Principles of cancer care

Last updated: May 30, 2022

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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. Anticancer 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., 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.

Characterizing the cancer [1]

  • 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. [2]
  • 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 profile: characterizes mutations, specific proteins, and tumor cell markers [1][3][4]
    • See “General oncology” for additional information.

Anticancer treatment plans [5][6]

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 “Preparation for cancer treatment”).
  • Establish treatment goals and clearly communicate them to the patient. [7]
    • 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 advance care planning for patients receiving palliative treatment.

Shared decision-making is vital in cancer care; patient and clinician priorities might be different. [8]

Anticancer therapies

Surgery [9]

  • 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
Resection margin Definition
R0
  • Complete removal: Resection margins are macro- and microscopically free of tumor tissue.
R1
  • Microscopically visible tumor tissue in resection margins
R2
  • Macroscopically visible tumor tissue remains.
  • The size/extent of residual tumor tissue is documented in the operative report.

Chemotherapy [10]

Radiation therapy

Other therapies

Assessing response to anticancer therapy

  • Hematopoietic tumors: usually determined by molecular analysis of a bone marrow aspirate or peripheral blood [14]
  • Solid tumors: varies according to the type of cancer ; clinical scores (e.g., RECIST) may be useful [15]
Categorizing the response of solid tumors to anticancer therapy
Response Characteristics

Complete response

  • No clinical or radiological evidence of tumor disease over a certain amount of time (based on tumor type)

Partial response

  • A decrease in tumor volume by a certain percentage (based on tumor type)

Stable disease

  • Minimal decrease or increase in size of tumor(s)

Progressive disease

  • Increase in the size of tumor(s)

Posttreatment care [16]

  • Monitoring for recurrent and second cancers [1]
  • Management of general health, comorbidities, and long-term complications arising from cancer or anticancer treatment
  • Promotion of a healthy lifestyle including regular physical exercise [19]

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

Prechemotherapy screening

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

Frailty assessment [20][21][22]

Assessment of organ function [24]

Prevention of complications

Additional evaluations

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 [40][41][42]

Obtaining permanent venous access [45][46]

Patients require a central venous catheter (CVC) if they will receive prolonged infusions of chemotherapeutic or vesicant agents or frequent blood sampling.

Types of permanent central venous catheters [45][46]
Advantages Disadvantages

Peripherally inserted central catheter (PICC)

  • Surgery is not required.
  • Low risk of procedural complication
  • Needs frequent flushes and dressing changes
  • Limited longevity
  • Risk of thrombophlebitis
Surgically implantable catheter (e.g., port-a-cath)
  • Requires surgery
  • Painful to access
Tunneled central venous catheter
  • Large size allows easy administration of blood products
  • Painless access
  • Requires surgery
  • Higher risk of infection than an implanted catheter

Multidisciplinary cancer care

Multidisciplinary care is associated with improvements in clinical outcomes and the patient's quality of life. [47]

Primary care involvement

  • Inform the patient's primary care provider of the diagnosis and treatment plan. [48]
  • The primary care provider's role may include: [49]
    • 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 [50][51][52]

Psychosocial support [53][54]

  • 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. [55][56][57]
  • Suggest local support groups for patients and families.

Specific referrals

Depending on the diagnosis and stage, up to ∼ 80% of patients with cancer have major depression, but it is often underdiagnosed and undertreated. [53][54]

Treatment-related emergencies

Infection in patients with neutropenia has a high risk of death and should be treated accordingly, with prompt aggressive treatment and close monitoring. [1]

Chemotherapy-induced nausea and vomiting (CINV) [59][60]

Definition [60][61]

Epidemiology

Management [59][60]

Examples of CINV prophylaxis regimens [59]
Emetogenicity of chemotherapeutic agents [60] 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)
  • Routine prophylaxis is not recommended.

Chemotherapy-induced diarrhea [64][65][66]

Definition [66]

Epidemiology

Management of uncomplicated diarrhea [64][66]

Management of complicated diarrhea [64][66]

Do not assume a diagnosis of chemotherapy-induced diarrhea before completing a thorough assessment; differential diagnoses include life-threatening infections, e.g., C. difficile infection and neutropenic enterocolitis. [66]

Anticancer therapy-induced myelosuppression [68]

Patients with cancer often require blood products that have been irradiated, are leukoreduced, and/or come from CMV seronegative donors. [70]

Anticancer therapy-induced anemia [71][72]

Anticancer therapy-induced thrombocytopenia [74][75][76]

Anticancer therapy-induced neutropenia [80][81][82]

Mucositis [84][85][86]

Epidemiology [84][86]

Prevention [84][85]

  • Educate the patient on good oral hygiene.
    • Use a soft toothbrush and brush twice daily.
    • Rinse the mouth 4–6 times a day with alcohol-free mouthwash.
    • Frequently inspect the oral mucosa.
  • Advise:
    • Regular lubrication of the lips with vaseline or paraffin
    • Ample fluid intake
    • Avoidance of alcohol, smoking, and spicy, acidic, or sharply edged food
  • 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:

Because of the high risk of mucositis, prophylaxis is recommended for patients receiving fluorouracil, high-dose regimens used for conditioning prior to HSCT, and radiotherapy. [84][85]

Management [84][85][86]

Provide adequate pain management to patients with mucositis. Consider initiating opioid analgesia early.

Extravasation of chemotherapeutic agents [87][88]

  • Reported in up to 6% of patients with cancer [88]
  • Clinical features include pain, pressure, and swelling at the IV site, leakage of infusion fluid, and alterations to IV flow. [88]

Prevention [87]

  • Provide appropriate training to staff who will place intravenous catheters and administer chemotherapy.
  • For peripheral IV catheterization:
    • Avoid:
    • Select flexible IV catheters; avoid winged steel infusion devices.
  • 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.

Management [87][88]

Extravasation of vesicants may lead to severe complications such as soft tissue necrosis or compartment syndrome. [88]

Chemotherapy-induced alopecia [89][90]

Epidemiology

  • Occurs in ∼ 65% of patients receiving chemotherapy [89]
  • Frequently causes considerable psychological distress [89][90]

Chemotherapeutic agents that frequently cause severe alopecia include doxorubicin, daunorubicin, paclitaxel, docetaxel, cyclophosphamide, irinotecan, and etoposide. [89]

Management during chemotherapy

  • Preventive strategies
    • Patient education [90]
      • Wash hair only when necessary and use a soft brush and satin pillowcase.
      • Avoid damage to the hair, e.g., bleaching, coloring, use of curling irons or hot rollers.
    • Use of scalp-cooling devices during chemotherapy [91]
  • Use of camouflage techniques, e.g., change of hairstyle, wigs, or headwraps [89]
  • Refer for psychological support if emotionally distressed. [89]

Scalp cooling is contraindicated in patients with hematologic malignancies because of the risk of reduced chemotherapy delivery to malignant cells in the scalp circulation. [92]

Post-chemotherapy treatment

  • Topical treatments may help promote regrowth.
  • Examples:

Other complications

Cancer-related emergencies

Cancer pain [99][100]

Pain is undertreated in as many as 80% of cancer patients; assess pain frequently, adjust pain management accordingly, and involve specialists early. [99]

Cancer-related fatigue [101][102]

Cancer anorexia-cachexia syndrome [103][104]

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

Deep vein thrombosis (DVT) [108][109]

Paraneoplastic syndromes

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