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 and 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. may include a combination of surgery, chemotherapy, 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., ) 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.
Characterizing the cancer 
- Confirmation of cancer
- Once confirmed, additional disease characteristics are determined in order to plan management.
- Based on histopathologic findings
- Usually classified from low-grade (well-differentiated) to high-grade (poorly differentiated or undifferentiated) tumors
- biopsies) : identifies the extent of spread with additional diagnostics (e.g., imaging,
- Molecular profile: characterizes mutations, specific proteins, and tumor cell markers 
- See “General oncology” for additional information.
Anticancer treatment plans 
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 .
- Perform a multidisciplinary pretreatment evaluation (see “Preparation for cancer treatment”).
- Establish treatment goals and clearly communicate them to the patient. 
- 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 therapy: typically a combination of different treatment modalities (e.g., surgery, chemotherapy, radiotherapy).
- Determine the timeline and estimated duration of treatment.
- Discuss possible enrollment in clinical trials with the patient.
- Discuss palliative treatment. for patients receiving
is vital in cancer care; patient and clinician priorities might be different. 
- 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.
|Assessing resection margins in cancer surgery|
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.”
- May be used with curative or palliative intent
- Options include external beam radiotherapy and brachytherapy.
- See also “Radiation therapy.”
- Cancer immunotherapy: e.g., checkpoint inhibitors, 
- Targeted therapy: e.g., monoclonal antibodies, small molecule inhibitors, immunotoxins 
- Hormone therapy: the use of hormone modulators to manage malignancies whose growth is accelerated by circulating hormones 
Assessing response to anticancer therapy
- Hematopoietic tumors: usually determined by molecular analysis of a bone marrow aspirate or peripheral blood 
- Solid tumors: varies according to the type of cancer ; clinical scores (e.g., RECIST) may be useful 
|Categorizing the response of solid tumors to anticancer therapy|
Posttreatment care 
- Monitoring for recurrent and 
- Management of general health, comorbidities, and long-term complications arising from cancer or anticancer treatment
- Promotion of a healthy lifestyle including regular physical exercise 
Cancer patients are at risk of recurrence and of developing a new primary cancer after successful treatment; regular follow-up is vital.
The following assessments should be performed to establish a baseline, identify potential complications, and determine fitness for treatment regimens.
Frailty assessment 
- Assess using a validated tool: , 
- Treatment may need to be adjusted for patients with limited physiologic reserve; consult geriatrics.
Assessment of organ function 
Prevention of complications
- Infection screening: to identify current or latent infections prior to chemotherapy or immunotherapy
- Dental evaluation 
- HLA typing: for transplant candidates
- LDH: prognostication in certain cancers, e.g., cancer of unknown primary site 
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.
Managing fertility during anticancer therapy 
- Perform a pregnancy test on all patients of childbearing age. 
- Refer patients to a reproductive specialist to discuss options for fertility preservation. 
- Provide to both men and women. 
Obtaining permanent venous access 
|Types of permanent central venous catheters |
| || |
|Surgically implantable catheter (e.g., port-a-cath)|| || |
|Tunneled central venous catheter|| || |
Multidisciplinary cancer care
Primary care involvement
- Inform the patient's primary care provider of the diagnosis and treatment plan. 
- The primary care provider's role may include: 
Nutritional assessment 
- Monitor weight, appetite, and nutritional intake.
- Consider dietitian consultation and provide as needed.
Psychosocial support 
- 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. 
- Suggest local support groups for patients and families.
- Older patients or patients with functional impairments: Refer to physical therapy and/or occupational therapy. 
- Patients with advanced cancer or overwhelming symptoms: Refer to palliative care (see “Overview of palliative medicine”).
- Suspected hereditary cancer syndrome: Refer for .
Depending on the diagnosis and stage, up to ∼ 80% of patients with cancer have major depression, but it is often underdiagnosed and undertreated. 
- Cancer treatment can result in life-threatening complications, e.g., febrile neutropenia, tumor lysis syndrome.
- See “Oncologic emergencies” and “Neutropenic fever”; for details on the diagnosis and management of these conditions.
Chemotherapy-induced nausea and vomiting (CINV) 
- Any nausea and vomiting associated with chemotherapy
- Further subcategorized as:
- Acute CINV: onset within 24 hours after chemotherapy
- Delayed CINV: onset between 24 and 120 hours after chemotherapy
- Anticipatory CINV: onset prior to chemotherapy as a conditioned response following nausea or vomiting with previous chemotherapy
- Breakthrough CINV: occurs despite the use of standard antiemetic prophylaxis
- Refractory CINV: occurs in patients with a history of CINV unresponsive to prophylactic and rescue antiemetic therapy during previous chemotherapy
- 30–60% of patients who receive chemotherapy develop CINV. 
- Risk factors include female sex, younger age, anxiety, and a history of motion or morning sickness. 
Base the antiemetic regimen on patient characteristics and the emetogenicity of the chemotherapeutic agents.
- Initial regimen
- antiemetics of a different class (e.g., olanzapine, benzodiazepines, dopamine receptor antagonists). or : Add
- benzodiazepines and/or behavioral therapy. : Optimize prophylaxis and consider
- Patients with active nausea/vomiting may require , including electrolyte correction.
|Examples of CINV prophylaxis regimens |
|Emetogenicity of chemotherapeutic agents ||Prophylaxis regimens|
|High (CINV in > 90% of patients)|
|Moderate (CINV in 30–90% of patients)|
|Low (CINV in 10–30% of patients)|
|Minimal (CINV in < 10% of patients)|| |
Chemotherapy-induced diarrhea 
- ≥ 3 loose or watery stools per day in patients receiving chemotherapy
- Subdivided into:
- Up to 80% of patients receiving chemotherapy 
- Irinotecan and 5-fluorouracil are most frequently associated with diarrhea. 
Management of uncomplicated diarrhea 
- Initiate .
- Recommend dietary interventions.
- Take precautions against perianal skin irritation.
- Consider loperamide. 
- Advise patients to seek immediate medical attention if symptoms of complicated diarrhea develop.
- Further management
Management of complicated diarrhea 
- Request diagnostic studies to assess for complications and rule out other causes of diarrhea.
- Admit for inpatient management and consider gastroenterology consult.
Do not assume a diagnosis of chemotherapy-induced diarrhea before completing a thorough assessment; differential diagnoses include life-threatening infections, e.g., and . 
Anticancer therapy-induced myelosuppression 
- One of the most common side effects, particularly during induction chemotherapy 
- Actively monitor for myelosuppression in all patients receiving chemotherapy or systemic radiotherapy.
- If myelosuppression is identified, start early management, which can include:
Anticancer therapy-induced anemia 
- Screen for and treat vitamin B12, folate, and iron deficiency anemia. 
- Transfusion of packed RBCs: indicated for severe anemia or certain patients with moderate anemia 
- Erythropoiesis-stimulating agents (ESA): Consider in select patients after . 
Anticancer therapy-induced thrombocytopenia 
- Initial management
- Discuss additional measures, such as pharmacological prophylaxis or treatment, with hematology.
Anticancer therapy-induced neutropenia 
- Advise patients on infection prevention measures. 
- Wash hands regularly.
- Avoid eating unwashed fruits or vegetables and undercooked meat, seafood, or eggs.
- Keep catheter sites clean and dry.
- Remain up-to-date on recommended vaccinations.
- Avoid contact with unwell individuals.
- Follow local health authority guidance on mask-wearing and social distancing to reduce the risk of COVID-19 infection.
Consider granulocyte colony-stimulating factor (e.g., filgrastim, pegfilgrastim) or granulocyte-macrophage colony-stimulating factor (e.g., sargramostim) for: 
- Patients with febrile neutropenia who are at high risk for complications
- Prophylaxis in certain patients receiving cancer treatment
- Antimicrobial prophylaxis (e.g., trimethoprim/sulfamethoxazole against Pneumocystis jirovecii pneumonia, fluconazole against invasive candidiasis) is limited to high-risk patients under specialist guidance. 
- Monitor frequently for signs of infection and maintain a low threshold for starting aggressive antimicrobial treatment (see “Neutropenic fever”).
- Mucositis is the presence of inflammatory or ulcerative lesions in the mouth or GI tract following anticancer treatment.
- Symptoms include oral pain, dysphagia, and diarrhea.
- 20–40% of patients receiving chemotherapy
- 60–85% of patients undergoing hemopoietic stem cell transplantation (HSCT)
- Almost all patients receiving head and neck radiation 
- Educate the patient on good oral hygiene.
- Refer for dental evaluation and treatment (e.g., repair or replace any poorly fitting prosthesis) prior to and during cancer therapy.
- Depending on the treatment regimen, consider the following in consultation with a specialist:
- Ensure nutritional support and hydration.
- Optimize systemic pain management (consider patient-controlled analgesia).
- Oral mucositis
- Gastrointestinal mucositis
Extravasation of chemotherapeutic agents 
- Reported in up to 6% of patients with cancer 
- Clinical features include pain, pressure, and swelling at the IV site, leakage of infusion fluid, and alterations to IV flow. 
- Provide appropriate training to staff who will place intravenous catheters and administer chemotherapy.
- For peripheral IV catheterization:
- Following IV catheterization, and prior to each infusion:
- Check for blood return.
- Flush with 10–20 mL of saline.
- Inspect for signs of extravasation.
- For prolonged infusions (≥ 12 hours), use central venous access.
- Immediately disconnect the infusion but leave the IV catheter in place.
- Aspirate as much medication as possible then remove the IV catheter.
- Mark the boundaries of infiltration with a nonwashable marker.
- Identify the extravasated medication and contact a specialist (e.g., oncology, plastic surgery) to start specific management.
- Elevate the limb and provide pain management as needed.
- Reassess regularly until fully healed. 
- Consult plastic surgery or orthopedic surgery if the affected area is extensive or the patient has symptoms of compartment syndrome.
Chemotherapy-induced alopecia 
- A form of temporary alopecia seen in patients receiving chemotherapy
- Hair regrowth typically occurs 2–6 months after stopping chemotherapy, but, in rare cases, hair loss is permanent. 
- Occurs in ∼ 65% of patients receiving chemotherapy 
- Frequently causes considerable psychological distress 
Management during chemotherapy
- Preventive strategies
- Use of camouflage techniques, e.g., change of hairstyle, wigs, or headwraps 
- Refer for psychological support if emotionally distressed. 
Scalp cooling is contraindicated in patients with hematologic malignancies because of the risk of reduced chemotherapy delivery to malignant cells in the scalp circulation. 
- Topical treatments may help promote regrowth.
- Additional complications may arise depending on the treatment modality and agents.
- Management typically includes optimization of fluids and electrolytes and symptomatic treatment.
- Severe treatment reactions might require terminating or modifying treatment.
- See “Chemotherapeutic agents” and “Radiation therapy” for a more comprehensive list of complications.
- Patients with cancer can develop life-threatening complications as a result of the disease (e.g., superior vena cava syndrome, leukostasis).
- See “Oncologic emergencies” for details on the diagnosis and management of these conditions.
Cancer pain 
- 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.”
Cancer-related fatigue 
- A chronic, distressing exhaustion that is severe, persistent, and not relieved with rest
- Occurs in approx. 80% of patients during chemotherapy or radiation therapy 
- Management 
- Identify and treat reversible causes. 
- Encourage physical activity.
Cancer anorexia-cachexia syndrome 
- A syndrome characterized by progressive wasting of skeletal muscle mass with or without loss of body fat that occurs in patients with advanced cancer 
- Occurs in ∼ 50% of patients with advanced cancer; typically a sign of poor prognosis 
- 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 
- Clinical features
- Management 
- Refer to a registered dietitian.
- Encourage oral nutrition; do not routinely use parenteral or enteral tube feeding in patients with advanced cancer. 
- Consider pharmacological therapy to increase appetite and weight gain. 
- Provide psychosocial support to patients and their families. 
Cancer anorexia-cachexia syndrome is an indicator of a poor prognosis.
Deep vein thrombosis (DVT) 
- 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 “Deep vein thrombosis” and “DVT prophylaxis.”