1. Patients should be screened for potential risk factors of cardiac toxicity and should receive care from a cardiologist, ideally one specializing in oncology. Dose adjustments, active cardiac surveillance, awareness of potential effects, and expert consultation early in the management of cancer are all effective measures for prevention of cancer treatment induced cardiac side effects.

2. Patients with diagnosed dysrhythmias may require prolonged monitoring with ambulatory recorders and possibly oncology specific cardiology follow up.

3. Standard therapy should be used to initially treat chemotherapy-associated ventricular dysrhythmia. Mexiletine may be the preferred antidysrhythmic due to dosing and mechanism.

4. Some dysrhythmias may abate after withdrawal of offending agent, but some dysrhythmias may be permanent and necessitate AICD placement

5. For patients who are administered IV fluid hydration, choice of fluids should be based on the risk associated with increased electrolyte content of non-isotonic solutions.

1. CIPN is not a single entity, and presentation varies based on the causative drug and cumulative dose.

2. While sensory symptoms are most common, CIPN may also present as motor and autonomic findings.

3. Duloxetine is the only medication with proven benefit for pain from CIPN.

4. CIPN places patients at risk for other injuries. Consider PT/OT for gait instability and weakness. Instruct patients to avoid extreme temperatures, pressure points like tight shoes, foot care, and inspection for unfelt injuries.

5. Cold sensitivity from oxaliplatin can be very distressing, particularly if laryngospasm occurs from cold air or a cold beverage. Patients with signs of oxaliplatin induced CIPN should be advised to take precautions to protect themselves from cold exposure.

1. Acute kidney injury (AKI) is common in patients with cancer and can lead to increased morbidity and mortality.

2. Presenting symptoms for acute renal failure (ARF) depend on the etiology and may be asymptomatic. A detailed history including type of cancer, current and past treatments can help elucidate the etiology.

3. Oncology patients can have AKI for many reasons; both cancers and their treatments are often associated with multiple different mechanisms of kidney injury.

4. Management of AKI includes treating the suspected underlying etiology.

5. Prompt involvement of a multidisciplinary team including Oncologists and Nephrologists may be necessary.

1. Hemorrhagic cystitis (HC) is a condition characterized by inflammation and bleeding of the bladder lining.

2. It is important to have a high index of suspicion for HC in patients who complain of urinary changes after starting chemotherapy or who have previously undergone pelvic radiation therapy.

3. Symptoms commonly include blood in the urine, increased urinary frequency and urgency, pain with urination and lower abdominal pain.

4. HC can present as mild non-infectious hematuria, but in more severe cases as gross hematuria with hemorrhage and clots causing acute urinary retention.

5. The best treatment is prevention and supportive care with saline diuresis and mesna.

1. Pharmacologic management of active seizure in cancer patients starts with benzodiazepines, followed by levetiracetam or lacosamide load. For refractory seizures, intubate and start a benzodiazepine infusion.

2. Tailor a differential diagnosis. Determine whether the seizure was focal or generalized. Obtain a history of their treatments, medications and recent changes, preceding symptoms, and determine if there are residual symptoms or deficits.

3. New seizures in any cancer patient should prompt imaging to evaluate for structural lesion, first with non-contrast CT head followed by gadolinium-enhanced MRI. Focal seizures suggest focal causation.

4. Continuous video EEG is preferred, as shorter EEG may fail to capture non-convulsive status epilepticus (NCSE).

5. Metabolic derangements can present with seizures and is common in patients with oncologic processes. Therefore, a high degree of suspicion and low threshold for repletion of electrolytes and correction of acid-base abnormality is imperative.

1. An initial assessment and stabilization of airway patency, breathing, and circulation should be performed. Once clinical stability is achieved, urgent neuroimaging should be obtained for rapid and accurate diagnosis of intracranial hemorrhage (ICH).

2. Complete a standardized neurologic assessment to determine baseline severity. The National Institutes of Health Stroke Scale (NIHSS), if the patient is awake or drowsy, or the Glasgow Coma Scale (GCS), if the patient is obtunded or comatose, should be performed and clearly documented.

3. Blood pressure management, treatment of thrombocytopenia (platelet goal of 100,000/mm3), reversal of coagulopathy, and evaluation of the need for early surgical intervention are the mainstays of ICH treatment.

4. Frequent neurological examinations, at least every hour, to detect early clinical deterioration and signs of increased intracranial pressure (ICP) should be part of the initial management algorithm.

5. A complaint of pain in cancer patients with thrombocytopenia may indicate life threatening bleeding. A complaint of headache in a cancer patient with thrombocytopenia, even without abnormal neurologic findings, is ICH until proven otherwise.

Obstetrician-gynecologists are frequently consulted during an episode of abnormal uterine bleeding (AUB) to stop bleeding acutely and to prevent further bleeding during cancer treatment. Women with hematologic malignancies, such as acute myelogenous leukemia (AML), are the most frequently affected and new onset heavy menstrual bleeding may be the chief complaint leading to their diagnosis. Cancer and cancer treatments including chemotherapy, total body irradiation, and conditioning regimens for bone marrow or stem cell transplant can induce thrombocytopenia and lead to AUB. Main treatment options include oral contraceptive pills (OCPs), gonadotropin-releasing hormone (GnRH) agonists, and progestin-only hormone therapy. Algorithms are available to guide treatment and medical management is first line, especially in patients who have not completed childbearing. The risk of venous thromboembolism and need for contraception are special considerations when choosing a treatment for AUB in this patient population.

The incidence of cancer during gestation has risen due to multiple factors such as advanced maternal age and improvement in cancer treatment, which has resulted in longer life span and a rising number of survivors who will then become pregnant. Whether a woman is diagnosed with cancer during pregnancy or becomes pregnant after surviving the disease, navigating treatment for both the mother and the fetus can seem daunting for patients as well as their care providers, as there is a higher risk of morbidity for these patients. This chapter aims to describe safe diagnostic and therapeutic options during pregnancy and includes special considerations regarding survivors’ treatment. Breast cancer, lymphoma, leukemia and cervical cancer are the focus of the chapter and obstetric management of patients with these malignancies is addressed, including antenatal care, delivery considerations and breastfeeding.

Premature ovarian insufficiency (POI) is a heterogeneous diagnosis caused by a multitude of factors including genetic, autoimmune, iatrogenic, social, and environmental. It is defined as loss of ovarian function prior to 40 years of age with subsequent secondary amenorrhea for at least 4−6 months in conjunction with elevated follicle stimulating hormone levels on two different measurements. Prompt recognition of symptoms should encourage thorough history-taking and work-up, as some causes of POI are associated with conditions requiring additional screening or medical management. Early initiation of hormone replacement therapy is necessary to prevent long-term sequelae from chronic hypoestrogenism such as cardiovascular events, poor bone health, and cognitive dysfunction. Extensive counseling with regards to future fertility and family building options is necessary as the diagnosis of POI can be psychologically devastating to many women.

Cervical cancer is the most common gynecologic malignancy worldwide and the third most common in the United States. While incidence and mortality rates have decreased significantly with improved access to screening and prevention methods in the United States, cervical cancer remains a significant cause of cancer morbidity and mortality in resource-limited countries. Human papillomavirus (HPV) infection is the cause of almost all cervical cancer and is associated with 99.7% of cervical cancer. Additional risk factors associated with HPV include early onset of sexual activity, multiple sexual partners, history of sexually transmitted infections, increased parity, and immunosuppression. Non-HPV-related risk factors include cigarette smoking, oral contraceptive use, and low socioeconomic status. Squamous cell carcinoma is the most common histologic subtype of cervical cancer, comprising around 70% of cases, and adenocarcinoma is the second most common histologic subtype, comprising approximately 25% of cases. Cervical cancer is staged clinically, and stage is the most important prognostic factor. Early-stage disease can generally be treated surgically with a hysterectomy. Fertility-sparing surgical options include cold knife conization and radical trachelectomy in select cases. Adjuvant therapy with chemotherapy, radiation, or chemoradiation may be required for early-stage disease with specific risk factors. Advanced-stage disease is primarily treated with chemoradiation. Using FIGO 2018 staging, five-year survival rates were 92−97% for stage IA tumors and 76−92% for stage IB tumors. Lymph node involvement is associated with worse prognosis with five-year survival rates near 40−60%. Routine screening with cervical cytology is recommended starting in young adulthood to identify and treat females with high-grade dysplasia. Routine HPV vaccination is recommended to protect against development of cervical cancer from persistent high-risk HPV infection.

It can be painful to witness the toll of cervical cancer on women offered next-to-no treatment options. Persons with cervixes who acquire the disease in places like Africa or Southeast Asia often experience a brutal life trajectory. In the absence of highly trained professionals, sophisticated medical facilities, and expensive surgical or radiation equipment, most cervical cancer patients in lower-income countries are sent home to die. These deaths can be protracted and lonely, with little access to palliative care. What’s more, the stigma of the disease – associated with “dirty” female reproductive organs and the smell of advanced cancer – can lead to social banishment in a sufferer’s final days. In higher-income countries, greater availability of treatment is still no guarantee of equity. Low-income patients in the United States are often cut off from insurance once cancer goes into remission, excluding them from critical follow-up. Pockets of inequity, the rural–urban divide, and inconsistent access to care mean women from affluent countries die inexcusably from a preventable cancer. The inhumane circumstances cervical cancer sufferers face worldwide remind us of this mission’s urgency.