Comparing Clinician-Assessed and Patient-Reported Performance Status for Predicting Morbidity and Mortality in Patients With Advanced Cancer Receiving Chemotherapy

Abstract

QUESTION ASKED: Does a patient-reported performance status (PS) measure for patients with advanced cancer predict clinical outcomes such as survival and service utilization, in comparison with a traditional clinician-reported PS measure? SUMMARY ANSWER: Both clinician-reported PS and patient-reported PS are associated with survival, emergency department (ED) visits, and hospitalizations , and the associations of patient-reported PS with clinical outcomes are stronger with repeated patient-reported PS measures over time. WHAT WE DID: A randomized controlled trial of symptom and PS reporting versus usual care was performed at Memorial Sloan Kettering Cancer Center from 2012 to 2016. We performed a secondary analysis of these data, using instances in which patients and clinicians reported PS within 1 week of each other. Patients could report PS as often as weekly. We also considered the EuroQOL EQ-5D, a five-item questionnaire measuring mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. The EQ-5D could be completed every 2 months. We evaluated agreement between patient and clini-cian PS measures. We determined whether patient or clinician PS predicted clinical outcomes and the associations between PS and EQ-5D subdomains. In a landmark analysis, we looked at whether repeated patient-reported PS measures over time improved outcome prediction. WHAT WE FOUND: Patient-reported and clinician-rated PS weakly agreed with one another (kappa 5 0.27). Both were prognostic for overall survival and use of the ED or hospital, although only clinician-rated PS retained prognostic significance in multivariate analysis (survival: hazard ratio [HR], 1.75; P , .0001 and ED/hospital: HR, 1.43; P 5 .02). Patient-reported PS improved prediction for survival (HR, 1.51; P , .001) and ED or hospital use (HR, 1.68; P , .001) when repeated over time, with the best model fit by Akaike's Information Criterion (AIC) when using mean values. Both patient-reported status and clinician-rated performance status (PS) were associated with EQ-5D subdomains (eg, 75%-77% with no usual activity deficits for PS 0, v 42%-51% for PS $ 1). BIAS, CONFOUNDING FACTORS, DRAWBACKS: Whether patient-reported PS and clinician-rated PS are true reflections of underlying PS is not known. Clinician-rated PS may subconsciously incorporate other prognostic factors beyond patient functioning. On the other hand, a single-item patient-reported PS measure may not be the optimal way to ascertain prognostic information about physical function from patients. REAL-LIFE IMPLICATIONS: It is feasible to obtain a patient-reported PS measure during chemotherapy for patients with advanced cancer and to repeat this measure over time when the patient is at home. Patient-reported PS may provide useful information for clinical trials and clinical care. Additional research should ascertain whether there is any added clinician or staff burden to incorporating this information into care delivery and whether a further optimized measure of patient physical function should be considered. abstract PURPOSE Performance status (PS) is assessed during cancer treatment to determine clinical trial eligibility, appropriateness for treatment, and need for supportive care. There is rising interest for patients to report this information directly. We determined whether clinician-and patient-reported PS were equally associated with mortality and service utilization in patients with cancer. METHODS A secondary analysis was conducted using data from an radiotherapy plus chemotherapy in which 441 patients with advanced cancer and clinicians reported PS using the Eastern Cooperative Oncology Group scale. Simple kappa statistics measured agreement between clinician-reported performance status (cPS) and patient-reported performance status (pPS). Associations of cPS and pPS with emergency department (ED) and hospital visits and overall survival were evaluated via Cox regression, competing risk regression, and Fisher's exact tests. RESULTS cPS and pPS correlated weakly (kappa 5 0.27). Both pPS and cPS were associated with survival, ED visits, and hospitalizations, but only cPS remained associated after adjustment (survival: HR, 1.75; P , .0001). The first available cPS predicted mortality more strongly than the first available pPS (HR for death, comparing PS $ 1 v 0: 2.05 for cPS and 1.41 for pPS). When pPS questionnaires were repeated over time and averaged, associations with outcomes were stronger as measured by AIC model fit. Both pPS and cPS were associated with EQ-5D subcomponents (eg, 75%-77% with no usual activity deficits for PS 0, v 42%-51% for PS $ 1). CONCLUSION Both clinician-reported PS and patient-reported PS provide useful information and can be considered for clinical trials and routine care.