Oncologic Emergencies: Recognition and Initial Management

The National Cancer Institute estimates that 14.5 million persons in the United States have cancer, and that number could reach 19 million by 2024.¹ Family physicians should be familiar with the most prevalent oncologic emergencies because stabilization is often necessary, in addition to referrals for managing the underlying malignancy and initiating palliative measures.² Some oncologic emergencies are insidious and take months to develop, whereas others manifest over hours, causing devastating outcomes such as paralysis and death.³ In many patients, cancer is not diagnosed until a related condition emerges. A patient-focused approach that includes education; cancer-specific monitoring; and team-based care, including palliative care, with continuous communication is recommended.⁴ Most oncologic emergencies can be categorized as metabolic, hematologic, structural, or treatment related (Table 1⁵).

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Concurrent palliative care consultation should be offered to patients with cancer at the time of diagnosis.	C	4
Emergent use of antibiotics in patients with cancer who present with febrile neutropenia improves survival rates.	B	22
New-onset back pain in patients with cancer should be evaluated as epidural spinal cord compression until it is ruled out.	C	3, 26
More permanent surgical solutions for management of malignant pericardial effusions, such as pericardial windows and indwelling pericardial catheters, are associated with improved patient outcomes compared with percutaneous pericardiocentesis alone.	B	29-31
Complications from newer immunotherapy treatments often present as nonspecific and vague symptoms, such as flulike illness and rash, requiring a high level of suspicion in patients undergoing cancer treatment.	C	40-42

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

TABLE 1. Summary of Oncologic Emergencies

Condition	Cancer association	Common presenting signs and symptoms	Consultation considerations
Metabolic
Tumor lysis syndrome	Hematologic malignancies, particularly acute leukemia, and high-grade lymphomas; solid tumors	Azotemia, hyperphosphatemia, hyperkalemia, hyperuricemia, acute renal failure, hypocalcemia	Oncology, nephrology, palliative care
Hypercalcemia of malignancy	Multiple myeloma; breast cancer; squamous cell carcinoma of the head or neck, lung, kidney, or cervix	Progressive decline in mental function, weakness, anorexia, thirst, constipation, nausea, vomiting, decreased urine output, possible coma	Oncology, endocrinology,...