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Evaluation of Patients with Advanced Cancer Using the
              Karnofsky Performance Status

                    JEROME W. YATES, MD, BRUCE CHALMER, MS, F. PATRICK McKEGNEY, MD


            The Karnofsky Performance Status Scale (KPS) was designed to measure the level of patient activity and
            medical care requirements. It is a general measure of patient independence and has been widely used
            as a general assessment of patients with cancer. Although there is a long history of use of the KPS for
            judging cancer patients, its reliability and validity have been assumed without formal investigation.
            The interrater reliability of the KPS was investigated in two ways, both of which gave evidence of moder-
            ately high reliability. The patients evaluated in their home were usually assigned a lower KPS score com-
            pared with a similar evaluation at the same time done in the outpatient clinic. Construct validity of the
            KPS was demonstrated by strong correlation with several variables relating to physical function. On-
            study KPS scores accurately predicted early death, but high initial KPS scores did not necessarily predict
            long survival. Patient deterioration with subsequent death within a few months could be predicted to a
            limited extent by a rapidly dropping KPS. These results suggest that the KPS has considerable validity
            as a global indicator of the functional status of patients with cancer and might be helpful for following
            other patients with chronic disease.
                                                    Cancer 45:2220-2224, 1980.



W      I T H T H E INCREASE  in clinical trials designed to
         evaluate chemotherapeutic agents in the treat-
ment of cancer, it became evident that some method
                                                                                              Methods
                                                                      A group of patients with advanced cancer, all of
                                                                    whom were being followed as part of the Cancer
of quantifying patients’ status relative to degree of in-           Rehabilitation Project at the Vermont Regional Cancer
dependence in carrying out normal activities and self-              Center, were assigned KPS scores at the time of their
care was needed. In 1948, Karnofsky and Burchena15                  admission to the project.6 One criterion for admission
described a numerical scale for this purpose. This has              to the study was a probable survival of three months
subsequently become known as the Karnofsky Per-                     to one year. The KPS scale as used is shown in Table 1 .
formance Status Scale (KPS). Although the KPS is                    The reliability of the KPS was evaluated two ways.
widely used for assessment of patients with cancer,                 First, scores were assigned to each patient by a nurse
its reliability and validity have generally been assumed            and a social worker independent of each other. During
without formal investigation. In this paper we evaluate             the course of the nurses’ training, simultaneous, in-
the reliability and validity of the KPS and its usefulness          dependent ratings of the same patients by nurses and
as a clinical tool.                                                 physicians proved to be virtually identical; we won-
   An earlier study from this institution of patients on            dered if this finding would hold for patients evaluated
chronic hemodialysis demonstrated lower performance                 at nearly, but not exactly, the same time, by other
scores for patients when seen in the home as com-                   project professionals most directly concerned with
pared with the clinic.3 The conclusion was that a more              evaluating the patients’ status. Both the nurse’s rating
realistic appraisal of activity was possible in the home.           and the social worker’s rating were based on contact
Concurrent home and clinic evaluations were planned                 with the patient either in the clinic or hospital. Second,
as a part of this study.                                            because part of the project involved periodic home
                                                                    visits by the social workers to collect research data, it
  From the Vermont Regional Cancer Center and the Departments       was possible to obtain KPS scores based on contact
of Medicine, Epidemiology and Psychiatry, College of Medicine,
University of Vermont.                                              with the patients in their home environment. The home
  This work was supported by NCI grant R18 17868.                   scores could then be compared with the clinic scores
  Address for reprints: Jerome Yates, MD, Vermont Regional          as a further check on reliability, provided the two
Cancer Center, The University of Vermont College of Medicine,
Burlington, VT 05401.                                               scores were sufficiently close in time. We considered
  Accepted for publication May 2, 1979.                             a difference of one week or less to be sufficiently
                                     0008-543X/80/0415/2220 $0.75 0 American Cancer Society

                                                                 2220
No. 8                                       USING
                           EVALUATION PATIENTS
                                   OF           THE KPS                               . Yates et al.                                     222 1

close for comparison. There were 52 patients for whom                        TABLR Karnofsky Performance Status Scale
                                                                                  1.
two clinic (or hospital) ratings within one week of each          100 Normal, no complaints, no evidence of disease
other were available, and 50 for whom one clinic rating            90 Able to carry on normal activity, minor signs or symptoms
and one home rating within one week of each other                       of disease
                                                                   80 Normal activity with effort, some signs or symptoms of disease
were available.                                                    70 Cares for self. Unable to carry on normal activity or to do
  In addition t o the KPS, data on a number of other                    active work
variables relating to both physical and psychological              60 Requires occasional assistance, but is able to care for most
                                                                        of his needs
status were collected for each patient by the social               50 Requires considerable assistance and frequent medical care
worker through a structured interview. Questions con-              40 Disabled, requires special care and assistance
cerning satisfaction, happiness, and affect were used in           30 Severely disabled, hospitalization is indicated although death
                                                                        not imminent
an attempt to elicit the patient’s own views of various            20 Hospitalization necessary, very sick, active supportive
aspects of their “quality of life.”1-2~4 interview
                                          The                           treatment necessary
format was evolved locally from results of several                 10 Moribund, fatal processes progressing rapidly
                                                                    0 Dead
earlier versions. The two affect variables (positive
and negative) were slightly modified versions of scales
developed by Bradburn based on his model of the
structure of psychological well-being.2 The Pearson                           TABLE . Variables used in Validity Analysis
                                                                                  2
correlations between the KPS and these additional                -~

variables were used to examine the construct validity                    Name                                     Description
of the KPS. For the purpose of this analysis, data                 1. Desire for food         “How has your desire for food been in the
taken from all patients on the project in a single month                                        past few days?”
(April 1978) were used (a total of 52 patients). The ad-           2. Sleep                   “How well have you been sleeping in the past
                                                                                                few nights?” (3-point scale: well, so-so,
ditional variables were described in Table 2.
                                                                                                or poorly)
   Finally for those patients who died during the course           3. Difficulty with         “Have you been having any difficulty
of the project (N = 104), it was possible t o evaluate the              balance                 keeping your balance in the past few
degree to which the KPS was correlated with duration                                            days?” (YesiNo)
                                                                   4. Difficulty on           “Have you been having any difficulty going
of survival. This evaluation was made in terms of both                  stairs                  up and down stairs in the past few days?”
the degree to which initial KPS scores were predictive                                          (YesiNo)
of duration of survival (for all 104 patients) and the             5. Pain level              “If zero is no pain at all, and 100 is more
                                                                                                pain than you could stand, what is your
degree to which successive KPS scores over time                                                 present level of pain?”
reflect the course of patients’ diseases.                          6 . Happiness              “Taken all together, how would you say
   Characteristics of the patient samples used in this                                          things are these days-would you say that
                                                                                                you are very happy, pretty happy, or
paper are given in Table 3. Although there was con-                                             not too happy?”                         (2)
siderable overlap among the various samples, no two of             7 . Positive affect        Number of “Yes” responses to five questions
them were identical; each sample consisted of those                                             about positive feelings experienced in
                                                                                                the past few weeks                      (2)
patients for whom the necessary data were available.               8. Negative affect         Number oT”No“ responses to five questions
                                                                                                about negative feelings experienced in
R e Lia bility                                                                                  the past few weeks                      (2)
                                                                   9. Satisfaction            “Which face (of seven, labeled from
                                                                        with life               delighted to terrible) comes closest to
   Figure 1 shows a scatterplot of the nurse KPS rating                                         expressing how you feel about your life
vs. the social worker ratings, with both ratings taken                                          as a whole?”                            (1)
in the clinic or hospital within one week of each other.          10. Overall                 “What is your estimate of your overall
The Pearson correlation between the two sets of ratings                condition                condition right now, on a scale of zero
                                                                                                 to loo?”
was .69 ( P< .001), indicating a moderate degree of


                                                    3.
                                                TABLE     Patient Characteristics

                                                  Sex                           Age                                 Primary cancer (%)
                            Total
   Reliability sample        no.         Female          Male          Mean              Range              Lung          Breast         Other

Nurse v . social worker      52           23             29            55            (22-82)                52            15             33
Clinic vs. home               50           25             25            59            (28-85)                36            20             44
Val idit y                    52           30             22            59            (37-85)                31            27             42
Deceased patients            104           42             62            57               (22-8 1)            48             6             46
2222                                                            15 1980
                                                          CANCERA~~                                                                Vol. 45

                                                                             being taken within seven days of each other, is shown
                                                                             in Figure 2. Although the Pearson correlation coef-

    ‘80
                                                                             ficient between the home and clinic scores (.66, P
                                                                             < .001) demonstrates a similar degree of interrater re-
                                                                             liability for the two clinic scores, there was a significant
                                                         4..                 tendency for the clinic scores to be greater than the
$
a                                     L.
                                                                             home scores; the average clinic score was over five
                                                                             points higher than the average home score (81 .O vs.
                                           n    n   e
                                                                             75.3, P < .003 by a paired t-test).

                                                                             Validity
                                                                                Table 4 shows correlations (Pearson) between the
                                                                             KPS and other variables for which data were gathered
                                                                             at the same time. The KPS was strongly correlated
                                                                             with the variables most closely related to physical
                                                                             functioning (especially difficulty with balance and
                                                                             difficulty on stairs), and less strongly (but still sig-
       OV     lb    2b    A 40       &I    $0       7b   Bb 40        A      nificantly) correlated with most of the variables related
                   SOCIALWORKER KPS RATING                                   to psychological status. The degree to which the KPS
FIG. 1.   Scatterplot of nurse vs. social worker KPS ratings (N   =   52).   may be useful as a predictor of survival can be seen in
                                                                             Figure 3, which shows a plot of on-study KPS scores
                                                                             vs. duration of survival for the 104 patients who have
interrater reliability. There was no tendency for either
                                                                             died. A graph of the mean KPS scores for deceased
nurses or social workers to rate patients higher; average
                                                                             patients taken at each of seven time points in the final
ratings for the two sets were within a half point of
                                                                             phase of their disease is shown in Figure 4. Because
each other (70.2 for the nurses, 69.7 for the social
                                                                             it was felt that the graph in Figure 4 might appear
workers, with no significant difference as evaluated by
                                                                             different for patients with lung cancer as compared to
a paired t-test). We were unable to discern any tendency
                                                                             other types of cancer, the mean KPS scores for patients
for certain types of patients to show greater disparities
                                                                             with lung cancer over time were compared with those
between the nurse rating and the social worker rating.
                                                                             for patients with other cancers. At each of the seven
   A scatterplot of the clinic KPS ratings vs. the home
                                                                             time points there was no significant difference (by t-test).
KPS ratings, again with the two ratings for each patient
                                                                                                     Discussion
                                                                                Many different measures are currently in use in
                                                                             clinical trials, including indices of disease status,
                                                                             checklists of symptoms, and signs and survival data.
                                                                             Because one of the major concerns of patients with
                                                                             advanced cancer is maintaining independence through
                                                                             self-care, it is desirable to be able to assess the patient’s
                                                                             degree of independent function. Earlier experience led
                                                                             to the KPS assessments done in the home and clinic at
                                                                             about the same time for comparison. Figure 2 indicates
0   40-
                                                                             the KPS at home were often lower than those deter-
z                                                                            mined in the clinic. This probably reflects a tendency for
d    30-
                                                                             patients’ problems to seem less severe outside their
                                                                             home and possibly a tendency for patients to put on a
     20-                                                                     “show” of well-being for clinic staff.“
          -                                                                     Correlations between the KPS and other variables
     10
                                                                             are shown in Table 4. The KPS showed a strong cor-
                                                                             relation with positive affect, but not negative, which
                                                                             suggests an explanation for the pattern of the cor-
                          HOME KPS RATING                                    relations. In a general sample of adults, Bradburn
    FIG.2 . Scatterplot of clinic vs. home KPS ratings (N   =   50).         found that negative affect was strongly associated with
No. 8                         EVALUATION PATIENTS
                                       OF      USINGT H E KPS                          .       Yatrs rt af.                                2223

the level of physical symptoms.2 However, when only                      TAB1.F   4.   Correlations (Pearson) between KPS and
                                                                                       Other Variables (45 5 N 5 49)
those individuals suffering from a physical illness were
considered, the level of symptoms was not correlated                                                                     Correlation
with negative affect. Similarly, having advanced cancer                           Variable                               with KPS*
was a source of negative feelings for all of the pa-                  I . Desire for food                            .40 ( P < .002)
tients in our sample, and it appears that variation in the            2. Sleep                                       .24 ( P < ,050)
degree to which their performance status was com-                     3. Difficulty with balance                     .61 ( P < .001)
                                                                      4. Difficulty with stairs                      .63 ( P < ,001)
promised did not make much difference in how much                     5 . Pain level                               -.37 ( P < ,006)
negative feeling the patients reported. On the other                  6. Happiness                                   . I 2 (not significant)
hand, Bradburn found that positive affect was related                 7. Positive affect                             .54 ( P < ,001)
                                                                      8. Negative affect                           -.09 (not significant)
to participation in novel activities and becoming in-                 9. Satisfaction with life                      .36 ( P < ,007)
volved with one’s environment. For our sample, the                   10. Overall condition                           .39 ( P < .004)
degree to which patients were able to participate in
                                                                   All variables except pain level and negative affect are coded
such activities was largely dependent on their physical
                                                                 +


                                                               such that a higher score represents a higher level of functioning.
status; hence the correlation between positive affect
and the KPS. Thus it is possible that although the
KPS is a useful overall indicator of physical status in        score was not predictive of long-term survival because
a number of aspects, it may not reflect variation in           many of the patients with high initial scores died
psychological status beyond that associated with               quickly. The KPS on Figure 4 reflects the progressive
physical dysfunction. The non-significant correlation          deterioration of patients’ physical condition, with a
of the KPS with happiness and the relatively weak              considerable drop in the last two months of life.
correlations of the KPS with overall condition and pain           The KPS is designed to assess independent function
level (which certainly have both physical and psycho-          and appears to have substantial validity as an indicator
logical bases), support this view.                             of overall physical status. In particular, the association
   It is clear from Figure 3 that for this group of patients   between low KPS scores and shortened life expectancy
a low KPS score was strongly associated with death             suggests that the KPS may be valuable as a stratifica-
within a relatively short time. Only one of the patients       tion variable in randomizing patients for clinical trials.
with an on-study KPS score of less than 50 survived            In addition, improvement in KPS associated with re-
longer than six months. On the other hand, a high KPS          sponse t o treatment can be used as one objective

                                       100              ..        .. . “ .        . .
                                       d                  . ..
                                                             .. . . . .
                                                            ..
                                                                         .....
                                                                                  .....
                                                                    . . . . .. ..... +
                                                                                                              .a
                                                                                                               .
                                                                                                                     a




                                                                                    .. .                                           -a



 FIG.3. Scatterplot of on-study
KPS scores vs. days before death
                                   a
                                   * 5 0                                          .        ..                               .a    ..ow


( N = 104).
                                                                                         ...
                                                                                        ...

                                       lot
                                        d                            1       1             I
                                              6I 6 0I ~ !I 5 4 0 ~ 4 2 0 ~ 3 0 0 2 4 0 l m 1 m06 0
                                                                                                   I      1         1        1         1       I



                                                                         DAYSBEFORE DEATH
C A N C E R A ~ 1980
                                                           15 ~                                                         Vol. 45

     loo   -                                               measure of that response. It does not seem to reflect
                                                           variations in psychological well-being measures, other
     90-                                                   than those associated with physical disability. How-
                                                           ever, its evident validity, reliability, and simplicity
                                                           make it quite helpful as a criterion in clinical trials
     80-
                                                           for patients with cancer, and potentially for patients

-
Lj
ui
+I
     70-
               P           I
                           I                               with other chronic diseases with a fatal outcome.
                                                             The evidence assembled in this study indicates that
                                                           the performance status, long assumed to be a useful
                                                           assessment of function, is in fact a fairly quantitative
     60-                                                   measure with consistency among observers and a close
8    50-                                                   correlation with deterioration in function as measured
                                                           by other quantifiable parameters.
ff
x    40-                                                                             REFERENCES
                                                             1. Andrews, F. M., and Withey, S. B.: Social Indicators of

3
z
     30-
                                                           Well-Being. New York, Plenum Press, 1976.
                                                             2 . Bradburn, N . M.: The Structure of Psychological Well-
                                                           Being. Chicago, Aldine Publishing Company, 1969.
                                                             3 . Brown, T. M., Feins, A., Parke, R. C . , and Paulus, D. A,:
     20-
                                                           Living with long-term home dialysis. A n n . Int. Med. 81:165-
                                                           170, 1974.
      1
      0    -                                                 4. Chalmer, B. J : Measuring “Quality of Life“ in Patients with
                                                           Advanced Cancer. Master’s thesis, U. of Vermont, 1978.
                                                             5. Karnofskv, D. A., and Burchenal, J. If.: The clinical evaluation
           I                       I   I   I      I    1
                   I   I       I                           of chemotherapeutic agents in cancer. In Evaluation of chemo-

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Kps and cancer patients

  • 1. Evaluation of Patients with Advanced Cancer Using the Karnofsky Performance Status JEROME W. YATES, MD, BRUCE CHALMER, MS, F. PATRICK McKEGNEY, MD The Karnofsky Performance Status Scale (KPS) was designed to measure the level of patient activity and medical care requirements. It is a general measure of patient independence and has been widely used as a general assessment of patients with cancer. Although there is a long history of use of the KPS for judging cancer patients, its reliability and validity have been assumed without formal investigation. The interrater reliability of the KPS was investigated in two ways, both of which gave evidence of moder- ately high reliability. The patients evaluated in their home were usually assigned a lower KPS score com- pared with a similar evaluation at the same time done in the outpatient clinic. Construct validity of the KPS was demonstrated by strong correlation with several variables relating to physical function. On- study KPS scores accurately predicted early death, but high initial KPS scores did not necessarily predict long survival. Patient deterioration with subsequent death within a few months could be predicted to a limited extent by a rapidly dropping KPS. These results suggest that the KPS has considerable validity as a global indicator of the functional status of patients with cancer and might be helpful for following other patients with chronic disease. Cancer 45:2220-2224, 1980. W I T H T H E INCREASE in clinical trials designed to evaluate chemotherapeutic agents in the treat- ment of cancer, it became evident that some method Methods A group of patients with advanced cancer, all of whom were being followed as part of the Cancer of quantifying patients’ status relative to degree of in- Rehabilitation Project at the Vermont Regional Cancer dependence in carrying out normal activities and self- Center, were assigned KPS scores at the time of their care was needed. In 1948, Karnofsky and Burchena15 admission to the project.6 One criterion for admission described a numerical scale for this purpose. This has to the study was a probable survival of three months subsequently become known as the Karnofsky Per- to one year. The KPS scale as used is shown in Table 1 . formance Status Scale (KPS). Although the KPS is The reliability of the KPS was evaluated two ways. widely used for assessment of patients with cancer, First, scores were assigned to each patient by a nurse its reliability and validity have generally been assumed and a social worker independent of each other. During without formal investigation. In this paper we evaluate the course of the nurses’ training, simultaneous, in- the reliability and validity of the KPS and its usefulness dependent ratings of the same patients by nurses and as a clinical tool. physicians proved to be virtually identical; we won- An earlier study from this institution of patients on dered if this finding would hold for patients evaluated chronic hemodialysis demonstrated lower performance at nearly, but not exactly, the same time, by other scores for patients when seen in the home as com- project professionals most directly concerned with pared with the clinic.3 The conclusion was that a more evaluating the patients’ status. Both the nurse’s rating realistic appraisal of activity was possible in the home. and the social worker’s rating were based on contact Concurrent home and clinic evaluations were planned with the patient either in the clinic or hospital. Second, as a part of this study. because part of the project involved periodic home visits by the social workers to collect research data, it From the Vermont Regional Cancer Center and the Departments was possible to obtain KPS scores based on contact of Medicine, Epidemiology and Psychiatry, College of Medicine, University of Vermont. with the patients in their home environment. The home This work was supported by NCI grant R18 17868. scores could then be compared with the clinic scores Address for reprints: Jerome Yates, MD, Vermont Regional as a further check on reliability, provided the two Cancer Center, The University of Vermont College of Medicine, Burlington, VT 05401. scores were sufficiently close in time. We considered Accepted for publication May 2, 1979. a difference of one week or less to be sufficiently 0008-543X/80/0415/2220 $0.75 0 American Cancer Society 2220
  • 2. No. 8 USING EVALUATION PATIENTS OF THE KPS . Yates et al. 222 1 close for comparison. There were 52 patients for whom TABLR Karnofsky Performance Status Scale 1. two clinic (or hospital) ratings within one week of each 100 Normal, no complaints, no evidence of disease other were available, and 50 for whom one clinic rating 90 Able to carry on normal activity, minor signs or symptoms and one home rating within one week of each other of disease 80 Normal activity with effort, some signs or symptoms of disease were available. 70 Cares for self. Unable to carry on normal activity or to do In addition t o the KPS, data on a number of other active work variables relating to both physical and psychological 60 Requires occasional assistance, but is able to care for most of his needs status were collected for each patient by the social 50 Requires considerable assistance and frequent medical care worker through a structured interview. Questions con- 40 Disabled, requires special care and assistance cerning satisfaction, happiness, and affect were used in 30 Severely disabled, hospitalization is indicated although death not imminent an attempt to elicit the patient’s own views of various 20 Hospitalization necessary, very sick, active supportive aspects of their “quality of life.”1-2~4 interview The treatment necessary format was evolved locally from results of several 10 Moribund, fatal processes progressing rapidly 0 Dead earlier versions. The two affect variables (positive and negative) were slightly modified versions of scales developed by Bradburn based on his model of the structure of psychological well-being.2 The Pearson TABLE . Variables used in Validity Analysis 2 correlations between the KPS and these additional -~ variables were used to examine the construct validity Name Description of the KPS. For the purpose of this analysis, data 1. Desire for food “How has your desire for food been in the taken from all patients on the project in a single month past few days?” (April 1978) were used (a total of 52 patients). The ad- 2. Sleep “How well have you been sleeping in the past few nights?” (3-point scale: well, so-so, ditional variables were described in Table 2. or poorly) Finally for those patients who died during the course 3. Difficulty with “Have you been having any difficulty of the project (N = 104), it was possible t o evaluate the balance keeping your balance in the past few degree to which the KPS was correlated with duration days?” (YesiNo) 4. Difficulty on “Have you been having any difficulty going of survival. This evaluation was made in terms of both stairs up and down stairs in the past few days?” the degree to which initial KPS scores were predictive (YesiNo) of duration of survival (for all 104 patients) and the 5. Pain level “If zero is no pain at all, and 100 is more pain than you could stand, what is your degree to which successive KPS scores over time present level of pain?” reflect the course of patients’ diseases. 6 . Happiness “Taken all together, how would you say Characteristics of the patient samples used in this things are these days-would you say that you are very happy, pretty happy, or paper are given in Table 3. Although there was con- not too happy?” (2) siderable overlap among the various samples, no two of 7 . Positive affect Number of “Yes” responses to five questions them were identical; each sample consisted of those about positive feelings experienced in the past few weeks (2) patients for whom the necessary data were available. 8. Negative affect Number oT”No“ responses to five questions about negative feelings experienced in R e Lia bility the past few weeks (2) 9. Satisfaction “Which face (of seven, labeled from with life delighted to terrible) comes closest to Figure 1 shows a scatterplot of the nurse KPS rating expressing how you feel about your life vs. the social worker ratings, with both ratings taken as a whole?” (1) in the clinic or hospital within one week of each other. 10. Overall “What is your estimate of your overall The Pearson correlation between the two sets of ratings condition condition right now, on a scale of zero to loo?” was .69 ( P< .001), indicating a moderate degree of 3. TABLE Patient Characteristics Sex Age Primary cancer (%) Total Reliability sample no. Female Male Mean Range Lung Breast Other Nurse v . social worker 52 23 29 55 (22-82) 52 15 33 Clinic vs. home 50 25 25 59 (28-85) 36 20 44 Val idit y 52 30 22 59 (37-85) 31 27 42 Deceased patients 104 42 62 57 (22-8 1) 48 6 46
  • 3. 2222 15 1980 CANCERA~~ Vol. 45 being taken within seven days of each other, is shown in Figure 2. Although the Pearson correlation coef- ‘80 ficient between the home and clinic scores (.66, P < .001) demonstrates a similar degree of interrater re- liability for the two clinic scores, there was a significant 4.. tendency for the clinic scores to be greater than the $ a L. home scores; the average clinic score was over five points higher than the average home score (81 .O vs. n n e 75.3, P < .003 by a paired t-test). Validity Table 4 shows correlations (Pearson) between the KPS and other variables for which data were gathered at the same time. The KPS was strongly correlated with the variables most closely related to physical functioning (especially difficulty with balance and difficulty on stairs), and less strongly (but still sig- OV lb 2b A 40 &I $0 7b Bb 40 A nificantly) correlated with most of the variables related SOCIALWORKER KPS RATING to psychological status. The degree to which the KPS FIG. 1. Scatterplot of nurse vs. social worker KPS ratings (N = 52). may be useful as a predictor of survival can be seen in Figure 3, which shows a plot of on-study KPS scores vs. duration of survival for the 104 patients who have interrater reliability. There was no tendency for either died. A graph of the mean KPS scores for deceased nurses or social workers to rate patients higher; average patients taken at each of seven time points in the final ratings for the two sets were within a half point of phase of their disease is shown in Figure 4. Because each other (70.2 for the nurses, 69.7 for the social it was felt that the graph in Figure 4 might appear workers, with no significant difference as evaluated by different for patients with lung cancer as compared to a paired t-test). We were unable to discern any tendency other types of cancer, the mean KPS scores for patients for certain types of patients to show greater disparities with lung cancer over time were compared with those between the nurse rating and the social worker rating. for patients with other cancers. At each of the seven A scatterplot of the clinic KPS ratings vs. the home time points there was no significant difference (by t-test). KPS ratings, again with the two ratings for each patient Discussion Many different measures are currently in use in clinical trials, including indices of disease status, checklists of symptoms, and signs and survival data. Because one of the major concerns of patients with advanced cancer is maintaining independence through self-care, it is desirable to be able to assess the patient’s degree of independent function. Earlier experience led to the KPS assessments done in the home and clinic at about the same time for comparison. Figure 2 indicates 0 40- the KPS at home were often lower than those deter- z mined in the clinic. This probably reflects a tendency for d 30- patients’ problems to seem less severe outside their home and possibly a tendency for patients to put on a 20- “show” of well-being for clinic staff.“ - Correlations between the KPS and other variables 10 are shown in Table 4. The KPS showed a strong cor- relation with positive affect, but not negative, which suggests an explanation for the pattern of the cor- HOME KPS RATING relations. In a general sample of adults, Bradburn FIG.2 . Scatterplot of clinic vs. home KPS ratings (N = 50). found that negative affect was strongly associated with
  • 4. No. 8 EVALUATION PATIENTS OF USINGT H E KPS . Yatrs rt af. 2223 the level of physical symptoms.2 However, when only TAB1.F 4. Correlations (Pearson) between KPS and Other Variables (45 5 N 5 49) those individuals suffering from a physical illness were considered, the level of symptoms was not correlated Correlation with negative affect. Similarly, having advanced cancer Variable with KPS* was a source of negative feelings for all of the pa- I . Desire for food .40 ( P < .002) tients in our sample, and it appears that variation in the 2. Sleep .24 ( P < ,050) degree to which their performance status was com- 3. Difficulty with balance .61 ( P < .001) 4. Difficulty with stairs .63 ( P < ,001) promised did not make much difference in how much 5 . Pain level -.37 ( P < ,006) negative feeling the patients reported. On the other 6. Happiness . I 2 (not significant) hand, Bradburn found that positive affect was related 7. Positive affect .54 ( P < ,001) 8. Negative affect -.09 (not significant) to participation in novel activities and becoming in- 9. Satisfaction with life .36 ( P < ,007) volved with one’s environment. For our sample, the 10. Overall condition .39 ( P < .004) degree to which patients were able to participate in All variables except pain level and negative affect are coded such activities was largely dependent on their physical + such that a higher score represents a higher level of functioning. status; hence the correlation between positive affect and the KPS. Thus it is possible that although the KPS is a useful overall indicator of physical status in score was not predictive of long-term survival because a number of aspects, it may not reflect variation in many of the patients with high initial scores died psychological status beyond that associated with quickly. The KPS on Figure 4 reflects the progressive physical dysfunction. The non-significant correlation deterioration of patients’ physical condition, with a of the KPS with happiness and the relatively weak considerable drop in the last two months of life. correlations of the KPS with overall condition and pain The KPS is designed to assess independent function level (which certainly have both physical and psycho- and appears to have substantial validity as an indicator logical bases), support this view. of overall physical status. In particular, the association It is clear from Figure 3 that for this group of patients between low KPS scores and shortened life expectancy a low KPS score was strongly associated with death suggests that the KPS may be valuable as a stratifica- within a relatively short time. Only one of the patients tion variable in randomizing patients for clinical trials. with an on-study KPS score of less than 50 survived In addition, improvement in KPS associated with re- longer than six months. On the other hand, a high KPS sponse t o treatment can be used as one objective 100 .. .. . “ . . . d . .. .. . . . . .. ..... ..... . . . . .. ..... + .a . a .. . -a FIG.3. Scatterplot of on-study KPS scores vs. days before death a * 5 0 . .. .a ..ow ( N = 104). ... ... lot d 1 1 I 6I 6 0I ~ !I 5 4 0 ~ 4 2 0 ~ 3 0 0 2 4 0 l m 1 m06 0 I 1 1 1 1 I DAYSBEFORE DEATH
  • 5. C A N C E R A ~ 1980 15 ~ Vol. 45 loo - measure of that response. It does not seem to reflect variations in psychological well-being measures, other 90- than those associated with physical disability. How- ever, its evident validity, reliability, and simplicity make it quite helpful as a criterion in clinical trials 80- for patients with cancer, and potentially for patients - Lj ui +I 70- P I I with other chronic diseases with a fatal outcome. The evidence assembled in this study indicates that the performance status, long assumed to be a useful assessment of function, is in fact a fairly quantitative 60- measure with consistency among observers and a close 8 50- correlation with deterioration in function as measured by other quantifiable parameters. ff x 40- REFERENCES 1. Andrews, F. M., and Withey, S. B.: Social Indicators of 3 z 30- Well-Being. New York, Plenum Press, 1976. 2 . Bradburn, N . M.: The Structure of Psychological Well- Being. Chicago, Aldine Publishing Company, 1969. 3 . Brown, T. M., Feins, A., Parke, R. C . , and Paulus, D. A,: 20- Living with long-term home dialysis. A n n . Int. Med. 81:165- 170, 1974. 1 0 - 4. Chalmer, B. J : Measuring “Quality of Life“ in Patients with Advanced Cancer. Master’s thesis, U. of Vermont, 1978. 5. Karnofskv, D. A., and Burchenal, J. If.: The clinical evaluation I I I I I 1 I I I of chemotherapeutic agents in cancer. In Evaluation of chemo-