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Bone Metastases

Summary of Key Points Incidence Bone metastasis is a major cause of (often prolonged) morbidity in persons with cancer. Bone metastasis is especially prevalent in persons with breast and prostatic cancers. Causes Disseminated tumor cells are attracted to vascular, osteoblastic, and hematopoietic niches in bone. Tumor cells within bone may remain dormant for prolonged periods under the control of microenvironmental signals. Osteolytic damage is mediated largely…

Brain Metastases and Neoplastic Meningitis

Summary of Key Points Incidence Central nervous system (CNS) metastases are common, affecting as many as 20% of patients with cancer. Less often, the dura, leptomeninges, skull base, or cranial nerves may be affected. The most frequent primary tumor types that give rise to brain metastases include lung cancer, melanoma, breast cancer, and renal cell carcinoma. Leptomeningeal dissemination (neoplastic meningitis) can occur in patients without known…

Spinal Cord Compression

Summary of Key Points Incidence Forty percent of cancer patients develop spinal metastases. Metastatic epidural spinal cord compression (MESCC) occurs in 2.5% of cancer patients within the last 5 years of life. The highest incidence of MESCC is in patients with myeloma and prostate and breast cancer. Etiology MESCC can be caused by epidural extension of vertebral metastatic disease, direct extension of tumor through the neural…

Superior Vena Cava Syndrome

Summary of Key Points Etiology Superior vena cava (SVC) syndrome is usually caused by a neoplastic process, predominantly primary lung carcinoma, with a disproportionate number of patients having small cell histology; non-Hodgkin lymphoma and metastatic tumors are the next most common. SVC syndrome can be iatrogenic; it is increasingly seen as a complication of a central venous catheter, pacemaker leads, or cardiac surgery. Anatomy and Physiology…

Acute Abdomen, Bowel Obstruction, and Fistula

Summary of Key Points Gastrointestinal Perforation Perforation affects approximately 20% of patients with acute abdominal emergencies. Bowel perforation can be caused by tumor rupture, tumor necrosis, adverse events of systemic therapy (e.g., targeted therapy, immunotherapy, steroids), radiation therapy, or inflammatory conditions. Surgical intervention should be considered unless the patient's overall prognosis is poor. Gastrointestinal Bleeding Bleeding affects approximately 15% of patients with acute abdominal emergencies. Efficient…

Caring for Patients at the End of Life

Summary of Key Points Oncology clinicians must assess patients' willingness to discuss prognosis and deliver this information clearly and truthfully. Patient decisions about resuscitation preferences and disease-directed therapy, including early drug development trials, should be discussed in the context of the patient's prognosis, values, and goals. A sense of purpose can be maintained by patients nearing the end of life who work on completing legacies, reconciliation,…

Second Malignant Neoplasms

Summary of Key Points Subsequent malignancies after successful treatment for cancer occur in a meaningful minority of persons. The etiology is often multifactorial and includes known hereditary conditions, unrecognized genetic predisposition, primary cancer, therapeutic exposures, age, and lifestyle practices. Guidelines for screening are available for some but not all situations; health care providers and patients should be aware of such guidelines. Further research is needed to…

Survivorship

Summary of Key Points The number of individuals in the United States living with a cancer history will continue to rise over the next decade, reaching over 20 million by the year 2026; more than two-thirds of these individuals will be older than 65. Cancer survivorship, the period between the end of active cancer treatment and a recurrence or death from some other cause, is a…

Rehabilitation of Individuals With Cancer

Summary of Key Points As cancer treatment improves, more patients are living longer with functional limitations, and quality-of-life issues become as important as survival. Rehabilitation must be patient centered and goal oriented. It requires an interdisciplinary team and the active participation of the patient. Impairments, activity limitations, and participation restrictions from cancer dramatically affect quality of life but are amenable to rehabilitation efforts. The focus of…

Pulmonary Complications of Anticancer Treatment

Summary of Key Points Radiation-Induced Lung Injury (Radiation Pneumonitis or Fibrosis) Risk factors include radiation dose and volume of lung irradiated, which may be expressed as mean lung dose or as the Vx, that is, the percentage of normal lung tissue irradiated to a dose above a certain threshold dose. Older age, comorbidities (including chronic obstructive pulmonary disease), and low performance status are risk factors. The…

Endocrine Complications

Summary of Key Points Endocrine dysfunction may occur as a direct result of cancer or may be an intended consequence of cancer therapy, such as occurs following castration, adrenal suppression, or thyroid ablation to control cancer growth. Endocrine dysfunction may be an unwanted but often unavoidable consequence of cancer therapy, such as surgery, radiation, chemotherapy, use of biologic agents, or hormone therapy. Hypopituitarism with clinically significant…

Neurologic Complications

Summary of Key Points Incidence of Chemotherapy- and Radiation Therapy–Induced Neurotoxicity The actual incidence of treatment-related neurotoxicity is unknown, but the frequency is increasing. Improvements in supportive care, but not neuroprotective regimens, have allowed dose escalation for many drugs, and thus neurotoxicity often is the dose-limiting factor. Increased survival of patients with cancer has resulted in an increasing prevalence of late-onset neurotoxicity. Newer treatments directed at…

Paraneoplastic Neurologic Syndromes

Summary of Key Points The paraneoplastic neurologic syndromes include an extensive group of immune-mediated disorders that can affect any part of the central or peripheral nervous system. Patients with paraneoplastic neurologic syndromes may have serum and cerebrospinal fluid antibodies that are highly specific for the presence of a cancer. The detection of these antibodies serves as a marker of paraneoplasia. Other antibodies are associated with specific…

Reproductive Complications

Summary of Key Points Reproductive complications resulting from cancer or its treatment are expected to increase as the number of cancer survivors increases. The risks of infertility related to cancer therapy and the available fertility preservation options should be discussed with all patients of reproductive age before cancer therapy begins. Oligospermia is present in more than 50% of patients with Hodgkin lymphoma and testicular cancer. Prostatectomy…

Cardiovascular Effects of Cancer Therapy

Summary of Key Points Cardiotoxicity in the context of anticancer therapy requires a deep appreciation for the differences and potential interactions between patient risk factors for cardiac disease and the cardiovascular risk profile for an anticancer drug. Understanding the structural, functional, and physiologic changes in the cardiovascular system that occur over the lifetime of the patient with cancer is critical to cancer therapy delivery and long-term…

Dermatologic Toxicities of Anticancer Therapy

Summary of Key Points Chemotherapy-Induced Alopecia Cytotoxic chemotherapy agents target hair follicles that are in the proliferative growing (anagen) phase, causing an “androgen effluvium.” Less common mechanisms include telogen effluvium. Chemotherapy-induced alopecia (CIA) is common. The incidence differs based on the agent, dose, and frequency of administration. Increased hair shedding and hair fragility occur, with a diffuse or patching alopecia that is noticeable when 25% to…

Oral Complications

Summary of Key Points Incidence Mucositis is a major dose-limiting toxic effect of chemotherapy for solid tumors developing in 5% to 40% of patients. Mucositis develops in 70% to 100% of patients receiving high doses of chemotherapy with bone marrow rescue. Mucositis is the most troublesome acute reaction for patients receiving radiation therapy to the oral cavity. Radiation therapy to the oral cavity frequently causes a…

Nausea and Vomiting

Summary of Key Points Incidence Nausea and vomiting are the most common of all chemotherapy-associated toxicities. Their occurrence is more frequent and severe with repetitive doses of chemotherapy. They can have a significant impact on quality of life and can influence patient compliance with treatment. Etiology Acute nausea and vomiting are often mediated by activation of serotonin type 3 receptors in the gastrointestinal tract. Delayed nausea…

Cancer Cachexia

Summary of Key Points Loss of appetite and weight are common in patients with advanced, incurable cancer and are associated with a poor prognosis. Although advanced, incurable cancer patients who have the cachexia syndrome may appear malnourished, nutritional support with either enteral or parenteral nutrition rarely provides a positive impact on clinical outcomes. For palliative purposes, corticosteroids and progestational agents improve appetite in patients who have…

Cancer-Related Pain

Summary of Key Points Incidence Cancer pain affects more than 30% of patients undergoing active cancer therapy. Moderate to severe pain occurs in more than 70% of patients during the later phases of their illness. Cancer pain is debilitating and significantly affects quality of life. Etiology of Pain Cancer pain can be of nociceptive, neuropathic, or sympathetically maintained origin. Cancer pain can be a result of…