3.1 Cancer, Hematologic, and Paraneoplastic Complications

Why cancer trajectories sit in Assessment and Planning

The Hospice and Palliative Credentialing Center (HPCC) Certified Hospice and Palliative Nurse (CHPN) examination is a 150-item RN specialty board. Domain 1, Patient Care: Assessment and Planning, contributes 25 scored items. Domain 1.C asks you to identify specific patterns of progression, complications, and treatment for life-limiting conditions. Cancer and hematologic disease still fill a large share of hospice censuses, so stems test whether you can name the curve, recognize the emergency, and match the intervention to goals of care—not whether you can run an inpatient oncology service.

Treat cancer as a family of trajectories, not one diagnosis. A CHPN item that only says “the patient has cancer” is incomplete until you know solid versus hematologic disease, recent disease-directed therapy, and whether the family still wants hospital rescue.

Solid-tumor versus hematologic curves

Solid tumors (lung, breast, colorectal, pancreas, prostate, and most other epithelial cancers) often follow the classic cancer curve: months of relatively preserved function, then a steep decline over days to a few weeks as tumor burden, anorexia-cachexia, and organ failure stack. Families who saw the patient walking last month are shocked by bedbound dying. Name that pattern early so the interdisciplinary team can time opioid planning, caregiver teaching, and visit frequency.

Hematologic malignancies—acute leukemias, aggressive lymphomas, multiple myeloma, myelodysplastic syndromes, and myeloproliferative neoplasms—are less linear. A patient with myeloma may look stable on Wednesday and be in septic shock from neutropenia on Thursday. Blast crisis, catastrophic bleeding from thrombocytopenia, transfusion dependence, and tumor lysis syndrome (TLS) after cytotoxics make prognostication noisier. Indolent diseases such as chronic lymphocytic leukemia or low-grade lymphoma can look like frailty for years, then transform. Do not score a heme patient against a solid-tumor “last month was good” story.

Hypercalcemia of malignancy

This is the metabolic emergency you will actually see on hospice. Humoral hypercalcemia from parathyroid hormone-related peptide is common in squamous lung, renal cell, and some breast cancers. Osteolytic hypercalcemia is common in myeloma and bone-metastatic breast cancer. Corrected calcium often exceeds 12 mg/dL before families call; severe cases exceed 14 mg/dL. When restoring thinking is a goal, give isotonic hydration first, then a bisphosphonate (zoledronic acid or pamidronate) or denosumab if renal impairment or prior bisphosphonate failure makes that the better choice. Calcitonin drops calcium faster but only for a day or two. If the goal is comfort dying and intravenous access is a burden, skip disease-directed calcium lowering and treat constipation, nausea, and confusion as comfort problems. The exam trap is transferring every high calcium to a hospital as if hospice had no other tools.

Spinal cord compression, SVC syndrome, obstruction, and fracture

Metastatic spinal cord compression is back pain plus a neurologic change until proven otherwise. Pain is often worse lying down. Weakness, a sensory level, urinary retention, constipation, and saddle anesthesia are late. Immediate dexamethasone, imaging if the patient would still accept radiation or surgery, and palliative radiation for radiosensitive disease (prostate, breast, myeloma, lymphoma) are the disease-directed package. On hospice, steroids plus bladder management and radiation only if the patient can travel and wants to preserve walking or continence. Surgery is for a selected single site, good enough performance status, and a goal of remaining ambulatory.

Superior vena cava (SVC) syndrome presents with facial and arm edema, plethora, dilated chest-wall collaterals, and dyspnea, classically in small-cell lung cancer and lymphoma. Head elevation, steroids, and palliative radiation or stenting can fit hospice when the goal is to sit up without choking.

Malignant bowel obstruction is common in ovarian, colorectal, and gastric cancer. Complete obstruction with ischemia is a surgical emergency only if life-prolongation is still the goal. Palliative packages include a time-limited nothing-by-mouth trial, a venting gastrostomy, octreotide to reduce secretions, dexamethasone for peri-tumor edema, and antiemetics. Do not keep a nasogastric tube indefinitely as treatment when the goal is a home death.

Pathologic fracture follows bone metastases (breast, prostate, lung, kidney, myeloma): sudden inability to bear weight, a rotated leg, or a snap with a transfer. Analgesia is never optional. Radiation, orthopedic fixation, and bone-modifying agents are goal-dependent.

Tumor fever, pancytopenia, TLS, and paraneoplastic syndromes

Tumor fever is a diagnosis of exclusion after infection is reasonably considered. Scheduled acetaminophen or a nonsteroidal drug can be comfort care. Do not start broad-spectrum antibiotics solely because the census sheet says cancer.

Pancytopenia from marrow replacement, prior chemotherapy, or myelodysplasia drives fatigue, bleeding, and infection risk. Hospice transfusion is a comfort intervention (dyspnea from anemia, bleeding from low platelets), not a number chase. Neutropenic precautions—protective isolation, visitor bans, raw-food rules—belong to disease-directed oncology. On hospice, the CHPN RN frames infection as a comfort decision: antipyretics, oral antibiotics if they reduce distressing fever, or no antimicrobials if the family has chosen a natural death.

TLS is more an acute-oncology emergency than a hospice daily event: hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and acute kidney injury after treatment of a high-burden, highly proliferative tumor (Burkitt lymphoma, acute lymphoblastic leukemia). You still need to recognize it so you do not miss a reversible catastrophe in a patient who still wants hospital care—and so you do not reflexively hospitalize a hospice patient whose stated goal is home dying after a last dose of cytotoxic therapy.

Paraneoplastic syndromes can disable a patient whose scan looks modest. Syndrome of inappropriate antidiuretic hormone (SIADH) from small-cell lung cancer causes euvolemic hyponatremia; treat confusion and seizures as comfort problems when fluid restriction no longer fits the home. Ectopic Cushing syndrome (also small-cell) produces hyperglycemia, hypertension, and proximal weakness. Paraneoplastic neuropathy and Lambert-Eaton myasthenic syndrome can be the reason function collapsed. Function, not tumor volume, drives the hospice conversation.

When palliative radiation or surgery still fits hospice

Hospice election generally means the patient forgoes therapy intended to cure or prolong life. Palliative radiation for painful bone metastases, bleeding, SVC syndrome, or cord compression, and selected surgery (venting gastrostomy, pathologic-fracture fixation, cord decompression) can still be appropriate when the intent is symptom relief, the burden is acceptable, and the program can arrange it. The CHPN RN coordinates with radiation oncology, surgery, and the hospice medical director. You do not order radiation in isolation, and you do not treat every hospital-based oncology protocol as forbidden or as mandatory.