Complications of cancer treatment

Pyrexia > 38 (or > 37.5 on 2 measurements 1hr apart) OR rigors OR unexplained hypotension/ tachycardia in a patient with neutrophil count < 1.0 x 10^9/L

Any pt presenting while on Ca Rx: ask about last Rx (duration, cycle, timing) and how it relates to onset of Sx, do FBC. Neutropenia commonly occurs after chemo but can be after radiotherapy

Initial mgmt: infection screen (blood cultures- peripheral and from Hickman line if present, MSU, CXR, swabs), start high dose broad spectrum IV ABx (empirical, according to local guidelines, confirm with microbiologist), and IV fliuds

Other Ix: FBC, biochemistry, coagulation screen (keep platelets above 20- may need cryoprecipitate and FFP), blood cultures, MSU, CXR, swabs.

Difficult to evaluate due to minimal immune response- CXR often normal, fever may be only sign of infection, only give paracetamol if needed for Sx relief as it can bring down temperature + prevent accurate evaluation of patient

Occurs due to death of a large number of tumour cells over a short time period.

Predisposing factors: large volume/sensitive tumour (germ cell, Burkitt's lymphoma, SCLC, leukaemia, neuroblastoma, sarcoma), renal impairment, male, age < 25. May be precipitated by chemo/radiotherapy, steroids, immune modifiers, surgery. Can be spontaneous

Metabolic state: hyperuricaemia, hyperkalaemia, hyperphosphataemia, hypocalcaemia, sudden release of preformed hormones may cause secondary metabolic emergency

Consequences: cardiac arrest/arrhythmias (usually that night, due to potassium disturbance), AKI (urate nephropathy, hyperuricaemia), DIC (cell death- activation of coagulation cascades and intravascular haemolysis)

Prevention: adequate hydration + urine output, low K diet, allopurinol, stop nephrotoxic drugs

Rx: treat electrolyte disturbance (PO/PR resonium, IV calcium gluconate, IV bicarb, insulin/dextrose, furosemide, hydration), haemodialysis (if renal impairment, esp if may cause chemo OD), PO/IV allopurinol

May occur with any chemo/radiotherapy. Particular importance in testicular germ cell tumours as they need orchidectomy + may require contralateral testis biopsy (<30 or contralateral testis is small- <12mL).

Always offer sperm storage to pts about to undergo surgery for testicular Ca (but beware delaying Rx)

50% men with testicular germ cell Ca will have low sperm count before chemo/radiotherapy. If sperm count is normal before Rx, it will return to normal in 2/3 men

Especially if aged < 30 at time of Rx.

Radiotherapy: increased risk of solid organ malignancy

Chemotherapy: increased risk of haematological malignancy

Latent period of 10-15yrs (5yrs for leukaemia) but risk remains increased for >20yrs after Rx.

Smoking independently increases risk

Bleomycin: pulmonary fibrosis/pneumonitis, dose-dependent, increased risk if >40 or renal impairment. All pts require lung function tests (including TLCO) before each cycle, + ask about cough/SOB. Consider omission of bleomycin in older patients/patients with metastatic disease.

Cisplatin: renal impairment, neuropathy, high tone hearing loss, highly emetogenic, severe vascular toxicity (MI, CVA)

Increased following cisplatin therapy and mediastinal/thoracic radiotherpay.

Nephrotoxic chemotherapy can cause hypertension.

Latency period of 5-8 yrs, extending up to 16yrs.

GPs should be informed of increased risk and patients should be advised not to smoke.

Sexual issues common following testicular cancer: sexual dysfunction, gender issues

Other psychological problems common following testicular/breast/head+neck/skin Ca: body image problems, relationship issues, anxiety + depression