ONCC’s Revised List of Oncologic Emergencies Includes irAEs

By Kate B. Hubbard, MSN, RN, OCN®, NPD-BC, Elaine S. DeMeyer, RN, MSN, AOCN®, BMTCN® - January 3, 2023

Oncology nurses should be prepared for emergencies in cancer because they can occur anytime from diagnosis to end-of-life care. The Oncology Nursing Certification Corporation (ONCC) outlines content for general oncology nursing and has updated its list of oncologic emergencies. The ONCC added 1 new emergency and immune-related adverse events (irAEs). To stay current in practice, oncology nurses need to know about these changes.

The Importance of Oncologic Emergencies

As the number of cancer diagnoses increases, oncologic emergencies will also increase. In the next 2 decades, it is estimated that the percentage of new cancer cases will increase by 30%. Almost two-thirds of cancer survivors will be older than 65 years by 2040. Patients with oncologic emergencies, especially older adults, can have worse outcomes than younger patients. Oncology nurses must be aware of this potential escalation in oncologic emergencies due to the aging cancer survivor population.

Although some oncologic emergencies are related to cancer treatment (eg, tumor lysis syndrome), they can also occur outside the active treatment period. For example, they can occur with presenting symptoms before diagnosis (eg, disseminated intravascular coagulopathy) or with advanced, end-stage disease (eg, superior vena cava syndrome). With more aggressive therapy and immune modulation (eg, stem cell transplantation and CAR T-cell therapy), some emergencies are more likely to occur.

Metabolic and Structural Oncologic Emergencies

Oncologic emergencies include metabolic and structural emergencies as well as irAEs, according to the ONCC. Oncology nurses must be able to identify each of the emergencies in these categories for prompt intervention. Although the ONCC does not list them in categories on its test content outline for the oncology certification exam, categorizing the emergencies can help nurses learn them. This list is essential information to review if you are planning on taking the OCN® exam.

Metabolic Emergencies Structural Emergencies
Anaphylaxis Cardiac tamponade
Disseminated intravascular coagulation (DIC) Extravasations
Hypercalcemia Increased intracranial pressure (ICP)
Hypersensitivity Obstructions: bowel or bladder
Sepsis and septic shock Pneumonitis
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Spinal cord compression (SCC)
Tumor lysis syndrome (TLS) Superior vena cava syndrome (SVCS)
Venous thromboembolism

In reviewing this ONCC list, you may notice other emergencies either in clinical practice or the literature not listed here. Four examples are:

  1. Carotid artery rupture
  2. Leukostasis
  3. Malignant pleural effusion
  4. Thrombotic thrombocytopenic purpura

Immune-Related Adverse Events 

irAEs are also on the ONCC list of oncologic emergencies. These side effects can result from immune activation by checkpoint inhibitors (eg, nivolumab, pembrolizumab), a type of immunotherapy. These distinct side effects can affect any organ system, although the liver, gastrointestinal tract, skin, and endocrine system are the most common. Since they sound alike (eg, hepatitis, colitis, and pneumonitis), nurses may refer to these autoimmune-mediated toxicities as the “itises” due to the suffix.

Immune-Related Adverse Events
Neurologic

·        Encephalitis

·        Guillain-Barré syndrome

·        Meningitis

·        Myasthenia gravis

·        Neuropathy

Hepatic

·        Hepatitis

·        Transaminitis

Eye

·        Conjunctivitis

·        Iritis

·        Retinitis

·        Scleritis

·        Uveitis

Renal

·        Nephritis

·        Renal failure

Pulmonary

·        Interstitial lung disease

·        Pleuritis

·        Pneumonitis

Endocrine

·        Diabetes

·        Hyperthyroidism

·        Hypophysitis

·        Hypothyroidism

Gastrointestinal

·        Colitis

·        Gastritis

·        Ileitis

·        Pancreatitis

Skin

·        Dermatitis

·        Pruritus

·        Psoriasis

·        Rash

·        Stevens-Johnson syndrome

·        Vitiligo

Oncology nurses must be prepared to recognize oncologic emergencies quickly in clinical practice to communicate changes in the patient’s condition to the provider for prompt intervention. By recognizing and responding to oncologic emergencies, oncology nurses can help to minimize complications, improve outcomes, and potentially maintain the patient’s quality of life.

References

National Cancer Institute Division of Cancer Control & Population Sciences: Statistics and Graphs

Oncology Nursing Certification Corporation: 2022 OCN® Test Content Outline 

Immune-Related Adverse Events of Immune Checkpoint Inhibitors: A Brief Review

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