What is a comprehensive approach to internal medicine oncology for a crash course exam, considering adult patients with a history of cancer or underlying health conditions?

Internal Medicine Oncology Crash Course Exam Guide

Core Screening and Assessment Protocols

All cancer patients must be systematically screened for anxiety and depression using validated instruments at diagnosis, during treatment transitions, and at regular intervals. 1

Essential Screening Tools

• PHQ-9 for depression: Score ≥10 indicates moderate-to-severe symptoms requiring intervention 1
• GAD-7 for anxiety: Score ≥8 indicates clinically significant anxiety 1, 2
• Hospital Anxiety and Depression Scale (HADS): Score ≥8 on either subscale warrants further assessment 2
• Screen at diagnosis, treatment initiation, completion, recurrence, and when clinically indicated 1

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Ovarian Cancer Management Framework

Patients with suspected ovarian cancer require comprehensive surgical staging with total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by platinum-based chemotherapy. 1

Clinical Presentation Recognition

• Palpable pelvic mass with ascites, abdominal distention 1
• Symptom triad: bloating, pelvic/abdominal pain, early satiety or urinary urgency/frequency without other source 1

Mandatory Workup Components

• Family history and genetic risk evaluation (do not delay treatment for counseling) 1
• Abdominal/pelvic CT or MRI with contrast 1
• CA-125 and tumor markers (inhibin, β-hCG, AFP, LDH, CEA as indicated) 1
• Chest imaging (X-ray or CT) 1
• CBC, chemistry panel with liver function tests 1
• GI evaluation specifically for mucinous histology 1

Treatment Algorithm

• Stage IA/IB Grade 1 with fertility preservation: Unilateral salpingo-oophorectomy with comprehensive staging 1
• Stage II-IV or no fertility concerns: TAH/BSO with cytoreductive surgery 1
• All patients: Referral to gynecologic oncologist before initiating chemotherapy improves survival 1
• First-line chemotherapy: Paclitaxel 175 mg/m² (3-hour infusion) followed by cisplatin 75 mg/m² demonstrates superior response rates, progression-free survival, and overall survival compared to cyclophosphamide-based regimens 1, 3

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Anxiety and Depression Management in Cancer Patients

Treat medical causes of anxiety first (uncontrolled pain, fatigue, electrolyte imbalances, delirium) before diagnosing primary psychiatric disorders. 1

Stepped Care Model for Depression

Mild Depression (PHQ-9: 5-9)

• Individually guided self-help or computerized CBT 1
• Structured physical activity programs 1
• Group-based psychosocial interventions 1

Moderate Depression (PHQ-9: 10-14)

• First-line pharmacotherapy: SSRIs (escitalopram 10-20 mg, sertraline 50-200 mg) or SNRIs (venlafaxine 75-225 mg, duloxetine) 4
• Individual CBT by licensed mental health professional 1
• Behavioral couples therapy if relationship contributes to depression 1

Severe Depression (PHQ-9: ≥15)

• Combination of pharmacotherapy plus individual psychotherapy 1
• Immediate psychiatric referral if suicidal ideation present 1
• Facilitate safe environment with one-to-one observation 1

Stepped Care Model for Anxiety

Mild Anxiety (GAD-7: 5-9)

• Education about anxiety symptoms and stress reduction strategies 1, 2
• Supportive care by primary oncology team 1

Moderate Anxiety (GAD-7: 10-14)

• Structured psychological interventions using empirically supported CBT manuals 1
• Consider pharmacotherapy: SSRIs or SNRIs as first-line 4, 2

Severe Anxiety (GAD-7: ≥15)

• Combination therapy: Pharmacotherapy plus individual psychotherapy 1, 2
• Benzodiazepines: Use only short-term (time-limited) due to abuse potential, dependence risk, and cognitive impairment 1, 4
• Benzodiazepine tapering: When discontinuing, reduce by 0.125-0.25 mg every 1-2 weeks, with longer tapers for potent agents like clonazepam 4

Critical Follow-Up Protocol

• Monthly assessment until symptoms resolve: compliance with referrals, medication adherence, side effects, treatment satisfaction 1, 2
• 8-week decision point: If minimal improvement despite good adherence, modify treatment (add intervention, change medication class, switch from group to individual therapy) 1, 2
• Use standardized instruments (PHQ-9, GAD-7, HADS) at weeks 4 and 8, not clinical impression alone 2

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Palliative Care Essentials

Constipation management in cancer patients requires prophylactic bowel regimens for all patients on opioids, with escalating interventions based on severity. 1

Constipation Management Algorithm

• Prevention: Stimulant laxative (bisacodyl 10-15 mg daily to TID) for all opioid-treated patients, goal of one non-forced bowel movement every 1-2 days 1
• If impacted: Glycerine suppository ± mineral oil retention enema, manual disimpaction with premedication (analgesic ± anxiolytic) 1
• Persistent constipation: Add polyethylene glycol, lactulose (30-60 mL BID-QID), magnesium hydroxide (30-50 mL daily-BID), or magnesium citrate (8 oz daily) 1
• Opioid-induced constipation: Methylnaltrexone 0.15 mg/kg subcutaneous every other day (maximum once daily) 1

Malignant Bowel Obstruction Management

• Assessment: Plain radiography usually sufficient; CT if surgical intervention contemplated 1
• Pharmacologic approach (preferred over surgery in dying patients): 1
  • Octreotide 150-300 mcg subcutaneous BID or continuous infusion (start early due to high efficacy) 1
  • Anticholinergics (scopolamine, hyoscyamine, glycopyrrolate) 1
  • Corticosteroids 1
  • Avoid prokinetics (metoclopramide) in complete obstruction; may benefit incomplete obstruction 1
• Invasive options: Endoscopic stenting, PEG tube for drainage, operative management only if improved quality of life is primary goal 1

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Lymphoma Management Principles

Rituximab combined with CHOP chemotherapy (R-CHOP) is standard first-line treatment for diffuse large B-cell lymphoma, demonstrating superior progression-free and overall survival. 5

DLBCL Treatment Protocol

• R-CHOP regimen: Rituximab 375 mg/m² plus cyclophosphamide, doxorubicin, vincristine, prednisone 5
• Dosing schedule: 6-8 cycles, each 21 days; rituximab administered on Days -7 and -3 before Cycle 1, then 48-72 hours prior to Cycles 3,5, and 7 (if applicable) 5
• Hazard ratio for progression/death: 0.32-0.36 favoring R-CHOP over CHOP alone 5

Pediatric Burkitt Lymphoma/B-ALL

• R-LMB protocol: Rituximab 375 mg/m² (six infusions) combined with LMB chemotherapy (high-dose methotrexate, cytarabine, cyclophosphamide, doxorubicin, etoposide, intrathecal therapy) 5
• Event-free survival hazard ratio: 0.32 (90% CI: 0.17-0.58) favoring rituximab addition 5

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Key Exam Pitfalls to Avoid

Common Clinical Errors

• Never dismiss health anxiety concerns as this increases anxiety and reduces trust; address underlying mechanisms 2
• Do not assume compliance with referrals; actively verify first appointment attendance and identify barriers 2
• Avoid benzodiazepine monotherapy for anxiety beyond short-term use; transition to SSRIs/SNRIs for definitive treatment 4
• Do not wait beyond 8 weeks to modify ineffective treatment; this delays recovery and increases suffering 2

Documentation Requirements

• Document PHQ-9 and GAD-7 scores at each assessment, not subjective impressions 2
• Record specific interventions, medication doses, and response at 4-week and 8-week intervals 2
• Note barriers to compliance and plans to address them 1

Neurological Red Flags Requiring Urgent Imaging

• New-onset headaches with seizures, altered consciousness, or focal deficits in anxious patients warrant urgent brain MRI with contrast to exclude CNS malignancy 6
• Progressive cognitive impairment or personality changes alongside anxiety symptoms require neurological evaluation before psychiatric diagnosis 6