Most emergencies can manifest in the blink of an eye. Whether it’s a medical emergency, a car accident, an act of nature, or something else, emergencies are sudden crises that require swift, immediate action.
For many patients with cancer, among the most distressing challenges along the treatment journey is the possibility of experiencing an oncologic emergency. Many of these widely varying complications are potentially life threatening, appearing quickly and without warning and heralding progressive disease.
The number of different, potentially deadly oncologic emergencies patients encounter can present significant challenges to healthcare providers and caregivers. Oncology nurses are crucial to recognizing and managing the signs and symptoms of oncologic emergencies.
Understanding Oncologic Emergencies
For patients and providers, understanding oncologic emergencies is the first step to mitigating potentially deadly complications in practice. Because the conditions vary greatly between patients, disease types, and stages of treatment, developing the knowledge base to recognize the signs and symptoms can be key to preventing serious problems.
According to ONS member Rebecca Martin, BSN, RN, OCN®, BMTCN®, staff nurse and educator at Froedtert Hospital and the Medical College of Wisconsin in Milwaukee, oncologic emergencies require hasty identification and action.
“Oncologic emergencies can occur upon diagnosis, throughout treatment, or during end-stage disease. They may be caused by the actual malignancy, its treatment, or a combination of both,” Martin says. “Without early recognition and effective treatment, oncologic emergencies may be life-threatening. These complications require prompt identification and treatment, and frequent head-to-toe assessment from the RN is critical in quick identification.”
ONS member Marcelle Kaplan, RN, MS, AOCN®, CBCN®, oncology nursing consultant and editor of the ONS book Understanding and Managing Oncologic Emergencies: A Resource for Nurses, says that oncology nurses have a responsibility to address and treat oncologic emergencies.
“Nurses have a key role in preserving a reasonable quality of life for patients who develop oncologic emergencies,” Kaplan says. “To accomplish this, nurses must be aware of which cancers increase a patient’s risk for a specific oncologic emergency and understand the pathologic mechanisms underlying those complications. When nurses are able to recognize subtle, early clinical signs and symptoms of an impending oncologic emergency, they can report their findings to the healthcare team so that appropriate physical, laboratory, and imaging assessments can be performed and treatments can be promptly initiated.”
A Need for Action and Education
Both Kaplan and Martin stress the importance of recognizing early signs and symptoms, as well as providing appropriate education and support to patients and caregivers as they cope with a potentially distressing event.
“Clear and honest explanation to patients and caregivers is important. Make sure they understand the possible signs and symptoms of pertinent oncologic emergencies, as well as the consequences of late recognition, “Martin says. “Provide written information of their disease, treatment, and the potential complications. Most importantly, provide a written list of signs and symptoms along with when and where to call. Then, practice. When they’re with you in the clinic or in the hospital, have them practice what they will say if they need to call the clinic, hospital, or answering service.”
Common Oncologic Emergencies in Patients With Cancer
Despite varying cancer types and treatment regimens, some oncologic emergencies occur more often than others. Being able to quickly recognize and intervene with these complications can potentially lead to better outcomes for patients.
“Most oncologic emergencies can be classified as metabolic, structural, or treatment-related emergencies,” Martin says. “Some emergencies may develop over the course of months, whereas others progress over hours, leading to devastating outcomes such as paralysis, coma, or death. In many cases, a malignancy is diagnosed as a result of the symptoms of an oncologic emergency.”
According to Martin and Kaplan, one of the most common metabolic emergencies is hypercalcemia of malignancy (HCM).
“The incidence of oncologic emergencies varies depending on whether the patient has a solid tumor or a cancer of the blood or lymphatic system,” Kaplan says. “But HCM, which is associated primarily with pathologic bone breakdown, occurs in up to 30% of patients with cancer, especially those with cancers of the breast, lung, and kidney and multiple myeloma. Coma and death are the end results of untreated HCM.”
Martin notes that structural or mechanical oncologic emergencies represent a spectrum of disorders.
“Structural emergencies result from the progression of a known malignancy or the initial sign of an undiagnosed malignancy,” she says. “In patients with a known malignancy, a high suspicion for structural emergencies including, spinal cord compression (SCC) or superior vena cava syndrome, is important. With the prevalence of cancer on the rise, patients presenting with these types of complications are expected to increase.”
Kaplan adds, “SCC occurs when vertebral bone fragments or a tumor mass impinges on the spinal cord, causing pain and potentially devastating neurologic impairments. Patients with cancers that metastasize to bone, especially breast, lung, and prostate cancers, as well as those with multiple myeloma, are at greatest risk for SCC.”
Tumor lysis syndrome (TLS) is another common oncologic emergency that can often appear after treatment begins.
“TLS is characterized by severe electrolyte imbalances caused by breakdown of tumor cells, leading to the release of tumor cellular contents into the systemic circulation,” Martin says. “The subsequent electrolyte imbalances include hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia. Acute renal failure, seizures, and cardiac dysfunction can follow as a result of metabolic abnormalities. Medications and hydration, as well as frequent electrolyte monitoring, will aid in the treatment of TLS.”
Depending on disease type, progression, and treatment, patients could experience completely different emergencies, and oncology nurses need to be prepared for any and all of them. Both Kaplan and Martin note the importance of recognizing and preparing for emergencies such as sepsis and septic shock, febrile neutropenia, infusion and hypersensitivity reactions, along with several other potential complications in practice.
Being Prepared to Handle Urgent Situations
Using existing resources, the experience of their colleagues, and remaining current on best practices of treating oncologic emergencies keep nurses sharp at recognizing and intervening when time is of the essence.
Kaplan recommends the ONS book Understanding and Managing Oncologic Emergencies: A Resource for Nurse—and not just because she’s the editor. “The sole focus of this resource is to provide nurses with most detailed, comprehensive, and up-to-date information about each of the oncologic emergencies described within its pages. The latest edition of the book includes a new chapter on cutaneous toxicities that have become more prevalent with increased use of targeted and immunotherapies and have the potential to be life threatening.”
Martin encourages nurses to know their patients and trust their educated instincts.
“Be prepared and know your patient’s diagnosis along with the oncologic emergencies associated with it. And trust your gut,” she stresses. “If you think there’s something going on with your patient and are worried about a potential complication, talk to the medical team. And always be assessing: a comprehensive, head-to-toe assessment is one of the most important skills for an oncology nurse to master. Slight changes to an assessment can be the presenting sign of a significant emergency.”
Kaplan and Martin agree that oncology nurses are in the perfect position, combining expert care, educational resources, and emotional support for their patients, to address potential life-threatening emergencies.
“As the population and lifespan of cancer survivors increase in association with advancements in cancer diagnosis and treatment, the potential for oncologic emergencies is also heightened,” Kaplan says. “Oncology nurses have a crucial role in the outcome of patients at risk of or experiencing an oncologic emergency. By teaching patients and caregivers preventive strategies, identifying early signs and symptoms, administering therapies and assessing their efficacy and side effects, managing symptoms, and providing education at the patient’s and caregivers’ level of understanding, it may be possible for patients to recover from one of these complications and maintain a reasonable quality of life.”