Classification system
ECOG Classification
ECOG Performance Status
The ECOG Performance Status grades a patient’s functional capacity from 0, fully active, to 4, completely disabled and confined to bed or chair, with 5 denoting death — and in orthopaedic oncology it is the single figure that most often decides whether a metastatic lesion is worth fixing.
What the ECOG category means
ECOG scores run from 0 to 5, where a lower score is better. The bands below are conventional reporting categories, not diagnostic cut-offs.
- Independent0–1
Working or capable of work. Reconstruction that is expected to last is generally worth the morbidity.
- Self-caring2–2
The boundary grade. It is where most systemic-treatment eligibility criteria are drawn and where surgical judgement is most finely balanced.
- Dependent3–5
Surgery is generally confined to what is needed for pain control, nursing care or an impending catastrophic fracture.
Published criteria and reliability
The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.
| Type | Value | Subscale | Population | Follow-up | Source |
|---|---|---|---|---|---|
| Criterion | Grade 2 versus grade 3 is set by whether the patient is up and about more than half of waking hours | — | Adults with cancer | — | Oken MM 1982 |
| Criterion | ECOG and Karnofsky performance status correlate but are not interchangeable; each ECOG grade spans a range of Karnofsky percentages | — | Adults with cancer assessed on both scales | — | Conill C 1990 |
Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.
How the score is calculated
Stated in full so the calculation can be independently checked, and reproduced by hand if needed.
A single grade is assigned by the clinician on a six-point scale. Grade 0 is fully active with no restriction on pre-disease activity. Grade 1 is restriction of physically strenuous activity, with the patient ambulatory and able to do light or sedentary work. Grade 2 is ambulatory and capable of all self-care but unable to work, up and about more than half of waking hours. Grade 3 is capable of only limited self-care, confined to a bed or chair more than half of waking hours. Grade 4 is completely disabled, incapable of any self-care and totally confined to bed or chair. Grade 5 is dead, included because the scale was designed as a trial data field. The distinction between grades 2 and 3 rests on the proportion of waking hours spent up and about rather than on a list of activities, and it is the boundary that most often changes a treatment decision. The scale is not the Karnofsky Performance Status: the two correlate but each ECOG grade covers a range of Karnofsky percentages, so converting between them loses information and should be stated when it is done.
Instrument profile
- Developer
- Marvin M. Oken and colleagues for the Eastern Cooperative Oncology Group; originally proposed by C. Gordon Zubrod
- Institution
- Eastern Cooperative Oncology Group, United States
- First published
- 1982
- Custodian
- ECOG-ACRIN Cancer Research Group
- Items
- 1
- Response format
- A single clinician-assigned grade from 0 to 5
- Score range
- 0 to 5
- Direction
- Lower score = better
- Completion time
- About 1 minutes
- Age range
- Adults
- Regions
- General Health
- Conditions
- Metastatic bone disease, Pathological fracture, Spinal metastasis, Primary bone tumour, Advanced cancer
- Procedures
- Prophylactic fixation of a metastatic lesion, Spinal instrumentation for metastasis, Endoprosthetic reconstruction, Palliative radiotherapy
- Validity
- One of the most consistently reproduced prognostic variables in oncology, and an input to the orthopaedic decision frameworks for metastatic disease. In the surgical setting its value is that it summarises what a patient will tolerate and how long they are likely to need the reconstruction to last.
- Reliability
- Agreement between observers is moderate and concentrated at the boundaries, particularly 1 versus 2 and 2 versus 3. Clinicians consistently rate patients as more able than patients rate themselves, so a patient-reported grade and a clinician-assigned grade are not the same measurement.
When to use the ECOG
Well suited to
- Deciding whether to fix a metastatic lesion prophylactically, alongside the Mirels score and the expected survival.
- Deciding whether to instrument a spine affected by tumour, alongside the SINS assessment of stability.
- Documenting baseline function in a referral to or from an oncology service, where it is the expected shorthand.
Limitations and poor fits
- As a measure of the limb or joint. It is a global functional grade; an orthopaedic outcome measure records what the affected part can do.
- Interchangeably with the Karnofsky scale without saying so.
- Graded during an acute event without also recording the pre-event baseline — a patient bed-bound by a painful pathological fracture may return to independence once it is fixed.
- As the sole basis for withholding surgery. Pain control and the ability to be nursed are legitimate indications at any grade.
ECOG compared with other instruments
Instruments measuring a related construct, with the practical difference between them.
| Instrument | Items | Range | What it adds |
|---|---|---|---|
| Mirels | 4 | 4–12 | Mirels' score estimates the risk of pathological fracture through a long bone metastasis by scoring four variables — site, pain, radiographic appearance and lesion size — from 1 to 3 each, giving a total from 4 to 12, where 9 or more is the conventional threshold for prophylactic fixation. |
| SINS | 6 | 0–18 | The Spinal Instability Neoplastic Score grades the mechanical stability of a spine affected by tumour by adding six components — location, mechanical pain, lesion quality, alignment, vertebral body collapse and posterolateral involvement — to a total from 0 to 18, where 0 to 6 is stable, 7 to 12 is indeterminate and 13 to 18 is unstable, and any total of 7 or more warrants surgical consultation. |
| ASA | 2 | 1–6 | The ASA Physical Status Classification grades a patient’s pre-operative systemic health from I, a normal healthy patient, to VI, a declared brain-dead organ donor, with an E modifier added for emergency procedures. |
| CCI | 17 | 0–37 | The Charlson Comorbidity Index is a weighted checklist of 16 comorbid conditions that produces a comorbidity score of 0 to 33, to which up to 4 points are added for age, and which estimates 10-year survival at roughly 98% for a total of 0, 90% for 2, 53% for 4 and 21% for 5. |
| PROMIS Global-10 | 10 | 16.2–67.7 | The PROMIS Global-10 is a 10-item general health questionnaire that yields two four-item summary scores — Global Physical Health and Global Mental Health — each reported as a T-score calibrated to the United States general population, where 50 is the population mean, 10 points is one standard deviation, and higher scores indicate better health. |
Copyright and permitted use
Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.
A published grading scale, reproduced universally in oncology practice, trials and registries with no licensing programme. No licence is required; attribution to the Eastern Cooperative Oncology Group is expected.
References
- Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP. Toxicity and response criteria of the Eastern Cooperative Oncology Group. American Journal of Clinical Oncology. 1982.
- Conill C, Verger E, Salamero M. Performance status assessment in cancer patients. Cancer. 1990.
Editorial status
This page has not yet been signed off by a named clinical reviewer. The scoring logic is stated in full above so it can be independently verified, and every threshold is traceable to its source. See our editorial methodology.