Systemic oncological therapy in breast cancer patients on dialysis

Table 1 Summary of key considerations for administering systemic therapies in breast cancer patients on hemodialysis

Drug	Class	Use in breast cancer	Dose adjustment in HD	Key considerations for ESRD on HD
Tamoxifen	Hormone therapy	ER-positive cancers	Yes	Monitor efficacy due to altered metabolism in HD. Reduced dose may be required
Anastrozole	Aromatase inhibitor	ER-positive cancers	Yes	Reduced clearance in HD; dose modification necessary. Monitor for reduced efficacy or increased toxicity
Letrozole	Aromatase inhibitor	ER-positive cancers	Yes	Adjust dosage for renal impairment. Monitor for adverse effects
Exemestane	Aromatase inhibitor	ER-positive cancers	Yes	Use with caution in HD. Limited data; consider alternative therapies
Cyclophosphamide	Alkylating agent	Various	Yes	Requires dose reduction. Administer post-HD due to renal excretion
Doxorubicin	Anthracycline	Various	Yes	Moderate dose reduction advised. Cardiotoxicity and clearance considerations. Administer on non-dialysis days
Paclitaxel	Taxane	Various	No	Generally safe without dose adjustment. Monitor for neuropathy and hypersensitivity reactions
Docetaxel	Taxane	Various	Yes (limited data)	Data on dialysis patients limited; likely requires dose adjustment. Monitor for neutropenia and fluid retention
Gemcitabine	Nucleoside analog	Various	No	Standard doses can be used; monitor for myelosuppression and pulmonary toxicity
Carboplatin	Platinum compound	Various	Yes	Dose adjustment based on renal function using the Calvert formula. Administer post-HD for optimal clearance
Methotrexate	Antimetabolite	Various	Yes	Contraindicated in high doses; significant dose reduction required. Avoid if possible
Trastuzumab	HER2-targeted therapy	HER2-positive cancers	No	Monitor for cardiotoxicity; minimal renal impact. Safe in ESRD on HD
Lapatinib	Tyrosine kinase inhibitor	HER2-positive cancers	Yes (limited data)	Safe in ESRD; dosage adjustments may be needed. Limited data available
Atezolizumab	Immunotherapy	Triple-negative breast cancer	Yes (limited data)	Limited data on ESRD patients. Monitor closely for immune-related adverse events
Vinorelbine	Antimitotic agent	Advanced breast cancer	Yes	Reduced initial dose recommended. Eliminated mainly through the liver, but renal adjustment necessary
Capecitabine	Prodrug to 5-FU	Various	Yes	Significant reduction in dosage needed. Monitor closely for toxicity, especially hand-foot syndrome and diarrhea
Fulvestrant	Hormone therapy	ER-positive cancers	No	No dose adjustment needed. Safe to use in ESRD patients on HD
Megestrol acetate	Progestin, antineoplastic	Cancer cachexia, appetite stimulant	No	Monitor for thrombosis risk, especially in ESRD patients
CDK 4/6 inhibitors (palbociclib, ribociclib, abemaciclib)	CDK 4/6 inhibitors	HR-positive metastatic breast cancers	Limited data	No clear dose adjustments; monitor for increased serum creatinine and potential nephroprotective effects
Cisplatin	Platinum-based chemotherapy	BRCA-1-mutated and TNBC	Yes	High risk of nephrotoxicity; use cautiously and with dose adjustments. Preferably administered immediately before HD sessions
5-FU	Antimetabolite	Various	Yes	Administer post-HD

5-FU: 5-fluorouracil; HD: Hemodialysis; ESRD: End-stage renal disease; ER: Estrogen receptor; HR: Hazard ratio; HER2: Human epidermal growth factor receptor 2; CDK: Cyclin-dependent kinase; TNBC: Triple-negative breast cancer.