How do you assess and manage cancer patients with significant comorbidities, particularly geriatric patients, using the Eastern Cooperative Oncology Group (ECOG) performance status scale?

ECOG Performance Status Assessment and Management in Cancer Patients with Comorbidities

In geriatric cancer patients with significant comorbidities, ECOG performance status alone is insufficient—you must perform a comprehensive geriatric assessment (GA) that includes functional status, comorbidities, cognition, nutrition, falls risk, and social support to accurately predict mortality, chemotherapy toxicity, and functional decline. 1

Why ECOG Alone is Inadequate in Older Patients

ECOG performance status fails to capture critical vulnerabilities in older cancer patients that directly impact treatment outcomes and survival. 1

• GA identifies clinically significant problems in 51.2% of older patients that routine oncology assessment misses, most commonly functional limitations (40.1%) and nutritional deficits (37.6%). 1
• The G8 screening tool independently predicts 1-year and 3-year mortality even when controlling for ECOG performance status and cancer stage, demonstrating that ECOG misses prognostically important information. 1, 2
• Comorbidity and functional status are independent variables—neither correlates well with the other, meaning ECOG cannot substitute for comorbidity assessment. 3
• Over two-thirds of patients aged 65+ have at least one comorbidity, and nearly one-fourth have four or more, which independently predict poorer survival, increased severe chemotherapy toxicity, hospitalizations, and early treatment discontinuation. 1

Structured Assessment Algorithm for Geriatric Cancer Patients

Step 1: Initial Screening (5-10 minutes)

Use the G8 screening tool as your first-line assessment for all patients aged 65+ considering chemotherapy. 1

• G8 score ≤14 indicates impairment and triggers comprehensive GA. 1
• G8 includes: appetite, weight loss, neuropsychological problems, BMI, number of medications, patient self-rated health, and age. 1
• Alternative: VES-13 (score ≥3 associated with mortality and chemotherapy toxicity; score ≥7 associated with functional decline). 1

Step 2: Comprehensive Geriatric Assessment Domains

When G8 ≤14 or for all patients aged 70+, perform full GA across seven domains: 1

Functional Status Assessment

• Activities of Daily Living (ADL): bathing, dressing, toileting, transferring, continence, feeding. 1
• Instrumental Activities of Daily Living (IADL): shopping, meal preparation, housekeeping, managing finances, telephone use, medication management. 1
• IADL impairment predicts chemotherapy toxicity and is included in the CRASH toxicity prediction tool. 1

Objective Physical Performance (1-5 minutes)

• Short Physical Performance Battery (SPPB): score <9 predicts functional decline, nursing home use, and mortality. 1
• Timed Up and Go (TUG): >12 seconds indicates increased fall risk; associated with 6-month mortality in patients receiving chemotherapy. 1
• Gait speed: independently predicts early mortality and functional decline. 1

Comorbidity Assessment

• Measure comorbidities using standardized tools (Cumulative Illness Rating Scale-Geriatric [CIRS-G] or Charlson scale). 1, 3
• Comorbidities such as congestive heart failure, diabetes, and pulmonary disease strongly influence life expectancy and must be considered in treatment decisions. 1
• Comorbidity is independent from functional status—both must be assessed separately. 3

Cognitive Assessment

• Mini-Cog is the preferred tool (administration <5 minutes): score 0-2 indicates significant cognitive decline requiring immediate intervention. 4
• Mini-Mental State Examination (MMSE) score <30 predicts nonhematologic chemotherapy toxicity in the CRASH tool. 1
• Montreal Cognitive Assessment (MoCA) is more sensitive than MMSE for detecting subtle decline. 4

Nutritional Status

• Mini Nutritional Assessment (MNA): score <28 predicts nonhematologic chemotherapy toxicity. 1
• Decreased food intake in past 3 months independently predicts mortality (HR 1.58 for one positive item). 1

Depression Screening

• Use Geriatric Depression Scale (GDS) to identify depression, which impacts treatment tolerance and outcomes. 1

Social Support and Polypharmacy

• Assess social activity/support networks. 1
• Use of >3 prescription drugs predicts mortality (HR 2.32 for two positive items including polypharmacy). 1

Step 3: Risk Stratification for Chemotherapy Toxicity

Use validated tools to predict grade 3-5 chemotherapy toxicity: 1

CARG Toxicity Tool (5 minutes, preferred)

• For patients aged 65+ starting any line of chemotherapy. 1
• Includes: falls history, hearing problems, walking limitations, medication difficulties, social activity interference, age, cancer type, chemotherapy dosing, hemoglobin, creatinine clearance. 1
• Available online: www.mycarg.org/Chemo_Toxicity_Calculator. 1

CRASH Tool (20-30 minutes)

• For patients aged 70+ starting chemotherapy. 1
• Hematologic toxicity risk: diastolic BP >72 mmHg, IADL score <26, LDH >459 U/L. 1
• Nonhematologic toxicity risk: ECOG PS, MMSE <30, MNA <28. 1

Critical Management Decisions Based on Assessment

ECOG 0-2 with Good GA

• Standard chemotherapy regimens appropriate. 1, 5
• Continue monitoring with GA domains throughout treatment. 1

ECOG 0-2 with Impaired GA (G8 ≤14)

• High-risk for toxicity despite good ECOG—consider dose reduction, single-agent therapy, or extended treatment intervals. 2
• Patients with ECOG 0-1 but low G8 scores have significantly shorter overall survival (median 7.7 months vs 25.6 months for high G8). 2

ECOG 3 or Higher

• ECOG 3 is a contraindication to standard chemotherapy in elderly patients—treatment-related mortality can reach 20%. 1, 5
• Only exception: poor performance status directly caused by malignancy and expected to improve with treatment. 5
• Otherwise, strongly recommend best supportive care alone or single-agent therapy if treatment pursued. 5
• Before any chemotherapy in ECOG 3 patients: calculate creatinine clearance, obtain CBC, comprehensive metabolic panel, and perform full GA. 5

Age >60 Years with AML

• Use patient performance status, comorbidities, and GA rather than chronologic age alone to select treatment. 1
• Predictive models incorporating temperature, hemoglobin, platelets, fibrinogen, age, and leukemia type predict CR probability and early death risk (available at http://www.aml-score.org/). 1

Common Pitfalls to Avoid

• Never rely on ECOG alone in patients aged 65+—it misses over half of clinically significant vulnerabilities. 1
• Do not assume good ECOG means good prognosis—G8 score independently predicts mortality even with ECOG 0-1. 1, 2
• Patient-reported performance status tends to be 0.31 points worse than physician-reported—averaging both improves prognostic accuracy (C-statistic 0.619 vs 0.596-0.604 individually). 6
• Comorbidity does not correlate with functional status—assess both independently. 3
• ECOG 3 patients should not receive standard chemotherapy unless poor status is malignancy-related and reversible. 5