Hospitalists are on the front lines of diagnosis and management of patients with cancer, the second-leading cause of death in the United States. The session on Oncology Emergencies addressed the enormous number of clinical issues that must be considered within this patient population.
“The real challenge in managing sick cancer patients lies in the data-free zones,” presenter Benjamin L. Schlechter, MD, of Beth Israel Deaconess Medical Center in Boston, said in an interview. “I think the oncologic emergency we forget to talk about most often is the early diagnostic period,” he noted. The focus of Dr. Schlechter’s Monday talk was on this time frame and the process of getting patients with an advanced malignancy from diagnosis to treatment safely, which remains a clinical challenge.
“These patients often present with vague symptoms that do not point to any particular diagnosis,” stated Dr. Schlechter. “Once we identify that a patient has a symptomatic new malignancy, it is critical to determine who needs a rapid work-up as an inpatient on a hospital medicine service and who can be managed as an outpatient.”
Dr. Schlechter explained that there are no randomized trials to guide diagnostic work-up of malignancy or even define an expedited work-up. On the other hand, there are extensive data on treatment of newly diagnosed cancers. Clinical trials that guide first-line cancer therapy have clear eligibility criteria, which should inform hospitalists’ work-ups. “These include torso imaging, biopsy of a metastatic site, and assessment of liver and kidney function,” Dr. Schlechter continued. “The reason kidney and liver function are so critical is that patients who have organ dysfunction cannot receive effective chemotherapy.”
During the presentation, Dr. Schlechter reminded attendees that two-thirds of all cancers are cured, and there are clear data showing that chemotherapy in the first-line setting improves quality and length of life in virtually all cases. He underscored how critical it is to get patients treated before they develop organ dysfunction. “We can also use fairly basic clinical and laboratory assessment to determine who has a hyperaggressive malignancy and who doesn’t,” he added. “If LDH [lactate dehydrogenase] or uric acid are elevated, something really dangerous is happening. If the transaminases and alkaline phosphatase are rising, liver function is in danger. If the kidneys are failing, we need to act quickly.”
Dr. Schlechter closed by saying, “There are huge challenges in studying this time frame in a patient’s illness, which is why the initial work-up of cancer remains a high-risk period.”