PSIport Neoplastic Disease Criterion: Active Disease Only
The neoplastic disease criterion in PSIport (Pneumonia Severity Index) refers to active neoplastic disease, not just any history of cancer. This is a critical distinction that directly impacts risk stratification and clinical decision-making for patients with community-acquired pneumonia.
Definition and Clinical Application
The PSI scoring system, which forms the basis of PSIport risk stratification, specifically defines neoplastic disease as active malignancy 1, 2. This means:
- Active cancer = currently present disease requiring treatment, under active surveillance, or not in complete remission
- History only = does not count toward PSI scoring if the cancer has been definitively treated and the patient is disease-free
The distinction matters because active neoplastic disease adds 30 points to the PSI calculation, potentially moving patients from lower risk classes (I-III, suitable for outpatient management) to higher risk classes (IV-V, requiring hospitalization) 1, 2.
Supporting Evidence from Multiple Clinical Contexts
This "active disease" interpretation is consistently applied across multiple clinical guidelines:
Cancer-Associated Thromboembolism Trials
The Hokusai-VTE Cancer, SELECT-D, and CARAVAGGIO trials all define their inclusion criteria as "active cancer" rather than cancer history 3. These studies specifically distinguish between:
- Active cancer (qualifying criterion)
- Cancer diagnosed within 2 years but not meeting active criteria (separate category in Hokusai-VTE)
- Remote cancer history (excluded)
JAK Inhibitor Safety Guidelines
The 2025 expert consensus on JAK inhibitors explicitly differentiates "current (or history of) malignancies" as separate considerations, with current malignancies carrying greater weight in risk-benefit decisions 4. This demonstrates that when history matters clinically, guidelines explicitly state it.
Liver Transplant Evaluation
Transplant guidelines specify that "history of a treated cancer is not an absolute contraindication" and recommend a 5-year interval between curative cancer treatment and transplantation 5. This clearly separates active from historical disease.
Clinical Implications
When applying PSIport criteria:
Count as neoplastic disease (adds 30 points):
- Currently receiving chemotherapy, radiation, or immunotherapy
- Metastatic disease present
- Hematologic malignancies not in complete remission
- Solid tumors under active surveillance with residual disease
Do NOT count as neoplastic disease (0 points):
- Cancer treated to complete remission >5 years ago
- Basal cell or squamous cell skin cancer (specifically excluded) 3
- Surveillance only after curative treatment with no evidence of disease
Gray zone requiring clinical judgment:
- Cancer diagnosed within past 2 years, treated to complete remission
- Low-grade indolent malignancies under observation only
- Recent completion of adjuvant therapy with no residual disease
Common Pitfalls to Avoid
Do not automatically assign points for:
- Remote cancer history without current disease activity
- Non-melanoma skin cancers (these are specifically excluded from most cancer-related risk criteria)
- Patients who completed curative treatment years ago and remain disease-free
Do assign points for:
- Any patient currently receiving cancer treatment
- Patients with known metastatic disease, even if asymptomatic
- Hematologic malignancies not documented to be in complete remission
The PSI was designed to identify patients at increased risk of mortality from pneumonia 1, 2. Active neoplastic disease increases this risk through immunosuppression, treatment-related complications, and overall disease burden—factors not present in patients with remote cancer history who are disease-free.