Abstract Background & Objectives Palliative systemic therapy is frequently underutilsed in patients with advanced non-small cell lung cancer, for many reasons. The aim of this study was to identify patient-reported factors that may predict for treatment decisions and survival in advanced NSCLC, using the Edmonton Symptom Assessment Scale (ESAS), which is a self-reported questionnaire that quantifies symptom burden by asking patients to rate the severity of 9 common symptoms. Methods With ethics approval, we analysed ESAS scores at initial oncology consultation for 461 patients with advanced NSCLC seen at The Ottawa Hospital Cancer Centre (TOHCC) from 2009 to 2012. Subgroup analysis was performed to determine if treatment strategies or overall survival (OS) were related to the total symptom burden, as defined by the sum of the individual ESAS symptom scores. Results The severity of the ESAS total symptom burden score was positively correlated with ECOG performance status (PS) (R=0.48, p<0.0001). Furthermore, patients with a higher symptom burden were less likely to receive systemic chemotherapy than those with fewer symptoms (43% versus 66%, p<0.0001), and had a significantly reduced OS (5.5 versus 9.9 months, p<0.0001). A higher ESAS symptom burden score was also associated with reduced OS by univariate analysis (HR1.78, 95% CI 1.45-2.18, p<0.0001), although multivariate analysis showed only a trend towards significance (HR1.27, 95% CI 0.99-1.62, p=0.06). Conclusions Overall, this demonstrates a novel role for the ESAS as a prognostic tool that could complement existing patient assessment models, such as ECOG PS, in the development of optimal treatment plans and estimation of survival, in patients with advanced lung cancer.