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)
    4. Adrenal Insufficiency
  2. Hematologic Complications
    1. Hyperleukocytosis or Leukemoid Reaction
    2. Leukostasis
    3. Blast Crisis
    4. Cytokine Release Syndrome (CRS, Cytokine Storm)
  3. Infectious and hematologic Cancer Complications
    1. Neutropenic Fever
  4. Vascular Complications (structural emergencies resulting in obstruction)
    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. Venous Thromboembolism
      1. Highest risk in the first 6 months of cancer diagnosis
      2. D-Dimer is often unhelpful given baseline elevation and higher risk of VTE (imaging is first-line study)
      3. Consider Khorana Risk Score (VTE Risk assessment specific to cancer patients)
        1. https://www.mdcalc.com/calc/3315/khorana-risk-score-venous-thromboembolism-cancer-patients
  5. Neurologic complications
    1. Epidural Spinal Cord Compression (e.g. Epidural Neoplasm)
    2. Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS)
  6. Gastrointestinal complications
    1. See gastrointestinal symptoms below
    2. Neutropenic Colitis (Neutropenic Enterocolitis, Typhlitis)
  7. Chemotherapy complications
    1. Chemotherapy Extravasation
  8. Radiation Therapy complications
    1. See Radiation Therapy for adverse effects
  9. Cancer Immunotherapy complications
    1. See Cancer Immunotherapy for adverse effects
    2. Serious complications include Pneumonitis and Pancreatitis
  10. 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: Oncology Consultation or Referral

  1. Urgent Indications
    1. New cancer diagnosis or significant progression of known cancer (for diagnostics and treatment)
    2. Oncology emergencies (see above)
    3. Cancer therapy complications (e.g. severe therapy adverse effects)
    4. Unclear treatment strategy in active cancer (aggressive treatment vs Palliative Care)
  2. Routine Indications
    1. Chemotherapy adjustment or adjunctive management
    2. Coordination of cancer treatment with other, comorbid medical condition management
    3. Transitions of Care (e.g. emergency department or hospital discharge)

VII. Management: Disposition

  1. Hospital Admission Indications
    1. Oncology emergencies (see above)
    2. Hemodynamic instability
    3. Severe, refractory Cancer Symptoms (e.g. intractable pain, respiratory distress)
    4. Complex management (e.g. multiple time-intensive interventions, high risk conditions)
    5. New or worsening significant neurologic symptoms (e.g. Spinal Cord Compression, Delirium)
    6. Socioeconomic barriers (e.g. no transportation, no support, Cognitive Impairment or Disability, remote home)
  2. Outpatient Management Indications (assumes oncology follow-up, consider Consultation)
    1. Controllable cancer related symptoms (see above)
    2. Low risk Neutropenic Fever (consult oncology)
    3. Clinically stable

VIII. 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)

IX. 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

X. 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/

XI. References

  1. Bierowski and Nyalakonda (2025) Crit Dec Emerg Med 39(6): 4-21
  2. Storey (1996) Primer of Palliative Care, AAHPM
  3. Albert (2017) Am Fam Physician 95(6): 356-61 [PubMed]
  4. Higdon (2018) Am Fam Physician 97(11):741-8 [PubMed]
  5. Ross (2001) Am Fam Physician 64(6):1019-26 [PubMed]
  6. Ross (2001) Am Fam Physician 64(5):807-14 [PubMed]

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