Pulmonary Function Testing Prior to Bleomycin

Primary Recommendation

The British College of Cancer guidelines recommend that baseline pulmonary function tests (PFTs) should not be used to predict toxicity risk or to decide whether to treat with bleomycin, as they are only weakly correlated with increased toxicity 1, 2
Baseline PFTs can be performed if feasible to serve as a reference point for comparison if toxicity is later suspected, according to the British College of Cancer guidelines 2, 3
The British College of Cancer guidelines state that PFTs should not be used in isolation to aid decisions about whether to treat with bleomycin 2, 3

The guideline's position reflects high-quality evidence showing that baseline PFT values do not reliably identify patients at risk, as stated by the British College of Cancer 1

Exercise caution with bleomycin in patients with significant smoking history, according to the British College of Cancer guidelines 4
Exercise caution with bleomycin in patients with pre-existing lung disease, particularly fibrosis or symptomatic pathology, as recommended by the British College of Cancer guidelines 5
The British College of Cancer guidelines state that there are no absolute contraindications to bleomycin use 2, 4

If bleomycin toxicity is suspected during treatment, HRCT is the investigation of choice, not PFTs, according to the British College of Cancer guidelines 1, 3, 5
PFTs may have a limited adjunctive role in corroborating HRCT findings when there is diagnostic uncertainty, as stated by the British College of Cancer guidelines 1, 2, 3

Do not rely on chest X-ray, as it has extremely low sensitivity for bleomycin toxicity, according to the British College of Cancer guidelines 1, 5
Do not use routine serial PFTs during treatment to monitor for toxicity, as recommended by the British College of Cancer guidelines 1
Recognize that cough is the most sensitive symptom for predicting toxicity, not PFT changes, according to the British College of Cancer guidelines 1, 5, 6

Before starting bleomycin, assess clinical risk factors, such as age, renal function, smoking, and pre-existing lung disease, as recommended by the British College of Cancer guidelines 2, 4
Consider baseline PFTs if readily available, but do not delay treatment to obtain them, according to the British College of Cancer guidelines 2, 3
During treatment, monitor clinically for new cough or dyspnea, and obtain HRCT immediately if new respiratory symptoms develop, as recommended by the British College of Cancer guidelines 1, 3, 5