The Karnofsky Performance Status Scale

An Examination of its Reliability and Validity in a Research Setting

VINCENT MOR, PHD,' LINDA LALIBERTE, MS,t JOHN N. MORRIS, PHD,S AND MO-IAEL WIEMANN, MD§

The Karnofsky Performance Status Scale (KPS)is widely used to quantify the functional status of cancer
patients. However, limited data exist documenting its reliability and validity. The K P S is used in the
National Hospice Study (NHS) as both a study eligibility criterion and an outcome measure. As part
of intensive training, interviewers were instructed in and tested on guidelines for determining the KPS
levels of patients. After 4 months of field experience, interviewers were again tested based on narrative
patient descriptions. The interrater reliability of 47 NHS interviewers was found to be 0.97. The construct
validity of the K P S was analyzed, and the K P S was found to be strongly related (P < 0.001) to two
other independent measures of patient functioning. Finally, the relationship of the K P S to longevity (r
= 0.30) in a population of terminal cancer patients documents its predictive validity. These findings
suggest the utility of the KPS as a valuable research tool when employed by trained observers.
Cancer 53:2002-2007, 1984.

F UNCTIONAL STATUS ASSESSMENTS are frequently used

to complement medical information to characterize
the impact of disease on the patient. Loss of function is
generally related to the cumulative physical, physiologic,
and psychological effects of the disease process. In cancer
therapy clinical trials, performance status has been shown
to be an important predictor of response to therapy and
survival.'**
The Karnofsky Performance Status Scale (KPS) is the
most widely used method of quantifying the functional
status ofcancer The KPS is an 1 1-point rating
scale which ranges from normal functioning ( 100)to dead
(0). Alternate categorizations have been developed and
Research conducted at Brown University, Program in Medicine, Sec-
tion of Community Health, Center for Health Care Studies, Providence,
Rhode Island.
Supported in part by the National Hospice Study funded by DHHS/
HCFA grant no. 99-P-97793/1-0, and grants from the Roberl Wood
Johnson Foundation and the John A. Hartford Foundation.
* Assistant Professor, Section of Community Health, Brown Uni-
versity, and Project Director of the National Hospice Study.
t Field Data Coordinator, Brown University National Hospice Study.
# Assistant Director, Department of Social Gerontological Research,
Hebrew Rehabilitation Center for Aged, Boston, Massachusetts.
8 Assistant Professor, Department of Medicine, Brown University,
Medical Oncologist, Roger Williams General Hospital, Providence,
Rhode Island.
Address for reprints: Vincent Mor, PhD, Brown University, Box G,
Providence, RI 029 12.
The authors thank Claudia Lee, Long Beach Memorial Hospital in
Long Beach, California, for her suggestionto retest the interrater reliability
of National Hospice Study interviewers.
Accepted for publication February 8, 1983.
are widely The KPS, or comparable measures,
have been used for research purposes to stratify patient
subsets exposed to various treatment intervention^.'.^ It
has also been used as an outcome measure to compare
differences in the functional abilities of patients before
and after exposure to an intervention.'
Despite widespread use, little systematic data s u p
porting the reliability or validity of the KPS exist. Use
of the JSPS has been criticized because of its subjective
nature, variability in scoring between observers, and the
tendency for the score to be influenced by acute but self-
limited events.'
In this article we report the results of analyses of the
reliability, construct, and predictive validity of the KPS.
The data on which these analyses are based were gathered
as a part of the National Hospice Study (NHS), a na-
tionwide evaluation of the impact of hospice care on the
quality of life and health care costs experienced by ter-
minally ill cancer patients. The KPS is routinely obtained
on all patients at study entry by raters exposed to training
procedures designed to counter the lack of interrater con-
sistency associated with clinical scales."
The NHS sample includes only those patients who are
at least 2 1 years of age, have a biopsy-confirmed diagnosis
of cancer (unless primary brain or pancreatic cancer di-
agnosed through computerized axial tomography (CAT)
scan), and have confirmed metastases for all primary caa-
cer sites with the exception of lung cancer and locally
advanced head and neck cancers. The sample described
in this article includes only hospice patients who were

2002
No. 9 THEKARNOFSKY PERFORMANCE
STATUSSCALE
TABLE1. Karnofsky Performance Status Index
~~~ ~~- ~~
General category
Able to cany on normal activity; no special care needed.
Unable to work, able to live at home and care for most
personal needs, varying amount of assistance needed.
Unable 10 care for self, requires institutional or hospital care
or equivalent, disease may be rapidly progressing.
admitted to the NHS between August 1, 1981 and July
31, 1982 who had died by November 30, 1982 and who
had a KPS score of 50 or less at the initial interview.
Methods
The NHS interviewer makes initial contact with the
NHS participant 3 to 10 days following admission to the
hospice. At this initial contact, the interviewer spends
approximately 1 hour with the patient and the patient’s
family, gathering information on pain, symptoms, sat-
isfaction with care, satisfaction with life, and services being
utilized. During this period, the interviewer has the o p
portunity to observe the patient’s subtle dependencies
and interactions within the existing support networks to
amve at a KPS assessment based on that single visit.
Additional selected functional assessment information is
gathered either independently by hospice clinical staff at
the time of the patient’s admission o r from the patient’s
family at the initial contact. The interviewer continues
to visit the patient and the patient’s family regularly until
the patient’s death.
Training
The NHS interviewers were selected primarily on the
basis of their prior interviewing and research experience.
Consideration was also given to their familiarity with
medical and insurance/billing terminology. There were
9 nurses among the 47 interviewers; the remaining 8 1%
had very limited clinical experience in a medical setting.
Prior to the training period, as a general background
the interviewers were asked to become familiar with ter-
minology contained in a medical glossary which had been
- Mor et a/. 2003
Index Specific criteria
100 Normal, no complaints, no evidence of disease.
90 Able to carry on normal activity, minor signs or symptoms of
disease.
80 Normal activity with effort. some signs or symptoms of
disease.
70 Cares for self, unable to carry on normal activity or to do
work.
60 Requires occasional assistance from others but able to care for
most needs.
50 Requires considerable assistance from others and frequent
medical care.
40 Disabled, requires special care and assistance.
30 Severely disabled, hospitalization indicated, death not
imminent.
20 Very sick, hospitalization necessary, active supportive
treatment necessary.
10 Moribound.
0 Dead.
prepared by NHS staff. Formal training began with an
orientation to the basic principles of cancer biology,
symptoms, epidemiology, and therapy. Led by a clinical
oncologist and an oncologic nurse, this 3-hour orientation
included practical exercises in which the interviewers
demonstrated their ability to abstract selected items of
information from the medical records of terminal cancer
patients.
Following this orientation, the interviewers took part
in a 2-hour training session conducted by the same clinical
team. The KPS index used by the NHS interviewers is
shown in Table I . Operational specifications were de-
veloped to provide objective guidelines for nonclinical
staff in the use of this judgement rating scale. The goal
of the training was to enable interviewers to rate and
compare patient profiles at subtly different performance
levels, generalizing this experience to include all types of
patients.
Following their introduction to the overall rating pro-
cess,interviewers were tested with a seriesof brief narrative
descriptions of patients and their respective KPS scores
until there was thorough agreement on the basis for each
particular rating.
Results
Reliability
As noted above, although the Kps is widely used by
clinicians, recent evidence suggests that ratings frequently
are not comparable.” In research applications, however,
raters using the KPS have been found to achieve at least
a moderate level of interrater agreement.I I Reliability re-
fers to the extent to which objects (patients) can be cat-
egorized, scored, or ordered in the same way by different
2004 CANCERMay I 1984 Vol. 53

TABLE2. Performance Level of Activities ical status is far more complicated. By comparing the
of Daily Living by Karnofsky Status KPS with other discrete observable variables which con-
Karnofsky performance status ceptually or theoretically tap the same measurement do-
(%) main, its construct validity can be e~a1uated.l~
Functional In the NHS, a series of independent physical func-
variables 10 20 30 40 50 Total
tioning measures is available with which to test the con-
Continence struct validity of the Karnofsky Performance Index. At
Unable 28.6 28.3 15.3 7.1 .9 12.0
Wlhelp 50.0 55.4 59.4 50.6 27.0 50.6 the time of intake, hospice staff complete a series of de-
Independent 21.4 16.3 25.3 42.3 72.2 31.4 tailed functional assessments on the subjects based on
Transfering inlout the general model of the Katz ADL Index.14The patient’s
of bed/chair
Unable 42.9 45.7 20.3 7.1 0.0 16.0 primary care person completes an overall physical QL
Wlhelp 57.1 44.6 60.2 58.4 27.0 52.5 (quality of life) assessment at the initial and each sub-
Independent 0.0 9.8 19.5 34.5 73.0 31.5 sequent interview contact. While the three sets of as-
Walking
Unable 50.0 57.6 36.4 18.4 .9 27.4 sessments are not identical in content or intent, they do
Wlhelp 50.0 33.7 48.3 49.8 32.2 44.6 measure facets of the same underlying phenomenon, pa-
independent 0.0 8.7 15.3 31.8 67.0 28.0 tient performance. Consequently, there should be a strong
Dressing
Unable 71.4 64.1 52.9 21.0 1.7 35.4 relationship between these other two sets of functional
Wlhelp 28.6 31.5 40.2 60.7 49.6 41.7 measures and the KPS. The descriptors of the various
Independent 0.0 4.3 6.9 18.4 48.7 17.0 KPS levels suggest not only a physical performance di-
Bathing
Unable 57.1 60.9 52.5 24.0 4.3 36.0 mension but also medical care needs. Symptom presence
Wfhelp 42.9 35.9 41.0 59.6 56.6 49.4 and extent of disease, therefore, should conceptually cor-
independent 0.0 3.3 6.5 16.5 39.1 14.6 relate with the KPS. Data regarding the presence and
Climbing stairs
Unable 78.6 87.0 71.3 51.7 10.4 57.0 severity of symptoms, including pain, are obtained from
Wlhelp 21.4 10.9 24.1 40.8 61.7 34.2 the patient during the initial interview. The patient’s
Independent 0.0 2.2 4.6 1.5 27.8 8.8 medical record was used to record the location and num-
Mobility outside home
Unable 78.6 83.7 63.6 43.1 16.5 51.8 ber of metastases.
W/help 21.4 15.2 34.5 52.4 66.1 43.1 The performance level for activities of daily living for
Independent 0.0 1.1 1.9 4.5 17.4 5.1 patients at different KPS scores is shown in Table 2. The
Overall 1.9 12.3 34.8 35.6 15.4 100.0 chi-square tests for all categories indicate that differences
in performance level for each KPS score are significant
No. = 685.
W: with. (Pc 0.001), with the proportion of patients able to func-
tion independently increasing as the patients’ KPS scores
increase. As the KPS scores decrease, the proportion of
assessors. To test whether consensus among interviewers patients unable to perform these activities with or without
was achieved, a written quiz similar to that given during assistance increases drastically, indicating a severely dis-
the training process was administered to interviewers after abled population at a KPS of <30.
4 months of field work. Forty-seven interviewers were A severity index was constructed from the functional
asked to rate 17 narrative examples of patients at widely variables listed in Table 2. For each variable, a score of
varying KPS levels. The results of this quiz were analyzed 0 was assigned if the patient could perform the activity
to determine interrater reliability. Interviewers’ ratings independently, a score of 1 was assigned if assistance was
were compared using Cronbach’s coefficient alpha, which necessary, and a 2 was assigned if the patient was unable
treats judges as items in a scale and the narrative scenarios to perform the activity. The scores range from 0 (most
as observations. This approach was supplemented by a functional) to 14 (least functional) and have been distri-
variant of the intraclass correlation suggested by Winer. ’* butionally categorized. Table 3 presents the severity index
Both approaches yielded interrater reliability coefficients for patients at each KPS level. The chi-square test indicates
of over 0.97 of a maximum of 1.00. This value is statis- -=
significant differences among categories (P 0.00 1) and
tically significant beyond the 0.00 1 probability level. a very strong relationship between increasing KPS scores
and higher functional status (contingency coefficient
Construct Validity
= 0.49). Over 50% of the cases in the two worst KPS
The KPS is a complex, synthetic measure of a patient’s levels are in the worst severity category, while 40% of the
activity levels. It is a multidimensional construct reduced patients with a KPS of 50 are in the “most functional”
to a unidimensional scale. One of the reasons for the severity category.
popularity of the KPS is precisely its concise approach The relationship between the KPS and the physical
to classifying and ranking patients whose individual clin- QL is given in Table 4. There are significant differences
No. 9 THEKARNOFSKY STATUSSCALE
PERFORMANCE - Mor ef al. 2005

(P< 0.001) between the KPS levels in the proportion of TABLE

3. Severity Index by Karnofsky Performance Status
persons with low physical QL values-the lower the KPS
Karnofsky Performance Status (7%)
values, the higher the proportion of persons with poor Severity
physical QL. The relationships between these two mea- index 10 20 30 40 50 Total
sures are very strong, as can be seen by the Kendall’s tau Most 0-2 0.0 2.2 5.7 11.6 40.0 12.5
statistic (0.35).Thus, both the interviewer and the patient’s Functional 3-5 0.0 5.4 9.6 18.7 30.4 15.4
primary care person (usually the spouse or a child) tend 6-8 28.6 8.7 21.4 31.5 22.6 23.7
to rate the patients similarly with respect to the physical Least 9-11 21.4 31.5 31.4 26.2 6.9 25.5
Functional 12-14 50.0 52.2 31.9 12.0 0.0 22.9
dimensions of performance status.
In addition to these functional variables, the degree of Total 1.9 12.3 34.8 35.6 15.4 100.0
pain reported by patients at various Kps scores was mea- Kendall’s Tau: 0.44; P i0.00I .
sured using a modified version of Melzack’s pain ques- No. = 685.
t i ~ n n a i r e . No
’ ~ significant relationship to the patient’s
KPS rating was found. Similarly, there was no significant
psychological causes (notwithstanding other complicating
relationship between the KPS score and other physical
factors), the more impaired the cancer patient, the more
symptoms reported by the patients. Although not sig-
advanced the systemic involvement and consequently,
nificant, shortness of breath showed a stronger relationship
the closer the patient is to death. Thus the KPS, as a
to performance status than either nausea, dry mouth,
measure of the degree of impairment, should be able to
constipation, dizziness, or fever. Patients’ experience of
predict the length of survival of terminal cancer patients.
pain and symptoms should logically limit their ability
An analysis of variance (ANOVA) with KPS as the
and willingness to perform normal daily activities. How-
independent variable and survival in days as the depen-
ever, for the extremely debilitated terminal patients r e p
dent variable was performed. The results presented in
resented in this sample, symptoms are not a relevant
Table 5 show a direct monotonic relationship between
factor in reduced performance status. The absence of
KPS and survival which is significant at beyond the 0.00 I
patients in the upper ranges of the KPS may detract from
probability level. Nine percent of the variance in survival
what would othenvise be a positive association between
is accounted for by the KPS as seen by the “eta squared”
reported symptoms and KPS in a population of patients
which is comparable to the standard R2 emerging from
with metastatic disease. Additionally, over 30% of the
regression analyses. However, as can be seen from the
500 patients in the sample able to respond to the pain
standard deviation in longevity associated with each Kps
question reported experiencing no pain at all. While most level, there is considerable overlap in the longevity dis-
patients reported at least one of the six symptoms, the
tributions of the various KPS levels. The median longevity
number of reported symptoms was also not related to
associated with each KPS level (uniformly lower than the
KPS. Clearly, for this sample of patients, reduced KPS
average) suggests very skewed distributions.
is not attributable to the experience of the more common
symptoms associated with cancer patients. The low KPS
is apparently associated with a systemic disease which TABLE4. Relationship Between Karnofsky Performance Status and
has reduced the patient’s vitality. Physical QL* at Initial Patient Interview
Primary cancer site as well as the location and number Collapsed physical QL* categories based
of metastatic sites was ascertained from patients’ medical on distribution at hospice intake
records. None of these factors was significantly related to Lower third Middle third Top third
the KPS score. Lung and brain metastatic involvement, Karnofsky of sample of sample of sample
which logically should have the greatest debilitating effect score (scores 0-1) (xom 2-5) (scores 6- 14)
~~~~~ ~ ~ ~

on functioning, were only moderately associated with a 10 69.2% 23.1% 7.7%

lower KPS. This pattern of findings suggests that disease 20 67.0 24.0 9.0
characteristicscan vary substantially among persons with 30 39.5 42.6 17.9
the same KPS. At earlier stages in the advance of met- 40 23.8 39.7 36.5
50 8.5 19.5 12.0
astatic disease, the location of the metastases and the
number of metastatic sites might be associated with the No. = 685.
rate of decline in KPS. Kendall’s Tau: 0.35.
Physical QL is a 15-point doubly anchored “ladder” index completed
by the PCP and designed specifically for use in the National Hospice
Predictive Validity Study (by J . Moms, S. Wright, and S. Shenvood of the Hebrew Re-
habilitation Center for Aged. The two anchors are defined as follows:
Lowest quality appliesto someone who is completely physically dependent
Since impairment among cancer patients suggests sys- on others, needs help with grooming, feeding. Highest qualify applies
temic breakdown attributable to pathophysiologic and to someone who is physically independent.
2006 CANCERMay 1 1984 VOl. 53

TABLE5. Analysis of Variance Relating Patients’ Karnofsky with KPS scores of 50 live longer than 36 days. Kendall’s
Performance Status Score to Longevity tau associated with this table is 0.30, which is significant
~ _ _ _ _ _ _ ~

Karnofsky Mean Standard Median beyond the 0.001 level. Interestingly, the proportion of
score longevity deviation longevity No. patients at each KPS level found in the mid-range lon-
gevity group is fairly comparable.
10 17.6 20.5 9.5 13
20 27.1 29.4 17.8 84 These analyses substantiate the predictive validity of
30 45.7 43.4 31.9 239 the KPS when applied to a sample of terminal cancer
40 64. I 52.4 46.7 244 patients. While the relationship is highly significant, its
50 72.0 52.8 59.7 105
predictive accuracy and therefore case-specific clinical
Overall 53.5 48.9 36.6 685 applicability is limited. Clearly, however, the lower KPS
F-ratio: 19.2. levels are much more likely to be “death-imminent.”
P < 0.001.
“Eta squared”: 0.09.
Longevity: days alive; KPS: Karnofsky performance status. Discussion
The wide use of the KPS among physicians and par-
To complement the ANOVA results, the ordinal KPS ticularly oncologists suggests it is a meaningful measure
score was regressed on survival in days. The purpose of of a patient’s functional status. However, for this or any
this analysis was to further examine the predictive qualities similar measure to be meaningful, it is essential that those
of the KPS. Confirming the ANOVA approach, a zero using it be systematically trained to assure a common
order correlation of 0.30 was obtained, signifying an R2 perspective. The training module designed for the current
of 0.09 which is significant at beyond the 0.001 level. evaluation could be readily adapted by other researchers
Each increase in one KPS level, e.g., 20 to 30, yields an and by clinicians working in a practice or research setting.
increase of approximately 15 days of survival. Regression Our finding of high levels of interrater reliability among
analyses also reveal that a higher proportion of prediction nonclinicians following exposure to training attests to the
errors (standardized residuals greater than or -2.0) + feasibility of using the KPS in systematic research efforts.
occur among patients with KPS levels of 40 and above; The functional variables adapted from Katz ADL In-
over 6%of cases with KPS scores of 40 or 50 were “errors,” dex14 and used to test the construct validity of the KPS
whereas only 4% of KPS level 30 and 2% of KPS level are objective and quantifiable. Thus, the strong relation-
20 were errors. Furthermore, significant errors of pre- ship between these variables and the KPS as shown in
diction were uniformly in the direction of longer lives. Table 2 suggests that although the KPS is a subjective
This is largely a function of the skewed longevity distri- rating, it is based on objective factors. The strong rela-
bution for this sample seen in the median being lower tionship obtained between the KPS and a single item
than the mean. physical QL judgement made by patients’ primary care
In view of these findings, a categoric form of longevity persons indicates the consistency with which the construct
was constructed. The proportion of “short-lived” and of performance status can be measured. This construct
“long-lived” patients at each KPS level was examined. validity, therefore, supports the view that the KPS is a
Three longevity groups were created: ( 1) 18 days or less; reliable measure of functional status.
(2) 29 to 36 days; and (3) more than 36 days. The results Perhaps most important is the finding that the KPS is
are presented in Table 6. As can be seen, the majority a predictor of length of survival in terminally ill cancer
of patients with KPS scores of 10 or 20 die within 18 patients. The predictive relationship that emerged, while
days of hospice admission, while most (70.4%) of those accounting for only 9% of the variation in longevity, is
consistent with other researchers’ efforts to predict lon-
gevity in chronically ill and aged population^.^^-^' The
TABLE6. Karnofsky Performance Status By Category more limited relationship to survival reported by Yates
of Patient Longevity
and associates” was presumably due to greater hetero-
KPS Level (7%) geneity in his sample. By limiting the sample to patients
with confirmed metastatic disease with an acknowledgedly
Patient longevity 10 20 30 40 50 Total
poor outcome, the relationship between performance sta-
1-18 d 71.4 52.2 29.1 13.9 8.7 24.2 tus and longevity becomes apparent. However, even in
19-36 d 21.4 25.0 27.6 26.6 20.9 25.8 this population, the predictive accuracy attained is in-
37 d or more 7.1 22.6 43.3 59.6 70.4 50.0
sufficient to guide clinical practice and decision-making.
Total 1.9 12.3 34.8 35.6 15.4 100.0 Perhaps the most effective use of the KPS when reliably
No. = 685. applied is as a stratifyingmeasure in research, particularly
KPS: Karnofsky Performance Status. in clinical trials in which patient survival constitutes an
No. 9 THEKARNOFSKY
PERFORMANCE
STATUSSCALE
outcome of interest or is related to other outcomes of
interest. In view of the strong relationship between KPS
and survival, even randomized clinical trials could gain
considerable power by using the KPS as a study eligibility
criterion and as a stratifying variable during analyses. On
the basis of the high short-term mortality among patients
in the lowest KPS groups, it might be reasonable to ex-
clude them from studies requiring some minimal exposure
time. The widespread use, ease of measurement, and gen-
eral acceptance of the measure make the KPS a reasonable
candidate as a stratifying variable as long as the reliability
of the raters is assured.
Future investigations into the predictors of survival
time among terminal cancer patients will explore other
factors, i.e.,concurrent disabling diseases, prior treatment
patterns, etc., that, together with the KPS, can refine such
predictions.
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