Revisiting the Association of ECOG Performance Status With Clinical Outcomes in Diverse Patients With Cancer

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Deepika Kumar Hematology/Oncology Department, Kaiser Permanente San Francisco Medical Center, San Francisco, CA

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Elad Neeman Department of Hematology-Oncology, The Permanente Medical Group (TPMG), Oakland, CA

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Shiyun Zhu Kaiser Permanente Northern California Division of Research, Oakland, CA

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Hongxin Sun Kaiser Permanente Northern California Division of Research, Oakland, CA

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Dinesh Kotak Department of Hematology-Oncology, The Permanente Medical Group (TPMG), Oakland, CA

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Raymond Liu Department of Hematology-Oncology, The Permanente Medical Group (TPMG), Oakland, CA

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Background: The ECOG performance status (PS) scale was developed to support national clinical trials, but the degree to which ECOG PS predicts clinical outcomes in patient subgroups outside of clinical trials is relatively unknown. This study examined associations between ECOG PS and adverse outcomes in a diverse community oncology population. Patients and Methods: In this retrospective cohort study, demographic and clinical characteristics, including the most recent ECOG PS between January 1, 2017, and December 31, 2019, were examined for patients receiving cancer treatment within Kaiser Permanente Northern California (KPNC). Proportional hazard models were used to evaluate the effect of ECOG PS on adverse outcomes. Results: A total of 21,730 patients were identified. Overall, most patients had an ECOG PS of 0 (42.5%) or 1 (42.5%). In multivariable analysis, an ECOG PS of 3 or 4 was associated with higher risk of 30-day emergency department visits (adjusted hazard ratio [aHR], 3.85; 95% CI, 3.47–4.26), 30-day hospitalizations (aHR, 4.70; 95% CI, 4.12–5.36), and 6-month mortality (aHR, 7.34; 95% CI, 6.64–8.11) compared with an ECOG PS of 0. Additionally, we found that upper gastrointestinal and stage IV cancers were associated with a higher risk of adverse outcomes compared with breast and stage I cancers, respectively. When adjusted for ECOG PS, African American race, Asian race, and female sex were associated with a lower risk of mortality than White race and male sex. An ECOG PS of 3 or 4 was more predictive of mortality in younger patients and those with breast cancer (P<.001). Conclusions: ECOG PS and upper gastrointestinal and stage IV cancers were independently associated with increased risk of emergency department visits, hospitalizations, and mortality, whereas African American and Asian race and female sex were associated with decreased risk of mortality. An ECOG PS of 3 or 4 was more predictive of an increased risk of mortality in younger patients and patients with breast cancer. These findings can enhance the use of ECOG PS for clinical decision-making and defining eligibility for clinical trials.

Submitted June 2, 2023; final revision received October 27, 2023; accepted for publication November 20, 2023. Published online April 23, 2024.

Author contributions: Study concept and design: Kumar, Neeman, Liu. Data acquisition: Zhu, Sun. Data analysis and interpretation: Zhu, Sun. Resources: Liu. Manuscript preparation: Kumar, Neeman, Liu. Final approval of the manuscript: All authors.

Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Data availability: The data underlying this article will not be shared.

Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2023.7111. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.

Correspondence: Deepika Kumar, MD, Hematology/Oncology Department, Kaiser Permanente San Francisco Medical Center, 2238 Geary Street, 8th Floor, San Francisco, CA 94115. Email: deepikakrao1@gmail.com

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