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When you have mesothelioma or another cancer related to asbestos exposure, you will be receiving treatment and care from multiple health care providers. Different types of specialists may be involved in your care, in addition to other types of healthcare providers such as nurses, hospitals, and other facilities. When a mesothelioma patient is receiving care and health care providers want to be able to have an understanding of how the patient is doing. While each specialist might have particular questions for the patient or concerns about specific symptoms and abilities, overall, the mesothelioma patient’s health care team will want to have a more objective understanding of how the patient is fairing on a day-to-day basis, and whether the patient requires assistance with normal activities that a person without mesothelioma would be able to do. This is known as a patient’s “performance status,” or PS for short.
Health care providers want to know a patient’s performance status so that they can have a better understanding of the types of treatments a patient may be able to have (or not have), including whether the patient is physically able to have treatments like chemotherapy or radiation, or whether the patient may be physically able to participate in a clinical trial. A patient’s performance status can also be used to determine whether the patient is physically able to have a surgical procedure conducted. The scales range from PS 0 to PS 4, with a patient at PS 0 being in the best condition and a patient at PS 4 being in the worst condition. Patients at PS 0 can conduct all activities of daily living (ADLs) on their own, while a person at PS 4 needs assistance with any and all ADLs. The following information can help to clarify how health care providers rate a patient’s performance status, what is involved in different performance status classifications, how health care providers understand activities of daily living, and why a patient’s performance status is so essential for obtaining care when you have malignant mesothelioma.
What is a Patient’s Performance Status?
The JAMA Network explains that a patient’s performance status is “an important part of cancer care and treatment.” The JAMA Network clarifies that a patient’s performance status can be classified from 0 to 4, with 0 being the most able and 4 being the least able. This performance status scale is also known as the Zubrod Scale. A patient’s performance status can also be classified from 100 to 10, with 100 being the most physically able and 10 being the least physically able. This performance status scale is known as the Karnofsky Scale. How do each of these scales work, and what kind of information do they give health care providers about a patient’s abilities to withstand certain treatments and to perform activities of daily living?
The Zubrod Scale, while classifies a patient’s performance status from 0 to 4, works like this:
- 0 = Normal activity, meaning that a patient can engage in all normal activities and does not show any signs of physical or mental issues that would interfere with their ability to perform regular day-to-day activities, including all activities of daily living (although it is possible that minor symptoms are present;
- 1 = Symptomatic and ambulatory but cares for self, meaning that the patient does have noticeable symptoms but is able to move around on their own and is generally able to care for themselves, but needs assistance with some activities of daily living;
- 2 = Ambulatory more than 50 percent of the time and requires occasional assistance moving around, meaning that the patient is only able to move around on their own about half of the time and otherwise requires assistance moving around, and requires help with most activities of daily living;
- 3 = Ambulatory less than 50 percent of the time and nursing care needed, meaning that the patient needs a significant amount of help moving around (such as getting out of bed), requires help with all activities of daily living, and may be anywhere from disabled to severely disabled; and
- 4 = Bedridden, or completely unable to move around, and may be near death.
Another scale that can be used to identify a patient’s performance status is known as the Karnofsky Scale. The Karnofsky Scale classifies a patient’s performance status from 100 to 10, and it works like this:
- 100 = Patient is normal and does now show any evidence of disease;
- 90 = Patient has minor symptoms but is able to perform all of their normal activities;
- 80 = Patient has symptoms but, with effort, can perform their normal activities;
- 70 = Patient has difficulty performing normal activities but is able to care for themselves;
- 60 = Patient requires some assistance but is generally able to care for themselves and to perform activities of daily living;
- 50 = Patient requires a significant amount of assistance performing activities of daily living;
- 40 = Patient is disabled and requires extensive assistance;
- 30 = Patient is severely disabled and requires full assistance with all activities of daily living;
- 20 = Patient is very sick and requires “active support treatment”; and
- 10 = Patient is near death.
According to the JAMA Network, the Zubrod Scale and the Karnofsky Scale correspond with one another at different points:
- 0 on the Zubrod Scale = 100-90 on the Karnofsky Scale;
- 1 on the Zubrod Scale = 80-70 on the Karnofsky Scale;
- 2 on the Zubrod Scale = 60 on the Karnofsky Scale;
- 3 on the Zubrod Scale = 50-30 on the Karnofsky Scale; and
- 4 on the Zubrod Scale = 20-10 on the Karnofsky Scale.
What Are Activities of Daily Living?
What are activities of daily living? Activities of daily living, or ADLs, help to measure a person’s abilities and functions. The term “activities of daily living” were used first in 1950 by Sidney Katz, the person who developed the Katz ADL scale that is used to evaluate a person’s ability to complete activities of daily living. There are now other assessment methods, as well, including the Barthel ADL Index and the Roper-Logan-Tierney model.
There are two different types of activities of daily living: basic ADLs and instrumental ADLs. Basic ADLs are necessary for daily survival, while instrumental ADLs involve social and emotional functioning.
Basic activities of daily living are any activities that a person must undertake on a daily basis in order to live a life. In general activities of daily living usually include the following:
- Personal hygiene ADLs, including bathing, brushing your teeth and flossing, brushing or combing your hair, and any other grooming tasks;
- Dressing, including selecting clothes to wear, putting them on, and changing out of clothes before bed;
- Eating and drinking, including whether a person can eat or drink on their own or whether they need assistance;
- Ambulatory ADLs, include a person’s ability to move from one location to another, and to walk from one area to another without assistance; and
- Continence-related ADLs include a person’s ability to use the bathroom.
Instrumental ADLs may include, for example:
- Providing companionship;
- Taking care of a household;
- Shopping; and
- Handling finances.
Why a Patient’s Performance Status Matters
The JAMA Network explains that there are a wide variety of factors that can influence a person’s ability to respond to cancer treatments, including mesothelioma. Some of those factors include, for example, the person’s age, the stage of their cancer, and the person’s other underlying conditions. While these factors certainly play a role in the way health care providers consider a patient’s ability to undergo certain treatments and to respond to those treatments, one of the best factors to use is a patient’s performance status. Indeed. The JAMA Network says “PS is one of the most important variables,” and a patient’s PS “is more important than a patient’s actual age in predicting how a patient is likely to do.”
Why is a patient’s PS so critical when the patient has been diagnosed with malignant mesothelioma or another asbestos-related cancer? In sum, as the JAMA Network underscores, “patients who have a worse PS and limited functional capacity tend to have more difficulty tolerating rigorous cancer treatments,” and “these patients have less favorable outcomes than more fit patients with better PS, regardless of the treatments given.”
In addition, a patient’s performance status can determine whether that patient is eligible to receive treatments through or to participate in clinical trials. Generally speaking, clinical trials are only available for patients who have a PS of 0 or 1 on the Zubrod Scale, or a 100 to 70 on the Karnofsky Scale. Patients who have worse performance status ratings or classifications will likely be ineligible for clinical trials, and they also are likely to be ineligible to receive more common treatments like chemotherapy, radiation, or surgery. Indeed, “the risks of using certain treatments in low-PS patients may far exceed the benefits.”
A patient’s PS will often change over time, and the PS usually worsens as the cancer advances or as the patient experiences side effects from cancer treatment. At the same time, when a patient has severely limited symptoms due to cancer, or when a low PS level is caused by cancer itself, various forms of treatment may be able to improve the patient’s performance status and could make the patient eligible for certain clinical trials.