Preparing for a Cancer-Related Emergency

Carmen Gonzalez, an associate professor of emergency medicine at MD Anderson Cancer Center in Houston, still remembers a patient who came to the emergency room 15 years ago. An internist by training, she had just begun working at MD Anderson.

The patient was a man in his 40s, a husband and father with sarcoma who was undergoing chemotherapy and had ignored a fever of more than 101 degrees Fahrenheit. The fever raged for one day, then two and then three. By the fourth day, he was so drowsy that his wife brought him to the ER. But it was too late. His cancer was survivable, but he died of sepsis, a severe blood infection that can result from a chemotherapy-induced low white blood cell count.

Gonzalez could have saved the patient from this oncologic emergency with antibiotics and intravenous fluids if only he’d come for help earlier. “His wife had to live with the sorrow of thinking his death could have been prevented, and their children had to live without a father—just because they thought he would get better,” she says.

Being Prepared

Deborah Mayer, an advanced practice oncology nurse and researcher at the University of North Carolina in Chapel Hill, says oncologic emergencies fall into two categories: those that can be prevented or managed early and those that are urgent. Serious oncologic emergencies requiring immediate medical attention include uncontrolled pain or bleeding, seizures and delirium.

Other symptoms may not warrant an immediate trip to the ER or a call to 911 but should be brought to the attention of healthcare providers to prevent a bad situation from becoming life-threatening. Basically, Mayer says, if symptoms are new or are getting worse, they should be brought to the attention of the patient’s cancer care team. “The real trick is to get the problem evaluated and let an oncology specialist decide the best approach,” she says. “If the patient doesn’t talk about the problems, it’s hard for the provider to guess.”

Not everyone who has cancer is at risk for an oncologic emergency, but all patients and their caregivers need to be aware of and to prepare for such a possibility. In fact, preparing for an emergency ahead of time can save precious minutes when patients end up in an emergency room that’s not affiliated with their care team. Most hospitals in the U.S. are not linked together via electronic medical records, so emergency room physicians, such as Gonzalez, often work in fits and starts when patients come through the doors already critically ill as they wait for patient records.

Gonzalez had a patient recently who came into the ER complaining of excruciating pain. She knew nothing about him other than his symptoms. The patient and family members could not tell her what diagnosis had been given, nor the treatment provided. They just knew he had “cancer.” But because he had jaundice and abnormal lab tests, he was sent to the intensive care unit. She says caring for him in the ER would have been much easier if she’d known right away what type of cancer he had and how the disease was being treated.

[Know Before You Go]

While symptoms such as pain and fever may be universal, oncologic emergencies can be cancer specific. Doctors evaluate and treat oncologic emergencies depending on many factors, including the type of cancer, the stage of the disease, the type of treatment, and whether the goal of treatment is curative, life extension or palliative.

For example, a cancer emergency will be handled differently for the patient who has a small tumor and expects to be cured than it will be for someone with advanced disease who may not have much longer to live, says Timothy Moynihan, an oncologist at the Mayo Clinic in Rochester, Minn. Although it’s difficult for doctors to foresee every scenario, Moynihan tells his patients a general set of rules. If they have mild symptoms, then they can probably wait a few days to call. For example, patients who develop symptoms of a cold when others in the household have colds might not be a cause for alarm. However, if symptoms worsen over time or if the patient is the only one in the household who is ill, it may be time to call the oncologist.

A fever of 101 degrees Fahrenheit or higher should never be ignored in someone actively receiving chemotherapy, Moynihan says. Such a patient should have a blood count checked to determine the treatment and the urgency of this situation. A new headache can mean something different for a person with brain cancer or potential brain metastases than it could for a patient without a history of cancer. “There are a wide variety of issues, and we try and tailor them to what we might anticipate patients will have, based on underlying disease,” Moynihan adds.

Best to Be Cautious

The key is for patients to bring any problems to their doctors’ attention right away, so the issue can be monitored. “If they wait and a family member calls and says the person is not responsive and the temperature is 103, that’s a problem,” Gonzalez says.

Another problem for people with cancer is that they often have no idea of what to expect, Moynihan says. Patients generally fall somewhere in the middle of the worry spectrum, from being overly anxious to almost unemotional, he adds. “It’s hard to talk about cancer patients as the ‘worried well.’ Some patients call too often because they’re scared all the time. Then some patients are too stoic and don’t want to call and bother the doctor,” Moynihan says. “Those are the ones to whom you really want to say ‘please call me.’ ”

Gonzalez says she hopes that emergency room physicians will learn to think more broadly about oncologic emergencies for patients with incurable cancer. “It’s very easy to quickly intubate a patient in the ER,” she says. “It takes five minutes for a patient who is short of breath.” But intubation may not reflect the wishes of certain patients or their families.

For patients with end-stage disease, Moynihan emphasizes that the answers aren’t so simple. There comes a time when oncologists will tell family members or patients not to call 911. For example, when the cancer has progressed to its final stage and the patient experiences an oncologic emergency, it might be best to contact the hospice care team, he says.

Gonzalez says it’s better to act with an abundance of caution. Chest pain might not have anything to do with the cancer, but it could be a sign of a heart attack. “Don’t ever assume,” Gonzalez says. “We can take care of your cancer, but you could die of a heart attack.”

Talking Points:

> Patients can prepare for oncologic emergencies by knowing detailed information about their cancer and treatment.

> If mild symptoms worsen over time, it may be necessary to call the oncologist.