Oncology Self-Assessment: Pain & Symptom Management and Palliative Care & End of Life Care

Aug 10, 2022

ASCO seeks to advance the education of all oncology professionals and ultimately facilitate and support enhanced patient care. The ASCO Oncology Self-Assessment Series on ASCO Connection consists of free case-based multiple-choice practice questions, educational links, and answer rationales from ASCO-SEP. 
Learn more about ASCO’s Educational products, such as the new 2022 ASCO-SEP Digital Subscription, which includes the digital book, access to education courses and virtual meeting-related content, plus over 900 practice questions in the Question Bank. Oncology trainees and Training Program Directors can visit Education Essentials for Oncology Fellows (EEOF) to learn more and register for the new 2022-23 cycle. 
Correct answers are listed at the bottom of the page.

Question 1: Pain and Symptom Management

A 62-year-old woman is receiving palliative chemotherapy for metastatic breast cancer to the lung and bone. She presents to the clinic before her next round of chemotherapy with sudden-onset shortness of breath and a cough. No one in her home has had similar symptoms. She has not been febrile, and her cough is nonproductive. Two days ago, she traveled by car from her relative’s house, which is six hours away. This morning, she noticed that she had more swelling in her legs than usual and she reports right mid-back pain when she takes a deep breath. A complete blood count shows her white blood count and differential to be within normal limits. A CT angiogram shows right lower lobe pulmonary embolus.
Which of the following treatments would be most appropriate?
  1. Subcutaneous heparin
  2. Warfarin
  3. Low molecular weight heparin, followed by oral warfarin
  4. Low molecular weight heparin or a direct oral anticoagulant

Question 2: Palliative Care and End of Life Care

You are asked to consult on a 70-year-old man in the intensive care unit who is intubated owing to respiratory failure. He is a heavy smoker of 60 packs a year. A chest CT scan revealed a large mediastinal mass with significant compression of the superior vena cava (SVC) and trachea. There is also evidence of multiple liver lesions and bilateral supraclavicular lymphadenopathy. Laboratory testing revealed a lactate dehydrogenase (LDH) level three times the upper limit of normal. His clinical condition is serious, with early evidence of disseminated intravascular coagulation (DIC) due to superimposed pneumonia; however, his blood pressure is normal. 
What is your recommendation for the next step in this patient's management?
  1. Refer to hospice care
  2. Obtain a supraclavicular lymph node biopsy
  3. Obtain a liver biopsy
  4. Refer to radiation therapy

Question 1 Rationale and References

Correct answer: D. Low molecular weight heparin or a direct oral anticoagulant
Rationale: There is phase 3 evidence to support the use of both low molecular weight heparin and direct oral anticoagulants to treat malignancy-associated venous thromboembolism (VTE) or pulmonary embolism (PE). Edoxaban has been shown to have reasonable efficacy and safety in the treatment of malignancy associated venous thromboembolism. Low molecular weight heparin is preferred over the use of warfarin.
  • Raskob GE, van Es N, Verhamme P, et al. Edoxaban for the treatment of cancer-associated venous thromboembolism. N Engl J Med. 2018;378(7):615-24. DOI: https://doi.org/10.1056/NEJMoa1711948
  • Young AM, Marshall A, Thirlwall J, et al. Comparison of an oral factor xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: results of a randomized trial (SELECT-D). J Clin Oncol. 2018;36(20):2017-23. DOI: https://doi.org/10.1200/JCO.2018.78.8034

Question 2 Rationale and References

Correct answer: B. Obtain a supraclavicular lymph node biopsy
Rationale: This patient most likely has small cell carcinoma. A biopsy is crucial to determine if this is a small cell carcinoma or lymphoma, as both conditions will respond quickly to systemic chemotherapy and improve the patient's outcome. Hospice care is not appropriate without ruling out these two diagnoses. Patients with poor performance status can still be treated if they are diagnosed with metastatic small cell lung cancer or aggressive lymphoma since these cancers are very chemo sensitive. A supraclavicular lymph node biopsy is the ideal procedure, as a liver biopsy would be dangerous in a patient with DIC. Radiation therapy should not be recommended without a confirmed diagnosis of malignancy.
  • Lo Russo G, Macerelli M, Platania M, et al. Small-cell lung cancer: clinical management and unmet needs new perspectives for an old problem. Curr Drug Targets. 2017;18(3):341-62. DOI: https://doi.org/10.2174/1389450117666160502152331
  • Kvale PA, Selecky PA, Prakash UB; American College of Chest Physicians. Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3 Suppl):368S-403S. DOI: https://doi.org/10.1378/chest.07-1391
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