Rogerio C. Lilenbaum, MD
During the past year, a new treatment paradigm has been validated for patients with advanced non-small cell lung cancer (NSCLC) and performance status 2 (PS2) who traditionally have been considered a “special population” unlikely to benefit from chemotherapy.
Yet accurately assessing patients’ performance status remains a challenge. And, some leading oncologists argue, it is time to stop labeling as “special” a group of patients who do have treatment options and who constitute a large proportion of those diagnosed with advanced disease.
Those were among the points that Rogerio C. Lilenbaum, MD, made during a presentation at the 7th Annual New York Lung Cancer Symposium November 10 in New York City, a one-day gathering hosted by Physicians’ Education Resource.
Lilenbaum has been studying therapies for patients classified as “special populations,” including the elderly and those with PS2 status, for more than a decade. As a thoracic oncologist in Miami Beach, Florida, Lilenbaum led a groundbreaking clinical trial that established the chemotherapy doublet of carboplatin and pemetrexed (Alimta) as an effective and superior treatment regimen for patients with PS2 status.
Lilenbaum has served since 2011 as chair of the Cancer Institute at the Cleveland Clinic in Weston, Florida, and previously worked as director of the Thoracic Oncology Program at Mount Sinai Medical Center in Miami Beach.
In January, Lilenbaum is scheduled to become chief medical officer of the Smilow Cancer Hospital at Yale- New Haven in Connecticut.
Lilenbaum began his presentation at the PER symposium by stressing the proportion of patients assessed as PS2.
“This is a heterogeneous group of patients,” said Lilenbaum. “A lot of different people fall into this designation of performance status 2. It is, however, a pretty significant percentage of our practice, at least 30%, if not 40% in some studies, depending on where they come fromâŽ¯if it’s ambulatory versus hospital, if it’s all lung cancer versus non-small cell. But it’s not an insignificant component of anybody’s practice for people who deal with lung cancer.”
An underlying question concerning research studies and management of patients with PS2 is whether they have been accurately assessed. Under the Eastern Cooperative Oncology Group (ECOG) scale, a PS2 patient is defined as one who is “ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.”1
“We’re not very good at assessing performance status,” said Lilenbaum. “Even though a scale has been available and has been widely known for over three to four decades, we don’t always utilize that scale very well in clinical practice.”
He noted, for example, that PS2 patients could be misclassified as either PS1 or PS3 in practice and research. “What is really a performance status 2 patient? They’re not the patients who come in on a stretcher, those who come in with the oxygen tank, and are wheelchairbound, and can’t really get up from the chair to the exam table. Those are not performance status 2 patients, and that’s a misconception that we’ve all had to deal with for a long time. These individuals are ambulatory. They’re capable of all self-care. They just can’t work. That’s the difference between PS2 and PS1,” Lilenbaum said.
Lilenbaum said there is a need for a formal instrument that results in a quantifiable metric with a reproducible result. He said that, beyond the traditional ECOG criteria, he uses an abbreviated form of a geriatric assessment test.
Mark G. Kris, MD
Mark G. Kris, MD, chief of the Thoracic Oncology Service at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City and a program director of the PER symposium, said the clinical assessment of a patient’s performance status should be detailed.
“You have to ask the questions that tell you how to determine performance status,” he said in an interview. “You have to ask, ‘Can you go to work? What activities can you do at home or can’t do?’ You have to specifically ask those questions. You cannot estimate it. And that’s the key thing. You have to read a performance status card or list or however you have it and ask the patient those questions.”