By Dr. Ileana Leyva

In an era of precision oncology, we closely track biomarkers, imaging findings and treatment response. Yet one of the strongest predictors of how a patient is truly doing often receives less attention: functional status.

When patients experience progressive fatigue, need more assistance with daily activities or spend more time in bed, clinicians and families may normalize these changes as expected consequences of cancer or treatment.

Yet progressive functional decline is frequently the clearest indication that an illness trajectory is changing. It is often a signal that warrants a broader conversation about prognosis, goals of care and whether the current treatment plan still aligns with what matters most to the patient.

As physicians, we routinely rely on objective measures to assess disease progression. While scans tell us how a tumor is behaving, functional status tells us how the patient is living. Both are essential to understanding prognosis and making care decisions that align with patient goals.

Looking Beyond the Disease

In oncology, performance status is already an established part of clinical decision-making. Measures like the Eastern Cooperative Oncology Group (ECOG) Performance Status help determine whether patients are likely to benefit from additional systemic therapy.

Too often, declining performance status triggers a discussion about whether another treatment is feasible. It should also prompt a conversation about whether another treatment is meaningful — whether the patient’s care plan continues to reflect their priorities.

Consider the patient whose cancer has progressed despite multiple lines of therapy. Hospitalizations become more frequent. Symptoms become harder to control. Walking across the room requires assistance. Meals become smaller. Recovery after each admission takes longer than the last.

Each of these changes represents more than a decline in function. Together, they paint a picture of an illness that is advancing.

When Functional Decline Changes the Clinical Equation

Functional decline should prompt clinicians to reevaluate assumptions. The clinical question is no longer only whether treatment can continue, but whether continued treatment remains consistent with the patient’s goals, priorities and likely outcomes.

Questions worth asking include:

• Has the patient’s overall condition changed more than the scan suggests?
• Are repeated hospitalizations helping the patient achieve their goals?
• What does the patient hope to accomplish in the weeks and months ahead?
• Would I be surprised if this patient died within the next year?

These conversations are often easier before a crisis develops. When patients still have the ability to participate fully in decisions, they can better express what matters most to them and understand the options available.

A Shift in Focus

One reason these conversations are delayed is the persistent misconception that hospice represents a last resort. In reality, hospice is a care model designed to support patients whose priorities have evolved as their illness progresses.

A hospice plan of care should incorporate the wishes and values of the patient and optimize the patient’s symptom management to allow for the best possible quality of life and function for as long as possible. Hospice is focused on maximizing comfort and preserving dignity, allowing patients to spend their remaining time in the place of their choice.

For patients with advanced cancer, hospice provides expert pain and symptom management while supporting emotional, psychosocial and spiritual needs. It also helps families navigate an increasingly complex stage of illness.

When referrals occur earlier, patients have more time to benefit from these services rather than receiving them only in the final days of life.

Recognizing functional decline allows us to make that transition thoughtfully instead of reactively.

Seeing the Whole Patient

Cancer care has never been solely about treating disease. First and foremost, we are caring for the person living with it.

By paying closer attention to functional status, we gain valuable insight into prognosis while creating opportunities for more meaningful conversations.

Modern cancer care offers more treatment options than ever before. Yet the measure of excellent care is not how long we continue treatment; it is how well we recognize when a patient’s needs and priorities have changed.

Functional decline is often the signal. The challenge for clinicians is deciding whether we are prepared to act on what it is telling us.

Learn more about how hospice supports patients with advanced cancer and refer patients to VITAS by calling (800) 938-7827 or visiting VITAS.com/Refer, available anytime 24/7/365. Download the VITAS mobile app for seamless, one-touch referrals by patient facesheet.

 Dr. Ileana Leyva is the regional medical director for VITAS® Healthcare in South Florida. Learn more about end-of-life care at VITAS.com.