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Performance Status and Symptom Scores of Women With Gynecologic Cancer at the End of Life
  1. Lori Spoozak, MD, MHS*,
  2. Hsien Seow, PhD,,§,
  3. Ying Liu, MSc§,
  4. Jason Wright, MD and
  5. Lisa Barbera, MD§,,#,**
  1. *Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Women’s Health, Albert Einstein College of Medicine, Bronx, NY;
  2. Department of Oncology, McMaster University, and
  3. Supportive Cancer Care Research Unit, Hamilton;
  4. §Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada;
  5. Department of Obstetrics & Gynecology, Columbia University College of Physicians & Surgeons, Division of Gynecologic Oncology, New York, NY;
  6. Department of Radiation Oncology and
  7. #Institute of Health Policy, Management and Evaluation, University of Toronto; and
  8. **Department of Radiation Oncology, Odette Cancer Centre, Toronto, Ontario, Canada.
  1. Address correspondence and reprint requests to Lisa Barbera, MD, Department of Radiation Oncology, Odette Cancer Centre, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5. E-mail: lisa.barbera{at}
  1. This study was presented at the 14th Biennial Meeting of the International Gynecologic Cancer Society, October 13 to 16, 2012, in Vancouver, British Columbia, Canada.


Objective The Palliative Performance Scale (PPS), which measures performance status (100 = best performance to 0 = dead), and the Edmonton Symptom Assessment System (ESAS), which measures severity of 9 symptoms, are routinely collected at ambulatory cancer visits in Ontario. This study describes the trajectory of scores in patients with gynecologic cancer in the last 6 months of life.

Methods An observational study was conducted between 2007 and 2010. Patients had ovarian/fallopian tube, uterine, and cervical cancer and required 1 or more PPS or ESAS assessment in the 6 months before death. Outcomes were the average PPS and ESAS scores per week before death. Using logistic regression, we analyzed the odds ratio of reporting a moderate to severe score for each symptom.

Results Seven hundred ninety-five (PPS) and 1299 (ESAS) patients were included. The average PPS score started at 70 and ended at 30, rapidly declining in the last 2 months. For ESAS symptoms, drowsiness, decreased well-being, lack of appetite, and tiredness increased in severity closer to death and were prevalent in more than 70% of patients in the last week of life. Patients with cervical cancer had increased odds of moderate to severe pain (1.74; 95% confidence interval, 1.30–2.32) compared with ovarian cancer.

Conclusions Trajectories of mean performance status had not reached the “end-of-life” phase until 1 week before death. A large proportion of the gynecologic cancer patients reported moderate to severe symptom scores as death approached. Pain was uniquely elevated in the cervical cancer cohort as death approached. Adequately managing the symptom burden appears to be a significant issue in end-of-life gynecologic care.

  • Symptoms
  • Performance status
  • End-of-life
  • Gynecologic cancer

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  • This study was conducted with the support of the Ontario Institute for Cancer Research through funding provided by the Government of Ontario. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-term Care (MOHLTC).

  • The authors declare no conflicts of interest.