Management of advanced non-small-cell lung cancer in patients with a performance status of 2

Patients with a poor performance status (PS) constitute a substantial fraction of patients with advanced non-small-cell lung cancer (NSCLC), yet these patients have been largely excluded from clinical research in the past decade. Despite the proven benefits of chemotherapy in patients with a good PS, cooperative group trials in the 1980s showed that patients with a PS of 2 did not benefit from chemotherapy and, in fact, had high rates of morbidity and mortality, a notion that came to dominate clinical practice for the next 2 decades. More recent studies demonstrate that these patients indeed have a worse prognosis than those with a better PS. However, chemotherapy seems to provide a benefit, at least in terms of symptom improvement, and may improve survival as well. A recent comparison of single-agent therapy with combination chemotherapy showed an advantage for patients with a PS of 2 treated with the combination regimen, without a detriment to quality of life. Dedicated studies in patients with a PS of 2 are urgently needed. More effective chemotherapy and better supportive care may allow extension of benefits of chemotherapy in advanced NSCLC to patients with a PS of 2. Ongoing trials are in progress to further test the role of molecular-targeted agents alone or in combination with standard chemotherapeutic agents in this subset of patients.