[I posted this under 'Internship' and got no replies, am trying again here.]
I'm starting my intern year with onoclogy (my weakest subject in pathology 😳 ). Any tips on what I should be prepared for?
I didn't have much exposure to Onc when I did my medicine elective, but what I did see didn't involve much on the intern's side of things. Seems like all he did was put in orders that went, in general, like this:
Chemo tx & dexamethasone
Blood sugar check BID
CMP/CBC daily
Odansteron
Protonix
Heparin
I'm sure there's more to it, so I'm wondering what that is.
Agreed, learning chemo regimens isn't necessary, but being a bit familiar with their toxicities might be helpful. Here are my tips I give to interns who wind up on oncology services at my institution.
Concerning oncologic emergencies, such as spinal cord compressions, superior vena cava syndrome, symptomatic brain mets with midline shifts are things that need to be addressed quickly. Steroids are the first line, then surgery. Neurosurgeons generally get first crack and if they can't help, then rad onc, except for non-CNS plasmacytomas/lymphomas which may be rapidly responsive to chemo. One of the most rewarding things I've seen is a patient admitted with a recent history of new focal neurologic weakness, caused by a cord compression/brain met that responds quickly (like within hours or overnight) to steroids and neurosurgery and/or radiation.
Dexamethasone is useful for alleviating immediate CNS symptoms from edema from mets, and for cord compressions. A careful and thorough neurologic exam is important for cancer patients with longstanding disease admitted emergently/urgently to insure there are no impending cord compressions/brain mets. Protonix to keep the dexa from stimulating stomach secretions and glucose checks to insure the dexa doesn't send blood sugars skyrocketing. Dexamethasone is not a benign treatment, but it is necessary in some cases to preserve neurologic function until the neurosurgeon or rad onc can get on the scene. This would be a good drug to get familiar with. Slow tapers are important, particularly with brain/cord mets post irradiation. Personally, I like a 6 day taper, but others are less chicken than me.
Chemo toxicities vary, but the most common is nausea/vomiting, changes in taste which render food unappetizing and result in decreased caloric intake with resulting admissions for dehydration/rehydration. Watch for peripheral neuropathies/neurotoxicities (foot and glove distributions) particularly with taxanes and platinum therapies. Dehydration/nutrition is a big factor in head and neck cancers.
Chemo combinations have their own toxicities and as you surmised and other have said, managing the side effects is key to a cancer patient's quality of life. There are a couple of small lab coat books on oncology drugs that are useful. The one that I use most is from Texas Oncology "Commonly Prescribed Medications in Radiation Oncology" and I think Sofia/Aventis has another more general one that you can get from a drug rep (sorry anti-drug rep people, but references are references and theirs is a reasonable one and on a resident's salary, cheap or free is better).
Depending on your mix of cases, there are several common chemo drugs you will see. ABVD (leukemias, lymphomas, hodgkins) = Adriamycin/doxorubicin, bleomycin, vinblastine, dacarbazine or if you are not a medical oncologist = A Big Vial of Drugs. Also CHOP and CHOP-R Cisplatin/Taxol common in gynecologic tumors, Cisplatin/etoposide (VP16) in lung tumors, cisplatin as a radiosensitizing agent, gemcitabine and the newer topotecan drugs. For colon cancers, FOLFOX/FOLFURI (5-FU + oxaliplatin) are used either alone or with AVASTIN (VEGF-inhibitor). Anti-growth factor receptor agents are finding increasing applications in combination with chemo, but cautions are needed. Bleeding is a big problem with Avastin and squamous cell carcinomas.
For some patients, eg esophageal CA, combined chemo/RT concurrently is the only hope for effective treatment. Watch how your fellows coordinate with the various services, to insure that chemo/rads/surgery are appropriately and timely started, if you get a chance.
Watch the chemistry, onc patients, particularly those undergoing treatment with rapidly growing tumors can have lots of metabolic changes (tumor lysis syndrome) quickly. Ca, Mg, K, P If you have many leukemia/lymphoma patients you'll likely see one of these.
A tissue diagnosis is very important, so a biopsy either excisional (surgeons/neurosurgeons) or interventional radiology (CT/MR/US guided biopsy) should be considered.
Radiation oncology, when indicated, is given generally daily for palliation of once a tissue diagnosis is available from the pathologist. Initial radiation treatments should be given on two consecutive days, and many radiation therapy departments may not be available on the weekends routinely, so a 5:30 Friday consult on a patient that has been in-house and worked up since Wednesday is likely to not start treatment until the following Monday. Hospitals are extremely sensitive to the costs, so if it is likely that a patient may need RT, then get the consult in sooner, rather than later, but preferably after the tissue diagnosis and imaging studies are in hand and the surgeons are on-board. A consult to rad-onc before the work up is complete may bring an occasional grumble from rad onc, but a heads up earlier in the week will be much more appreciated in case the patient needs urgent palliative treatment than a last minute Friday afternoon call.
Staging workup: see
http://www.nccn.org/ Clinical Practice Guidelines for the various consensus opinions, imaging studies (generally an MR for CNS work up, CT for lung/chest, bone scan for boney mets, bone survey for diseases that cause lytic lesions), if your institution has it available ask about PET or PET/CT for lung or suspected lung cancers.
Aside from the medical management of these patients, a small drop of kindness and understanding will go a long ways. These patients are frequently emotionally fragile, and if they aren't, their families are, so a gentle touch will go a long way. Good luck
