What assessments are necessary for evaluating a patient for chemotherapy?

Pre-Chemotherapy Evaluation

Before initiating chemotherapy, you must perform a geriatric assessment in patients ≥65 years old, obtain baseline organ function tests (complete blood count, comprehensive metabolic panel including liver and renal function), assess performance status, and evaluate nutritional status and comorbidities. 1

Essential Laboratory Tests

Baseline Hematologic and Chemistry Panel

• Complete blood count with differential to assess hemoglobin, white blood cell count, and platelet count 1
• Comprehensive metabolic panel including:
  • Liver function tests (ALT, AST, alkaline phosphatase, bilirubin) 1, 2
  • Lactate dehydrogenase (LDH) 1, 2
  • Serum creatinine and calculated creatinine clearance 1
  • Electrolytes including sodium 1
  • Calcium 2

Renal Function Assessment

• Creatinine clearance calculation is mandatory, as it determines chemotherapy dosing and eligibility for nephrotoxic agents like cisplatin 1
• Patients with eGFR <60 mL/min require dose adjustments or alternative regimens (e.g., carboplatin instead of cisplatin) 2
• Note: Plasma creatinine and estimated GFR (MDRD equation) are unreliable for detecting declining renal function during nephrotoxic chemotherapy; direct GFR measurement may be needed for serial monitoring 3

Performance Status and Functional Assessment

Standard Oncology Assessment

• ECOG Performance Status or Karnofsky Performance Status must be documented 1
• Performance status is an independent prognostic factor and determines treatment intensity 4

Geriatric Assessment for Patients ≥65 Years (Mandatory)

The 2018 ASCO Geriatric Oncology Guidelines establish that geriatric assessment should be standard practice for all older patients receiving chemotherapy. 1

Core Domains to Assess:

• Functional status: Instrumental Activities of Daily Living (IADLs) - ability to manage medications, finances, household chores 1
• Falls risk: Single question about falls in past 6 months (one or more vs. none) 1
• Cognition: Mini-Cog (3-minute test) or Blessed Orientation-Memory-Concentration test 1
• Depression: 15-item Geriatric Depression Scale (score >5 requires follow-up) 1
• Nutrition: Document unintentional weight loss >10% from baseline or BMI <21 kg/m² 1
• Comorbidities: Thorough history or validated comorbidity tool 1
• Polypharmacy: Number of medications 1

Chemotherapy Toxicity Risk Prediction Tools:

• CARG Toxicity Calculator (preferred for speed): 11 items including age, falls, hearing, walking ability, medication management, social activity limitations, cancer type, chemotherapy dosing, hemoglobin, and creatinine clearance; provides risk estimate for grade 3-5 toxicity in <5 minutes 1
• CRASH Tool (more comprehensive): Separately estimates hematologic toxicity risk (using diastolic BP >72 mmHg, IADL score <26, LDH >459 U/L) and nonhematologic toxicity risk (using ECOG PS, MMSE <30, MNA <28); takes 20-30 minutes 1

Life Expectancy Estimation:

• Use Schonberg Index or Lee Index from ePrognosis to estimate noncancer life expectancy ≥4 years 1
• Variables include age, sex, comorbidities (diabetes, COPD, CHF), functional status (ADLs, IADLs, mobility), smoking status, BMI, and self-reported health 1

Additional Disease-Specific Assessments

Staging and Metastatic Workup

• Chest X-ray at minimum 1
• CT scan of chest, abdomen, and pelvis for complete staging in solid tumors 1, 2
• Bone scan if alkaline phosphatase elevated or bone pain present 2

Nutritional Assessment

• Unintentional weight loss >10% from baseline 1
• BMI <21 kg/m² indicates poor nutrition associated with mortality 1
• Consider Mini Nutritional Assessment (MNA) or G8 screening tool 1

Pre-Treatment Requirements for Specific Chemotherapy Regimens

Cisplatin-Based Regimens

• Normal renal function (creatinine clearance typically >60 mL/min) 1, 2
• Adequate hydration protocol must be planned (IV fluids before and after each cycle) 1
• No preexisting neuropathy 1
• Patients with renal impairment are ineligible; use carboplatin-based alternatives 2

Intraperitoneal (IP) Chemotherapy

• Normal renal function before starting 1
• Appropriate performance status to tolerate increased toxicity 1
• No medical problems that could significantly worsen (e.g., preexisting neuropathy) 1
• Patients must be counseled about increased myelosuppression, renal toxicity, abdominal pain, neuropathy, GI toxicity, metabolic toxicity, and hepatic toxicity compared to IV chemotherapy alone 1

Common Pitfalls to Avoid

• Do not rely on serum creatinine alone for renal function assessment; always calculate creatinine clearance 1, 3
• Do not skip geriatric assessment in older patients even if ECOG performance status appears good; GA identifies vulnerabilities not captured by standard oncology assessments and predicts chemotherapy toxicity better than performance status alone 1
• Do not use estimated GFR (MDRD) for serial monitoring during nephrotoxic chemotherapy; it fails to detect declining renal function in 27% of patients, leading to inappropriate dosing 3
• Do not proceed without adequate organ function: Ensure hemoglobin ≥10 g/dL (or appropriate for regimen), adequate liver function, and appropriate renal function for the planned regimen 1

Documentation Requirements

• Goals of systemic therapy must be discussed and documented before initiation 1
• Adequate organ function and performance status must be confirmed and documented 1
• For older patients, geriatric assessment results should inform treatment selection and be used to develop an individualized care plan 1