A review published in the April 15 issue of American Family Physician recommends effective practice strategies for the primary care clinician when treating patients who have been diagnosed with cancer.
“Care of patients with cancer can be enhanced by continued involvement of the primary care physician,” write George F. Smith, MD, from the University of Minnesota, and Timothy R. Toonen, MD, from Minnesota Oncology Hematology, both in St. Paul. “The physician’s role may include informing the patient of the diagnosis, helping with decisions about treatment, providing psychological support, treating intercurrent disease, continuing patient-appropriate preventive care, and recognizing and managing or comanaging complications of cancer and cancer therapies.”
After the diagnosis of cancer, roles and responsibilities of the primary care clinician include being a case manager, maintaining regular contact, being available, researching community resources and covered services, addressing ongoing health maintenance needs, offering appropriate pain management, evaluating for pathologic depression and other psychopathology, being aware of treatment options, and communicating with and supporting the patient.
Cancer-related symptoms and adverse effects of cancer treatment often coincide and may include nausea, febrile neutropenia, pain, fatigue, depression, and emotional distress. In patients with cachexia caused by cancer, megestrol improves weight gain and appetite (evidence level A). 5-Hydroxytryptamine antagonists can effectively control acute nausea associated with chemotherapy.
Anemia secondary to chemotherapy should be treated with epoetin alfa (level A). Chemotherapy-induced anemia usually starts several weeks after treatment onset. Other causes of anemia, such as bleeding, hemolysis, or nutritional deficiency, should be ruled out. If hemoglobin level is less than 11 g/dL (110 g/L), the patient should be treated with recombinant erythropoietin (epoetin alfa or darbepoetin alfa).
Adverse effects of chemotherapy may include diarrhea, typically starting 7 to 10 days after onset of treatment. Testing should include stool bacterial culture, stool Clostridium difficile antigen, and fecal occult blood testing. If tests results are positive for C difficile, the patient should be treated with metronidazole. Otherwise, an antimotility agent such as loperamide or diphenoxylate/atropine may be helpful.
Alopecia may also begin 7 to 10 days after initiating chemotherapy. The remaining hair should be shaved from the head, and the patient may wear wigs or scarves.
While awaiting culture results, the clinician should systematically evaluate febrile neutropenia and treat it early with empiric antibiotics. Patients with febrile neutropenia and any of the following should be considered high risk and treated intravenously in the hospital: inpatient status, serum creatinine level greater than 2 mg/dL (180 µmol/L), liver function test results more than 3 times the normal limit, uncontrolled or progressive cancer, pneumonia, significant comorbid illness, prolonged severe neutropenia, absolute neutrophil count less than 100 per mm3 (0.1 × 109 per L); and absolute neutrophil count less than 500 per mm3 (0.5 × 109 per L) for more than 7 days.
Patients with febrile neutropenia and most or all of the following should be considered low risk and treated daily with antibiotics at an outpatient clinic or at home: outpatient status, no comorbid illness, short duration of neutropenia, creatinine level less than 2 mg/dL, liver function test results 3 or fewer times the normal limit, good functional status, active, and independent.
Cancer-related pain, depression, and fatigue are often underrecognized and undertreated. Brief screening tools to evaluate fatigue and emotional distress may improve diagnosis and management. Therapies useful for treating cancer-related fatigue may include exercise prescription, activity management, and psychosocial interventions.
In patients undergoing chemotherapy and radiation therapy, exercise helps to reduce fatigue and improve functional status (level B). Cancer-related fatigue may also respond to psychosocial intervention (level B), and massage with or without aromatherapy may relieve anxiety and improve psychological well-being (level B).
Adverse effects of radiation therapy vary to some extent depending on the site of irradiation. Oral mucositis should be treated with saline/bicarbonate lavage; viscous lidocaine, diphenhydramine elixir, simethicone, or Gelclair (EKR Therapeutics, Cedar Knolls, New Jersey; oral gel that forms a protective coating that provides durable pain relief); and/or sucralfate oral suspension.
Antifungal treatments (nystatin [swish and swallow] or fluconazole or itraconazole [orally]) should be given for thrush. Xerostomia should be treated with sialogogues such as pilocarpine, or may be prevented in part by intravenous amifostine infusion daily before radiation therapy.
Temporomandibular joint fibrosis may respond to stretching exercises. Osteoradionecrosis of the jaw should be managed by completing dental work before starting radiation therapy, as well as with treatment with hyperbaric oxygen and/or pentoxifylline.
Radiation pneumonitis should be treated with prednisone, 30 to 60 mg daily for 2 to 3 weeks, with appropriate tapering. Pulmonary fibrosis should be managed with supportive care, including oxygen, bronchodilators, and/or pentoxifylline.
Prostate irradiation may result in obstructive uropathy, which should be treated with α-blockers (eg, terazosin, doxazosin, and tamsulosin) or finasteride.
Diarrhea associated with bowel irradiation should be managed with low-residue diet, loperamide, diphenoxylate/atropine, cholestyramine, and/or octreotide. Proctitis may respond to hydrocortisone cream, glucocorticoid retention enemas, mesalamine suppositories, or sulfasalazine.
The clinician must remain vigilant for signs and symptoms that can warn of cancer-related emergencies, such as spinal cord compression, hypercalcemia, tumor lysis syndrome, pericardial tamponade, and superior vena cava syndrome. These mandate immediate evaluation and treatment to improve outcomes.
“More than 1.3 million patients are diagnosed with cancer every year in the United States, and a typical family physician will have three or four patients each year who are given a new diagnosis of cancer,” the authors conclude. “These patients and their families face not only a life-threatening disease but a flurry of subspecialty consultations, medical tests, and treatments that may be difficult and disruptive. During the course of the patient’s cancer care, the family physician can remain an important resource for the patient and family, providing an empathetic and credible source of information, support, and advice as well as medical treatment for intercurrent illness, preoperative evaluation, postoperative care, and coordination of subspecialty care.”
The authors have disclosed no relevant financial relationships.
Am Fam Physician. 2007;75:1207-1214.
Clinical Context
Up to 3 to 4 of an individual primary care clinician’s patients may be diagnosed with cancer in a given year, and the primary care clinician is frequently the professional charged with delivering the news of the diagnosis. The current review suggests that clinicians use the “SPIKES” mnemonic as a tool to remember recommended practice for delivering an unfavorable diagnosis to patients:
S: Set up an interview
P: Perception — ask what the patient knows
I: Invitation — explore the patient’s wishes regarding knowing his or her diagnosis
K: Knowledge and information — warn the patient that bad news is coming and explain the diagnosis
E: Emotions and Empathy — provide empathetic statements
S: Strategy and Summary — discuss treatment options if the patient is ready, and confirm the patient’s understanding of the diagnosis and plan
The current review also highlights the role of the primary care clinician once patients begin treatment of cancer by focusing on particularly common problems in this difficult period of patients’ lives.
Study Highlights
Nausea and vomiting affect 70% to 80% of patients treated with chemotherapy. While medications such as lorazepam, metoclopramide, and prochlorperazine may be used with chemotherapy infrequently associated with nausea, 5-hydroxytryptamine antagonists should be used for more significant cases of nausea and vomiting. Of these agents, which include ondansetron, granisetron, dolasetron, and palonosetron, palonosetron has a longer half-life than dolasetron and may be more effective in reducing delayed emesis following chemotherapy. Concomitant administration of dexamethasone may increase the efficacy of 5-hydroxytryptamine antagonists in reducing acute emesis.
Neutropenic patients with a single temperature reading higher than 38.3°C should be considered to have neutropenic fever, and patients with an absolute neutrophil count less than 500 per mm3 for more than 7 days are considered high risk and should be hospitalized.
No single antibiotic regimen is uniformly recommended for all febrile neutropenic patients. Outpatient therapy usually uses a fluoroquinolone or amoxicillin/clavulanate. Empiric inpatient therapy of neutropenic fever may center on monotherapy with a carbapenem or antipseudomonal cephalosporin, or clinicians may select combination antibiotic therapy. Regardless of the choice of antibiotic, treatment of neutropenic fever should last 10 to 14 days.
The use of epoetin alfa among cancer patients with anemia can improve quality of life, and the maximum incremental benefit of this medication occurs when the hemoglobin level is between 11 and 12 mg/dL.
Fatigue in patients with cancer may result from pain, emotional distress, sleep disturbance, anemia, nutrition, activity level, or other comorbid conditions. Exercise programs as well as other psychosocial interventions, such as support groups and stress management, can improve fatigue among patients with cancer.
Nutrition in patients with cancer may be improved if they eat small, frequent meals. Because of a theoretical effect in reducing the efficacy of chemotherapy and radiotherapy, intake of antioxidant vitamins should be limited to the upper-limits-of-normal levels.
Cachexia can occur in up to 80% of patients with advanced cancer. However, neither megestrol nor corticosteroids have been demonstrated to improve muscle mass or performance over time.
Pearls for Practice
The SPIKES mnemonic highlights important steps in the recommended procedure for delivering an unfavorable diagnosis, such as a cancer diagnosis, to patients.
The current review recommends the use of 5-hydroxytryptamine antagonists for the treatment of nausea, oral or intravenous antibiotics for the treatment of neutropenic fever, and exercise prescriptions for the treatment of fatigue among patients with cancer. However, there is no adjunctive medical therapy that is effective for cachexia in cancer patients for the long term.
Reviewed by Dr. Ramaz Mitaishvili
