Cancer patients must be vigilant about potential medical emergencies

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Some medical conditions that may not be a big problem for some people could be medical emergencies in people who have cancer or a history of cancer. It's something both doctors and patients need to be aware of. So today I'm talking with Dr. Ali Wazir. He's completing specialty training at Upstate in the field of hematology/oncology, and he presented an educational seminar at Upstate recently on this subject. Welcome to The Informed Patient, Dr. Wazir.

Now to start, I don't want to alarm people. How common are oncologic emergencies?

Ali Wazir, MBBS: Well, it's not a straightforward answer because you have to define the term. Cancer is quickly becoming the second most common cause of death in America. Cardiovascular disease still being a majority. Strokes and other causes are in second place, but cancers are quickly catching up. And the thought is in the next few years it may take the second position. The cancer rates are still on the high side.

So if you keep that in mind, and you define oncological emergencies a bit narrowly as emergencies directly related to patients who have cancer. If you do that, it's not an uncommon reason to end up in the hospital for cancer care. Unfortunately, it's also a very common way for people to officially find out the first time whether they have cancer or not. It's a very common presentation at diagnosis. So it's hard to put numbers because this is a basket term for many different clinical conditions, but you could say, just looking at the numbers that it's a fairly common occurence now.

Host Amber Smith: Now in your presentation at Upstate, you talked about a specific symptom -- a back pain, which gets worse when you lay down -- and how this could be a symptom of something called malignant spinal cord compression. What is that?

Back pain and America is by far the most common reason for a referral to emergency department. That is such a common thing. And you know, more than 90% of the time, this is going to be something benign, you know, like, as you get older, your muscles, they lose elasticity. Your joints face wear and tear. You can have bone problems or fractures for other reasons. But then there's a subset of this, which is something that is more concerning and something that you need to take really importantly. When I mentioned the fact that you have back pain that is worse while laying down or persists while you're laying down, that was kind of like referring to the red flags of back pain. These include things like any neurological symptoms that are present along with the back pain. It also includes things like focal tenderness, that is like, when you press on a certain part of the back, it elicits a pain. So the whole point of this is that back pain is a common thing, so you need to be very conscious about things that make it different from the run-of-the-mill back pain. If someone with cancer has been found to have developed spinal cord compression, does that, maybe, indicate that the cancer has spread?

Ali Wazir, MBBS: Unfortunately the fact that you develop spinal cord compression means essentially three things. Number one, it means that cancer has already passed into the bone. Most of the cancers in the back are not cancers that arise from the back. They are cancers that came from somewhere else, traveled through the blood, and then reached the bones of the back and then, in the vertebral body, grew into the spinal cord space, causing the symptoms of pain and the other symptoms of focal tenderness and neurological compromise. It means that it's metastatic. It has already gotten into the blood and into the bone. There are exceptions to this with some cancers such as multiple myeloma, systemic disease, as you call it. But apart from that, for all the other cancers and new lymphomas, to an extent, the fact that you have cancer-causing pain in the back already means that like stage four cancer.

The other thing that tells us is that the cancer, it has spread and it has become fast growing. When cancer starts, for a lot of the cancers there will be months to sometimes years where there is very slow growth. So, the way to think about this: for a cancer to go from one cell to a hundred thousand cells can take a long time, but for a cancer to go from a hundred thousand cells to a million cells or two million cells that are causing problems is a much faster process. This has been known since the seventies, how cancer cells divide and how they propagated.

Host Amber Smith: So if somebody had a history of cancer a while back and survived it, and now they've developed a spinal cord compression, is that something to consider is whether the cancer has come back?

Ali Wazir, MBBS: Oh, absolutely. So, I hate being an alarmist. But unfortunately, for cancer, any stage of cancer, even early stage cancer, there is that chance that it will come back. And this is particularly true for two of the more common kinds of cancers that we have, breast cancer and melanoma, where they can have like long periods of senescence. Like, there'll be long periods, like, let's say someone had melanoma that were localized, that was resected, and this was maybe over 20 years ago. It's not unusual, it's not unheard of to have metastatic disease that can also progress to the back and cause some problems. So unfortunately with a lot of cancers, once you've had the curative surgery, and the curative chemotherapy you have potentially curative disease, it's never 100%. The re are patients who unfortunately will come back with either localized recurrence or metastatic recurrence. So if you have back pain and it has all those red flags, and if you have a history of cancer, even in the past 20 years, I would say, that really needs that to make you think, and that's something that needs to be investigated.

Host Amber Smith: Well, let me ask you about something else that could be an emergency. What qualifies as a fever in someone who's in treatment for cancer?

Ali Wazir, MBBS: A lot of the chemotherapies for cancer, they're designed to kill off cells that rapidly reproduce. So that's why you can have a lot of GI (gastrointestinal) symptoms because you have the linings in your GI tract are being affected because their cells have a quick turnover. So that's why cancers can have effects on skin, mucous membranes. But another set of cells that rapidly reproduce are your blood cells. Your red blood cells, all of them in your body, the millions of them, are replaced all the time. You know, your white cells, your marrow, can pump out up to a billion cells, and some of these cells only last like six hours in your blood. So, these are very active tissues. Cancer medications will affect these cells. So if you have cancer therapy, one of the things you may have heard is the doctor saying that he wanted to monitor your treatment count, monitor your red blood cell count, and also what your white cell count. And in the white cell count, we are very focused on the neutrophils. So these are a type of white cell that protect us against certain bacterial infections. So this number -- it's called the ANC for the absolute neutrophil count -- and if this is low, your body essentially is not as protected against bacterial infections as you would hope.

But specific to your question, a fever is an early warning sign in your body for a bacterial infection. So a fever in a patient who does not have a competent immune system because of the chemotherapy is something that you cannot disregard. So a fever for a patient with cancer is very strictly defined. This hasn't changed in a long time. One reading above 100.9, or 100.4 with the repeated readings within an hour is the definition for fever. And anybody who has cancer therapy, their doctor is going to tell them that you need to have a thermometer at home, you need to know how to use it, and even if you're not having symptoms, but you feel feverish, you feel warm, you need to check the temperature. And if it's higher than this number, 100.9 on one occasion or 100.4 on two occasions, (Some people say 15 minutes apart, but if you look at the book definition, it's, like, an hour apart) that is a real fever. It's called a febrile neutropenia.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with Dr. Ali Wazir. He's completing a fellowship in hematology/oncology at Upstate, and we're talking about oncologic emergencies, medical issues that might arise in people in treatment for cancer.

So in your presentation recently, you talked about some issues that involve the heart and circulatory system, something called malignant pericardial tamponade. What is that? And what causes it?

Ali Wazir, MBBS: This is in the same vein as the first thing we discussed, where your cancer has entered a space that is confined, you know, like, let's say you have a cancer that's impinging on the spinal canal. In the same sense, the cancer can impenge into your vascular structures. It can, like for example, impinge into your SVC, (superior vena cava blood vessel), which is the main vein that takes all the blood from the top part of your body into your heart, and that's called SVC syndrome. That is a common cause of issues in patients with lung cancer. But another thing cancer can do, and this is not particularly common, but it's not unheard of for central cancer, because it's so geographically close to the center of your chest, it can invade into the peritoneum. And what's the peritoneum? The peritoneum is the covering around your heart. Your heart is surrounded by pericardial fluid, which is a very small amount, but this acts as a lubricant, and it's pumping all the time. So this space is normally empty. But sometimes it can fill up with blood or cancer cells or a lot of fluids. And when this happens very rapidly, your heart, essentially what happens to it is it cannot pump against certain pressures. There's a plumbing problem. And if you think about the heart, it's a pump, in parallel. So essentially think of it as two pumps. One pump is pumping the bloodthat comes from all of your body, so from the vessels that we talked about, the SVC, (superior vena cava), but also the inferior vena cava, it goes to the right side of the heart and it pumps to the lungs. And this is a low pressure system. At the left side of your heart is a high pressure system with thick walls that can kind of like fight the pressure, and this part of the heart is the main pump that kind of takes the blood back from the lungs to the rest of your body. So the sac that we talked about, if the inside of it is filled with fluid very rapidly or blood or cancer cells, your heart cannot expand, especially the right side of your heart. It stops expanding. And this is called pericardial tamponade. This is life threatening. If this is not ameliorated, patients can lose their life, very rapidly actually. Let's say you have a diagnosis of cancer, and you're having symptoms of shortness of breath. You're having symptoms of not being able do the same things you're able to do like a day before. And you have to remember this is quick, usually. It's not something that takes too long. So you have a rapid decrease in your activity level, let's say, or if you have, other issues such as swelling in your legs, for example, the veins in your neck become very prominent for whatever reason, all these kind of subtle signs will need to be brought up to the doctor because this could be a sign of an oncological emergency that we call pericardial tamponade. So you have to kind of remember that you can have the same disease from non-cancerous causes, such as rheumatoid arthritis, et cetera, but it can also happen in cancer.

Host Amber Smith: Why is the level of calcium in the body a concern for someone with cancer or with a cancer history?

Ali Wazir, MBBS: A lot of cancers can cause bone diseases. Your body has very good ways of adjusting calcium levels through the kidneys or through the amount of calcium that's absorbed from the gut. Your body can adjust for this. But in patients who have a high load of cancer in the bone, it's an aggressive cancer that's what we call osteolytic mets, so that's mets to the bone that kind of break down the bone, or some cancers that can produce a hormone that normally regulates your calcium levels called PTH (parathyroid hormone.) It can make molecules that look very similar. And any of these reasons it'll cause you to essentially have a very increased calcium level. A very high calcium level, the symptoms are really, actually kind of hard to detect at first, to be honest. That's the earliest symptoms of hard to detect. But typically what you will hear from patients who are going through this is that, "Doctor, I'm just constipated. Uh, I haven't gone in a couple of days." They'll say that they feel fatigued, they feel tired. They can also mention things like changes in sleep. They can also mention that, their family members can mention that they're acting kind of agitated. They're acting, not themselves. So these, these are the typical symptoms of hypercalcemia. All of these things can kind of point out the fact that you may have a very high calcium level that can happen at a number of cancers actually.

Host Amber Smith: With more and more cancer patients being treated with immunotherapies, what sorts of oncologic emergencies might develop? The thing that has really changed the cancer landscape in the last 10 years is immunotherapy, so the use of immune therapy to fight cancer. The biggest thing about this is you're using your own immune system to recognize the foreigners of cancer. Because when you look at a cancer under a microscope, it doesn't look like any tissue in your body. This kind of therapy, it doesn't have the same side effects as classical chemotherapy. So you don't have the nausea and vomiting and the blood counts being affected, but it comes with its own sets of problems, which is very important for patients to recognize.

It's important because the treatment for all of these problems, when your immune system fights your own body, is fairly simple. You just slow down the immune system by using a drug like steroids, et cetera. But it's very important for patients to recognize this very early. And we do counsel our patients a lot about this, but it's important for them to realize that it could be anything. Your immune system can attack any tissue in your body. It could be a rash. It could be diarrhea from your immune system affecting your colon, for example, or your large intestine. It could be the immune system attacking your thyroid, causing thyroid problems. It could be your immune system attacking your lung tissue, causing what we call pneumonitis. They have to be very vigilant, because this isn't like a normal chemotherapy. This can happen a month or even a couple of months after the starting of treatment, and less predictable than a classical chemotherapy. I think a lot of our patients now are on these very powerful drugs, and they have been almost miraculous in changing the lives of our patients. But it's very important that they, they need to realize that sometimes, on a rare occasion, that they can also cause oncologic emergencies. And the key thing is to recognize it early and to treat it early

Host Amber Smith: So patients who are taking immunotherapy probably have a pretty close relationship with their oncologist, staying in touch with them about any sort of side effects they may be having?

Ali Wazir, MBBS: Absolutely. And the problem with this is that there's no one set of symptoms we can tell the patient, right? It's not like "look out for diarrhea, or look out for fever." It could be a host of things, you know, going from rash to all the way to having a thyroid problem, even development of diabetes mellitus. You can develop diabetes mellitus in your sixties and seventies while on this medication. The thing is that you have to be kind of eternally vigilant for it because there's no time limit for it as well. Once you get started on the therapies, they can go on for a year, two years, three years, for a lot of our patients, and it is true that does happen in the early part of the therapy, the first one to three months, but it can also happen at the later part of the therapy, even if they have been on it for a long time. Unfortunately, while on the treatment, sometimes it does have side effects. The most important thing is to recognize it early, because if you catch it early, it's easier to treat. And the chance of it being widespread is much less.

Catching it early is a big help for the doctors and the patients. You need to have the lines of communication, very clear that like, "OK, I have a symptom; how can I reach my cancer doctor? How can I give them this information?" Because it may sound innoucuous to you. It may be something like, "hey I'm just having a little more diarrhea," but that could be very important, and it could be something that could require even a hospital admission.

Host Amber Smith: Let me ask you before we wrap up, if a cancer patient develops, say, chest pain, do they go to the emergency department, or do they call their oncologist, or do they contact their primary care doctor? Who oversees their medical care?

A patient's cancer doctor has information that his other doctors don't. He can recognize things that other doctors, just because of the training, may not know is of particular importance. So we all agree that the cancer doctor needs to get this information. So this is done differently in different settings. So I can tell you at Upstate how it works. At Upstate 24 hours a day, seven days a week, there is someone on who is responsible for taking all these patient calls. It's a line where the patients can call us, and we can look at the chart and they can tell us the symptoms, that "hey, this is happening, that is happening. What should I do? Should I go to the emergency department, yes or no?" And then we can make a note of it and we can send it to the other doctors who are at the emergency department, so at least they have a preliminary idea of this is the patient's cancer, this is what we think they're going through.

Ali Wazir, MBBS: So I would say if you are a cancer patient, and all your life you're a person who wouldn't like going to the doctors, would kind of tough it out and all that, you know, unfortunately with this diagnosis, things have changed. And you have to be more alert and observant because unfortunately, a lot of the therapies and the cancer itself don't give you a lot of time to take moves that can improve the outcome. The patient themself has to be vigilant that if you can't get ahold of anybody else, just go to the emergency department. There's always some kind of mechanism of getting in touch with the oncologist, even in smaller practices, even in the after hours.

Host Amber Smith: Well, you've educated us in several oncologic emergencies, and I appreciate you making time to do that, Dr. Wazir. My guest has been Dr. Ali Wazir from Upstate Medical University. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at glenviewelectric.com/Informed. This is your host, Amber Smith, thanking you for listening.