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Cancer Symptom
Aka: Cancer Symptom, Oncologic Complication, Cancer Complication, Palliative Care, Cancer Emergencies, Oncologic Emergencies, Cancer Emergency, Oncologic Emergency, Oncology Emergency
- See Also
- End-Of-Life Care
- Hospice
- Epidemiology: Symptom Prevalence
- Asthenia (Fatigue): 90%
- Anorexia: 85%
- Cancer Pain: 76%
- Nausea: 68%
- Constipation: 65%
- Sedation or confusion: 60%
- Dyspnea: 12%
- Management: Approach
- Target the underlying cause of symptoms (e.g. treat the Dyspnea leading to anxiety)
- Medication initiation and titration
- Start medications at low dose and titrate to effect
- Transition as needed dosing to scheduled dosing and to longer acting agents
- Proactively prevent symptoms if possible
- Medication delivery
- Consider alternative formulations that allow for difficult patient Swallowing and Somnolence
- Some medications may be reformulated by compounding pharmacies
- Sublingual medications (mucous membranes must be moist)
- Concentrated and dissolving medications
- Transdermal patches, creams and gels
- Rectal suppositories
- Management: Cancer Emergencies
- Metabolic Cancer Complications
- Tumor Lysis Syndrome
- Syndrome of Inappropriate Antidiuretic Hormone: SIADH
- Malignant Hypercalcemia (Hypercalcemia of Malignancy)
- Infectious and hematologic Cancer Complications
- Neutropenic Fever
- Vascular Complications
- Malignant Cardiac Tamponade
- Pericardial Effusion is present in up to one third of cancer patients
- Most common cancer causes of Pericardial Effusion are metastatic lung and Breast Cancer
- Superior Vena Cava Syndrome
- Hyperviscosity Syndrome (includes Polycythemia Vera and Leukostasis)
- Neurologic complications
- Epidural Spinal Cord Compression
- Gastrointestinal complications
- See gastrointestinal symptoms below
- Neutropenic Colitis (Neutropenic Enterocolitis, Typhlitis)
- Chemotherapy complications
- Chemotherapy Extravasation
- Radiation Therapy complications
- See Radiation Therapy for adverse effects
- Cancer Immunotherapy complications
- See Cancer Immunotherapy for adverse effects
- Serious complications include Pneumonitis and Pancreatitis
- References
- Aurora and Herbert in Majoewsky (2013) EM:Rap 13(10): 1-4
- Long, Long and Koyfman (2020) Crit Dec Emerg Med 34(11): 17-24
- Higdon (2006) Am Fam Physician 74:1873-80 [PubMed]
- Zuckerman (2012) Blood 120(10): 1993-2002 [PubMed]
- Management: Symptoms
- Mouth and Dental
- Includes Dry Mouth and excessive oral secretions
- See Mouth Care in Cancer
- Dermatology
- See Fungating Growths
- See Radiation Dermatitis
- Pain
- See Cancer Pain
- See Cancer Pain Management
- See Cancer Pain Medications
- See Cancer Pain Opioid
- Dehydration in Cancer Patients
- See Cachexia in Cancer
- See Hypodermoclysis
- Only treat if it improves quality of life
- Risk Intravenous Fluids: Iatrogenic Pulmonary Edema
- Hypercalcemia of Malignancy
- Most common serious Palliative Care metabolic effect
- Always keep in mind and test for it!
- Fluids effectively treat Hypercalcemia in most cases
- Gastrointestinal
- See Nausea in Cancer
- See Diarrhea in Cancer
- See Constipation in Cancer
- See Cachexia in Cancer
- See Gastrointestinal Bleeding
- Pulmonary
- See Dyspnea in Cancer
- Neurologic and Psychiatric
- See Mood Disorders in Cancer
- See Delirium in Cancer
- Rheumatology and Musculoskeletal
- See Fatigue in Cancer
- Radicular symptoms should be evaluated with advanced imaging
- Cancer patients may not present with typical red flag symptoms (e.g. cauda equina, bilateral involvement)
- Cerebral Edema
- Treat with Dexamethasone (and concurrent H2 Blocker)
- Fluid Third Spacing
- Malignant Ascites
- See Pleural Effusion in Cancer
- Management: Special circumstances
- Terminal patients who choose not to eat or drink
- Some patients will choose to hasten their own death
- Competent patients may refuse to take nourishment
- Study looked at suffering, pain and duration to death
- Patients died within 2 weeks of stopping intake
- Low level of pain and suffering
- Ganzini (2003) N Engl J Med 349:359-65 [PubMed]
- Pill burden
- Discontinue pills that do not affect quality of life (antihypertensives, Hyperlipidemia agents, diabetes medications)
- Eliminate medications with significant adverse effects (e.g. Anticholinergic Medications cause Constipation)
- Management: Hospice Comfort Kit
- Antpyretics for fever
- Acetaminophen 650 mg suppository SL or PR every 4 hours as needed for fever
- Opiates for pain, Shortness of Breath (caution: highly concentrated)
- See Cancer Pain Opioid
- Morphine 20 mg/ml 5-10 mg (0.25 to 0.5 ml) every 3 hours as needed for pain, Shortness of Breath
- Oxycodone 20 mg/ml 5-10 mg (0.25 to 0.5 ml) every 3 hours as needed for pain, Shortness of Breath
- Benzodiazepines for anxiety
- Lorazepam 2 mg/ml 0.5 to 1 mg SL or PR every 4 hours as needed for anxiety
- Antipsychotics for Nausea, Agitation
- Haloperidol 2 mg/ml 0.5 to 1 mg SL or PR every 4 hours as needed for Nausea or Agitation
- Risperidone 2 mg/ml 0.5 to 1 mg SL or PR every 4 hours as needed for Nausea or Agitation
- Anticholinergics for excessive oral secretions
- Hyoscamine 0.125 mg SL every 6 hours as needed for excessive oral secretions
- Atropine 1% ophthalmic drops SL every 6 hours as needed for excessive oral secretions
- Resources
- End of Life Physicians Education Resource
- http://www.eperc.mcw.edu
- Fast Facts offers an excellent clinician resource
- National Cancer Institute
- http://www.cancer.gov/cancertopics/pdq/supportivecare
- Center to Advance Palliative Care
- http://www.capc.org/
- American Academy of Hospice and Palliative Medicine
- http://www.aahpm.org/
- References
- Storey (1996) Primer of Palliative Care, AAHPM
- Albert (2017) Am Fam Physician 95(6): 356-61 [PubMed]
- Higdon (2018) Am Fam Physician 97(11):741-8 [PubMed]
- Ross (2001) Am Fam Physician 64(6):1019-26 [PubMed]
- Ross (2001) Am Fam Physician 64(5):807-14 [PubMed]