Supportive care

Oncologic emergencies

• Febrile neutropenia (FN): see the dedicated block below. Antibiotics within 1 hour is the single highest-yield action.
• Tumor lysis syndrome (TLS): see the dedicated block below.
• Superior vena cava (SVC) syndrome:
  • Presentation: facial, neck, and arm swelling; dyspnea; distended neck and chest wall veins; plethora; cough. True emergency with airway compromise (stridor), cerebral edema (altered mental status), or hemodynamic compromise (hypotension, unprovoked syncope).
  • Common causes: NSCLC, small-cell lung cancer, lymphoma; also catheter-associated thrombosis.
  • Management: obtain tissue diagnosis before treatment when the patient is stable (histology dictates therapy). Head elevation. Chemosensitive tumors (SCLC, lymphoma, germ cell) respond to chemotherapy; radiation for others; endovascular stenting gives the most rapid relief for severe or refractory obstruction. Steroids help only steroid-responsive tumors (lymphoma). Anticoagulate catheter-associated thrombus.
• Malignant epidural spinal cord compression:
  • Presentation: back pain (earliest and most common) then motor weakness, a sensory level, and (late) bowel/bladder dysfunction. Pretreatment ambulatory status is the strongest predictor of post-treatment ambulation, so treat before the deficit becomes fixed.
  • Common primaries: breast, lung, prostate, myeloma, lymphoma.
  • Management: start dexamethasone immediately on clinical suspicion; urgent MRI of the whole spine (skip lesions are common). Definitive treatment is decompressive surgery followed by radiation for select surgical candidates (Patchell) versus radiation alone; radiosensitive tumors (lymphoma, myeloma, SCLC) respond well to radiation.
• Hypercalcemia of malignancy:
  • Mechanisms: PTHrP (humoral, most common; squamous cell, renal, breast), osteolytic bone destruction (myeloma, breast bone mets), tumor 1,25-dihydroxy vitamin D (lymphoma), rarely ectopic PTH.
  • Symptoms: polyuria, dehydration, constipation, nausea, confusion ("stones, bones, groans, psychiatric moans").
  • Management: aggressive IV isotonic saline first; calcitonin for rapid but short-lived lowering (tachyphylaxis within ~48 h); IV bisphosphonate (zoledronic acid) or denosumab (preferred if bisphosphonate-refractory or renal impairment) for durable control; glucocorticoids for vitamin D-mediated (lymphoma); dialysis for severe or renal failure. Avoid loop diuretics unless the patient is volume-overloaded.
• Hyperviscosity syndrome:
  • Causes: Waldenstrom macroglobulinemia (IgM, most common), myeloma (IgA/IgG), and hyperleukocytosis (AML, ALL, or CML in blast crisis).
  • Triad: mucosal bleeding, visual changes (retinal, "sausage-link" retinal veins on fundoscopy), and neurologic symptoms (headache, confusion, somnolence).
  • Management: plasmapheresis for paraprotein-driven disease; leukapheresis for symptomatic hyperleukocytosis; then treat the underlying malignancy. Avoid RBC transfusion before apheresis (can acutely worsen viscosity).

Chemotherapy-induced nausea/vomiting (CINV)

See the dedicated note: Antiemetics / CINV, for full emetogenic-risk tables, drug classes, and regimens.

• Risk classification: high (cisplatin, AC, ifosfamide ≥2 g/m²/dose) > moderate (oxaliplatin, carboplatin AUC <4, doxorubicin <60 mg/m², cyclophosphamide <1,500 mg/m²; carboplatin AUC ≥4 is high risk and requires an NK1 antagonist) > low > minimal.
• Acute (<24 h), delayed (>24 h), anticipatory, breakthrough, refractory.
• High-emetic regimen: 4-drug, 5-HT3 (palonosetron) + dexamethasone + NK1 (aprepitant or fosaprepitant) + olanzapine.
• Moderate: 5-HT3 + dexamethasone ± NK1 ± olanzapine.
• Olanzapine (5 to 10 mg × 4 days): broadly effective add-on; sedation.
• Breakthrough: prochlorperazine, lorazepam, metoclopramide, haloperidol.
• Anticipatory: benzodiazepines plus behavioral therapy.

Febrile neutropenia (FN)

• Definition: ANC <500 (or <1,000 with expected drop) plus temp ≥38.3°C single OR ≥38.0°C for 1 hr.
• Initial management: blood cultures (at least 2 sets: each central-line lumen plus a peripheral vein if a line is present); urine culture and CXR only for symptoms, signs, or an indwelling urinary catheter, broad-spectrum IV antibiotics within 1 hr.
• Empiric antibiotics: cefepime, piperacillin-tazobactam, or imipenem/meropenem. Add vancomycin only for specific reasons (skin/soft tissue, hemodynamic instability, line infection, MRSA-colonized; severe mucositis only if on fluoroquinolone prophylaxis with empiric ceftazidime).
• Persistent fever >4 to 7 d in high-risk patients with expected prolonged neutropenia (>7 d), add empiric antifungal (voriconazole, caspofungin, liposomal amphotericin).
• MASCC score ≥21: low risk, consider outpatient management with oral antibiotics (ciprofloxacin plus amoxicillin-clavulanate).

• Indication: regimens with ≥20% FN risk; or 10 to 20% with high-risk patient features (age >65, prior FN, comorbidities).
• Pegfilgrastim (long-acting, once per cycle) or daily filgrastim (and biosimilars) are equally acceptable; pegfilgrastim often chosen for convenience.

Tumor lysis syndrome (TLS)

• Risk: bulky lymphoma (Burkitt), AML, ALL, CLL with high WBC, rapid-acting therapy (e.g., venetoclax ramp-up).
• Cairo-Bishop criteria: laboratory TLS (≥2 of potassium, phosphate, uric acid, calcium abnormalities) plus clinical TLS (kidney injury, arrhythmia, seizure).
• Prevention: aggressive IV hydration (about 3 L/m²/day); rasburicase for high-risk (unless contraindicated); allopurinol for intermediate/low risk.
• Allopurinol: xanthine oxidase inhibitor; requires 24 to 72 h to prevent de novo uric acid formation and does NOT reduce existing plasma uric acid. Typically 300 mg/day.
• Rasburicase: recombinant urate oxidase; converts uric acid to allantoin, so it both prevents and rapidly reverses hyperuricemia. Single-dose 0.2 mg/kg or fixed 6 mg. The EFC 4978 trial showed reduced TLS with rasburicase (with or without allopurinol). Rasburicase AEs: peripheral edema (~50%), vomiting (~38%), hyperbilirubinemia (~16%), sepsis (~12%), fluid overload (~12%).
• Rasburicase is contraindicated in G6PD deficiency: G6PD-deficient patients cannot break down the hydrogen peroxide generated when uric acid is oxidized to allantoin, causing severe hemolysis (and methemoglobinemia). Rule out G6PD deficiency before use.
• Treatment: fluids, electrolyte management, dialysis if severe. Avoid urinary alkalinization (reserve only for refractory acidosis).

Mucositis and dermatologic toxicities

• Mucositis: cryotherapy with 5-FU/melphalan. Magic mouthwash, topical analgesics, parenteral nutrition if severe.
• Hand-foot syndrome (capecitabine, 5-FU, doxorubicin): emollients, urea-based creams, dose reduction.
• Acneiform rash (anti-EGFR): doxycycline plus topical hydrocortisone, sunscreen.

Anemia, thrombocytopenia, neutropenia

• Anemia:
  • ESAs (epoetin, darbepoetin): risk-benefit; not for curative-intent settings (↓ OS in some trials). Start ESA only if Hb <10 (non-curative intent); use lowest dose to reduce transfusions; do not exceed ~12.
  • Transfuse for Hb <7 to 8 (symptomatic).
  • IV iron for absolute or functional deficiency.
• Thrombocytopenia:
  • Transfuse platelets <10K (prophylactic) or <20K with risk factors, or <50K with bleeding.
  • TPO mimetics (avatrombopag, romiplostim): chemo-induced thrombocytopenia, off-label (not FDA-approved for CIT); romiplostim per NCCN for selected persistent CIT; avatrombopag phase 3 negative.

Cancer-associated thromboembolism (VTE)

• Khorana score for risk stratification (BMI, hemoglobin, leukocytes, platelets, primary site).
• Primary prevention: consider rivaroxaban or apixaban for high-risk ambulatory patients (Khorana ≥2).
• Treatment: DOACs (apixaban, rivaroxaban, edoxaban) preferred for most cancer-associated VTE (CARAVAGGIO, Hokusai-VTE Cancer, ADAM-VTE).
• LMWH for GI/GU malignancies with bleeding risk, or with DOAC drug interactions.
• Duration: minimum 3 to 6 mo; consider extended if active cancer.

Bone health

• Bone-modifying agents (zoledronic acid or denosumab): for solid-tumor bone mets, myeloma bone disease, aromatase-inhibitor-associated osteoporosis.
• Watch for osteonecrosis of the jaw (ONJ): dental clearance before starting a bone-modifying agent.
• Osteoporosis on aromatase inhibitor: calcium plus vitamin D, monitor BMD, treat if T-score <-2.0.

Infections in cancer patients

See the dedicated note: Infections in Cancer Patients, for full prophylaxis and neutropenic-fever workup.

• PJP prophylaxis (TMP-SMX): prolonged steroids (>20 mg/day for 4 wks), purine analogs, alemtuzumab, T-cell depleting therapy.
• HBV reactivation: screen ALL patients before rituximab (and cytotoxic chemo). Entecavir/tenofovir prophylaxis if HBsAg+; for HBsAg-negative/anti-HBc+, give prophylaxis with high-risk therapy (anti-CD20, HSCT), otherwise monitor with prompt treatment on reactivation.
• VZV prophylaxis: bortezomib, daratumumab, allogeneic HSCT, autologous SCT.
• CMV: allogeneic HSCT, fludarabine, alemtuzumab.
• Vaccinations: inactivated OK; AVOID live vaccines on chemo (≥3 mo after) and for ≥6 mo after rituximab/anti-B-cell therapy (until immune recovery). RSV: single dose for all adults ≥75 and ages 50 to 74 at increased risk (including immunocompromise); not given annually.

Immunotherapy toxicity (irAE)

See the dedicated note: Immune Checkpoint Inhibitor Toxicity (irAEs), for the organ-by-organ grading and management tables.

• Common: dermatitis, colitis, hepatitis, pneumonitis, endocrinopathies (thyroid, hypophysitis, T1DM, adrenal).
• Management principle: Grade 1, observe; G2, hold plus steroids 0.5 to 1 mg/kg; G3, hold plus IV methylprednisolone 1 to 2 mg/kg plus consider infliximab/MMF/vedolizumab; G4, permanent discontinuation.
• Endocrine irAE may not need IO discontinuation: replace hormones (levothyroxine, hydrocortisone, insulin).
• Myocarditis (rare, fatal): high-dose steroids plus cessation; consider abatacept/ATG.

CAR-T toxicities

• CRS (cytokine release syndrome): grade by ASTCT criteria. Tocilizumab plus steroids.
• ICANS (immune effector cell-associated neurotoxicity): dexamethasone IV; do NOT use tocilizumab for ICANS alone (worsens it).
• Monitoring: FDA eliminated the autologous CAR-T REMS (June 2025); patients stay near the treating center and avoid driving for 2 weeks (previously 4 and 8 weeks, respectively) after infusion.

Symptom management (other)

• Cancer-related fatigue: exercise (best evidence); screen for anemia, thyroid, depression.
• Hot flashes (post-aromatase inhibitor or ovarian suppression): SSRIs, SNRIs (venlafaxine), gabapentin, oxybutynin.
• Anorexia/cachexia: megestrol (with VTE risk), olanzapine (low-dose), dronabinol (modest data).

High-yield supportive care pearls

• Olanzapine add-on for high-emetic CINV regimens.
• FN: antibiotics in 1 hour. MASCC ≥21 = potentially low risk; outpatient only if also clinically stable, tolerating PO, with reliable follow-up/transport and no prolonged profound neutropenia expected.
• GCSF prophylaxis for ≥20% FN risk.
• DOACs > LMWH for most cancer VTE.
• Rasburicase contraindicated in G6PD.
• HBV screen before rituximab (and chemo).
• PJP prophylaxis on prolonged steroids.
• Dental clearance before bisphosphonate/denosumab.
• IO endocrinopathies often need replacement, not discontinuation.
• Tocilizumab for CRS, NOT for isolated ICANS.
• Cord compression: dexamethasone plus whole-spine MRI immediately; treat before the deficit fixes.
• Hyperviscosity: plasmapheresis; do not transfuse RBCs first.

2024-2026 Supportive Care Updates

• CINV: olanzapine 5 to 10 mg now standard 4th drug (with NK1 + 5-HT3 + dexamethasone) for HEC per NCCN/ASCO 2024 guidelines (Navari NEJM 2016; J-FORCE for 5 mg dose). Akynzeo (netupitant + palonosetron) and fosnetupitant approved for HEC.
• Anti-emetic in the BTKi/CDK4-6 era: many oral targeted agents have low emetogenic risk; tailor antiemetics.
• Cancer-related fatigue: armodafinil/modafinil weak evidence; methylphenidate trialed; non-pharmacologic interventions (CBT, exercise) preferred per NCCN 2024.
• Tumor lysis prophylaxis: rasburicase for high-risk (G6PD screen first); allopurinol for moderate risk; aggressive IV fluids; avoid alkalinization (only for refractory acidosis).
• Cancer cachexia: anamorelin (in Japan); ponsegromab (anti-GDF15) phase 2 promising; megestrol/dronabinol historical.
• Antimicrobial stewardship in FN: early discontinuation is reasonable in selected stable, afebrile patients (How Long trial); unexplained FN is traditionally treated until ANC recovery, and documented infections need site-specific durations; levofloxacin prophylaxis selectively in high-risk.
• Bone health: zoledronic acid every 12 weeks non-inferior to every 4 weeks for bone mets and myeloma (CALGB 70604, OPTIMIZE-2, ZOOM).
• VTE prophylaxis in cancer: per Khorana ≥2, apixaban or rivaroxaban (CASSINI, AVERT).
• Anemia in MF: momelotinib (Ojjaara), FDA Sep 2023 for MF with anemia (MOMENTUM, SIMPLIFY-1); JAK1/2 + ACVR1 inhibitor addresses transfusion dependence.
• Lower-risk MDS anemia: luspatercept (Reblozyl), FDA expanded Aug 2023 to first-line ESA-naive lower-risk MDS anemia (COMMANDS: TI-response 58.5% vs 31.2% epoetin-alfa, Platzbecker Lancet 2023).
• Imetelstat (Rytelo), telomerase inhibitor, FDA Jun 2024 for lower-risk MDS with transfusion-dependent anemia after ESA failure (IMerge: 8-wk TI 40% vs 15%).
• CIT (chemo-induced thrombocytopenia): avatrombopag: phase 3 in relatively chemo-naive solid-tumor CIT was negative (Al-Samkari Lancet Haematol 2022), but phase 2 ACT-GI in persistent CIT in GI cancers was positive (70% vs 17% corrected CIT without chemo delay, JCO 2026); not FDA-approved for CIT.
• PJP in CAR-T recipients: continue TMP-SMX (or atovaquone/dapsone) ≥6 to 12 mo post-infusion; CD4 lymphopenia commonly persists >12 mo (Rejeski Blood Adv 2024).