| CIRCUMSTANCE AND RATIONALE: |
|
| 1 |
Higher-dosage cisplatin ( 75 mg/m2 or more). The higher dosages require prolonged i.v. fluids, as well as extended monitoring of intake and output. Additional medications such as i.v. furosemide may be needed, as well as frequent laboratory studies. |
|
Lower dosages can be given in an outpatient setting, since the amount of required pre- and post-treatment hydration can be accomplished over four to six hours. |
| 2 |
"Special procedure" chemotherapy. This includes intra-arterial chemotherapy and chemo-embolization (usually via the hepatic artery). Such procedures require several days’ close and continuous observation. |
| 3 |
Induction therapy for acute leukemia. Such patients are generally quite ill, require multiple i.v. chemotherapeutic agents, become more ill during and after treatment, require multiple transfusions of blood products, as well as i.v. antibiotics and other agents, and require prolonged continuous observation. |
| 4 |
Stem cell/bone marrow transplantation with high-dose chemotherapy. Hospitalization requirement is usually stated in the protocol. A newer trend in some centers is to administer such chemotherapy as an outpatient, and then admit the patient during the period of blood count nadirs or during periods of complications. |
| 5 |
"High-dosage chemotherapy," without bone marrow or stem cell support. In some cases, chemotherapy dosages are significantly increased (for example, high-dosage cyclophosphamide in breast cancer or sarcomas). These patients may require close and prolonged observation. |
| 6 |
Severely emetogenic chemotherapy. Outpatient antiemetic therapy was ineffective on a prior occasion in treating severe chemotherapy-related nausea and vomiting. Subsequent treatment should be given in the hospital where frequent doses of multiple i.v. antinausea medications and i.v. fluids can be administered for 24 hours or longer to prevent resulting dehydration. Sometimes combination chemotherapy programs include agents which given individually are not problematic, but which may cause severe nausea if given together. Severe nausea also occurs with certain single agents, such as dacarbazine, nitrogen mustard or streptozocin, and hospitalization is needed in cases where prior outpatient use of antinausea drugs has been unsuccessful in preventing this side effect. |
| 7 |
Ifosfamide therapy. This anticancer drug produces severe bladder toxicity unless a uroprotective agent, Mesna®, is given simultaneously. Both drugs are intravenous, but the half-life of Ifosfamide is much longer than the half-life of Mesna®, which needs to be continued for perhaps 12 hours after the Ifosfamide ends. Although some oncologists give patients Mesna® to self-administer at home 6 and 12 hours later via an indwelling venous access line, in some cases hospitalization is required to be sure the Mesna® is given at the appropriate time, perhaps with i.v. fluids and nausea medications as well. |
| 8 |
Combination radiation therapy + chemotherapy programs in which unusual circumstances apply. Examples would be severe nausea and vomiting, need for continuous i.v. hydration and significant immobility due to weakness and/or pain. |
| 9 |
Coexistent medical problems (comorbidities) requiring separate and continuous observation, evaluation and treatment. Examples would include pulmonary or cardiac disease, diabetes and metabolic problems. |
| 10 |
Complex chemotherapy programs requiring more than 6 hours of continuous observation and drug administration. An example would be the "eight drugs in one day" protocol for brain tumors. |
| 11 |
Initial dose of chemotherapy while hospitalized. When cancer has just been diagnosed, it may be important to begin therapy immediately. The initial dose of conventional chemotherapy (otherwise usually given in the office) may be administered shortly before the last day of hospitalization. |
| 12 |
Hospitalization for unrelated problem. When a patient on maintenance chemotherapy, e.g., weekly, is hospitalized for another reason (such as diabetes control), it may be inappropriate to delay scheduled maintenance chemotherapy. |
| 13 |
Prevention of a significant side effect that occurred during a prior outpatient administration. An example would be cisplatin in dosages lower than 75 mg/m2, which nevertheless resulted in transient significant renal impairment. It may be wise to admit such a patient for the next and subsequent courses of cisplatin to allow 24 hour or longer i.v. fluid administration. |
| 14 |
High-dose methotrexate protocols requiring very specific i.v. fluid loading techniques, alkalinization and blood sampling for methotrexate levels, as well as urine pH measurements. |
| 15 |
Intraperitoneal chemotherapy can be given on an outpatient basis, but sometimes hospitalization is required. |
| 16 |
Certain investigational treatment protocols require a hospital setting, or it may be required for close and frequent observation, or for collection of blood or other samples. |
| 17 |
If chemotherapy administration is mandatory despite comorbidities. The patient is bed-bound and cannot obtain adequate clinical or laboratory monitoring as an outpatient (no home nursing care is available). There are patients for whom chemotherapy administration is mandatory despite the presence of active infection, fever of unknown origin, or low white cell or platelet count. |
| 18 |
Selected special circumstances other than those listed above for which inpatient chemotherapy is indicated and appropriate. This might reflect a particular chemotherapy drug or program, or a particular type of cancer, or both. Such circumstances may need to be justified on a case-by-case basis by the attending physician. An example would be the need to monitor verapamil infusions given to decrease P50-glycoprotein resistance. |
