Cancer/Chronic Disease

Cancer

1. In all patients, be opportunistic in giving cancer prevention advice (e.g., stop smoking, reduce unprotected sexual intercourse, prevent human papillomavirus infection), even when it is not the primary reason for the encounter.
2. In all patients, provide the indicated evidence-based screening (according to age group, risk factors, etc.) to detect cancer at an early stage (e.g., with Pap tests, mammography, colonoscopy, digital rectal examinations, prostate-specific antigen testing).
3. In patients diagnosed with cancer, offer ongoing follow-up and support and remain involved in the treatment plan, in collaboration with the specialist cancer treatment system. (Don’t lose track of your patient during cancer care.)
4. In a patient diagnosed with cancer, actively inquire, with compassion and empathy, about the personal and social consequences of the illness (e.g., family issues, loss of job), and the patient’s ability to cope with these consequences.
5. In a patient treated for cancer, actively inquire about side effects or expected complications of treatment (e.g., diarrhea, feet paresthesias), as the patient may not volunteer this information.
6. In patients with a distant history of cancer who present with new symptoms (e.g., shortness of breath, neurologic symptoms), include recurrence or metastatic disease in the differential diagnosis.
7. In a patient diagnosed with cancer, be realistic and honest when discussing prognosis. (Say when you don’t know.)

• Note: For pain control, see the key features on chronic disease and palliative care. See also the key feature on depression.

Chronic Disease

1. In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:
   • acute complications of the chronic disease (e.g., diabetic ketoacidosis).
   • acute exacerbations of the disease (e.g., asthma exacerbation, acute arthritis).
   • a new, unrelated condition.
2. Regularly reassess adherence (compliance) to the treatment plan (including medications).
3. In patients with chronic disease:
   1. Actively inquire about pain.
   2. Treat appropriately by:
      • titrating medication to the patient's pain.
      • taking into account other treatments and conditions (e.g., watching for interactions).
      • considering non-pharmacologic treatment and adjuvant therapies.
4. In patients with chronic disease, actively inquire about:
   • the psychological impact of diagnosis and treatment.
   • functional impairment.
   • underlying depression or risk of suicide.
   • underlying substance abuse.
5. Given a non-compliant patient, explore the reasons why, with a view to improving future adherence to the treatment plan.

Follow-up of Patient with Chronic Disease / Cancer

• Maintain regular contact and timely access
• Health promotion
  • Exercise (decrease mortality for patients who are more physically active as well as symptom control)
  • Diet
  • Smoking cessation
  • Alcohol/drugs
  • Barrier contraception
  • Vaccination
    • HPV
    • Flu
• Management of long-term effects (see palliative)
  • Functional impairment
    • Personal and social consequences of illness
    • Work
    • Family
  • Psychological impact of diagnosis and treatment
    • Coping
    • Depression, risk of suicide
    • Substance abuse
  • Adherence/Compliance to treatment
    • Regular visits
    • Blister pack
    • Decrease pill burden (long-acting, combination)
  • Symptom management
    • Pain management
    • Nausea/Vomiting (Opioid induced, Gastroparesis, CNS - raised ICP )
    • Constipation/Diarrhea
    • Feet paresthesias
    • Lymphedema
    • Sedation / Insomnia
    • Dyspnea
    • Anorexia / Fatigue
    • Dry mouth / Dysphagia
  • New symptoms
    • Recurrence of malignancy or metastatic disease
    • Late side effect of treatment
    • Acute complications or exacerbation of the chronic disease (e.g., diabetic ketoacidosis).
    • New, unrelated condition
• Surveillance and screening
  • See Periodic Screening
  • Individualize care plan and screening depending on risk factors
• Care coordination
  • Nurse
  • Oncology
  • Radiation oncology

Oncology Emergencies

Spinal Cord Compression

• New/escalating back pain at rest, may progress to motor/sensory neurologic deficits
• MRI whole spine
• Treat with steroids, and consider surgery/radiotherapy

Superior Vena Cava Obstruction

• Lung cancer, lymphoma
• Treat symptoms (SOB, pain, anxiety)
• Treat with steroids, radiotherapy, chemotherapy, stents

Hypercalcemia

• Multiple myeloma, breast, NSCLC
• Symptomatic (weakness, confusion, coma) above corrected calcium >3mmol/L
• Treatment
  • Stop calcium intake (supplements)
  • IV hydration (eg. NS 200-300mL/h for urine output of 100-150mL/h)
  • Severe if calcium>3.5mmol/L and symptomatic
    • Consider calcitonin +/- zoledronic acid/pamidronate
      • Consider denosumab in longterm control
    • Consider glucocorticoids in lymphomas, sarcoid, granulomatous
    • Consider calcimimetic and hemodialysis if renal failure or calcium >5mmol/L

Pericardial Tamponade

• Percutaneous or surgical drainage of pericardial effusion

Tumor lysis syndrome

• Myalgia, dark urine, seizure, AKI
  • Supportive care
    • Hydration, follow potassium, creatinine, phosphate, calcium and uric acid
  • Consider rasburicase for uric acid

Febrile neutropenia

• T>38, ANC<0.5
  • Empiric antibiotics and pan-culture