Supportive Care
What this domain tests
Supportive care items test prophylaxis and management of treatment toxicity - emesis, febrile neutropenia, mucositis, bone health, tumor lysis, anemia and fertility - where the answer is usually a specific threshold, agent or timing rule.
Core rules
- Antiemesis: match to emetogenic risk. Highly emetogenic regimens (cisplatin, anthracycline–cyclophosphamide) need a 5-HT3 antagonist, an NK1 receptor antagonist, dexamethasone and olanzapine; moderate-risk regimens need a 5-HT3 antagonist plus dexamethasone. Give prophylaxis before chemotherapy, not after vomiting starts.
- Febrile neutropenia: a single oral temperature ≥38.3 °C or ≥38.0 °C sustained over one hour with neutrophils <0.5 × 10⁹/L. Start empiric antipseudomonal beta-lactam (piperacillin–tazobactam or cefepime) within 60 minutes; add vancomycin for catheter infection, hypotension or suspected gram-positive disease, and an aminoglycoside for instability.
- G-CSF primary prophylaxis when febrile neutropenia risk exceeds 20%, or 10–20% with additional risk factors; give 24–72 hours after chemotherapy completion, never concurrently.
- Tumor lysis syndrome: hydration plus allopurinol for low/intermediate risk; rasburicase for high risk or established hyperuricemia. Rasburicase is contraindicated in G6PD deficiency and pregnancy.
- Bone health: bisphosphonates or denosumab with calcium and vitamin D in androgen deprivation, aromatase inhibitor therapy and bone metastases; obtain dental review and avoid invasive dental work during therapy because of osteonecrosis of the jaw.
- Anemia: erythropoiesis-stimulating agents are restricted, generally avoided when cure is the goal and when the hemoglobin is above 10 g/dL; transfuse for symptomatic anemia.
- Fertility and sexuality counselling should precede gonadotoxic therapy, with sperm banking, oocyte or embryo cryopreservation and consideration of GnRH agonists in breast cancer.
Worked example
A 24-year-old with Burkitt lymphoma, LDH five times normal, uric acid 9 mg/dL and bulky disease. He is at high risk of tumor lysis syndrome. Start aggressive intravenous hydration and rasburicase, monitor potassium, phosphate, calcium and uric acid every 6–8 hours, check G6PD before rasburicase, and avoid potassium in fluids.
Traps
- Giving allopurinol as sole prophylaxis in high-risk Burkitt disease - rasburicase is required.
- Administering G-CSF on the same day as chemotherapy.
- Missing G6PD deficiency and causing hemolysis with rasburicase.
- Continuing bisphosphonates through dental extraction without planning.
- Using an ESA in a patient being treated with curative intent.
Palliative Care and Oncologic Emergencies
What this domain tests
This domain tests recognition of time-critical emergencies with a single correct first action, along with symptom control: opioid conversion, dyspnea, delirium and goals-of-care communication.
Core rules
- Malignant spinal cord compression: back pain, motor weakness, sensory level and bladder dysfunction. Start dexamethasone 16 mg (or 10 mg) immediately on clinical suspicion, then urgent MRI of the whole spine within 24 hours; treatment is surgical decompression when feasible, otherwise radiotherapy. Do not wait for imaging before giving steroids in a patient with a convincing deficit.
- Superior vena cava syndrome: facial swelling, distended neck veins, orthopnea. Elevate the head, obtain CT imaging, and treat by histology-directed therapy; stenting for severe airway or cerebral edema; radiotherapy for radiosensitive tumors. Emergency airway management is the priority if stridor is present.
- Hypercalcemia of malignancy: correct calcium for albumin (or use ionized calcium), give intravenous saline, then a bisphosphonate (zoledronic acid) or denosumab, with calcitonin for rapid control. Look for the driver - PTHrP, bone metastases or myeloma.
- Malignant pericardial tamponade: hypotension, raised JVP, pulsus paradoxus; urgent echocardiogram and pericardiocentesis.
- Opioid prescribing: follow the WHO ladder, prescribe regular plus breakthrough doses (typically 10–15% of the total daily dose), and use laxatives prophylactically. Equianalgesic conversion: oral morphine 30 mg ≈ oral oxycodone 15–20 mg ≈ subcutaneous morphine 10 mg. Rotate when toxicity or inadequate analgesia occurs. Naloxone reverses respiratory depression but must be titrated to avoid precipitating severe pain and withdrawal.
- Communication: explore goals of care, discuss ceilings of treatment, and record advance care planning decisions; early palliative care alongside oncology treatment improves quality of life and, in some trials, survival.
Worked example
A 61-year-old with metastatic prostate cancer reports two days of progressive leg weakness and urinary retention. Give dexamethasone 16 mg immediately, order urgent whole-spine MRI, catheterize for retention and call the spinal team. Surgery followed by radiotherapy is preferred if he is operable and has a single compressive level; if not, radiotherapy alone. Delay here converts a walking patient into a paraplegic.
Traps
- Waiting for MRI before starting dexamethasone in suspected cord compression.
- Giving a bisphosphonate alone for hypercalcemia without saline rehydration first.
- Converting opioids without reducing the dose for incomplete cross-tolerance (typically 25–50% reduction).
- Withholding palliative care discussion because the patient is still on active treatment.