Medical problems that may seem routine in patients without cancer often mean something different or have a different cause in cancer patients and may be much more serious, requiring urgent treatment. Managing these problems promptly and effectively is a challenge faced by all cancer centers.
The University of Texas MD Anderson Cancer Center has a unique solution: its own dedicated emergency department (ED), also known as the Emergency Center. “We have the only true ED in the nation dedicated solely to cancer patients,” said Terry Rice, M.D., an assistant professor in the Department of Emergency Medicine and medical director of the Emergency Center.
In addition to classic oncologic emergencies, cancer patients may experience a broad spectrum of medical problems related to their cancer. “Even nonspecific symptoms such as lethargy, confusion, nausea, or fever require special attention in a patient with cancer,” Dr. Rice said. Awareness of common problems that can lead to emergencies in cancer patients helps ED physicians provide prompt and appropriate care.
Common oncologic emergencies
Classic oncologic emergencies are usually categorized according to their cause: the cancer treatment or the underlying disease. Emergencies resulting from the cancer itself include life-threatening metabolic abnormalities such as severe electrolyte imbalances; organ insufficiency; and hematological abnormalities such as leukostasis, hyperviscosity syndrome, and symptomatic cytopenias. Other disease-related oncologic emergencies include complications of solid tumor progression, such as mass effects in the brain or spinal cord or organ failure due to invasion or obstruction. Treatment-related emergencies include chemotherapy-induced nausea and vomiting, diarrhea, fever in neutropenic patients, mucositis, and graft-versus-host disease.
In a broader sense, however, any urgent problem that is potentially more severe in cancer patients than in the general population might be considered an oncologic emergency. Summarized here are some of the emergencies seen most often in the MD Anderson ED.
Current and former cancer patients are at higher risk than people without cancer for opportunistic infections, which may lead to sepsis. “Both cancer and its treatment can disrupt normal immune responses,” Dr. Rice said, “and most cancer patients, whether they are currently in treatment or are longer-term survivors, are at high risk for unusual infections that might go unrecognized in some acute care settings. The presenting symptoms may be atypical or nonspecific, such as fever, lethargy, or shortness of breath.”
Many patients seen in the MD Anderson ED have neutropenic fever, which may be related to cancer or, more often, its treatment. Current guidelines recommend that antibiotic therapy begin within 1 or 2 hours of neutropenic fever onset in cancer patients. However, these guidelines sometimes go unmet in the general medical setting owing to a lack of recognition of the neutropenia until blood test results are available and to practitioners’ general reluctance to give antibiotics without knowing the cause of a fever. Either of these reasons can cause a dangerous delay in treatment.
In cancer patients with fever or other infection-related symptoms, neutropenia should be suspected immediately. “At our ED,” Dr. Rice said, “we know from patients’ history and medical records that they are likely to be neutropenic, and we treat them very aggressively. Blood specimens are drawn immediately for culture, and appropriate antibiotic therapy is initiated without delay.”
Spinal cord compression
Back pain due to spinal cord compression, a fairly common presentation of cancer patients at conventional EDs, is also common at the MD Anderson ED. Spinal cord compression may be seen in patients with multiple myeloma or any cancer that metastasizes to the bone.
In cancer patients, spinal cord compression, often a sign of disease progression and impending neurological deficit, is a medical emergency that must be recognized and treated immediately. In any cancer patient who presents with back pain, spinal cord compression should be suspected and magnetic resonance imaging of the spine obtained immediately. Treatment consists of immediate steroid therapy to reduce swelling as well as radiation therapy or surgery to relieve the pressure on the spine.
“Neurological deficits caused by spinal cord compression often are not reversible,” Dr. Rice said. “We want to start treatment at the time the patient has pain, before the weakness or sensory loss starts.”
Metastatic cancer to the brain often manifests as neurological symptoms. The symptoms depend on the area of the brain affected. Seizure is one of the most common and serious neurological symptoms.
Seizures in cancer patients require immediate imaging and treatment. As in patients with spinal cord compression, steroid therapy is usually begun immediately and radiation therapy started the next day. Patients with seizures resulting from brain metastases may also be assessed for gamma knife radiosurgery, which can shrink tumors and reduce symptoms.
MD Anderson patients may visit the ED with new, worsening, or breakthrough cancer-related pain. These patients often require tightly scheduled opiates and may require additional treatment for associated symptoms such as nausea, diarrhea, and dehydration.
One of the most common presentations in the ED at MD Anderson is abdominal pain. In some cases, abdominal pain is a surgical complication; in others, it is due to progressive disease. Immediate recognition and treatment of the source of the abdominal pain are essential. The source may be something as simple as constipation, but bowel obstruction or perforation is not uncommon.
“In cancer patients, bowel obstruction may be handled differently and treated in a more conservative way,” said Patricia Brock, M.D., an assistant professor in the Department of Emergency Medicine and a surgeon who has worked in the MD Anderson ED almost 5 years. “We may not use nasogastric tubes as frequently, for example. In some cases, patients are palliated with hydration, octreotide, and steroids.”
Nausea and vomiting
Nausea and vomiting have many different causes and are common reasons for patient visits to healthcare practitioners. In cancer patients, however, severe nausea and vomiting may be due to the treatment or to the cancer itself. Nausea and vomiting are usually treated aggressively with anti-emetic drugs such as ondansetron and steroids.
Emergencies related to specific treatments
Oncologic emergencies related to specific treatments vary widely. Some chemotherapy drugs can result in the reactivation of a chronic infection, such as hepatitis B, resulting in acute liver failure. Knowledge about the patient’s treatment makes it easier for ED physicians, in consultation with the patient’s oncologist, to initiate the appropriate diagnostic and therapeutic processes.
In addition, new cancer treatments can have unusual side effects. For example, the new agent ipilimumab, which stimulates the immune system, can cause life-threatening adverse effects due to the activation and proliferation of T cells. Among these effects are inflammation of the hypophyseal portion of the brain and severe diarrhea from colitis.“In our ED,” Dr. Rice said, “we have heightened awareness of the new therapies that are being introduced and their unusual side effects.”
Although many emergencies in cancer patients are related to the cancer or its treatment, many others are not. Any medical condition, as well as its treatment, must be considered in light of a patient’s cancer. For example, a cancer patient who is being treated with an anticoagulant for stroke prevention may have bleeding problems if he or she becomes thrombocytopenic as a result of his or her cancer or its treatment.
Furthermore, cancer patients can have the same emergencies that occur in patients without cancer. “A patient with cancer also can have a myocardial infarction or appendicitis,” Dr. Brock said. “As ED physicians in a cancer center, we can’t just forget about the more common problems. We have to keep that whole list in mind as well as the lists of cancer- and treatment-related problems.”
Education about oncologic emergencies
One of the goals of the MD Anderson ED staff is to educate community clinicians about the special kinds of medical problems that occur more often, or differently, in cancer patients. MD Anderson is sponsoring a conference in November that will help community ED physicians acquire a skill set that they can use in their own EDs to evaluate patients with oncologic emergencies.
“As the population ages,” Dr. Brock said, “cancer will be more and more prevalent. Increasingly, ED practitioners are going to see patients with oncologic emergencies. Our goal is to increase physicians’ awareness of the types of problems cancer patients and survivors may experience.”
For more information, contact Dr. Patricia Brock at 713-745-9911 or Dr. Terry Rice at 713-563-2098. For information about the November 13–14 conference for ED practitioners, please call 713-745-9911 or visit www.mdanderson.org/conferences.
OncoLog, July 2015, Volume 60, Issue 7
The Emergency Center: First of Its Kind
The MD Anderson Emergency Center is the only ED in the United States dedicated to cancer patients. A true ED in all senses, it operates under the ethical and legal guidelines of the U.S. Emergency Medical Treatment and Active Labor Act. “As a full-fledged ED,” Dr. Rice said, “we have all the resources needed to handle almost any emergency that a conventional ED can handle. However, our focus is on internal medicine– and surgery-related problems specific to cancer patients.” Recently, MD Anderson granted department status to the Emergency Center faculty, which made it the first academic department of emergency medicine dedicated to oncologic emergencies.
MD Anderson’s ED evolved over time. Its predecessor was an open ward staffed by nurses who would triage patients with urgent problems and call oncologists to see patients on an unscheduled basis. This not only played havoc with physician and clinic schedules but also forced patients to wait longer than necessary to receive care. As the number of patients using the facility grew, several internists were hired to staff the unit, and in 2007 the ED moved into a fully equipped and dedicated new facility.
The ED now treats about 70 patients each day. There are 45 beds plus five chairs for patients with less urgent problems. “Our length of stay is longer than that of conventional EDs, which is why we need so many beds,” Dr. Rice said. “The reason it takes so long to care for our patients in the ED is that our patients are very sick and have multiple problems; a lot of them receive fluids and blood products as well as intravenous antibiotics.” Just over half of the patients who come through the ED are admitted to the hospital, a much higher proportion than in a conventional ED.
The majority of the MD Anderson ED physicians are trained in internal medicine, which gives them a strong background in the serious metabolic and hematological problems that can occur in cancer patients. Others are trained in infectious diseases, surgery, or emergency medicine. “The diversity of physician backgrounds and training is a huge asset,” Dr. Brock said. “It enables us to draw on one another’s expertise to deliver exceptional care.”