What treatment approach is recommended for patients with a poor Eastern Cooperative Oncology Group (ECOG) performance status?

Treatment Approach for Patients with Poor ECOG Performance Status

For patients with poor ECOG performance status (PS ≥3), palliative/best supportive care alone is recommended as the primary treatment approach, without systemic therapy.

Assessment of Performance Status

• The Eastern Cooperative Oncology Group Performance Status (ECOG PS) Scale and the Karnofsky Performance Status (KPS) Scale are commonly used to assess the functional status of cancer patients 1
• Poor performance status is defined as:
  • ECOG PS score ≥3 (confined to bed/chair >50% of waking hours or completely disabled)
  • KPS score <60% (requires considerable assistance and frequent medical care) 1

Treatment Algorithm Based on Performance Status

For Patients with Poor Performance Status (ECOG PS ≥3 or KPS <60%):

• Offer palliative/best supportive care only without systemic therapy 1
• Focus on symptom management and quality of life 1
• Treatment should be based on comfort rather than disease modification 1
• Avoid aggressive interventions that may cause more harm than benefit 1

For Patients with Better Performance Status (ECOG PS ≤2 or KPS ≥60%):

• Systemic therapy or chemoradiation can be offered in addition to palliative/best supportive care 1
• Two-drug cytotoxic regimens are preferred over three-drug regimens due to lower toxicity 1
• Regimen selection should consider medical comorbidities and toxicity profiles 1

Evidence Supporting This Approach

• Patients with ECOG PS ≥3 have extremely poor outcomes with systemic therapy:

  • Median survival of only 7 days for ECOG PS 4 patients with SCLC receiving chemotherapy 2
  • High rate (30%) of early deaths when chemotherapy is given to poor PS patients 2
  • Increased likelihood of in-hospital death (28.6% vs 15.1%) compared to good PS patients 3

• Immune checkpoint inhibitors show significantly worse outcomes in poor PS patients:

  • Overall survival of 3.1 months for ECOG PS ≥2 vs 12.6 months for ECOG PS 0-1 3
  • Overall response rate of only 8% for poor PS vs 23% for good PS patients 3

Special Considerations

• In select cases where poor PS is directly attributable to the cancer itself (rather than comorbidities or frailty), treatment may be considered if it might improve functional status 1
• For dying patients, parenteral hydration and nutrition are unlikely to provide benefit for most patients 1
• In acute confusional states, short and limited hydration may be used to rule out dehydration as a precipitating cause 1

Important Caveats

• Clinical trials have generally excluded patients with poor performance status (ECOG PS 3-4), so evidence for treatment in this population is limited 1
• Even trials designed for populations considered "unfit" for standard therapy typically only allow patients with ECOG PS 0-1 1
• The American Society of Clinical Oncology recommends increasing emphasis on quality of life and symptom management for patients with poor performance status, particularly in the last months of life 1
• Treatment given in the last months of life may delay access to end-of-life care, increase costs, and add unnecessary symptom burden 1