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Chemotherapy doses used to be capped for larger people for fear of overdose. The American Society of Clinical Oncology guideline found that up to 40 per cent of people with obesity were given reduced doses, that the feared extra toxicity is unfounded, and recommends full doses based on actual body weight.
What changed. Doses based on body surface area grow with weight, and prescribers have capped the surface area at a fixed value or dosed on ideal rather than actual weight. The 2012 guideline from the American Society of Clinical Oncology reviewed studies published from 1996 to 2010, mostly in breast, ovarian, colon and lung cancer, and found that up to 40 per cent of obese patients received limited doses not based on actual body weight. It recommended full weight-based doses, particularly when the aim is cure, found no evidence that short or long-term toxicity was increased, and said most data showed myelosuppression the same or less pronounced in obese patients. It judged fixed dosing rarely justified, with exceptions for a few drugs.
The 2021 update. Sixty mostly retrospective studies published from 2010 to 2020 supported the same conclusion. The update extended it: full approved doses of immunotherapy and targeted therapy should also be offered to obese adults, and toxicity should be handled the same way whatever a person's size. It named sarcopenia and body composition as the main question still open.
What precision means here. Dose capping is a deliberate loss of precision, a dose below the one the regimen was tested at. The guideline removes that. It does not make surface-area dosing itself any more precise, and the guideline abstracts do not put a figure on how much survival capping costs.
Body surface area is calculated from actual height and weight without an upper cap, and the per-square-metre or per-kilogram dose of the tested regimen is given in full.
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