Cancer Symptom

Aka: Cancer Symptom, Oncologic Complication, Cancer Complication, Palliative Care, Cancer Emergencies, Oncologic Emergencies, Cancer Emergency, Oncologic Emergency, Oncology Emergency

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II. Epidemiology: Symptom Prevalence

  1. Asthenia (Fatigue): 90%
  2. Anorexia: 85%
  3. Cancer Pain: 76%
  4. Nausea: 68%
  5. Constipation: 65%
  6. Sedation or confusion: 60%
  7. Dyspnea: 12%

III. Management: Approach

  1. Target the underlying cause of symptoms (e.g. treat the Dyspnea leading to anxiety)
  2. Medication initiation and titration
    1. Start medications at low dose and titrate to effect
    2. Transition as needed dosing to scheduled dosing and to longer acting agents
    3. Proactively prevent symptoms if possible
  3. Medication delivery
    1. Consider alternative formulations that allow for difficult patient Swallowing and Somnolence
    2. Some medications may be reformulated by compounding pharmacies
    3. Sublingual medications (mucous membranes must be moist)
    4. Concentrated and dissolving medications
    5. Transdermal patches, creams and gels
    6. Rectal suppositories

IV. Management: Cancer Emergencies

  1. Metabolic Cancer Complications
    1. Tumor Lysis Syndrome
    2. Syndrome of Inappropriate Antidiuretic Hormone: SIADH
    3. Malignant Hypercalcemia (Hypercalcemia of Malignancy)
  2. Infectious and hematologic Cancer Complications
    1. Neutropenic Fever
  3. Vascular Complications
    1. Malignant Cardiac Tamponade
      1. Pericardial Effusion is present in up to one third of cancer patients
      2. Most common cancer causes of Pericardial Effusion are metastatic lung and Breast Cancer
    2. Superior Vena Cava Syndrome
    3. Hyperviscosity Syndrome (includes Polycythemia Vera and Leukostasis)
  4. Neurologic complications
    1. Epidural Spinal Cord Compression
  5. Gastrointestinal complications
    1. See gastrointestinal symptoms below
    2. Neutropenic Colitis (Neutropenic Enterocolitis, Typhlitis)
  6. Chemotherapy complications
    1. Chemotherapy Extravasation
  7. Radiation Therapy complications
    1. See Radiation Therapy for adverse effects
  8. Cancer Immunotherapy complications
    1. See Cancer Immunotherapy for adverse effects
    2. Serious complications include Pneumonitis and Pancreatitis
  9. References
    1. Aurora and Herbert in Majoewsky (2013) EM:Rap 13(10): 1-4
    2. Long, Long and Koyfman (2020) Crit Dec Emerg Med 34(11): 17-24
    3. Higdon (2006) Am Fam Physician 74:1873-80 [PubMed]
    4. Zuckerman (2012) Blood 120(10): 1993-2002 [PubMed]

V. Management: Symptoms

  1. Mouth and Dental
    1. Includes Dry Mouth and excessive oral secretions
    2. See Mouth Care in Cancer
  2. Dermatology
    1. See Fungating Growths
    2. See Radiation Dermatitis
  3. Pain
    1. See Cancer Pain
    2. See Cancer Pain Management
    3. See Cancer Pain Medications
    4. See Cancer Pain Opioid
  4. Dehydration in Cancer Patients
    1. See Cachexia in Cancer
    2. See Hypodermoclysis
    3. Only treat if it improves quality of life
    4. Risk Intravenous Fluids: Iatrogenic Pulmonary Edema
  5. Hypercalcemia of Malignancy
    1. Most common serious Palliative Care metabolic effect
    2. Always keep in mind and test for it!
    3. Fluids effectively treat Hypercalcemia in most cases
  6. Gastrointestinal
    1. See Nausea in Cancer
    2. See Diarrhea in Cancer
    3. See Constipation in Cancer
    4. See Cachexia in Cancer
    5. See Gastrointestinal Bleeding
  7. Pulmonary
    1. See Dyspnea in Cancer
  8. Neurologic and Psychiatric
    1. See Mood Disorders in Cancer
    2. See Delirium in Cancer
  9. Rheumatology and Musculoskeletal
    1. See Fatigue in Cancer
    2. Radicular symptoms should be evaluated with advanced imaging
      1. Cancer patients may not present with typical red flag symptoms (e.g. cauda equina, bilateral involvement)
  10. Cerebral Edema
    1. Treat with Dexamethasone (and concurrent H2 Blocker)
  11. Fluid Third Spacing
    1. Malignant Ascites
    2. See Pleural Effusion in Cancer

VI. Management: Special circumstances

  1. Terminal patients who choose not to eat or drink
    1. Some patients will choose to hasten their own death
    2. Competent patients may refuse to take nourishment
    3. Study looked at suffering, pain and duration to death
      1. Patients died within 2 weeks of stopping intake
      2. Low level of pain and suffering
      3. Ganzini (2003) N Engl J Med 349:359-65 [PubMed]
  2. Pill burden
    1. Discontinue pills that do not affect quality of life (Antihypertensives, Hyperlipidemia agents, diabetes medications)
    2. Eliminate medications with significant adverse effects (e.g. Anticholinergic Medications cause Constipation)

VII. Management: Hospice Comfort Kit

  1. Antpyretics for fever
    1. Acetaminophen 650 mg suppository SL or PR every 4 hours as needed for fever
  2. Opiates for pain, Shortness of Breath (caution: highly concentrated)
    1. See Cancer Pain Opioid
    2. Morphine 20 mg/ml 5-10 mg (0.25 to 0.5 ml) every 3 hours as needed for pain, Shortness of Breath
    3. Oxycodone 20 mg/ml 5-10 mg (0.25 to 0.5 ml) every 3 hours as needed for pain, Shortness of Breath
  3. Benzodiazepines for anxiety
    1. Lorazepam 2 mg/ml 0.5 to 1 mg SL or PR every 4 hours as needed for anxiety
  4. Antipsychotics for Nausea, Agitation
    1. Haloperidol 2 mg/ml 0.5 to 1 mg SL or PR every 4 hours as needed for Nausea or Agitation
    2. Risperidone 2 mg/ml 0.5 to 1 mg SL or PR every 4 hours as needed for Nausea or Agitation
  5. Anticholinergics for excessive oral secretions
    1. Hyoscamine 0.125 mg SL every 6 hours as needed for excessive oral secretions
    2. Atropine 1% ophthalmic drops SL every 6 hours as needed for excessive oral secretions

VIII. Resources

  1. End of Life Physicians Education Resource
    1. http://www.eperc.mcw.edu
    2. Fast Facts offers an excellent clinician resource
  2. National Cancer Institute
    1. http://www.cancer.gov/cancertopics/pdq/supportivecare
  3. Center to Advance Palliative Care
    1. http://www.capc.org/
  4. American Academy of Hospice and Palliative Medicine
    1. http://www.aahpm.org/

IX. References

  1. Storey (1996) Primer of Palliative Care, AAHPM
  2. Albert (2017) Am Fam Physician 95(6): 356-61 [PubMed]
  3. Higdon (2018) Am Fam Physician 97(11):741-8 [PubMed]
  4. Ross (2001) Am Fam Physician 64(6):1019-26 [PubMed]
  5. Ross (2001) Am Fam Physician 64(5):807-14 [PubMed]

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Related Studies

Ontology: Palliative Care (C0030231)

Definition (MSHCZE) Péče zmírňující pouze příznaky onemocnění, neléčí základní příčinu nemoci.(Stedman, 25th ed)
Definition (MEDLINEPLUS)

Palliative care is treatment of the discomfort, symptoms, and stress of serious illness. It provides relief from distressing symptoms including

  • Pain
  • Shortness of breath
  • Fatigue
  • Constipation
  • Nausea
  • Loss of appetite
  • Problems with sleep

It can also help you deal with the side effects of the medical treatments you're receiving.

Hospice care, care at the end of life, always includes palliative care. But you may receive palliative care at any stage of an illness. The goal is to make you comfortable and improve your quality of life.

NIH: National Institute of Nursing Research
Definition (NCI_CDISC) The patient- and family-centered active holistic care of patients with advanced, progressive disease. Essential components of palliative care are: pain and symptom control, communication regarding treatment and alternatives, prognosis, and available services, rehabilitation services, care that addresses treatment and palliative concerns, intellectual, emotional, social, and spiritual needs, terminal care, support in bereavement. The goal of palliative care is an achievement of the best quality of life for patients and their families.
Definition (NCI_NCI-GLOSS) Treatment given to relieve the symptoms and reduce the suffering caused by cancer and other life-threatening diseases. Palliative cancer therapies are given together with other cancer treatments, from the time of diagnosis, through treatment, survivorship, recurrent or advanced disease, and at the end of life.
Definition (NCI) The patient- and family-centered active holistic care of patients with advanced, progressive disease. Essential components of palliative care are: pain and symptom control, communication regarding treatment and alternatives, prognosis, and available services, rehabilitation services, care that addresses treatment and palliative concerns, intellectual, emotional, social, and spiritual needs, terminal care, support in bereavement. The goal of palliative care is an achievement of the best quality of life for patients and their families.
Definition (MSH) Care alleviating symptoms without curing the underlying disease. (Stedman, 25th ed)
Concepts Health Care Activity (T058)
MSH D010166
SnomedCT 395079002, 393128009, 394079005, 103735009
English Palliative Treatment, Palliative Treatments, Treatment, Palliative, Treatments, Palliative, Care, Palliative, Palliative Care, Palliative Therapy, Therapy, Palliative, Palliative treatment (context-dependent category), PALLIATIVE THER, THER PALLIATIVE, palliative care (treatment), palliative care, care palliatives, cares palliative, therapy palliative, care palliative, palliative treatment, Palliative treatment (situation), Palliative treatment, Comfort Measures, symptom management, palliation, palliative therapy, comfort care, Palliative care, Palliative care (regime/therapy), Palliative care, NOS, Palliative care (regime/therapy)(procedure), Comfort Care, Symptom Management, Symptoms Management
Italian Cura palliativa, Terapia palliativa, Trattamento palliativo, Assistenza palliativa
Swedish Palliativ vård
Spanish tratamiento paliativo (categoría dependiente del contexto), Cuidados Paliativos, tratamiento paliativo (situación), tratamiento paliativo, Atención Paliativa, cuidados paliativos (procedimiento), cuidados paliativos (régimen/tratamiento), cuidados paliativos, Cuidados paliativos, Tratamiento Paliativo
Japanese ｶﾝﾜｹｱ, 緩和ケア, 姑息療法(緩和ケア), 待期療法(緩和ケア), 緩和療法, パリアティブケア
Finnish Lievityshoito
Russian PALLIATIVNOE LECHENIE, PALLIATIVNAIA MEDITSINSKAIA POMOSHCH', ПАЛЛИАТИВНАЯ МЕДИЦИНСКАЯ ПОМОЩЬ, ПАЛЛИАТИВНОЕ ЛЕЧЕНИЕ
Czech Paliativní péče, paliativní terapie, paliativní léčba, paliativní péče
French Thérapie palliative, Traitement palliatif, Soins palliatifs
Croatian PALIJATIVNA NJEGA, PALIJATIVNA TERAPIJA, PALIJATIVNA SKRB
Polish Chirurgia paliatywna, Leczenie paliatywne, Opieka paliatywna
Hungarian Palliatív kezelés
Norwegian Palliativ pleie, Palliativ behandling, Lindrende behandling
Portuguese Cuidados Paliativos, Assistência Paliativa, Cuidado Paliativo, Cuidados paliativos, Tratamento Paliativo
Dutch palliatieve zorg, Therapie, palliatieve, Zorg, palliatieve
German Palliativbehandlung, Palliative Behandlung, Palliativpflege
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Oncologic complications and emergencies (C0851630)

Concepts Disease or Syndrome (T047)
Italian Complicanze ed emergenze oncologiche
Japanese 腫瘍性合併症および緊急状態, ｼｭﾖｳｾｲｶﾞｯﾍﾟｲｼｮｳｵﾖﾋﾞｷﾝｷｭｳｼﾞｮｳﾀｲ
Czech Onkologické komplikace a náhlé příhody
English Oncologic complications and emergencies
Hungarian Oncologiai komplikációk és sürgősségi esetek
Portuguese Complicações e urgências oncológicas
Spanish Complicaciones y urgencias oncológicas
Dutch oncologische complicaties en spoedgevallen
French Complications et urgences oncologiques
German Onkologische Komplikationen und Notfaelle
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Oncologic complication (C2242489)

Concepts Pathologic Function (T046)
English Oncologic complication
Spanish Complicación oncológica
Dutch oncologische complicatie
German onkologische Komplikation
Japanese ｼｭﾖｳｶﾞｯﾍﾟｲｼｮｳ, 腫瘍合併症
Czech Onkologická komplikace
Portuguese Complicação oncológica
Italian Complicazione oncologica
French Complication oncologique
Hungarian Oncologiai komplikáció
Derived from the NIH UMLS (Unified Medical Language System)

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