Palliative Care, Survivorship, and Communication
Olga Kozyreva, MD
Keith Eaton, MD, PhD
A 56-year-old woman with borderline resectable pancreatic cancer is admitted for severe mucositis following cycle 2 of neoadjuvant chemotherapy with FOLFIRINOX. Molecular testing reveals a UGT1A*28 mutation. She requests palifermin to minimize chemotherapy-associated mucositis for her next cycle.
How would you respond and what is the significance of her molecular findings when managing her mucositis risk?
View Answer
No, palifermin is only FDA approved for the prevention of chemotherapy-induced oral mucositis (OM) in patients with hematologic malignancies receiving myelotoxic therapy requiring hematopoietic stem cell transplantation.
Patients with the UG1T1A*28 polymorphism are at risk of severe toxicity following administration of irinotecan. Further cycles may require dose reduction or elimination of irinotecan to minimize toxicity.
Prevention: Oral cryotherapy can reduce the severity of mucositis in patients receiving bolus 5-FU-containing regimens.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 36-year-old woman with metastatic EGFR-mutated non-small cell lung cancer (NSCLC) presents to you complaining of a new painful rash associated with pruritus. Physical examination reveals diffuse, erythematous, follicular papules on the skin of her nose, cheeks, and the “V” region of her neck and chest.
What is the most likely etiology of her rash?
View Answer
Diagnosis: EGFR inhibitor (erlotinib) rash.
The development of a rash on EGFR therapy is associated with tumor regression or stability.
Patients starting EGFR inhibitor therapy can receive preemptive therapy with oral tetracyclines and topical steroids to minimize the prototypical acneiform eruption associated with these drugs.
Other targeted drugs with similar rash: everolimus, temsirolimus, sorafenib, and sunitinib.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 65-year-old man with a history of metastatic urothelial carcinoma presents with a new mucocutaneous rash 2 weeks following his first dose of pembrolizumab. On examination, he has erythematous papules and papulovesicles involving his bilateral upper and lower extremities, trunk, and back. Additionally, examination of his oropharynx reveals hemorrhagic plaques on the buccal mucosa.
What additional diagnostic tests would you require and how would you manage this patient?
View Answer
Urgent dermatology consultation and skin biopsy to evaluate for Stevens-Johnson syndrome (SJS)/TEN.
Additionally, SJS/TEN secondary to immune checkpoint inhibitor should be treated with inpatient admission, administration of high-dose corticosteroids (1-2 mg/kg/d), consideration of IVIG, as well as urgent consultation with ophthalmology and urology.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 56-year-old sommelier with a new diagnosis of squamous cell carcinoma of the neck presents for counseling prior to undergoing definitive chemoradiation therapy. He asks if there is any medication he can take to prevent symptoms of treatment-associated dry mouth (xerostomia).
What do you advise?
View Answer
There is no FDA-approved medication for the prevention of radiation-induced xerostomia in the setting of combined modality therapy for head and neck cancer.
Amifostine is a thiol with chemoprotectant and radioprotectant properties that works through a scavenging effect on toxic-free radicals. Amifostine is the only FDA-approved medication for the prevention of xerostomia, but it is recommended mostly for patients receiving RT alone for head and neck cancer. The efficacy of amifostine in the setting of combined modality therapy for head and neck cancer is uncertain.
Palliative treatment for radiation-induced xerostomia that could be considered include parasympathetic drugs (pilocarpine, cevimeline), artificial saliva, and a soft moist diet.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 66-year-old male with newly diagnosed metastatic small cell lung cancer is brought to the emergency department by his family for 2 days of worsening lethargy and confusion. On examination, he is alert but oriented only to himself and euvolemic. CT of the head shows no evidence of hemorrhage or brain metastasis. Laboratory tests are notable for a Na of 120 mEq/L, K 4.0 mEq/L, BUN 9 mg/dL, Cr 0.94, and serum osmolality 260 mOsm/kg. Urinalysis reveals a sodium of 60 mEq/L and a urine osmolality of 600 mOsm/kg.
What is the diagnosis and how would you manage this patient?
View Answer
Diagnosis and management: Paraneoplastic syndrome of inappropriate antidiuretic hormone (SIADH), and this patient with symptomatic hyponatremia need urgent inpatient admission for correction.
SIADH is suspected on the basis of serum Osm <275 mOsm/kg, urine osmolalty >100 mOsm/kg, and urine sodium >40 mmol/L.
Diagnostics: Check TSH and cortisol to rule out hypothyroidism and adrenal insufficiency.
Urgent treatment: Raise the serum Na by 4 to 6 mEq/L over 1 to 2 hours with 3 % saline followed by slower correction over next 48 hours.
Additional treatment considerations: Fluid restriction, salt tabs, loop diuretics, tolvaptan, and treat malignancy.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
What is the role of febuxostat in patients presenting with tumor lysis syndrome?
View Answer
Febuxostat can be considered for the prevention of TLS in cancer patients who cannot tolerate allopurinol or rasburicase.
Febuxostat is an inhibitor of xanthine oxidase that is FDA approved for the management of chronic hyperuricemia in patients with gout.
Advantages: No dose adjustments necessary for renal impairment.
Disadvantages: Cost, limited safety/efficacy data in cancer setting, interaction with azoathioprine and mercaptopurine (use with caution).
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 43-year-old female with metastatic breast cancer is admitted for management of symptomatic hypercalcemia of malignancy. Rank the following treatment options for hypercalcemia of malignancy in order of timing of onset of effect on serum calcium levels (1 = soonest; 5 = latest):
Dexamethasone, denosumab, calcitonin, 0.9% sodium chloride, and zoledronic acid.
View Answer
A 43-year-old female with metastatic breast cancer is admitted for management of symptomatic hypercalcemia of malignancy. Rank the following treatment options for hypercalcemia in order of timing of onset of effect on serum calcium levels (1= soonest; = latest)
Rank list:
0.9% sodium chloride (#1, immediate onset)
Calcitonin (#2, 4-6 hours)
Zoledronic acid (#3, 48 hours)
Dexamethasone (#4, 7 days)
Denosumab (#5, 7-10 days)
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 56-year-old patient presents with a 2-month history of clumsiness, ataxia, and difficulty speaking. She has a history of CLL and completed treatment with bendamustine-rituximab 6 months ago. She undergoes diagnostic workup with an MRI, LP, and brain biopsy.
What findings on clinical examination, lumbar puncture, MRI, and brain biopsy would support a diagnosis of progressive multifocal leukoencephalopathy (PML)?
View Answer
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Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 43-year-old female with breast cancer in follow-up while undergoing adjuvant taxane-based chemotherapy. She is a seamstress and is worried about developing chemotherapy-induced peripheral neuropathy (CIPN). She asks you if you advise she take acetyl-L-carnitine (ALC) to prevent the development chemotherapy-induced peripheral neuropathy.
What should you say?
View Answer
Supplemental acetyl-L-carnitine is not recommended and may worsen CIPN.
A phase III trial (N = 409) found no evidence of efficacy and a statistically significant worsening of CIPN after 24 weeks of receiving ALC. This was the first trial to support that a nutritional supplement could worsen CIPN.
ASCO clinical guidelines recommend strongly against the use of ALC.
Suggested Readings:
Hershman DL, Unger JM, Crew KD, et al. Randomized double-blind placebo-controlled trial of acetyl-L-carnitine for the prevention of taxane-induced neuropathy in women undergoing adjuvant breast cancer therapy. J Clin Oncol. 2013;31:2627-2633.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A patient with metastatic pancreatic cancer on chronic opioids presents with complaints of abdominal discomfort related to move his bowels. After a full workup to rule out obstruction, his complaints are felt to be secondary to constipation from opioids.
What supportive therapy could be prescribed to address opioid-induced constipation and what is the mechanism of action?
View Answer
Methylnaltrexone is a mu-receptor antagonist indicated for opioid-induced constipation.
Other supportive are measures to address constipation may include fluids, fiber, laxatives, suppository/enema for impaction, and prokinetics (ie, metoclopramide).
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 67-year-old gentleman presents to the emergency department complaining of urinary retention and weakness in his lower extremities. Physical examination is notable for relatively symmetric paralysis of the limbs and loss of sensation below T10. He has a pacemaker that is not compatible with MRIs.
What alternative imaging modality could you consider to further evaluate the reason for his weakness? How would you further manage this patient?
View Answer
CT myelography should be considered in patients like this gentleman who cannot undergo MRI but have clinical symptoms concerning for cord compression.
The most common neoplastic causes of spinal epidural metastases are breast cancer, prostate cancer, lung cancer, NHL, renal cell cancer, and myeloma.
Treatment of malignant spinal cord compression includes steroids, pain management, surgical decompression for radioresistant tumors, high-grade obstruction or spine instability, and radiation for radiosensitive tumors.
Lymphoma, myeloma, and seminoma are regarded as highly responsive to radiotherapy. Breast, prostate, and ovarian tumors are associated with an intermediate response to radiotherapy.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
In which clinical situations are erythropoietin-stimulating agents (ESA) not appropriate?
View Answer
ESAs are not recommended for anemia unrelated to chemotherapy in patients with malignancy, unless (1) patients have known myelodysplastic syndrome (MDS) with a serum erythropoietin level ≤500 U/L or (2) patients have concomitant anemia secondary to chronic kidney disease. ESAs should also be avoided when treating cancer patients with curative intent.
ESAs may reduce the frequency of red blood cell transfusion in anemic nonmyeloid cancer patients receiving chemotherapy; however, ESAs have not been shown to improve survival, quality of life (QOL), or patient-reported outcomes.
The use of ESAs requires adequate iron stores before use and are typically employed for Hgb <10 g/dL.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
Match the clinical scenario with the appropriate management option(s) for diarrhea.
A. Steroids
B. Infliximab
C. Octreotide
D. Telotristat
E. Imodium
F. Lomotil
G. Dilute tincture of opium
H. Metronidazole
1. A 68-year-old patient with metastatic melanoma receiving pembrolizumab with steroid refractory diarrhea
2. A 45-year-old man with functional carcinoid tumor with active diarrhea
3. A 58-year-old patient with radiation proctitis and active diarrhea
4. A 76-year-old patient with non-small cell lung cancer receiving docetaxel and confirmed Clostridium difficile colitis
View Answer
Match the clinical scenario with the appropriate management option(s) for diarrhea.
A. Steroids
B. Infliximab
C. Octreotide
D. Telotristat
E. Imodium
F. Lomotil
G. Dilute tincture of opium
H. Metronidazole
1. (B, C) A 68-year-old patient with metastatic melanoma with steroid refractory diarrhea from checkpoint inhibitor
2. (C, D) A 45-year-old man with functional carcinoid tumor with active noninfectious diarrhea
3. (E, F, G) A 58-year-old patient receiving chemotherapy-radiation for anal cancer with active noninfectious diarrhea
4. (H) A 76-year-old patient with non-small cell lung cancer receiving docetaxel and confirmed Clostridium difficile colitis
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
An 83-year-old female with a new diagnosis of cholangiocarcinoma with peritoneal carcinomatosis is admitted with a 2-week history of worsening abdominal pain with nausea, vomiting, and inability to tolerate oral intake. CT abdomen reveals a complete colonic bowel obstruction. She is seen by General Surgery and recommended for nonoperative management given multiple comorbidities and limited life expectancy.
What class of antiemetics should be avoided in this setting?
View Answer
Prokinetic agents such as metoclopramide should be avoided in the setting of complete bowel obstruction.
Key elements of management of a malignant bowel obstruction include establishing the patient’s goals of care, surgical consult, nasogastric decompression, consultation with GI for consideration of G-tube or palliative self-expanding metal stents (SEMS), and medical therapy for symptom control using parenteral opioids, antiemetics, antispasmodics, and antisecretory agents.
Corticosteroids may help manage nausea and reduce tumor-related bowel edema, increasing the likelihood of spontaneous resolution of the obstruction.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 56-year-old male with a history of pancreatic cancer in remission ×5 years and localized melanoma of the scalp status post resection 3 years ago presents with worsening abdominal distension over the last 6 weeks. His examination is notable for a protuberant abdomen with a fluid wave. The patient undergoes a paracentesis with symptomatic improvement.
What biochemical studies of the ascitic fluid would support a diagnosis of malignancy-associated ascites?
View Answer
Malignant ascites is often exudative, resulting in a low SAAG gradient ([serum albumin] − [ascitic fluid albumin]). Other features concerning for malignancy-associated ascites include bloody appearance, RBC count >100/µL, high LDH, and cytology evaluation positive for malignancy.
Other causes of exudate ascites include infection, pancreatitis, and nephrotic syndrome.
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 45-year-old patient with stage IV lung adenocarcinoma with a complete response after recently completing 6 cycles of chemotherapy reports excessive fatigue and a sedentary lifestyle. After a comprehensive evaluation for pain, mood disorders, endocrinopathy, and sleep disorders, it is determined that he has cancer-associated fatigue.
What are prospective management strategies to advise this patient?
View Answer
Management strategies of cancer-associated fatigue include the following:
Physical activity (level 1 evidence)
Cognitive behavioral therapy
Methylphenidate
Modafinil (limited evidence)
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 78-year-old patient with diffuse large B-cell lymphoma receives multiagent chemotherapy without G-CSF prophylaxis and presents to the hospital 8 days later with neutropenic fever. He undergoes a chest x-ray, blood cultures, and urine culture without any identifiable source of infection. He is initiated on filgrastim, cefepime, and antipyretic support while being monitored for clinical recovery.
What are the management considerations for a patient with neutropenic fever and what clinical scenarios would justify the addition of vancomycin in this patient?
View Answer
Gut translocation results in transient gram-negative bacteremia among most patients with neutropenic fever (NF) after receiving cytotoxic chemotherapy. Thus, in addition to gram-negative coverage (cefepime, piperacillin-tazobactam [if concern for anaerobe], or meropenem [if concern for ESBL]), vancomycin should be supplemented in patients with hemodynamic instability, skin or catheter site infection, concern for methicillin-resistant Staphylococcus aureus pneumonia, and blood cultures with gram-positive bacteria.
Risk stratification for neutropenia by chemotherapy given
High risk: >20% NF, intermediate risk: 0% to 20% NF, low: <10% NF
High risk → G-CSF prophylaxis
Low risk → No G-
Intermediate +/− GCSF depend on patient risk factors
Suggested Readings:
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 54-year-old woman presents with newly diagnosed early-stage breast cancer.
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