title: Trajectory of performance status and symptom scores for patients with cancer during the last six months of life.
abstract: OBJECTIVE
  Ontario's cancer system is unique because it has implemented two standardized assessment tools population-wide to improve care: the Edmonton Symptom Assessment System (ESAS) measures severity of nine symptoms (scale 0 to 10; 10 indicates the worst) and the Palliative Performance Scale (PPS) measures performance status (scale 0 to 100; 0 indicates death). This article describes the trajectory of ESAS and PPS scores 6 months before death.
  
  
  METHODS
  Observational cohort study of cancer decedents between 2007 and 2009. Decedents required ≥1 ESAS or PPS assessment in the 6 months before death for inclusion. Outcomes were the decedents' average ESAS and PPS scores per week before death.
  
  
  RESULTS
  Ten thousand seven hundred fifty-two (ESAS) and 7,882 (PPS) decedents were included. The mean age was 65 years, half were female, and approximately 75% of assessments occurred in cancer clinics. Average PPS score declined slowly over the 6 months before death, starting at approximately 70 and ending at 40, declining more rapidly in the last month. For ESAS symptoms, average pain, nausea, anxiety, and depression scores remained relatively stable over the 6 months. Conversely, shortness of breath, drowsiness, well-being, lack of appetite, and tiredness increased in severity over time, particularly in the month before death. More than one third of the cohort reported moderate to severe scores (ie, 4 to 10) for most symptoms in the last month of life.
  
  
  CONCLUSIONS
  In this large outpatient cancer population, trajectories of mean ESAS scores followed two patterns: increasing versus generally flat. The latter was perhaps due to available treatment (eg, prescriptions) for those symptoms. Future research should prioritize addressing symptoms that worsen over time.
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. seowh@mcmaster.ca
authors.forename: Hsien
authors.initials: H
authors.lastname: Seow
authors.forename: Lisa
authors.initials: L
authors.lastname: Barbera
authors.forename: Rinku
authors.initials: R
authors.lastname: Sutradhar
authors.forename: Doris
authors.initials: D
authors.lastname: Howell
authors.forename: Deborah
authors.initials: D
authors.lastname: Dudgeon
authors.forename: Clare
authors.initials: C
authors.lastname: Atzema
authors.forename: Ying
authors.initials: Y
authors.lastname: Liu
authors.forename: Amna
authors.initials: A
authors.lastname: Husain
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sussman
authors.forename: Craig
authors.initials: C
authors.lastname: Earle
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001007:Anxiety / Q000209:etiology; D003863:Depression / Q000209:etiology; D004417:Dyspnea / Q000209:etiology; D005221:Fatigue / Q000209:etiology; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications / Q000453:epidemiology / Q000523:psychology*; D009864:Ontario / Q000453:epidemiology; D010166:Palliative Care; D011788:Quality of Life; D012720:Severity of Illness Index; D018434:Sickness Impact Profile; D013315:Stress, Psychological / Q000209:etiology*; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult