Principles of cancer care

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Cancer is one of the greatest health care concerns for patients and their health care providers. An individual's lifetime risk of developing cancer is approximately 40% and cancer is the second leading cause of death in the United States. Once cancer is confirmed, further diagnostics to assess the tumor grade and tumor stage are required, and a comprehensive assessment of the patient (e.g., evaluation of nutritional status, social support, and mental health) should be performed. Treatment (curative or palliative) is based on the characteristics of the tumor and the ability of the patient to tolerate therapy. Cancer therapy may include a combination of surgery, chemotherapy, cancer immunotherapy, radiation therapy, and/or targeted therapy. Complications arise frequently as a result of cancer progression or as a consequence of cancer treatment; proactive management (e.g., prophylactic antiemetic regimens for chemotherapy) may greatly improve patients' quality of life. The majority of cancer treatment is managed by oncologists but all health care providers will see patients who have cancer as a comorbidity and should be familiar with common treatments, complications, and the need for multidisciplinary cancer care.

For details on complications of cancer treatment, see “Complications of cancer therapy” and “Radiation injuries.”

Characterizing the cancer ^[2]

• Confirmation of cancer
  • Typically confirmed if malignant cells are identified on histopathologic analysis of a tissue sample
  • If the location is challenging to biopsy or the patient is frail and has advanced disease, the diagnosis may be assumed based on characteristic imaging and/or tumor markers. ^[3]
• Once confirmed, additional disease characteristics are determined in order to plan management.
  • Tumor grading
    • Based on histopathologic findings
    • Usually classified from low-grade (well-differentiated) to high-grade (poorly differentiated or undifferentiated) tumors
  • Tumor staging: identifies the extent of spread with additional diagnostics (e.g., imaging, biopsies)
  • Molecular testing: characterizes mutations, specific proteins, and tumor markers ^[2][4][5]
• See “General oncology” for additional information.

Anticancer therapies

Surgery ^[6]

• Complete resection (potentially curative): The entire tumor is removed along with a margin of surrounding healthy tissue.
• Partial resection (typically palliative): The tumor is debulked to facilitate systemic therapy and/or provide symptom relief.

Chemotherapy ^[7]

• Curative chemotherapy: an aggressive regimen of chemotherapeutic agent(s) administered with the intention of achieving complete remission
  • Induction chemotherapy: chemotherapy utilized to drastically reduce the tumor cell count
  • Consolidation chemotherapy: chemotherapy utilized to eradicate remaining tumor cells
  • Maintenance chemotherapy: low-dose chemotherapy utilized to maintain remission
  • Neoadjuvant therapy: chemotherapy and/or radiation before elective surgery
  • Adjuvant therapy: chemotherapy and/or radiation after surgery
• Palliative chemotherapy: a regimen of chemotherapeutic agents used to reduce local symptoms and/or prolong survival
• See also “Chemotherapeutic agents.”

Radiation therapy

• May be used with curative or palliative intent
• Options include external beam radiotherapy and brachytherapy.
• See also “Radiation therapy.”

Other therapies

• Cancer immunotherapy: e.g., immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy ^[8]
• Targeted therapy: e.g., monoclonal antibodies, small molecule inhibitors, immunotoxins ^[9]
• Hormone therapy: use of hormone modulators to manage malignancies whose growth is accelerated by circulating hormones ^[10]

Assessing response to anticancer therapy

• Hematopoietic tumors: usually determined by molecular analysis of a bone marrow aspirate or peripheral blood ^[11]
• Solid tumors: varies according to the type of cancer ; clinical scores (e.g., RECIST) may be useful ^[12]

Postcancer treatment care ^[13]

• Monitoring for recurrent and second cancers ^[2]
• Management of general health, comorbidities, and long-term complications arising from cancer or anticancer treatment
  • Physical complications include cardiotoxicity, neuropathy, premature menopause, lymphedema, and chronic pain. ^[14]
  • Psychosocial sequelae include anxiety, PTSD, and fear of recurrence. ^[15]
• Promotion of a healthy lifestyle including regular physical exercise ^[16]
• See also: “Cancer survivorship.”

Cancer patients are at risk of recurrence and of developing a new primary cancer after successful treatment; regular follow-up is vital.

Cancer treatment plan ^[17][18]

Treatment plans are typically developed and overseen by a multidisciplinary team (e.g., medical oncology, surgical oncology, radiation oncology, palliative care).

• Educate the patient about the nature of their disease and treatment options to facilitate shared decision-making.
• Perform a multidisciplinary pretreatment evaluation (see “Prechemotherapy screening” and “Multidisciplinary cancer care”).
• Establish treatment goals and clearly communicate them to the patient. ^[19]
  • Curative therapy: The aim is to cure the disease.
  • Palliative therapy: The aim is to prolong survival or relieve symptoms and improve the quality of life.
• Select anticancer therapy: typically a combination of different treatment modalities
• Determine the timeline and estimated duration of treatment.
• Discuss possible enrollment in clinical trials with the patient.
• Discuss advance care planning for patients receiving palliative treatment.

Shared decision-making is vital in cancer care; patient and clinician priorities might be different. ^[20]

Prechemotherapy screening

The following assessments should be performed to establish a baseline, identify potential complications, and determine fitness for treatment regimens.

Frailty assessment ^[21][22][23]

• Assess using a validated tool: Eastern Cooperative Oncology Group (ECOG) scale , Karnofsky performance status ^[24]
• Treatment may need to be adjusted for patients with limited physiologic reserve; consult geriatrics.

Assessment of organ function ^[25]

• Routine laboratory studies
  • CBC
  • CMP
  • Liver chemistries ^[26]
• ECG and echocardiogram ^[27]
• Baseline imaging (as indicated) ^[28]

Prevention of complications

• Infection screening: to identify current or latent infections prior to chemotherapy or immunotherapy
  • Common: HIV screening, viral hepatitis panel ^[29][30][31]
  • Consider: HSV, VZV, tuberculosis ^[32][33]
• Immunizations
  • Verify vaccination status and titers if necessary.
  • Provide missing and additional immunizations as indicated. ^[34][35][36]
• Dental evaluation ^[37][38]

Unrecognized asymptomatic or latent infections may develop into life-threatening illnesses when patients become immunosuppressed. Screen patients for common infections and consult an infectious diseases specialist for management.

Additional evaluations

• HLA typing: for transplant candidates
• LDH: prognostication in certain cancers, e.g., cancer of unknown primary site ^[39][40]
• Pregnancy test: for all patients of childbearing age ^[41]
• Further testing may be indicated depending on planned treatment, e.g., ASCVD risk assessment before cardiotoxic cancer therapy. ^[42]

Reproductive care for patients with cancer ^[41][43][44]

• Refer patients to a reproductive specialist to discuss options for fertility preservation. ^[45][46]
  • Egg harvesting and cryopreservation
  • Semen cryopreservation
  • Ovarian transposition ^[47]
• Provide counseling on contraceptive options to both men and women. ^[41]

Obtaining long-term venous access ^[48][49]

• A central venous catheter (CVC), e.g., Hickman line , Port-a-cath , PICC line , is indicated for:
  • Prolonged infusions of chemotherapeutic or vesicant agents
  • AND/OR frequent blood sampling
• Consult general or vascular surgery if required.
• See “Comparison of long-term CVCs” for details on CVCs that suit individual patient needs.

Multidisciplinary cancer care

Multidisciplinary care is associated with improvements in clinical outcomes and the patient's quality of life. ^[50]

Primary care involvement

• Inform the patient's primary care provider of the diagnosis and treatment plan. ^[51]
• The primary care provider's role may include: ^[52]
  • Provision of preventive care measures, e.g., immunizations
  • Diagnosis and management of common complications
  • Patient referrals, e.g., to psychiatry or hospice care

Nutritional assessment ^[53][54][55]

• Monitor weight, appetite, and nutritional intake.
• Consider dietitian consultation and provide specialized nutrition support as needed.

Psychosocial support ^[56][57]

• Identify and treat mental health comorbidities using validated screening tools, e.g., Patient Health Questionnaire-9 (PHQ-9).
• Refer to psychiatry/psychologist as appropriate.
• Offer a social work consultation. ^[58][59][60]
• Suggest local support groups for patients and families.

Depending on the diagnosis and stage, up to ∼ 80% of patients with cancer have major depression, but it is often underdiagnosed and undertreated. ^[56][57]

Other referrals

• Older patients or patients with functional impairments: Refer to physical therapy and/or occupational therapy. ^[61]
• Suspected hereditary cancer syndrome: Refer for genetic counseling.
• Patients with advanced cancer or overwhelming symptoms: Refer to palliative care.

Cancer-related emergencies

• Patients with cancer can develop life-threatening complications, e.g., superior vena cava syndrome, and leukostasis.
• See “Oncologic emergencies” for details on the diagnosis and management of these conditions.

Cancer pain ^[62][63]

• Cancer pain, caused by either the primary cancer, metastatic disease, and/or associated treatment, can be difficult to control.
• For further information including dosages, see “Pain management in palliative care.”

Pain is undertreated in as many as 80% of patients with cancer; assess pain frequently, adjust pain management accordingly, and involve specialists early. ^[62]

Cancer-related fatigue ^[64][65]

• A chronic, distressing exhaustion that is severe, persistent, and not relieved with rest
• Occurs in approx. 80% of patients during chemotherapy or radiation therapy ^[64]
• Management ^[64][65]
  • Identify and treat reversible causes. ^[64]
    • Blood tests: CBC, inflammatory markers, liver chemistries, BMP, thyroid function tests
    • Urinalysis
    • Depression screening, e.g., PHQ-9
  • Encourage physical activity.
  • Consider:
    • Psychosocial interventions
    • A short-term course of corticosteroids in patients with metastatic disease

Cancer anorexia-cachexia syndrome ^[66][67]

• A syndrome characterized by progressive wasting of skeletal muscle mass with or without loss of body fat that occurs in patients with advanced cancer ^[66]
• Occurs in ∼ 50% of patients with advanced cancer; typically a sign of poor prognosis ^[66]
• Results from an excess of proinflammatory cytokines (IL-1, IL-6, IFN-γ, and TNF-α) as a result of tumor growth → ↑ basal metabolic rate and catabolism ^[68]
• Clinical features
  • Weight loss
    • > 5% of total body weight in 6 months
    • OR > 2% weight loss if ongoing and BMI is < 20 kg/m² or muscle mass is depleted
  • Muscle wasting; (temporal, deltoid, and quadricep regions) and loss of subcutaneous fat
  • Decreased appetite
  • Fatigue
  • Dependent edema and ascites
• Management ^[66]
  • Refer to a registered dietitian.
  • Encourage oral nutrition; do not routinely use parenteral or enteral tube feeding in patients with advanced cancer. ^[66]
  • Consider pharmacological therapy to increase appetite and weight gain. ^[66]
    • First line: short-term trial of progesterone analog or corticosteroid
    • Cannabinoid (e.g., dronabinol) use remains controversial. ^[66][69][70]
  • Provide psychosocial support to patients and their families. ^[67]

Cancer anorexia-cachexia syndrome is an indicator of a poor prognosis.

Cancer-related constipation ^[71][72]

Defined based on the Rome IV diagnostic criteria for primary constipation in adults

Epidemiology

• 40–90% of patients with advanced cancer experience constipation. ^[71]
• More common in patients receiving opioids

Risk factors for constipation in patients with cancer

Cancer-related constipation can be caused by the malignancy itself, other cancer-related complications, and cancer therapy; it is often multifactorial.

• Due to cancer
  • Structural, e.g., abdominal masses, peritoneal carcinomatosis
  • Neurological, e.g., CNS tumors
• Secondary to cancer
  • Metabolic, e.g., hypercalcemia, uremia
  • Pain, inactivity
  • Poor oral intake, dehydration
• Risk factors for primary constipation, e.g., low fiber intake
• Cancer therapy-induced constipation
• Other constipation-inducing medications, e.g., opioids, antiemetics

Management

• Nonpharmacological management of constipation
• Laxatives ^[71]
  • Osmotic laxatives
    • Polyethylene glycol (preferred)
    • Lactulose
  • Stimulant laxatives (may not be tolerated by patients who are weak or debilitated)
    • Senna ^[71]
    • Bisacodyl
• Provide treatment of fecal impaction as needed.
• See also “Approach to constipation in adults” and “Management of constipation.”

Deep vein thrombosis (DVT) ^[73][74]

• Patients with cancer are at an increased risk of DVT formation, DVT recurrence, and bleeding during DVT treatment.
• Tailor management to the patient, including the type of cancer and anticancer therapy.
• See “VTE prophylaxis in active cancer” and “Anticoagulation for DVT in active cancer.”

Paraneoplastic syndromes

• Cancer can cause a wide range of paraneoplastic syndromes, with symptoms ranging from mild to severe.
• See “Paraneoplastic syndromes” for further information.

Definition

• Cancer survivor: anyone diagnosed with cancer, from the time of diagnosis throughout their lives ^[75]

Epidemiology

• Approximately 18 million cancer survivors in the US ^[76]
  • ♀ > ♂
  • Approximately 67% aged ≥ 65 years
• > 40% of individuals born in the US will be diagnosed with cancer. ^[77]

Management

General principles

• An individualized survivorship care plan to optimize coordinated patient care should be created by the treating oncologist.
• Follow-up care includes:
  • Surveillance for cancer spread and recurrence
  • Risk assessment for and management of long-term complications of cancer therapy
  • Assessment of ongoing physical, emotional, and psychosocial needs
  • Adult health maintenance, including screening for second cancers and promoting a healthy lifestyle

An individualized survivorship care plan to guide follow-up care can help facilitate effective communication and coordination among healthcare providers. ^[77]

Surveillance ^[75][77]

Cancer survivors should be monitored for cancer spread and recurrence based on the primary cancer and treatment received.

• Monitoring may include:
  • Physical examination
  • Laboratory studies
  • Imaging
• Details of monitoring, including recommended frequency for follow-up visits, should be included in each patient's survivorship care plan.
• See also:
  • Surveillance after prostate cancer treatment
  • Surveillance after colorectal cancer treatment
  • Surveillance of Hodgkin lymphoma
  • Surveillance after breast cancer treatment
  • “Follow-up” in “Treatment of cervical cancer”

Health maintenance ^[75][77]

• Primary prevention strategies for adult health apply, e.g.:
  • Prevention of atherosclerotic cardiovascular disease
    • Smoking cessation
    • Physical activity ^[16]
    • Healthy diet
    • Blood pressure screening
    • Weight management
    • Low alcohol consumption
  • Age-appropriate immunizations
• Screening for complications and comorbidities, e.g.:
  • Cancer screening
    • All age-appropriate screening as recommended
    • Screening for second cancers varies depending on risk factors and treatment received. ^[2]
  • Psychosocial screening for adults (see also “Depression in patients with cancer”)
  • Monitoring for other long-term complications of cancer care, e.g., secondary osteoporosis, accelerated cardiovascular disease

Psychosocial issues ^[15][75]

Cancer survivors are at increased risk for psychosocial issues.

• Mental health disorders
  • Common disorders include major depressive disorder, generalized anxiety disorder, and PTSD.
  • Management includes: ^[78]
    • Cognitive behavioral therapy
    • Psychoeducation
    • Mindfulness-based stress reduction
    • Pharmacotherapy, e.g., SSRIs
• Medical financial hardship ^[76][79]
  • Includes worry about finances, delaying or forgoing medical treatment because of the cost, difficulty paying medical bills, and bankruptcy
  • Assess for risk factors, e.g.:
    • Age < 50 years
    • Uninsured or underinsured, e.g., those with high-deductible health plans
    • Lower income
    • Long-term survivors of childhood cancer
  • Refer cancer survivors at risk for medical financial hardship to social work.
• Other psychosocial issues: fear of recurrence, difficulties around returning to work