Treatment and Management of the Clinical Manifestations of Advanced Breast Cancer

OBJECTIVES

People with advanced breast cancer (ABC) experience complex and debilitating physical symptoms of their disease that can have a profound effect on quality of life. This report provides an overview of the clinical manifestations related to different metastatic sites in ABC and potential oncologic emergencies.

DATA SOURCES

Date sources include peer-reviewed papers sourced in electronic databases (CINAHL, MEDLINE, Google Scholar) and national and international best practice guidelines.

CONCLUSION

People living with ABC experience multiple symptoms of disease that can impact on quality of life and physical functioning. The most common sites of metastatic disease are bone, lung, liver and brain. Clinical manifestations of ABC include pain, pathologic fractures, pleural effusions, and ascites. Potential oncologic emergencies related to these metastatic sites include hypercalcemia, malignant spinal cord compression, superior vena cava obstruction, and raised intracranial pressure.

IMPLICATIONS FOR NURSING PRACTICE

It is important for nurses to have informed knowledge and understanding of these clinical manifestations. This will enable them to be vigilant and perform targeted patient evaluation to assess signs and symptoms with a view to identifying potentially life-threatening emergencies and initiating interventions or appropriate referral or follow-up accordingly.

Malignant Superior Vena Cava Syndrome: A Scoping Review

Malignant superior vena cava syndrome (SVCS) is a clinical problem that results from the obstruction of blood flow in the superior vena cava by an underlying malignancy. This may occur due to external compression, neoplastic invasion of the vessel wall, or internal obstruction with bland or tumor thrombus. Although symptoms are typically mild, SVCS can cause neurologic, hemodynamic, and respiratory compromise. Classic management options include supportive measures, chemotherapy, radiation therapy, surgery, and endovascular stenting. New targeted therapeutics and techniques have also recently been developed, which may have a role in management. Nevertheless, few evidence-based guidelines exist to guide treatment of malignant SVCS, and these recommendations are typically restricted to individual disease sites. Furthermore, there are no recent systematic literature reviews that address this question. Here, we present a theoretical case to frame this clinical problem and synthesize updated evidence published in the past decade relating to the management of malignant SVCS through a comprehensive literature review.

The Effects of a Simulation-Based Experience with Standardized Participants on Learning and Clinical Decision-Making Related to Nursing Management of Oncologic Emergencies

Upon entry-to-practice, graduate nurses must be able to effectively manage oncologic emergencies to ensure best patient and family outcomes. Thus, nurse educators must develop active teaching strategies to prepare prelicensure nursing students with appropriate nursing oncology knowledge and skills. The purposes of this study were to determine the effect of simulation-based experiences (SBEs) with standardized participants (SPs) involving a patient and family member on baccalaureate nursing students' confidence and competence, anxiety and self-confidence with clinical decision-making, and satisfaction and self-confidence in learning using SBEs related to management of oncologic emergencies within a seminar-style course. A longitudinal, one-group, convergent mixed-methods design was used. Baccalaureate nursing students enrolled in a senior seminar participated in two SBEs. Study data were collected pre-seminar, pre-SBE, and post-SBE. Twenty-five senior nursing students participated in this study. There was a significant increase in students' confidence and self-perceived competence, and a significant decrease in anxiety and increase in self-confidence with clinical decision-making related to the nursing management of oncologic emergencies over time. All seven student groups in the hypercalcemia SBE, and five student groups in the hypersensitivity reaction SBE demonstrated objective competence. Qualitative themes identified included: realism, critical thinking, and benefits for professional practice. Study findings support the use of SBEs with SPs to enhance nursing students' confidence and competence, and to increase self-confidence and reduce anxiety with clinical decision-making related to the management of oncologic emergencies in a seminar-style course. The inclusion of a family member enhanced the realism of complex SBEs.

Tumor Lysis Syndrome: Implications for Oncology Nursing Practice

OBJECTIVES

To provide an overview of tumor lysis syndrome, which is one of the metabolic oncologic emergencies.

DATA SOURCES

A review and synthesis of empirical articles.

CONCLUSION

One of the metabolic oncologic emergencies identified by the Oncology Nursing Society is tumor lysis syndrome. This condition is life-threatening and is characterized by metabolic derangements that can lead to acute kidney injury and multiple organ dysfunction. Normal intracellular components (potassium, phosphorus, and nucleic acids) spill into the bloodstream when cancer cells die. If the tumor is large and highly responsive to chemotherapy, the resulting cascade of dead tumor cells may overwhelm normal homeostatic mechanisms. The cells enter the bloodstream faster than they can be cleared by the kidneys. This results in hyperkalemia and hyperphosphatemia. Nucleic acids convert to uric acid in the liver with a resultant hyperuricemia. Excess uric acid in the kidneys can lead to uric acid nephropathy and renal insufficiency. Phosphorus binds with calcium, leading to hypocalcemia from the formation of calcium phosphate precipitate or crystals. These crystals can also lead to renal insufficiency or acute kidney injury, which can lead to a metabolic acidosis and exacerbation of the hyperkalemic state. These metabolic derangements define presence of tumor lysis syndrome.

IMPLICATIONS FOR NURSING PRACTICE

Multidisciplinary collaboration and communication is essential to identifying patients at risk prior to treatment. Meticulous nursing care in terms of prevention and treatment is critical to patient survival.

Validation of the EPIPHANY index for predicting risk of serious complications in cancer patients with incidental pulmonary embolism

PURPOSE

The EPIPHANY index was developed to classify cancer associated pulmonary embolism (PE) into different risk categories using decision tree modeling. In this study, we tried to externally validate this index in a distinct group of patients solely composed of incidental PE (IPE).

METHODS

A retrospective study of patients diagnosed with IPE in two Emergency Departments in the USA and South Korea from 2013 to 2014 was performed. The primary outcome was the occurrence of a serious medical complication within 15 days of presentation to ED. Thirty-day complication was the secondary outcome. Cumulative hazard curves for each prognostic category were drawn to show the change in hazards over time.

RESULTS

A total of 258 patients with IPE were included (193 from MD Anderson Cancer Center and 65 from Asan Medical Center). Serious complication within 15 days occurred in 23 (8.9%) patients. The risk of overall 15-day and 30-day serious complications increased with each category (low, intermediate, and high risk: 3.4, 8.9, and 23.8%, P = 0.033; 6.9, 9.5, and 33.3%, P = 0.011). Cumulative hazard curves for each prognostic category were drawn and the survival functions factored by prognostic categories were significantly different over 15 days (P = 0.015) and 30 days (P = 0.001).

CONCLUSIONS

Our study suggests the EPIPHANY index could be a useful adjunct tool in risk stratification of cancer patients with IPE.

Emergency oncology: development, current position and future direction in the USA and UK

The need for supportive and palliative care services in patients with cancer is well established. However, the emerging unique challenges of acutely unwell patients with cancer necessitate the need for research into the optimal strategies and pathways for their management. The clinical challenges of emergency oncology alongside its increasing financial burden have led to an interest as to the best strategies for delivering this care. In the USA and UK, varying models of emergency and acute care are developing. There is a clear need for non-oncology physicians with an interest in the management of oncological emergencies to be at the heart of this work. This paper considers the current situation in the USA and UK and the future directions for the delivery of this care.

Supportive care in pediatric oncology: oncologic emergencies and management of fever and neutropenia

Advancements in the care of children with cancer have, in part, been achieved through improvements in supportive care. Situations that require prompt care can occur at the time of presentation as well as during treatment. This article discusses the approach to children with fever and neutropenia, a complication encountered daily by care providers, as well as oncologic emergencies that can be seen at the time of a child's initial diagnosis: hyperleukocytosis, tumor lysis syndrome, superior vena cava syndrome, and spinal cord compression.

Tumor lysis syndrome: new challenges and recent advances

Tumor lysis syndrome (TLS) is an oncologic emergency triggered by the rapid release of intracellular material from lysing malignant cells. Most common in rapidly growing hematologic malignancies, TLS has been reported in virtually every cancer type. Central to its pathogenesis is the rapid accumulation of uric acid derived from the breakdown of nucleic acids, which leads to kidney failure by various mechanisms. Kidney failure then limits the clearance of potassium, phosphorus, and uric acid leading to hyperkalemia, hyperphosphatemia, and secondary hypocalcemia, which can be fatal. Prevention of TLS may be more effective than treatment, and identification of at-risk individuals in whom to target preventative efforts remains a key research area. Herein, we discuss the pathophysiology, epidemiology, and treatment of TLS with an emphasis on the kidney manifestations of the disease.

Oncologic issues in the older adult in critical care

This article describes the pathophysiologic changes that occur with aging as they relate to cancer and cytotoxic therapies, implications related to drug therapy, and complications of treatment modalities as they relate to older persons with cancer who may potentially be admitted to the intensive care unit. Knowledge of these issues is essential for health care providers, so that they can face the complex challenges and optimize the outcomes of critically ill older persons with cancer.