NEWS

Subtle Signs May Mask Cancer-Related Emergencies

Jean McCann

Cancer-related emergencies may be overlooked as more patients seek treatment in an outpatient setting, many experts agree. Among the reasons cited: oncologic emergencies can be difficult to detect, are small in number, and come in many manifestations.

"I would suspect [cancer] in someone with unexplained fever, weight loss, or obviously where I felt a mass," said Patricia Lee, M.D., an assistant professor in the department of emergency medicine at the University of Illinois, Chicago. "Also, I would suspect it in someone who had unexplained bleeding from the rectum, an older woman with vaginal bleeding, or someone with neurologic findings, like weakness."

But, said Lee, there are "all kinds of presentations," and whether an oncologic emergency is recognized as such depends largely on the training of an individual physician. Lee, who will speak on this topic at the annual meeting of the American College of Emergency Physicians in October in Las Vegas, said most board-certified emergency physicians would recognize a cancer-related emergency, but those working in underserved medical areas with training in other fields might have more difficulty.

Similarly, other experts in the field say, recognizing these emergencies is easier in the emergency rooms of cancer centers where patients are known to have cancer, or in large academic medical centers, than in small community hospitals where emergency room physicians generally see few oncologic emergencies.

According to the American Hospital Association, in 1997 — the latest year for which statistics are available — there were more than 9 million emergency room visits nationwide. Of these, Lee estimates, probably less than 5% are oncologic emergencies, although this number may increase as the population ages.

Spinal cord compression is the major cancer-related emergency. But a 1997 article in the Pediatrics Clinics of North America lists a host of other potential problems in both children and adults, including superior vena cava syndrome, brain herniation, and tumor lysis syndrome, which has a variety of metabolic consequences.

On the Rise

At the University of Texas M. D. Anderson Cancer Center, Houston, the volume of cancer-related emergencies has already "increased substantially," said Carmelita Escalante, M.D., chief of internal medicine and director of the ambulatory and emergency centers. Escalante said that there are more patient referrals and "patients are living longer — so they require more care, and when they get ill, the acuity [of the complicatons] is higher."

Spinal cord compression is especially tricky, according to Escalante. While early on, the signs of this cancer-related complication may be subtle — making detection more difficult, if a patient presents to the emergency center already experiencing leg weakness and paralysis, full recovery is unlikely, she said.

At Memorial Sloan-Kettering Cancer Center, New York, said Brian Meltzer, M.D., head of the urgent care center, spinal cord compression is ruled out first in "any patients with new onset of progressive back pain, new weakness, or sensory symptoms in their extremities, or who have any form of urinary retention or incontinence, or bowel incontinence." Patients are given high dose steroids "even while we are waiting to get an imaging study," he said.



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Dr. Brian Meltzer

 
Meltzer said another medical problem that might be overlooked as being cancer-related is pulmonary embolism where patients present with shortness of breath. Usually in this situation, he said, nuclear and helical computerized tomography scans are done before beginning treatment with anticoagulants to avoid bleeding complications.

At Memorial, Meltzer indicated, oncologic emergencies are also on the rise — roughly half caused by treatment-related complications and half by the cancer itself. "Over the last 3 years we've been tracking this, and our numbers have been increasing 10% to 15% a year." Part of the reason, he said, is that patient referrals have increased to the unit's growing number of internal medicine physicians who deal only with cancer-related emergencies.

Neutropenic Fever

Still another oncologic emergency is fever related to neutropenia. When patients experience neutropenic fevers and they live at a distance, "we tell them to go to their local emergency room," Escalante said. "The emergency physicians there may call M. D. Anderson to determine what treatment to consider. A lot of times local physicians will stabilize our patients and send them on, or they may hospitalize them for a few days."

Tumor Lysis Syndrome

Aric Greenfield, M.D., a medical oncologist at University Hospitals in Cleveland, said that tumor lysis syndrome can also be a major emergency. "People usually present with acute kidney failure, with things like somnolence, myoclonus, pericarditis, pulmonary edema, or congestive heart failure," he said.

Moreover, more than half of cancer patients with emergencies fail to call their oncologists before going to the emergency room, Greenfield commented. Some people go to the ER like it's a revolving door of a clinic," he said. "I have patients like that. They don't bother calling. They just show up in the emergency room."

Some patients with leukemia turn up in emergency rooms with hyperleukocytosis and white blood cell counts in the hundreds of thousands, requiring leukophoresis immediately. They can have an acute myocardial infarction or stroke because of stasis in their blood vessels.

Mark Austerfeld, M.D., an associate clinical professor at the University of Kansas and a urologist, said bladder cancer patients may go to an emergency room with urinary outflow obstruction due to blood clots. Occasionally, patients with kidney cancers that invade blood vessels can also form clots, he said.



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Dr. Mark Austerfeld

 
A study reported in the July 1995 Annals of Emergency Medicine identified 284 out of the 5,640 adult admissions to Methodist Hospital, a community teaching hospital in Minneapolis, as having a cancer history. Of these patients, 122, or 43%, of them experienced oncologic emergencies. The most common presentations were gastrointestinal (48%), pain (40%), neurologic symptoms (38%), cardiac (25%), and pulmonary (23%).

Lead author Karen Swenson, an oncology nurse, and her colleagues said emergency personnel may face challenges from the acute symptoms of "undiagnosed malignancy, vague disease-related symptoms, or complications of cancer treatments" with little information available in the literature.



             
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