What is the appropriate Eastern Cooperative Oncology Group (ECOG) performance status for a 71-year-old woman with advanced high-grade serous carcinoma, extensive peritoneal carcinomatosis, well-controlled hypertension, atrial fibrillation, and a prior ischemic stroke?

ECOG Performance Status Assessment for a 71-Year-Old Woman with Advanced High-Grade Serous Carcinoma

Based on the clinical scenario described—a 71-year-old woman with advanced high-grade serous carcinoma, extensive peritoneal carcinomatosis, well-controlled hypertension, atrial fibrillation, and prior ischemic stroke—the ECOG performance status is most likely 2 or 3, depending on her current functional capacity and symptom burden. 1, 2

Understanding the ECOG Scale

The ECOG Performance Status is a 5-level scale (0-4) that assesses functional status based on ability to perform daily activities and self-care, with higher scores indicating worse performance status: 2

• ECOG 0: Fully active, able to carry on all pre-disease activities without restriction 3
• ECOG 1: Restricted in physically strenuous activity but ambulatory and able to carry out light work 3
• ECOG 2: Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours 3
• ECOG 3: Capable of only limited self-care; confined to bed or chair more than 50% of waking hours 3
• ECOG 4: Completely disabled; cannot carry on any self-care; totally confined to bed or chair 3

Key Clinical Assessment Points

To accurately determine this patient's ECOG score, you must evaluate: 1

• Ambulatory capacity: Can she walk independently? Does she require assistance for walking one block? 1
• Self-care abilities: Can she perform activities of daily living (bathing, dressing, eating) independently? 1
• Time spent in bed or chair: Is she confined to bed/chair more or less than 50% of waking hours? 3
• Work capacity: Can she perform any work activities or light housework? 3
• Symptom burden from peritoneal carcinomatosis: Does she have ascites, bowel obstruction, or pain requiring regular opioids? 1

Critical Treatment Implications

If ECOG 0-1 (Unlikely Given Extensive Disease)

• Eligible for aggressive systemic therapy including multi-agent chemotherapy 2
• Appropriate for clinical trial enrollment 2

If ECOG 2 (Most Likely Scenario)

• Systemic therapy remains an option with careful monitoring, as patients with ECOG 2 have intermediate performance status and are increasingly included in clinical trials 2
• Two-drug regimens are preferred over three-drug regimens (equivalent to KPS 60-70) 2, 4
• Heightened monitoring for treatment-related toxicity is essential 2

If ECOG 3-4 (Possible Given Extensive Carcinomatosis)

• Best supportive/palliative care only—systemic chemotherapy should NOT be offered 1, 2
• This threshold is equivalent to KPS <60% 1, 4
• Chemotherapy in this population postpones end-of-life care discussions and introduces unnecessary toxicity without survival benefit 2

Special Considerations for Older Adults

In this 71-year-old patient, ECOG performance status alone is insufficient for treatment decision-making. 1, 5

You should also assess: 1

• Geriatric vulnerabilities: History of falls, hearing impairment, limitations in walking, medication management difficulties 1
• Comorbidity burden: Her atrial fibrillation, hypertension, and prior stroke significantly influence life expectancy and treatment tolerance 1
• Cognitive function: Use Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MOCA) 1
• Nutritional status: Mini Nutritional Assessment (MNA) predicts chemotherapy toxicity 1
• Objective physical performance: Timed Up and Go (TUG >12 seconds indicates fall risk), gait speed, or Short Physical Performance Battery (SPPB <9 predicts functional decline) 1

The CARG chemotherapy toxicity calculator incorporates ECOG status with geriatric domains (falls, hearing, ambulation, medication management) to predict grade 3-5 toxicity risk more accurately than performance status alone in older adults. 1, 2

Common Pitfalls to Avoid

Age-related bias: Clinicians systematically assign worse ECOG scores to patients >65 years compared to younger patients despite no objective difference in measured physical activity. 2, 5 Use objective physical performance tests (TUG, gait speed, SPPB) to counteract this bias. 1

Subjectivity and inter-rater variability: ECOG assessment is inherently subjective with only moderate inter-observer agreement (Kappa 0.44), particularly for borderline scores. 3, 5 When uncertain between ECOG 2 versus 3, the distinction is critical because it determines eligibility for systemic therapy versus palliative care only. 1, 2

Failure to distinguish cause of poor performance: Current ECOG scoring does not differentiate whether poor performance stems from disease burden versus comorbidities versus treatment toxicity. 2, 5 If reduced performance is primarily tumor-driven (e.g., symptomatic ascites, bowel obstruction from carcinomatosis), systemic therapy may improve functional capacity, justifying treatment even at ECOG 2. 2

Single time-point assessment: ECOG should be reassessed regularly as the patient's physical state changes with disease progression or treatment response. 5

Practical Algorithm for This Patient

1. Assess current functional status using the specific criteria above (ambulatory capacity, self-care, time in bed/chair) 3
2. Perform objective physical testing (TUG, gait speed) to validate subjective ECOG assignment and counteract age bias 1
3. Determine if performance limitations are disease-driven (ascites, obstruction, pain) versus comorbidity-driven (stroke sequelae, cardiac limitations) 2
4. If ECOG 2 with disease-driven symptoms: Consider systemic therapy with two-drug regimen and close toxicity monitoring 2
5. If ECOG 3-4: Initiate palliative care only, with aggressive symptom management and goals-of-care discussions 1, 2
6. Incorporate geriatric assessment using CARG toxicity calculator or comprehensive geriatric assessment to refine treatment decisions 1