Oncology consults

For residents · Rotation prep

Inpatient oncology consults usually fall into four buckets: a new suspected cancer, a patient on treatment who is now sick, an oncologic emergency, and goals of care. Figure out which bucket you are in before you walk into the room.

Before you see the patient

Is the patient already known to an oncologist? If so, find their last note and treatment plan, and plan to contact them. The outpatient oncologist knows the patient best.
Build the cancer timeline (see Presenting an oncology patient).
Know the current regimen, the date of the last dose and where they are in the cycle. Day 10 after chemotherapy means a very different fever than day 25.
Know the patient’s performance status and what they have been told about their disease.

The new suspected cancer

Tissue is the issue. Nothing happens without a biopsy. Choose the safest, most accessible site that also gives the highest stage, so one biopsy diagnoses and stages.
Ask for a core biopsy rather than fine needle aspiration when possible. Modern treatment needs enough tissue for molecular testing.
If lymphoma is on the differential, avoid steroids before the biopsy whenever it is safe to do so. They can make the tissue nondiagnostic.
Staging imaging appropriate to the suspected cancer, and brain imaging when the disease and symptoms call for it.
Tumor markers support but rarely make a diagnosis. The exceptions worth knowing: AFP and beta-hCG in a young man with a mediastinal or retroperitoneal mass.
Often the right inpatient plan is a diagnosis plus a fast outpatient appointment. Not every new cancer needs inpatient treatment.

Oncologic emergencies

Emergency	Recognize it	First moves
Neutropenic fever	ANC under 500 (or expected to fall below 500) with a single temperature of 38.3 °C or 38.0 °C sustained over an hour	Cultures, then broad-spectrum antipseudomonal antibiotics within the first hour. Don’t wait for counts or imaging.
Tumor lysis syndrome	High potassium, phosphorus and uric acid, low calcium, rising creatinine; high-risk with bulky, fast-growing tumors	Aggressive IV fluids, uric acid control (allopurinol or rasburicase; check G6PD before rasburicase), frequent labs, early nephrology.
Hypercalcemia of malignancy	Confusion, constipation, dehydration, kidney injury	IV fluids, calcitonin for a fast effect, then a bisphosphonate or denosumab. Stop calcium and vitamin D.
Spinal cord compression	New back pain in a cancer patient, weakness, sensory level, bowel or bladder changes	Dexamethasone, urgent MRI of the whole spine, early radiation oncology and spine surgery input.
SVC syndrome	Facial and arm swelling, dilated chest veins, dyspnea	Assess the airway, get a tissue diagnosis if none exists, involve interventional radiology and radiation oncology.
Leukostasis	Very high blast count with hypoxia, confusion or vision changes	Urgent cytoreduction; avoid raising viscosity with unnecessary red cell transfusion.
Hyperviscosity	High paraprotein (often IgM) with headache, vision changes, bleeding	Plasmapheresis and treatment of the underlying disease.
Brain metastases with edema	Headache, seizure, focal deficits	Steroids for symptomatic edema, seizure management, neurosurgery and radiation oncology input.

First moves are a starting point for discussion with your attending, not a protocol. Follow your institutional pathways.

Immunotherapy toxicities

Ask about checkpoint inhibitors in every patient with cancer, even if the last dose was months ago.
They can cause inflammation anywhere: colitis, hepatitis, pneumonitis, thyroiditis, hypophysitis, adrenal insufficiency, nephritis, dermatitis, myositis and myocarditis.
Rule out infection, grade the toxicity, and know that steroids are the backbone of treatment for higher grades.
Myocarditis is rare but deadly. Check troponin, an ECG and CK when anything suggests it, especially with myositis or ocular symptoms.
Check TSH and morning cortisol when fatigue, hypotension or hyponatremia doesn’t add up.

Complications of chemotherapy

Nausea and vomiting, mucositis, diarrhea (irinotecan, fluoropyrimidines), neuropathy, cardiotoxicity (anthracyclines, trastuzumab), pneumonitis, thrombosis.
Know the expected count nadir, usually around days 7 to 14 after cytotoxic chemotherapy.
Note whether growth factor support was given with the last cycle.

Goals of care

Find out what the patient understands about their illness before sharing new information.
Prognosis, code status, hospice eligibility and symptom control are oncology questions too. Involve palliative care early, not as a last step.
Never give a new cancer diagnosis or a prognosis without your attending’s agreement on the plan.