1 Eastern Cooperative Oncology Group (ECOG) Tool: Assessment Tool Critique Aaron Adrianne Antonio, BScN RN School of Nursing, York University NURS5840: Advanced Health Assessment and Diagnosis II Nicole Ilavsky, BScN, RN, MScN, PHCNP February 9, 2022 2 Introduction In oncology, performance status (PS) is a measurement used to assess cancer patients' functional level and self-care capabilities (Azam et al., 2019). Determining performance status plays a crucial role in oncologic treatment decisions and serves as a prognostic indicator for patients with advanced malignancy. It is also used in clinical trials to measure patients' responses to the new cancer treatment and their quality of life (Broderick et al., 2019). To assess a patient's PS, health care professionals can utilize different diagnostic tests. One example is the well-established Eastern Cooperative Oncology Group (ECOG), a globally recognized tool used as standard criteria for measuring how cancer disease and treatment impact a patient's daily living abilities (Oken et al., 1982). In my experience as a Nurse Practitioner student in a complex malignant hematology clinic, the ECOG tool has always been incorporated as part of my routine assessment to assess patients’ responses to chemotherapy. This paper aims to critique the ECOG and provide a literature review of the tool. Description of the tool ECOG, a standardized, international language of oncology practice, is a tool that assesses the functional level of cancer patients and is used to determine their response in cancer treatment, research, and triage (Simcock & Wright, 2020). It is typically scored by healthcare providers during clinic visits and is decided by them after history taking and assessment of activities of daily living. As described in the tool, 0 scores for being fully active, carrying on all pre-disease performance without restriction; 3 for being capable of only limited self-care; being confined to bed or chair more than 50% of waking hours; and 0 for dead (Oken et al., 1982). See Appendix A. The tool is easy to use and does not require training as it is numerically based with an explanation beside each number that best describes functional level (Kelly & Shahkroni, 2016). Despite the 3 attempt to be adopted in a general patient population, the tool is specifically designed for cancer patients (Broderick et al., 2019). Review and critique of literature related to the tool First developed in 1974, the ECOG criteria were initially used as standardized toxicity and treatment response in clinical trials of cancer therapies. The ECOG PS was developed from the 70-year-old Karnofsky performance score (KPS), summarized, and simplified into a 5-point scale. Despite being a standard tool used in oncology, Broderick et al. (2019) argued that literature explaining the validity of the ECOG tool has not been optimal. This is supported by Simcock & Wright (2020) in their argument that ECOG is still far from being universal despite its widespread use in oncology. However, in a survival analysis done by Jang et al. (2014), they contended that the ECOG tool had provided a validated prognostic power that has become a helpful metric amongst oncology health care professionals because of its brevity and simplicity. In terms of reliability, Venkatesan et al. (2010) showed a very high interobserver reliability between two oncologists in assessing 209 cancer patients using the ECOG tool. A study done by Wang et al (2014) at Princess Margaret Cancer Centre, concluded that ECOG has a similar predictive and prognostic ability to determine whether a patient can tolerate cancer treatment compared with other tools such as Karnofsky Performance Status (KPS) and the Palliative Performance Scale (PPS). The implementation of the tool cannot be generalized to a broader population. Given the widespread adoption of ECOG PS in cancer care as part of the assessment, a curious aspect is that it has not been more widely adopted outside of oncology, apart from some minimal usage in renal and geriatric medicine, where it can be used as a predictive tool for mortality in older adult (noncancer) inpatients with pneumonia (Piaralli et al., 2018). However, despite being widely recognized in oncology populations, a substantial number of clinicians still decide to continue the 4 use of chemotherapy despite a poor ECOG score (Tisnado et al., 2016). In addition, only 14 % of multidisciplinary meetings and discussions incorporate ECOG scores in deciding treatment options (Young et al., 2015). Clinical Application Providing ECOG scores is highly subjective, and it depends on the individual assessment and judgment of each health care professional assessing the patient, thus vulnerable to biases. This is supported by Kerrigan et al. (2020) as they explained that interpretation and impression of functional level are highly individualized between patients. Because of its subjectivity, health care professionals are at risk of overscoring and underscoring a patients’ performance status, which can be detrimental to a patient’s health (Simcock &Wright, 2020). For example, overscoring is associated with a poorer prognosis in solid tumours and hematological malignancies (Blagden et al., 2013; Liu et al., 2016). Therefore, the highly subjective nature of the ECOG tool can be problematic when it is solely used to determine a cancer patient's response to chemotherapy treatment. The median sensitivity and specificity of the ECOG tool in oncology practice were 15% and 100 %, respectively (Rojas et al., 2013). When compared to other diagnostic tools, such as Vulnerable Elders Survey-13 (VES-13), 68% and 75%; Rockwood, 47% and 88%; Balducci, 94% and 50%, ECOG tool is less sensitive and specific in measuring the vulnerability and frailty of older adults with cancer (Rojas et al., 2013). The ECOG has been proven to have both prognostic and predictive utility. For example, the score has been shown to align closely with the benefit of using cytotoxic chemotherapy in lung cancer (Pignon et al., 2008). It also helps in the prognostication in a palliative care setting and can predict depression in cancer patients (Jang et al., 2014; Miwata et al., 2019). Many medical oncologists may pause before giving chemotherapy in a patient with a PS of 3 and instead 5 consider palliative care (Kerrigan et al., 2020). In addition, surgeons would hesitate to operate on a patient with a PS of 2 (Pignon et al., 2008). Lastly, ECOG seems unidimensional and fails to include other factors that impact functional status. For example, in a case study done by Simcock and Wright (2020), they found that ECOG does not incorporate the impact of cognition, mood, social status, and outlook of cancer patients. It does not also consider geriatric syndromes and problems such as delirium, falls, pressure ulcers, constipation, smoking, alcohol excess, vision problems, social isolation, and loneliness, which can all cause changes in functional status (Simcock &Wright, 2020). Several performance scales can be used in conjunction with the ECOG tool to achieve a more holistic assessment. For example, using GAD- 7 and PHQ – 9 to assess anxiety and depression common in cancer patients (Young et al., 2015). Lastly, the Comprehensive Geriatric Assessment is also encouraged to be used to identify broader medical, psychosocial, and functional limitations of cancer patients, leading to more coordinated health care services (Devons, 2002). Actual Report Mr. M V is a 74-year-old male diagnosed with Acute Myeloid Leukemia last November 2021. He is currently receiving the treatments of Azacitidine and Venetoclax. The patient stated that he experiences shortness of breath on exertion; however, he can still carry out light housework. He does not feel fatigued and even said his energy level has improved since his last clinic visit. He is alert and oriented and walks independently using a roller walker. Physical assessment reveals normal power in all limbs with good muscle tone. With this assessment, the patient’s ECOG score is 1, which means that he is restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. Through this ECOG score, I can identify that patient is tolerating and shall continue his current chemotherapy regimen. He does not require treatment modification or referral at this point. 6 The use of the ECOG tool to evaluate cancer patients' performance status in primary care has provided vital information on whether a patient requires further supportive care, less toxic chemotherapy regimens, or an individualized care plan (Burtin et al., 2020). Determining their performance score can determine the next course of treatment and thus affects their health. It is crucial to weigh the risks versus the benefits of therapy with all cancer treatments seen in primary health care. There may be times when chemotherapy could reduce rather than increase life expectancy (Azam et al., 2019). Therefore, a holistic, careful assessment with cancer patients undergoing chemotherapy treatment while maintaining communication and collaboration with patients’ oncologists is required to ensure cancer patients’ safety and well-being. Conclusion The performance status is an essential component of the assessment of cancer patients because it provides an estimated picture of their functional statuses. As a widely recognized and established tool, ECOG can assess patients' responses to chemotherapy treatment. In this critique, I find that the tool is highly subjective and prone to biases, which ultimately can affect the management of cancer patients. In addition, the tool is deemed unidimensional and does not consider a multitude of factors that affects cancer patients’ response to chemotherapy treatment. As future Nurse Practitioners, we have a critical opportunity to improve our assessment of the PS of patients holistically. The ECOG tool developed almost half a century ago may not capture the nuances of the patient experience in today's oncology treatment landscape. This means invoking more patient-reported metrics and a more in-depth assessment of their psychosocial needs. This also warrants further research and understanding on how providers assess PS in people of differing education levels, socio-economic status, or race. As a future clinician, it is my goal to ensure accurate, patient-centred evaluations across all demographics to provide equitable access to the highest quality treatment and management. 7 References Azam, F., Latif, M. F., Farooq, A., Tirmazy, S. H., AlShahrani, S., Bashir, S., & Bukhari, N. (2019). Performance status assessment by using ECOG (Eastern Cooperative Oncology Group) score for cancer patients by oncology healthcare professionals. Case Reports in Oncology, 12(3), 728–736. https://doi.org/10.1159/000503095 Blagden, S. P., Charman, S. C., Sharples, L. D., Magee, L. 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Journal of Pain and Symptom Management, 49(2), 258–264. https://doi.org/10.1016/j.jpainsymman.2014.06.006 12 Appendix ECOG Performance Status Scale GRADE ECOG PERFORMANCE STATUS 0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work 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 Capable of only limited self-care; confined to bed or chair more than 50% of waking hours 4 Completely disabled; cannot carry on any selfcare; confined to bed or chair 5 Dead Oken, M. M., Creech, R. H., Tormey, D. C., Horton, J., Davis, T. E., McFadden, E. T., & Carbone, P. P. (1982). Toxicity and response criteria of the Eastern Cooperative Oncology Group. American Journal of Clinical Oncology, 5(6), 649–655.