Appropriate Chemotherapy Dosing For Obese Adult Patients With Cancer

Publication Date: April 2, 2012
Last Updated: March 14, 2022


The Panel recommends that actual body weight be used when selecting cytotoxic chemotherapy doses regardless of obesity status. There is no evidence that short- or long-term toxicity is increased among obese patients receiving full weight–based chemotherapy doses. Most data indicate that myelosuppression is the same or less pronounced among the obese than the non-obese when administered full weight–based doses.

The Panel recommends full weight–based chemotherapy dosing for morbidly obese patients with cancer, subject to appropriate consideration of other comorbid conditions. Data are extremely limited regarding optimal dose selection among the morbidly obese and other special subgroups. More studies are needed to evaluate optimal agents and agent combinations for obese and morbidly obese patients with cancer; however, on the basis of available information, it seems likely that the same principles regarding dose selection for obese patients apply to the morbidly obese.

The Panel recommends that full weight–based chemotherapy doses (IV and oral) be used in the treatment of the obese patient with cancer, particularly when the goal of treatment is cure. Selecting reduced doses in this setting may result in poorer DFS and OS rates. There are compelling data in patients with breast cancer that reduced dose-intensity chemotherapy is associated with increased disease recurrence and mortality. Although data in other malignancies are more limited, based on improved survival observed with chemotherapy compared with controls, a dose-response relationship exists for many responsive malignancies. Therefore, although data are not available to address this question for all cancer types, in the absence of data demonstrating sustained efficacy for reduced-dose chemotherapy, the Panel believes that the prudent approach is to provide full weight–based chemotherapy dosing to obese patients with cancer, especially those receiving treatment with curative intent. Most of the data in support of full weight–based dosing come from the treatment of early-stage disease. Data supporting the use of full weight–based doses in the advanced disease setting are limited.

Clinicians should follow the same guidelines for dose reduction, regardless of obesity status, for all patients, depending on the type and severity of toxicity, any comorbid conditions, and whether the treatment intention is cure or palliation. There is no evidence to support the need for greater dose reductions for obese patients compared with non-obese patients. If a dose reduction is employed in response to toxicity, consideration should be given to the resumption of full weight–based doses for subsequent cycles, especially if a possible cause of toxicity (eg, impaired renal, hepatic function) has been resolved. The Panel recognizes the need for clinicians to exercise judgment when providing care for patients who have experienced grade 3 or 4 chemotherapy toxicity. The presence of obesity alone should not alter such clinical judgment.

The Panel recommends consideration of fixed dosing only with select cytotoxic agents (eg, carboplatin and bleomycin). On the basis primarily of neurotoxicity concerns, vincristine is capped at a maximum dose of 2.0 mg when used as part of the CHOP (cyclophosphamide, hydroxydoxorubicin [doxorubicin], vincristine, prednisone) and CVP (cyclophosphamide, vincristine, prednisone) regimens. Several other cytotoxic chemotherapeutic agents have been used in clinical trials at a fixed dose independent of patient weight or BSA. However, it is not clear that fixed dosing is optimal for any of these other agents.

The Panel recommends that BSA be calculated using any of the standard formulas (eg, Mosteller, DuBois and Dubois, Haycock, Gehan and George, Boyd formulas). There is no evidence to support one formula for calculating BSA over another.

The Panel recommends further research into the role of pharmacokinetic and pharmacogenetic information for guiding the dosing of IV and oral chemotherapeutic agents for adult patients with cancer who are obese. It should be emphasized that there is a paucity of information on the influence of obesity on the pharmacokinetics of most anticancer drugs from properly powered trials. This is the result, in part, of empiric eligibility restrictions from the outset in clinical trials and a lack of pharmacokinetic analyses performed and published for this subpopulation. Overall, there are insufficient pharmacokinetic data to reject the recommendation to use a full weight–based dosing strategy for chemotherapeutic agents in patients with cancer who are obese, regardless of route of administration and/or infusion time.

Recommendation Grading




Appropriate Chemotherapy Dosing for Obese Adult Patients With Cancer

Authoring Organization

Publication Month/Year

April 2, 2012

Last Updated Month/Year

May 15, 2023

Document Type


External Publication Status


Country of Publication


Document Objectives

To provide recommendations for appropriate cytotoxic chemotherapy dosing for obese adult patients with cancer.

Target Patient Population

Obese adults patients needing chemotherapy for cancer

Target Provider Population

Medical oncologists, pharmacists, oncology nurses

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, health systems pharmacist, physician, physician assistant


Treatment, Management


obesity, cancer, chemotherapy, overweight, weight based dosing

Source Citation

DOI: 10.1200/JCO.2011.39.9436 Journal of Clinical Oncology 30, no. 13 (May 01, 2012) 1553-1561.

Supplemental Methodology Resources

Data Supplement, Evidence Tables