Can a patient with cancer undergo chemotherapy?

Can Patients with Cancer Undergo Chemotherapy?

Yes, patients with cancer can undergo chemotherapy, but eligibility depends critically on performance status, organ function, treatment intent (curative versus palliative), and specific cancer type. 1, 2

Eligibility Requirements Before Initiating Chemotherapy

Performance Status Assessment

• The National Comprehensive Cancer Network recommends combination chemotherapy only for patients with ECOG performance status 0-2 for most solid tumors 2
• Patients with poor performance status or visceral disease demonstrate poor tolerance to multiagent programs and achieve few complete remissions 1, 2
• Single-agent or lower-intensity regimens should be used for patients with compromised performance status 2

Organ Function Requirements

Renal Function:

• Adequate renal function is mandatory before initiating platinum-based chemotherapy 1, 2
• Actual creatinine clearance must be calculated using the Cockcroft-Gault equation or 24-hour urine collection, not serum creatinine alone 3
• For cisplatin-based regimens, glomerular filtration rate must be ≥60 mL/min 1, 2
• In patients with GFR <60 mL/min, carboplatin must be substituted for cisplatin in all regimens 1, 2

Hematologic Function:

• Neutrophil count must be ≥1,500 cells/mm³ for solid tumors 4
• Platelet count must be ≥100,000/mm³ 2, 4
• For AIDS-related Kaposi's sarcoma, neutrophil count must be ≥1,000 cells/mm³ 4

Hepatic Function:

• Patients with hepatic impairment are at increased risk of grade III-IV myelosuppression 4
• Dose adjustments are required based on transaminase and bilirubin levels 4

Cardiac Function:

• The presence or absence of cardiac disease is a major determinant of chemotherapy regimen selection 1, 2
• Liposomal doxorubicin should be preferentially used over conventional doxorubicin in patients with cardiac risk factors 2

Treatment Intent Classification

Curative Intent Chemotherapy

The National Comprehensive Cancer Network recommends curative regimens for chemotherapy-sensitive malignancies with good-risk features, defined as ECOG performance status 0-1, no visceral metastases, and normal organ function 2

Curative regimens should NOT be used when:

• Treating with primary or adjuvant chemotherapy for early-stage breast cancer, non-small cell lung cancer, lymphomas, and testicular cancer where ESAs may promote tumor growth 1
• Exception: Small cell lung cancer shows no negative impact on survival with ESAs 1

Examples of curative intent regimens:

• BEP for testicular cancer 2
• Dose-dense MVAC for bladder cancer 2
• Adjuvant AC-T for breast cancer: paclitaxel 175 mg/m² IV over 3 hours every 3 weeks for 4 courses following doxorubicin-containing combination chemotherapy 4

Palliative Intent Chemotherapy

For patients undergoing palliative treatment, chemotherapy can be considered preferentially over transfusion 1

Palliative regimens prioritize:

• Symptom control 2
• Quality of life maintenance 2
• Survival prolongation in advanced/metastatic disease 2

Examples of palliative regimens:

• Gemcitabine/carboplatin for patients unable to tolerate cisplatin 2
• Single-agent taxanes for metastatic breast cancer 2

Life Expectancy-Based Treatment Algorithm

Years to Months Life Expectancy

• Patients with good performance status are likely interested in continuing anticancer therapy to prolong survival and reduce cancer-related symptoms 1
• Chemotherapy may be superior to best supportive care and may prolong survival in advanced-stage cancers 1

Months to Weeks Life Expectancy

• Patients should consider potential discontinuation of anticancer treatment 1
• Offer best supportive care, including referral to palliative care or hospice 1
• Focus shifts from prolonging life toward maintaining quality of life 1

Weeks to Days Life Expectancy

Dying patients should NOT be given anticancer therapy, but should receive intensive palliative care focusing on symptom control and preparation for the dying process 1

Critical Contraindications and Precautions

Absolute Contraindications

• Neutrophil count <500 cells/mm³ for a week or longer requires 20% dose reduction in subsequent courses 4
• Severe peripheral neuropathy requires 20% dose reduction 4
• Pregnancy during treatment with radiation therapy, chemotherapy, or endocrine therapy 1

Special Populations

Patients with Chronic Kidney Disease:

• CKD is an independent indication for ESA therapy, but ESAs should be avoided during active cancer therapy 1
• For patients with CKD receiving palliative chemotherapy, ESAs may be favored over transfusions with careful dosing for target Hb between 10-12 g/dL 1

Elderly Patients:

• Never assume normal renal function based on serum creatinine levels in elderly patients, as actual creatinine clearance is likely much lower and may preclude use of cisplatin-based chemotherapy 3

Common Pitfalls to Avoid

1. Do not base surgical decisions solely on MRI findings without additional tissue sampling 1
2. Do not assume absence of regular menses implies lack of fertility, particularly if the patient is taking tamoxifen 1
3. Do not use hormone-based birth control regardless of hormone receptor status 1
4. Do not perform palliative gastric resection unless patient is symptomatic 1
5. Do not switch ESA products in patients with antibody-mediated anemia, as antibodies may cross-react 1