What conditions or factors would rule a patient out for chemotherapy?

Absolute and Relative Contraindications to Chemotherapy

Chemotherapy should be withheld in patients with ECOG performance status >2, as these patients show no survival benefit and experience increased toxicity; additionally, inadequate organ function—specifically creatinine clearance insufficient for platinum agents, baseline thrombocytopenia <100,000/mm³, absolute neutrophil count <1,000/mm³, or significant cardiac disease precluding anthracycline use—represents absolute contraindications. 1, 2, 3

Performance Status Thresholds

Poor performance status is the single most important factor ruling out chemotherapy eligibility. 2

• ECOG/WHO performance status >2 is an absolute contraindication to combination chemotherapy for most solid tumors, as these patients demonstrate poor tolerance to multiagent programs, achieve few complete remissions, and derive no survival benefit 1, 3
• Patients with ECOG PS >2 should receive best supportive care only rather than chemotherapy 2
• For advanced gallbladder cancer specifically, only patients with ECOG 0-2 (or 0-1 in some guidelines) should receive gemcitabine-cisplatin chemotherapy 2
• Patients who are rapidly deteriorating clinically should not receive chemotherapy regardless of formal performance status score 2

Organ Function Requirements

Renal Function

• Adequate creatinine clearance is mandatory for cisplatin-based combinations, and baseline renal function determination via creatinine clearance is required before initiating platinum-based therapy 1, 2
• In patients with glomerular filtration rate <60 mL/min, carboplatin must be substituted for cisplatin in all regimens, though therapeutic equivalence data are limited 1, 2
• Baseline hearing loss represents a relative contraindication to cisplatin due to ototoxicity risk 4
• Comorbid illnesses such as congestive heart failure or urinary problems that limit intravenous saline hydration preclude cisplatin use 4

Hematologic Function

• Platelet count ≥100,000/mm³ is required for safe carboplatin administration 1
• Absolute neutrophil count ≥1,000/mm³ is typically required for chemotherapy administration 1
• Baseline thrombocytopenia and bleeding risk represent relative contraindications to carboplatin 4

Cardiac Function

• The presence of significant cardiac disease is a major determinant ruling out certain chemotherapy regimens, particularly anthracycline-based regimens 1, 2
• Liposomal doxorubicin should be preferentially used over conventional doxorubicin in patients with cardiac risk factors, though severe cardiac disease may preclude any anthracycline use 1
• Patients at risk of cardiac complications should receive non-anthracycline, taxane-based regimens such as docetaxel and cyclophosphamide as alternatives 4

Hepatic and Biliary Function

• Biliary drainage must be optimized before chemotherapy initiation in jaundiced patients—proceeding without adequate drainage increases toxicity without benefit 2

Disease-Specific Contraindications

Breast Cancer

• Most luminal A tumours, except those with the highest risk of relapse (extensive nodal involvement), require no chemotherapy 4
• In luminal HER2(−) cancers with contraindications for chemotherapy or patient refusal, selected cases may receive the combination of targeted agents (endocrine therapy and trastuzumab) instead 4
• Low-risk 'special histological subtypes' of triple-negative breast cancer such as secretory juvenile, apocrine, or adenoid cystic carcinomas may not require adjuvant chemotherapy 4

Lung Cancer

• Diabetes represents a relative contraindication to cisplatin due to limitations in using corticosteroids for emesis prophylaxis 4

Comorbidity Considerations

• Patients with serious comorbidities should receive regimens with lower toxicity profiles or be excluded from chemotherapy entirely 2
• The risk of specific toxicities may preclude certain agents: baseline hearing loss contraindicates cisplatin, baseline thrombocytopenia contraindicates carboplatin, and peripheral neuropathy may preclude taxane-based regimens 4, 1

Critical Timing Considerations

Do not delay chemotherapy in eligible patients waiting for further disease progression—chemotherapy should be initiated early in the disease course when patients are relatively fit and not deteriorating rapidly, as this correlates with improved outcomes. 2

Common Pitfalls to Avoid

• Never treat patients with ECOG PS >2 with standard chemotherapy, as they experience increased toxicity without survival benefit 2, 3
• Do not proceed with chemotherapy before optimizing biliary drainage in jaundiced patients with hepatobiliary malignancies 2
• Avoid concomitant use of chemotherapy with endocrine therapy in luminal HER2(−) breast cancers—these should be given sequentially 4
• Do not use high-dose chemotherapy with stem cell support in breast cancer, as this approach has been proven ineffective 4