1578185 - McGraw-Hill Professional © CHAPTER 175 Overview of Cancer and Treatment Jennifer Duff, MD Merry Jennifer Markham, MD Key Clinical Questions What types of biopsies can aid in the diagnostic workup of cancer? How is the cancer stage determined? What are the goals of therapy in the neoadjuvant, adjuvant, and palliative setting? What are the different types of systemic therapies commonly used in the treatment of cancer? What are the approaches to treating chemotherapy-related nausea, vomiting and mucositis? When are modified blood products recommended for cancer patients and what are the transfusion thresholds for anemia and thrombocytopenia? EPIDEMIOLOGY Cancer is a group of diseases characterized by uncontrolled proliferation of abnormal cells that invade surrounding tissue and carry the potential to metastasize. Environmental 1578185 - McGraw-Hill Professional © and lifestyle risk factors and genetic susceptibility all contribute to an individual’s risk of developing cancer. In 2015, more than 1.6 million Americans will be diagnosed with cancer, and approximately 600,000 cancer-related deaths will occur. The most common cancers afflicting men and women are prostate and breast, respectively, followed by lung and colorectal. Overall, lung cancer is the leading cause of cancer-related mortality, followed by colorectal cancer. The incidence of lung and colon cancer in men is steadily declining, perhaps reflecting decreased tobacco use and emphasis on colorectal cancer screenings. Lung cancer incidence in women is finally starting to decrease after rising over the last few decades, reflecting the delayed uptake in smoking (and later, smoking cessation) by women compared to men. DIAGNOSIS AND STAGING Biopsy of a primary and/or metastatic site of a presumed malignancy is necessary to provide histologic confirmation of a cancer diagnosis. Involving a hematologist-oncologist early in the workup of a newly diagnosed cancer patient can be helpful in guiding the appropriate testing, biopsy sites, or biopsy techniques. For example, different biopsy techniques—including fine needle aspiration (FNA), core needle biopsy, excisional biopsy, or laparotomy—may be utilized depending on the type of cancer suspected. An FNA alone is inadequate in the diagnosis of lymphomas as the morphology of the nodal tissue is crucial in determining lymphoma subtype. Core needle biopsies and excisional or incisional biopsies provide a larger volume of tissue for pathologic evaluation of morphology and for molecular or genetic analysis. When a hematologic malignancy, such as lymphoma, is suspected, sending a fresh, not fixed, specimen for comprehensive immunophenotyping using flow cytometry is important in yielding the correct diagnosis. Finally, in addition to confirming a cancer diagnosis, the biopsied tissue specimen may guide therapeutic decisions. For example, molecular biomarkers, such as HER2Neu for breast cancer and KRAS/NRAS for colon cancer ...

1. 1578185 - McGraw-Hill Professional ©
CHAPTER 175
Overview of Cancer and Treatment
Jennifer Duff, MD
Merry Jennifer Markham, MD
Key Clinical Questions
What types of biopsies can aid in the diagnostic workup of
cancer?
How is the cancer stage determined?
What are the goals of therapy in the neoadjuvant, adjuvant, and
palliative setting?
What are the different types of systemic therapies commonly
used in the
treatment of cancer?
What are the approaches to treating chemotherapy-related
nausea, vomiting and
mucositis?
When are modified blood products recommended for cancer
patients and what
are the transfusion thresholds for anemia and
thrombocytopenia?
EPIDEMIOLOGY
Cancer is a group of diseases characterized by uncontrolled

2. proliferation of abnormal
cells that invade surrounding tissue and carry the potential to
metastasize. Environmental
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and lifestyle risk factors and genetic susceptibility all
contribute to an individual’s risk of
developing cancer. In 2015, more than 1.6 million Americans
will be diagnosed with
cancer, and approximately 600,000 cancer-related deaths will
occur. The most common
cancers afflicting men and women are prostate and breast,
respectively, followed by lung
and colorectal. Overall, lung cancer is the leading cause of
cancer-related mortality,
followed by colorectal cancer. The incidence of lung and colon
cancer in men is steadily
declining, perhaps reflecting decreased tobacco use and
emphasis on colorectal cancer
screenings. Lung cancer incidence in women is finally starting
to decrease after rising over
the last few decades, reflecting the delayed uptake in smoking
(and later, smoking
cessation) by women compared to men.
DIAGNOSIS AND STAGING
Biopsy of a primary and/or metastatic site of a presumed
malignancy is necessary to
provide histologic confirmation of a cancer diagnosis. Involving
a hematologist-oncologist
early in the workup of a newly diagnosed cancer patient can be
helpful in guiding the
appropriate testing, biopsy sites, or biopsy techniques. For

3. example, different biopsy
techniques—including fine needle aspiration (FNA), core needle
biopsy, excisional biopsy,
or laparotomy—may be utilized depending on the type of cancer
suspected. An FNA alone
is inadequate in the diagnosis of lymphomas as the morphology
of the nodal tissue is
crucial in determining lymphoma subtype. Core needle biopsies
and excisional or
incisional biopsies provide a larger volume of tissue for
pathologic evaluation of
morphology and for molecular or genetic analysis. When a
hematologic malignancy, such
as lymphoma, is suspected, sending a fresh, not fixed, specimen
for comprehensive
immunophenotyping using flow cytometry is important in
yielding the correct diagnosis.
Finally, in addition to confirming a cancer diagnosis, the
biopsied tissue specimen may
guide therapeutic decisions. For example, molecular
biomarkers, such as HER2Neu for
breast cancer and KRAS/NRAS for colon cancer, have
implications for the oncologist’s
choice of antineoplastic agents used during therapy.
Accurately staging patients to determine the extent of their
disease is critical in
determining prognosis and for guiding treatment decisions.
Staging often involves
radiographic imaging (such as computed tomography [CT] or
positron emission
tomography [PET] scans) or endoscopic or surgical
visualization to determine local and
distant organ involvement. Comprehensive radiologic imaging
is not always necessary in
the staging process when the cancer appears to be locally

4. confined and has a low
likelihood of distant involvement (eg, early stage breast
cancer). Serum tumor markers
have a role in the staging of some cancers, such as testicular
and ovarian cancers. Bone
marrow biopsy or lumbar puncture may be important in the
staging of various
hematologic malignancies. Decisions about type of staging
studies needed for an
individual patient should be made in conjunction with a
consulting hematologist-
oncologist.
Solid organ tumors are staged by the American Joint Committee
on Cancer (AJCC)
TNM classification system, where T refers to tumor size or
degree of mucosal infiltration
of the primary tumor, N describes lymph node involvement, and
M refers to the presence or
absence of metastatic disease. Lymphomas have their own
unique staging systems and,
as in solid tumors, prognosis and treatment options vary with
stage.
Typically, early stage (stages I and II) solid tumors lack lymph
node involvement and
are curable. Stage III solid organ cancers are often referred to
as locally advanced and
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typically involve regional lymph nodes. Metastatic, or stage IV,
solid organ cancers are
generally incurable but are often treatable. However, some solid

5. tumors, including
colorectal and breast cancers, and melanoma with limited
metastatic sites, have curative
potential with a multidisciplinary treatment approach.
TREATMENT
A CASE EXAMPLE
Ms J, a 55-year-old woman, presented with intermittent rectal
bleeding and difficulty
passing bowel movements. A colonoscopy revealed a friable,
partially circumferential
mass in the rectum. Biopsy of the mass confirmed a moderately
well-differentiated
adenocarcinoma. Staging with contrasted CT of the chest,
abdomen, and pelvis, did not
show any distant metastatic disease. Further staging with
endoscopic ultrasound
confirmed a stage IIIA (T3N1M0) rectal cancer. She was treated
with neoadjuvant
chemoradiation using oral capecitabine with daily radiation
therapy for 5.5 weeks. After
completing neoadjuvant treatment, she underwent a low anterior
resection with an end-to-
end anastomosis. The surgical pathology showed moderate
treatment response with
down-staging of the disease and no involved lymph nodes. She
completed 3 out of 4
months of curative adjuvant systemic chemotherapy with
fluorouracil, leucovorin, and
oxaliplatin, stopping 1 month short due to side effects. For the
next 3 years, she had no
radiographic or clinical evidence of recurrent disease until she
developed persistent right
upper quadrant abdominal pain. Computed tomography imaging
demonstrated

6. innumerable hypodensities in the liver and scattered nodules in
the lungs, all concerning
for metastatic disease. A core biopsy of a liver lesion confirmed
metastatic colorectal
adenocarcinoma. Mutational testing of the tissue confirmed
wild-type KRAS and NRAS
genes. She was treated with palliative chemotherapy consisting
of fluorouracil, leucovorin,
irinotecan, and bevacizumab with good tumor response and
relief of pain symptoms.
However, restaging imaging after 8 months demonstrated
peritoneal carcinomatosis,
consistent with progressive disease. Her treatment was switched
to irinotecan plus
cetuximab. She tolerated this regimen poorly with a declining
performance status. After
two cycles, the chemotherapy was discontinued and she was
enrolled in Hospice. She
lived another 2.5 months without treatment, allowing her to
travel with her family prior to
her death.
This case illustrates the continuum of cancer care in an initially
curable cancer that
ultimately relapsed and progressed, resulting in death. In this
example, neoadjuvant,
adjuvant, and palliative treatment regimens were utilized, each
intended to accomplish a
specific goal. Neoadjuvant therapy was used to improve surgical
outcomes and reduce the
risk of local tumor recurrence. Adjuvant therapy was used to
eradicate micrometastatic
disease and reduce the likelihood of systemic recurrence.
Palliative chemotherapy was
used to improve disease control, survival, and to relieve cancer -
related symptoms.

7. The optimal treatment of cancer patients often requires a
multidisciplinary, team-based
approach, with collaboration among all health care providers
involved including surgeons,
radiation oncologists, medical oncologists, radiologists,
pharmacists, nursing, social
workers, psychologists, and nutritionists. Providing patient-
centric care for cancer patients
extends beyond formulating treatment plans; it involves
understanding patients’ emotional
well-being, their psychosocial needs, and recognition of
socioeconomic barriers that may
impede safe care. Early identification of depression or anxiety,
inadequate support
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systems, or insufficient understanding of the diagnosis and
treatment goals, is crucial in
providing humanistic oncology care.
SURGERY, SYSTEMIC THERAPY, RADIATION THERAPY
Surgical resection of the tumor burden is the gold standard
therapy for achieving cure in
most solid-organ cancers. Lymphomas and other hematologic
malignancies, small-cell
lung cancer, locally advanced non–small-cell lung cancer, and
prostate and cervical
cancer are among those malignancies that have curative
potential with chemotherapy or
radiation therapy alone, or a combination of these treatment
modalities. The extent of

8. surgical resection depends on the operative risk, size and
location of the primary tumor,
involvement of surrounding tissues, and the degree of lymph
node dissection indicated.
For certain high-risk, complex surgeries, such as
esophagectomy for esophageal cancer,
surgeon and hospital experience and higher surgical volume
yield improved outcomes for
patients, and referral to an experienced surgeon in a high-
volume center is important.
Similarly, for the gynecologic cancers, outcomes are improved
for women who have
surgical resection by a gynecologic oncologist rather than a
general surgeon or
gynecologist.
Systemic therapy is an umbrella term encompassing a variety of
cancer treatments,
including chemotherapy, biologic (or targeted) therapy,
immunotherapy, and hormonal
therapy. Oncologists’ choice of a chemotherapy regimen is
based on current evidence-
based national guidelines, the goals of treatment (curative vs
palliative), and patient
performance status. Multiagent chemotherapy regimens are
often selected in the curative
setting or when maximum disease control is preferred and
feasible. Single-agent
chemotherapy is often selected when palliation is desired. When
chemotherapy agents are
combined, they are often selected due to diverse mechanisms of
action and
nonoverlapping side effects in order to maximize efficacy while
minimizing undesirable
toxicity to the patient.

9. Cytotoxic chemotherapy drugs lead to cancer cell death through
a variety of
mechanisms that interfere with the cell growth cycle. Each class
of chemotherapy drugs
carries its own unique set of side effects, some of which are
short term and only occur
transiently during treatment, while others may occur during or
after treatment and result in
permanent morbidity (Table 175-1). The drugs in the vinca
alkaloid, platinum, and taxane
classes may result in varying degrees of motor or sensory
neuropathy. Anthracyclines (eg,
doxorubicin) are associated with a risk of cardiac toxicity in the
short and long term,
including cardiomyopathy and/or arrhythmias.
TABLE 175-1 Chemotherapy Drug Classes and Usual
Toxicities
Chemotherapy Class Examples of Drugs Side Effects
Alkylating agents Cyclophosphamide
Ifosfamide
Dacarbazine
Temozolomide
Chlorambucil
Myelosupression
Dose-related emesis
Pneumonitis
Syndrome of inappropriate ADH
(SIADH)
Secondary leukemias
Anthracyclines Doxorubicin Myelosupression

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Daunarubicin
Epirubicin
Mucositis
Cardiotoxicity
Vesicant
Antimetabolites 5-fluoruracil
Capecitabine
Pemetrexed
Methotrexate
Myelosuppression
Mucositis
Gastrointestinal (nausea, vomiting,
diarrhea)
Platinum agents Carboplatin
Cisplatin
Oxaliplatin
Renal Toxicity
Neuropathy
Nausea/vomiting
Myelosuppression
Taxanes Docetaxel
Paclitaxel
Myelosupression
Hypersensitivity reactions
Neuropathy

11. Topoisomerase I
inhibitors
Irinotecan Diarrhea
Early onset (1-6 h from infusion),
due to inhibition of
acetylcholinesterase; treated with
atropine
Later onset, from mucosal
damage; treated with aggressive
loperamide dosing
Topoisomerase II
inhibitors
Etoposide Myelosuppression
Nausea/vomiting
Secondary acute myelogenous
leukemia
Vinca alkaloids Vincristine
Vinblastine
Vesicant
Peripheral neuropathy, motor and
sensory
Autonomic neuropathy (such as
ileus)
Cranial nerve palsies
SIADH
Myelosuppression with vinblastine
Systemic cancer therapies are continuously evolving and novel
biologics and
immunotherapies have an important and growing role in the

12. treatment of malignancy.
Biologic agents, also referred to as targeted therapies, are
directed toward specific
intracellular characteristics or pathways of tumors. One of the
first targeted therapies was
imatinib, the oral drug that inhibits the Bcr-Abl tyrosine kinase,
the constitutive abnormal
gene product of the Philadelphia chromosome in chronic
myeloid leukemia. Monoclonal
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antibodies selectively target specific cell antigens found
predominantly on tumor cells. For
example, rituximab is an anti-CD20 monoclonal antibody
which, when paired with
chemotherapy, has substantially improved response rates and
survival in B-cell non-
Hodgkin lymphoma. Other monoclonal antibodies include
bevacizumab, which binds to
the vascular endothelial growth factor protein interfering with
angiogenesis; cetuximab,
which binds to the EGFR receptor to prevent downstream
signals involved in tumor growth
and proliferation; trastuzumab and pertuzumab, which work
through targeting the HER2
receptor; and ado-trastuzumab (also known as T-DM1) which
combines trastuzumab with
a chemotherapeutic to target delivery of the cytotoxic agent
specifically to cancer cells.
Immunotherapy refers to those agents aimed at stimulating the
immune system to
overcome the immune evasion triggered by the malignancy. For

13. example, Sipuleucel-T, an
autologous immunotherapy approved in advanced prostate
cancer, primes a patient’s
antigen presenting cells to promote an immune response against
their disease. Newer
immunotherapy agents block immune checkpoints such as the
cytotoxic T-lymphocyte-
associated antigen 4 (CTLA-4) and the programmed death 1
(PD-1) receptor, thus
enhancing antitumor immunity. Ipilimumab used in metastatic
melanoma is an antibody
directed against CTLA-4, and pembrolizumab and nivolumab
are anti-PD-1 antibodies
both used for metastatic melanoma. Nivolumab is also approved
for use in metastatic
squamous cell non–small-cell lung cancer.
Hormonal, or endocrine, therapy refers to agents that modulate
hormones that are a
driving factor in the growth and proliferation of a tumor. They
function through several
mechanisms, some of which include direct hormone receptor
blockade, interfering with
hormone production by the pituitary and adrenal glands and
ovaries, and inhibiting
peripheral hormone conversion. The treatment of breast and
prostate cancers frequently
incorporates hormonal therapies such as antiestrogenic agents
including the aromatase
inhibitors (eg, anastrazole, letrozole, and exemestane) and
selective estrogen receptor
modulators (eg, tamoxifen) and LHRH agonists (eg, goserelin).
Radiation therapy consists of delivering high-energy x-rays or
other particles to a
specified body region, resulting in DNA destruction and tumor

14. death. Common radiation
therapy techniques include external beam radiation, 3-D
conformational radiation therapy
(3-D CRT), intensity modulated radiation therapy (IMRT),
stereotactic and proton beam
radiation therapy. All of these methods have varying degrees of
precision in targeting the
tumor to minimize the impact on surrounding healthy tissue.
Internal radiation therapy, or
brachytherapy, involves placing radioactive material into or
near the tumor tissue; this
technique is often used in the treatment of prostate or cervical
cancer.
Radioimmunotherapy is a method to target radiation to a tumor
site using monoclonal
antibodies attached to radioactive substances.
Radiation therapy may be used as a neoadjuvant, adjuvant, or
palliative therapy. More
than half of all cancer patients will receive radiation at some
point during their treatment
course. Radiation therapy can be used to shrink the tumor
burden, allowing for a less
extensive surgical procedure and/or improved cosmesis (eg,
performing a lumpectomy
instead of a mastectomy for a breast mass). It may also be used
to reduce the risk of local
cancer recurrence or to palliate tumor-related symptoms, such
as bleeding or pain. For
some cancers, such as head and neck or cervical cancer,
modified doses of chemotherapy
may be administered simultaneously with radiation to enhance
the radiation effect.
PRACTICE POINT

15. 1578185 - McGraw-Hill Professional ©
Workup and evaluation for cancer
Involve a hematologist-oncologist early in the workup to advise
on diagnostic studies
or biopsy site/technique.
A biopsy is necessary to confirm a histologic diagnosis.
Consider a biopsy approach that will obtain the most tissue for
diagnosis and allow
for molecular analysis, if appropriate. Typically core needle
biopsies are preferred over
fine needle aspirates.
Staging imaging should consist first of a contrasted CT chest,
abdomen, pelvis.
Not all stage IV malignancies are incurable. Some solid tumors,
including colorectal
and breast cancer with oligometastatic disease, may be cured
using a
multidisciplinary approach.
Comprehensive cancer treatment utilizes a multidisciplinary
team of physicians, often
including medical oncologists, surgeons, and radiation
oncologists.
INPATIENT MANAGEMENT OF COMMONLY
ENCOUNTERED SCENARIOS
Cancer treatment can result in complications leading to
hospitalization. Some of the
commonly encountered inpatient scenarios include febrile
neutropenia, nausea, vomiting,
diarrhea, severe anemia or thrombocytopenia necessitating
transfusion, and tumor lysis
syndrome.

16. Nausea and vomiting
Prevention of nausea and vomiting is the most widely used
supportive care measure in
cancer treatment, and the development of new classes of
antiemetics have had significant
impact on the ability of patients to tolerate chemotherapy.
Despite these efforts, nausea in
the cancer patient may be encountered in the inpatient setting. It
is important to consider
potential reasons for nausea and vomiting other than cancer
treatment, such as altered
gut motility, bowel obstruction, electrolyte disturbance, brain
metastases, narcotic use, or
dyspepsia. Several antiemetics have been developed in the last
decade that have
substantially reduced the incidence of treatment-related emesis
by interfering with the
effect of endogenous neurotransmitters such as dopamine,
histamine, and serotonin at
the chemoreceptor trigger zone. The categories of available
antiemetics include
corticosteroids, benzodiazepines, cannabinoids, NK-1 receptor
antagonists, serotonergic
and dopaminergic receptors antagonists, and the atypical
antipsychotic olanzapine.
Antiemetics may be administered intravenously, orally, or per
rectum, with rare use of
intramuscular delivery due to discomfort and the risk of tissue
fibrosis with repeated
doses. Prior to administration of chemotherapy, one or more of
these agents are
administered depending on the emetogenic potential of the
chemotherapy regimen. The
5HT3-receptor antagonists are among the most effective agents

17. in preventing
chemotherapy-related emesis. Benzodiazepines such as
lorazepam are valuable in the
prevention of anticipatory nausea triggered by the anxiety of
receiving chemotherapy and
are typically used simultaneously with other antiemetics. For
patients who develop
breakthrough nausea and vomiting despite these preventative
efforts, treating with an
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antiemetic from a different class is helpful (Table 175-2) (see
Chapter 97 [Nausea and
Vomiting]).
TABLE 175-2 Antiemetics Used for Breakthrough Nausea and
Vomiting
Antiemetic Drug Drug Class Dose/Frequency
Dexamethasone Steroid 4-12 mg PO/IV daily
Dronabinol Cannabinoid 5-10 mg PO 3-6 h
Lorazepam Benzodiazepine 0.5-2 mg PO/IV q 6 h
Metoclopramide Prokinetic 10-40 mg PO/IV q 4-6 h
Olanzopine Atypical antipsychotic 2.5-5 mg PO daily
Ondansetron 5-HT3 receptor
antagonist
8-24 mg PO or 8-12 mg IV (max 32
mg/d)
Prochlorperazine Phenothiazine 10 mg PO/IV q 6 h
Promethazine Phenothiazine 12.5-25 mg PO/IV q 4-6 h
Scopolamine Other 1 transdermal patch q 72 h

18. Mucositis
Another potential consequence of both chemotherapy and
radiation is damage to rapidly
dividing epithelial cells of the mucosa lining the oropharynx
and the gastrointestinal tract
leading to mucositis. Oral mucositis is defined as painful
inflammation of the oral mucosa
manifesting as erythema, ulcerations, and soft white patches.
This particularly afflicts
patients treated with 5-flurouracil, methotrexate, high-dose
chemotherapy used prior to
hematopoietic stem cell transplantation, or those undergoing
radiation treatments to the
head and neck. It typically develops within 7 to 10 days from
initiation of chemotherapy
and lasts several weeks. There are few remedies available to
expedite recovery and
supportive measures to minimize discomfort are the mainstay of
treatment. Palifermin, a
keratinocyte growth factor, is approved in patients receiving
high-dose chemotherapy in
the setting of hematopoietic stem cell transplant to decrease the
incidence and duration of
severe mucositis. Other management strategies include mouth
rinses (avoiding alcohol
based), topical anesthetics, mucosal coating agents, analgesics,
and lubricants (Table
175-3). One effective regimen that is frequently prescribed is a
mixture of a mucosal
coating agent with a topical anesthetic. Opioids may be required
for patients whose
discomfort is not relieved with topical treatments.
TABLE 175-3 Mucositis Management

19. Bland Rinses
Topical
Anesthetics
Mucosal
Coating
Lubricating
Agents Analgesia
0.9% normal
saline
Lidocaine
-2% viscous
Benzocaine
Milk of
Magnesia
Kaopectate
Artificial saliva Opioids
- Patient
controlled
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er97.html
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- Mix 1 teaspoon
of table salt in
32 ounces of
water

20. Sodium
bicarbonate
solution
- Mix 0.5
teaspoon salt
and 2
tablespoons
sodium
bicarbonate in
32 ounces water
Spray or gel
Diphenhydramine
solution
Amphojel
- Cellulose film-
forming agents
eg, Zilactin
analgesia [PCA]
- Elixir
- Transdermal
patches
Anemia and thrombocytopenia
Cancer patients may be hospitalized for symptomatic anemia
necessitating red cell
transfusion. The anemia may be directly related to
chemotherapy myelosuppression or it
may be multifactorial secondary to anemia of chronic disease,
nutritional deficiencies,
cancer infiltrating the marrow, or impaired erythropoietin

21. production. The hemoglobin
threshold at which to initiate red cell transfusion depends on the
goals of care.
Transfusion guidelines recommend that cancer patients be
transfused in a manner
similarly to other noncardiac, hospitalized patients, for
example, transfusion is considered
when the hemoglobin (Hgb) is between 7 and 8 g/dL, using the
minimum number of units
necessary. If the Hgb is less than 9 g/dL and the patient is
symptomatic from the anemia,
transfusion is also reasonable. For patients with advanced
cancer and anemia,
transfusion may provide palliation and subjective benefit
according to small observational
studies. For patients who would benefit from an increased
hemoglobin but decline red cell
transfusion, erythropoietin stimulating agents (ESAs) and iron
infusions are alternative
approaches to enhancing red cell production. Because studies
using both available ESAs—
epoetin and darbepoetin alfa—report a potential risk of
increased tumor growth and
chance of death from cancer, the use of ESAs are typically
reserved for patients with
incurable malignancies and not generally used when the goal of
treatment is cure.
The threshold at which to transfuse platelets depends on a
patient’s risk of bleeding,
need for invasive procedures, and whether they are critically ill
versus clinically stable.
Patients have been observed to be at increased risk of
spontaneous bleeding with severe
thrombocytopenia, defined as platelet counts less than 5000/μL.
There has been no

22. observed difference in bleeding risk between platelet counts of
10,000/μL versus 20,000/
μL in clinically stable patients. Thus, it is recommended to
consider platelet transfusion
for all patients with platelets less than 10,000/μL. There are
some clinical scenarios where
different platelet triggers are recommended. For example, in
patients with coagulopathy,
on anticoagulation, or if there is an anatomic lesion at risk for
bleeding, transfuse platelets
if the platelet count is less than 20,000/μL. One may also
consider transfusing platelets to
achieve a platelet count over 50,000/μL if an invasive surgi cal
procedure is planned or
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transfusing platelets to achieve a platelet count over 100,000/μL
in the case of bleeding or
surgery within the central nervous system.
Certain groups of cancer patients, such as those with
neutropenia or those who have
received or are being considered for stem cell transplant, may
require certain modifications
to transfused blood products. Leukoreduction is a common
modification that depletes the
blood product of leukocytes, thus minimizing the risk for
alloimmunization against
leukocyte antigens. Leukocyte contamination of red cell
products results in febrile
nonhemolytic transfusion reactions (FNHTR), and
leukoreduction reduces the risk of this
complication. Leukoreduction also substantially decreases the

23. risk of cytomegalovirus
(CMV) transmission by blood transfusion. Most health care
facilities in the United States
have adopted universal leukoreduction of blood products;
however, in centers that have
not implemented this, leukoreduced products should be
considered for patients with the
following characteristics: past history of FNHTR, prior history
of solid organ or
hematopoietic stem cell transplant, planned solid organ or
hematopoietic stem cell
transplant, immunocompromised CMV negative patients, and
patients requiring chronic
transfusions.
Irradiated blood products are recommended for
immunocompromised patients at risk
for transfusion-related graft versus host disease (GVHD), a
condition with high mortality.
The blood products are exposed to gamma irradiation, thereby
inactivating the donor
lymphocytes responsible for this phenomenon. Irradiated blood
products should be
considered in these specific patient scenarios: current or prior
treatment with
chemotherapy agents in the purine analog class (eg, fludarabine,
cladribine); a diagnosis
of Hodgkin lymphoma (compared to other lymphomas, patients
with Hodgkin lymphoma
are at higher risk for developing transfusion-related GVHD);
previous hematopoietic stem
cell transplantation; receiving blood products from a related
donor; and patients needing
HLA-matched platelets. Patients with acute leukemia do not
require irradiated blood
products unless they are receiving conditioning therapy in

24. preparation for allogeneic stem
cell transplant. In summary, the decision to transfuse blood
products should be
individualized for each patient and the risks of transfusion must
be carefully considered.
Venous thromboembolism prophylaxis
Cancer itself is associated with a hypercoaguable state, and
treatment with chemotherapy
further contributes to the risk of thrombotic complications.
Deep venous thrombosis (DVT)
is the most common thrombotic complication seen in patients
with cancer. Compared to
patients without cancer, those with cancer are at a substantially
elevated risk of
thrombosis after surgical procedures and extended DVT
prophylaxis beyond hospital
discharge is sometimes considered. It is essential to be mindful
of this elevated risk and to
provide appropriate DVT prophylaxis to hospitalized cancer
patients (see Chapter 252
[Venous Thromboembolism Prophylaxis for Hospitalized
Medical Patients]).
PRACTICE POINT
Caring for a hospitalized cancer patient
Cancer produces a state of hypercoagulability. All patients
should be offered deep
venous thrombosis prophylaxis while hospitalized.
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25. 1578185 - McGraw-Hill Professional ©
Breakthrough nausea/vomiting can be controlled with a variety
of medications,
including antiemetics, prokinetic agents, steroids, atypical
antipsychotics, and
benzodiazepines.
First-line treatment for supporting mucositis includes saline
washes and topical
agents. Opioids may be necessary for pain relief.
Certain populations of cancer patients are recommended to have
leukoreduced blood
products to minimize the risk of febrile nonhemolytic
transfusions reactions and
reduce the risk of CMV transmission. Irradiated blood products
are reserved for
patients at risk for transfusion related graft versus host disease.
For most cancer patients, transfuse the minimum number of
blood products necessary
to maintain a hemoglobin between 7 and 8 g/dL and a platelet
count greater than
10,000/μL.
SUGGESTED READINGS
Bensinger W, Schubert M, Ang KK, et al. NCCN Task Force
Report: prevention and
management of mucositis in cancer care. J Natl Compr Canc
Netw. 2008;6(Suppl 1):S1-
S21.
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti
A, eds. AJCC Cancer Staging
Manual, 7th ed. New York, NY: Springer; 2010.
Gerber DE, Chan TA. Recent advances in radiation therapy. Am

26. Fam Physician.
2008;78(11):1254-1262.
Jordan K, Sippel C, Schmoll HJ. Guidelines for antiemetic
treatment of chemotherapy-
induced nausea and vomiting: past, present, and future
recommendations. Oncologist.
2007;12(9):1143-1150.
Szczepiorkowski ZM, Dunbar NM. Transfusion guidelines:
when to transfuse. Hematology
Am Soc Hematol Educ Program. 2013;638-644.
CAT 2 Oncology Test Prep Questions
Oncology Questions
1. Which of the following best describes curative intent
related to oncology treatment?
a. Treatment meant to reduce symptoms.
b. Treatment meant to limit metastatic growth or spread.
c. Treatment meant to eradicate presence of cancer for 5
years.
d. Treatment means to eradicate presence of cancer for a
lifetime.
2. Which of the following complications related to cancer
or cancer treatment can result in death?
a. Superior Vena Cava Syndrome
b. Tumor Lysis Syndrome
c. Infection
d. All of the above.
3. When would it be appropriate to consult the palliative
care team to see an oncology patient?
a. For complex symptom management
b. For psychosocial support and advanced care planning

27. when undergoing treatment with curative intent
c. When hospice care might be the best way to support the
patient upon discharge from the hospital
d. All of the above
4. What is the Gold Standard for diagnosing spinal cord
compression related to oncologic disease?
a. CT myelogram
b. MRI
c. Physical Exam
d. X-ray