Recommendations for Primary Care of the Patient With Cancer

April 30, 2007 — 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 ?-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.

Source: http://www.medscape.com/viewarticle/555842?src=mp