awareness of the estimated life expectancy helps patients to prepare for death and select end-of-life care, as well as select the place of death.8-10 Performance status is commonly used as a prognostic tool when the patient enters palliative care.4 The Karnofsky performance status (KPS), palliative performance scale (PPS), and Eastern Cooperative Oncology Group (ECOG) scale are the 3 most commonly used scales for performance status assessment
in patients with cancer. The KPS, developed in 1948, is an 11-point scale that runs from 100 (normally activity) to 0 (death), at intervals of 10.2 The PPS, developed in 1996, is a modification of the KPS, and it integrates oral intake and level of consciousness into an 11-point scale that is used in palliative care setting.11 The ECOG scale, developed in 1982, ranks patients from 0 to 5, with 0 denoting fully active without restriction and 5 denoting death.1 The KPS and ECOG are extensively used at various points during cancer patient care, 1
Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital Linkou Branch, School of Medicine, Chang Gung University, Taoyuan, Taiwan 2 Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan 3 Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital Keelung Branch, Keelung, Taiwan Corresponding Author: Wen-Chi Chou, MD, Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, School of Medicine, Chang Gung University, No. 5 Fuxing Street, Guishan Township, Taoyuan County 333, Taiwan. Email: [email protected]
Downloaded from ajh.sagepub.com at Monash University on November 14, 2015
American Journal of Hospice & Palliative Medicine®
2 while PPS is used specifically in the palliative care setting. A highly significant linear correlation, as well as similar ability to prognosticate in patients with advanced cancer, has been reported for the KPS, PPS, and ECOG scales in the palliative care setting.12 In the acute care and community setting, the ECOG scale is interchangeable with the KPS and the PPS as a functional and prognostic tool.13 In a direct comparison, the ECOG scale and KPS were both reported to have good interobserver reliability, but the interobserved variability was lower for the ECOG scale.14 Compared to KPS and PPS, the ECOG scale is relatively simple and easy to employ in practice. We hypothesize that sequential assessments of the ECOG scale would enhance prognostic information in patients with terminally ill cancer under palliative care. The aim of our study was to assess the utility of the ECOG scale assessments at days 1 and 8, as well as the change in the ECOG scale between the 2 assessments, as prognostic tools for patients with terminal cancer in a palliative care consultation service (PCCS).
Methods
Figure 1. Study flow chart.
Patient Selection A total of 2392 patients with terminally ill cancer who received PCCS care between January 2006 and December 2011 at a single medical center in Taiwan (Chang Gung Memorial Hospital, Linkou) were selected for analysis in this study. All patients had pathologically or radiographically verified malignancies and were referred to PCCS based on their clinicians’ judgment that they would benefit from palliative care and were unlikely to survive for >6 months. All patients completed ECOG scale assessments on days 1 and 8 of PCCS care. Patients were stratified by ECOG scale at days 1 and 8 for survival analysis. Patients stratified into different ECOG scales at day 1 were further categorized into ECOG scale change (day 8 ECOG to day 1 ECOG scale, Dscale) as ‘‘deteriorated,’’ ‘‘no change,’’ and ‘‘improved’’ group for survival analysis. The change in ECOG scales in 1-week interval was calculated because palliative care was provided to patients on a weekly basis. The study design is presented in Figure 1. The study protocol was approved by the institutional review board of the hospital.
hospice ward or home hospice care, or discharge from the hospital under stable condition.
Data Collection Patient demographics, including age, sex, referring medical department, and primary cancer origin, were recorded at the first consultation by a nurse specialist with a formulated ‘‘patient record form,’’ developed by the Bureau of Health Promotion in Taiwan.15 The patient record form included the ECOG scale and 29 patient-assessed distress symptoms. The ‘‘patient record form’’ was recorded at each visit by a palliative care physician or nurse specialist. The survival time was defined from the first day of ECOG assessment to the day of death. For outpatients, the date of death was obtained from the cancer registration center in our institute or from the National Register of Death Database in Taiwan. All patients were censored until death or, if alive, 180 days. For all patients, the overall median survival was 32.0 days (range, 8-180 days). The survival and death rates based on ECOG scale assessment at days 1 and 8 under care of PCCS are shown in Table 2. The day 1 performance status assessment assigned 4.5%, 11.3%, 32.4%, and 51.8% of the patients to the ECOG scale 1, 2, 3, and 4, respectively. For patients with initial ECOG scale 1, 2, 3, and 4, the death rates were 74.8%, 84.4%, 91.9%, and 93.8%, respectively, and the median survival durations were 82, 49, 34, and 24 days, respectively. The day 8 ECOG performance status assessment assigned 4.4%, 9.1%, 27.4%, and 59.1% of the patients to the ECOG scale 1, 2, 3, and 4, respectively. For patients with day 8 ECOG scale 1, 2, 3, and 4, the death rate was 69.8%, 80.3%, 90.2%, and 95%, respectively, and the median survival durations were 92, 58, 32, and 16 days, respectively. The adjusted HRs were significantly different when comparing ECOG scale day 1 (Figure 2) and day 8 (Figure 3) assessments. A subgroup survival analysis according to Dscale in the patient groups stratified by day 1 ECOG scale is shown in
Table 3 and Figure 4. For ECOG scale, 1 patient categorized as Dscale ‘‘no change’’ group and ‘‘deteriorated’’ group, the death rates were 68.5% and 88.2%, respectively and the median survival durations were 96 and 53 days, respectively. For ECOG scale, 2 patients categorized as Dscale ‘‘improved’’ group, no change group, and deteriorated group, the death rates were 70.4%, 79.7%, and 93.6%, respectively, and the median survival durations were 114, 65, and 30 days, respectively. For ECOG scale, 3 patients categorized as Dscale improved group, no change group, and deteriorated group, the death rates were 86.3%, 90.3%, and 96.5%, respectively, and the median survival durations were 63, 38, and 23 days, respectively. For ECOG scale, 4 patients categorized as Dscale improved group and no change group, the death rates were 81.6% and 94.8% respectively, and the median survival durations were 49 and 23 days respectively. The median survival calculated according to Dscale stratification showed significant in-group difference in each ECOG scale group (all P value
