Febrile Neutropenia Risk: MASCC and CISNE

The decision at the bedside is not whether this is febrile neutropenia — it is whether this patient is low-risk enough for oral antibiotics or discharge. Two published instruments answer it and they were derived in different populations, so they disagree in a way that is informative rather than annoying. This page computes both from one set of entries and shows them together, with the population each was built on stated. Neither score overrides clinical judgement, and neither was designed to.

Last updated 19 Sep 2026

Is this patient low-risk enough for oral or outpatient treatment?

MASCC and CISNE, computed together

Burden of illnessMASCC item, worth 5 or 3 points. These two options are alternatives and their points are not added together — which is why the published table’s rows sum to 29 while the stated maximum is 26. It is a global clinical impression of how unwell the patient looks, and it is the most subjective item in the score.

Systolic blood pressureMASCC item, 5 points for the absence of hypotension. Hypotension in febrile neutropenia is a reason to admit whatever any score says.

Chronic obstructive pulmonary diseaseThis selector feeds both scores with opposite polarity: MASCC gives 4 points for its absence, CISNE gives 1 point for its presence. Enter it once and both arms are handled.

Tumour type and fungal historyMASCC item, 4 points. The item is a single row in the published table combining both conditions, not two separate rows — a distinction worth getting right, because splitting it is one of the ways reproductions of this score go wrong.

Dehydration requiring parenteral fluidsMASCC item, 3 points for its absence. Note that it is dehydration needing intravenous fluids, not dehydration of any degree.

Status when the fever beganMASCC item, 3 points. A patient already in hospital for another reason when the fever started is at higher risk, and this item captures that rather than describing where they should be managed now.

AgeMASCC item, 2 points, and the smallest weight in the score. CISNE does not use age at all.

ECOG performance statusCISNE item, 2 points, and jointly the heaviest item in that score. It is the performance status at baseline, not the patient’s state during the fever.

Stress-induced hyperglycaemiaCISNE item, 2 points. Defined on the capillary or blood glucose at presentation: above about 6.7 mmol/L (121 mg/dL) in someone without diabetes, or above about 13.9 mmol/L (250 mg/dL) in someone with diabetes or taking corticosteroids.

Chronic cardiovascular diseaseCISNE item, 1 point. A documented history of cardiovascular disease, not a cardiovascular risk factor.

MucositisCISNE item, 1 point. Grade 2 is symptomatic mucositis that still allows a modified oral intake — which matters here, because it is also the point at which oral antibiotics become unreliable.

Monocyte countCISNE item, 1 point. The only laboratory item in either score other than the neutrophil count that defined the episode. A monocyte count this low indicates deeper marrow suppression than the neutrophil count alone conveys.

Does CISNE apply to this patient?CISNE was derived and validated only in clinically stable patients with solid tumours receiving chemotherapy of mild to moderate myelotoxicity. Outside that group its score is computed here but should not be used. MASCC’s derivation cohort was heterogeneous and included acute leukaemia and transplant recipients.

24of 26Example

A 63-year-old having adjuvant chemotherapy for a colorectal cancer attends with a temperature of 38.6°C and a neutrophil count of 0.3 × 10⁹/L. She looks well and has no symptoms beyond the fever, her blood pressure is 118/74, she has no COPD and no dehydration, she came from home, and she has a solid tumour with no fungal history. Her baseline ECOG is 2 because of a hip problem, she has treated ischaemic heart disease, her glucose is 5.4 mmol/L, she has no mucositis, and her monocyte count is 0.4 × 10⁹/L. She is clinically stable.

Both scores, and the arithmetic check on each

MASCC = burden of illness (5 if none or mild, 3 if moderate, 0 if severe) + 5 if no hypotension + 4 if no COPD + 4 if solid tumour or no previous fungal infection + 3 if no dehydration + 3 if outpatient + 2 if under 60.
Maximum = 5 + 5 + 4 + 4 + 3 + 3 + 2 = 26, which is the published maximum. The moderate-symptoms row is not added to the mild row; the two are alternatives.
Low risk at 21 or above.

CISNE = 2 if ECOG 2 or worse + 2 if stress-induced hyperglycaemia + 1 if COPD + 1 if chronic cardiovascular disease + 1 if mucositis NCI grade 2 or worse + 1 if monocytes below 0.2 × 10⁹/L.
Maximum = 2 + 2 + 1 + 1 + 1 + 1 = 8, which is the published maximum.
0 is low risk, 1 to 2 intermediate, 3 or more high.

MASCC: Multinational Association for Supportive Care in Cancer risk index, 0 to 26, higher is safer
CISNE: Clinical Index of Stable Febrile Neutropenia, 0 to 8, higher is more dangerous

Worked example

A 63-year-old having adjuvant chemotherapy for a colorectal cancer attends with a temperature of 38.6°C and a neutrophil count of 0.3 × 10⁹/L. She looks well and has no symptoms beyond the fever, her blood pressure is 118/74, she has no COPD and no dehydration, she came from home, and she has a solid tumour with no fungal history. Her baseline ECOG is 2 because of a hip problem, she has treated ischaemic heart disease, her glucose is 5.4 mmol/L, she has no mucositis, and her monocyte count is 0.4 × 10⁹/L. She is clinically stable.
MASCC item by item: no symptoms 5, no hypotension 5, no COPD 4, solid tumour with no fungal history 4, no dehydration 3, outpatient when the fever began 3, age 63 so 0
MASCC = 5 + 5 + 4 + 4 + 3 + 3 + 0 = 24 → 21 or above, so low risk
CISNE: ECOG 2 scores 2; no hyperglycaemia 0; no COPD 0; cardiovascular disease 1; no mucositis 0; monocytes 0.4, so 0
CISNE = 2 + 0 + 0 + 1 + 0 + 0 = 3 → high risk
The two scores disagree, and that is the finding. MASCC says she may be a candidate for oral or outpatient management; CISNE — which was built on exactly this population, a clinically stable solid-tumour patient — says a third of patients scoring 3 or more develop serious complications
She is a stable solid-tumour patient, so CISNE applies in full. Admit, and treat intravenously
Change one entry and it flips. Bring her baseline ECOG to 1 and CISNE falls to 1, which is intermediate rather than high, and the case for a short observed course becomes arguable — on the same MASCC of 24

What each score was derived on

The reason to run both is in the last two rows. Where they apply to the same patient and disagree, CISNE was designed to catch the failure mode MASCC has — the apparently stable solid-tumour patient who scores low risk and then deteriorates.
	MASCC	CISNE
Derivation population	Heterogeneous febrile neutropenia — solid tumours, acute leukaemia and transplant recipients together	Clinically stable adults with solid tumours on chemotherapy of mild to moderate myelotoxicity; leukaemia and transplant excluded
Outcome predicted	Serious medical complications during the episode	Serious complications in patients who already look well enough to consider discharge
Range and direction	0 to 26; higher is safer	0 to 8; higher is more dangerous
Threshold	21 or above is low risk	0 low, 1 to 2 intermediate, 3 or more high
Known weakness	Misclassifies on the low-risk side — serious complications in up to about 10% of those it calls low risk	Does not apply outside stable solid-tumour patients, which is a large part of the febrile neutropenia population
Use it when	Any febrile neutropenia, including haematological malignancy	Only for a clinically stable patient with a solid tumour

The definition the whole page sits on

Risk stratification happens after treatment has started, not instead of it. No score on this page is a reason to delay the first dose.
Term	Definition
Fever	A single oral temperature of 38.3°C or more, or 38.0°C or more sustained over one hour
Neutropenia	Absolute neutrophil count below 1.0 × 10⁹/L
Severe neutropenia	Absolute neutrophil count below 0.5 × 10⁹/L, or expected to fall below it
The first action	Empirical broad-spectrum intravenous antibiotics within one hour, before any result comes back — this precedes any risk score

Why two scores, and what to do when they disagree

The MASCC risk index was published in 2000 from a heterogeneous international cohort of febrile neutropenic patients — solid tumours, acute leukaemia and transplant recipients together — and it predicts serious medical complications during the episode. Its seven weighted items add to 26, and a score of 21 or more identifies a low-risk group. It has been validated repeatedly and it is the instrument named in guidelines for the whole febrile neutropenia population, which is its main advantage: it applies to everybody.

Its main weakness is the side of it that people want to use. Because the decision being made is usually whether to send somebody home, the low-risk end carries the clinical weight, and that is where MASCC is weakest — serious complications have been reported in up to about a tenth of patients it classifies as low risk. A score built to identify a high-risk group is being asked to certify a low-risk one, and it does that less well than its overall performance suggests.

CISNE was designed to fix exactly that. Its derivation population was deliberately narrow: clinically stable adults with solid tumours receiving chemotherapy of mild to moderate myelotoxicity — in other words, the patients in whom the discharge question is actually being asked. Within that group it separates a genuinely low-risk category, scoring 0, with complications in about 1 per cent, from an intermediate group at 1 to 2 with about 6 per cent, and a high-risk group at 3 or more with about a third. Its six items are heavily weighted towards chronic comorbidity and baseline function rather than towards how ill the patient looks today, which is what allows it to find the people who look well and are not.

So when the two disagree in a stable solid-tumour patient, the disagreement is not noise — it is the thing CISNE was constructed to detect, and the safer instrument in that population is CISNE. Outside that population the comparison does not arise, because CISNE should not be used at all: a haematology patient or a transplant recipient falls outside its cohorts entirely, and its number is arithmetic without evidence behind it. And in every case both scores sit downstream of two decisions neither of them makes. Empirical broad-spectrum intravenous antibiotics go in within an hour of presentation, before any score is calculated. And no patient goes home who cannot swallow, cannot be observed, or cannot get back to hospital quickly — conditions that appear in no score and override both.

Frequently asked questions

Which score should I use?

MASCC applies to any patient with febrile neutropenia, including those with haematological malignancy, because its derivation cohort included them. CISNE applies only to clinically stable adults with solid tumours receiving chemotherapy of mild to moderate myelotoxicity. If your patient falls inside CISNE’s population, run both — that is the situation the two were designed to be compared in, and the ASCO and IDSA guideline names both.

MASCC says low risk and CISNE says high risk. What do I do?

If the patient is a clinically stable solid-tumour patient, follow CISNE and admit. That combination is the specific failure mode CISNE was built to detect: MASCC’s low-risk category contains a minority of patients who look well and nevertheless develop serious complications, and CISNE’s comorbidity-weighted items are what separate them. The disagreement is informative rather than contradictory.

Why does the maximum MASCC score not equal the sum of the rows in the published table?

Because the two burden-of-illness rows — 5 points for no or mild symptoms, 3 for moderate — are alternatives rather than additive, and the published table lists them as separate rows. Adding every row gives 29; adding only one burden row gives the stated maximum of 26. Reproductions of this score that reach 25 or 27 have usually split the tumour item into two rows or inflated the dehydration weight, and the total is what exposes it.

Can a low score send a patient home on oral antibiotics?

Not on its own. A low-risk score makes outpatient management a possibility; three further conditions decide it. The patient has to be able to take and absorb oral medication, which mucositis and vomiting both defeat. There has to be a reliable route back — someone at home, a telephone, transport, and a named contact for readmission within an hour. And the treating clinician has to agree, because both instruments misclassify individuals and neither was built to be used without judgement.

Do I calculate the score before starting antibiotics?

No. Empirical broad-spectrum intravenous antibiotics are given within an hour of presentation, before cultures return and before any risk stratification. Fever is defined as a single oral temperature of 38.3°C or more, or 38.0°C or more sustained over an hour, in a patient whose neutrophil count is below 1.0 × 10⁹/L or expected to fall below 0.5 × 10⁹/L. Risk scoring decides what happens next, not whether treatment starts.

Related calculators

References

Klastersky J, Paesmans M, Rubenstein EB, et al. The Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol. 2000;18(16):3038-3051.
Carmona-Bayonas A, Jiménez-Fonseca P, Virizuela Echaburu J, et al. Prediction of serious complications in patients with seemingly stable febrile neutropenia: validation of the Clinical Index of Stable Febrile Neutropenia in a prospective cohort of patients from the FINITE study. J Clin Oncol. 2015;33(5):465-471.
Taplitz RA, Kennedy EB, Bow EJ, et al. Outpatient management of fever and neutropenia in adults treated for malignancy: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018;36(14):1443-1453.
Smith TJ, Bohlke K, Lyman GH, et al. Recommendations for the use of WBC growth factors: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2015;33(28):3199-3212.

Medical Disclaimer: The tools and content provided here are for educational and reference purposes only. They are not intended to substitute for professional medical advice, diagnosis, or treatment. Clinical decisions should always be based on the comprehensive assessment of a qualified healthcare professional.