67.3 Primary Care During Cancer Treatment & Survivorship

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

67.3 Primary Care During Cancer Treatment & Survivorship

Key Takeaways Explain This Topic AI

Febrile neutropenia is a single oral temperature of at least 38.3 C, or at least 38.0 C sustained an hour, with an ANC below 500/uL or expected to fall below 500 within 48 hours, and it requires empiric antipseudomonal antibiotics within 1 hour.

New diarrhea, hepatitis, pneumonitis, thyroiditis, or hypophysitis in a patient on a checkpoint inhibitor is an immune-related adverse event; grade 2 or higher events require holding the drug and starting corticosteroids.

New back pain in a patient with known malignancy warrants immediate dexamethasone and urgent MRI of the entire spine before neurologic deficits develop.

Anthracycline cardiotoxicity is dose-dependent and largely irreversible near a cumulative doxorubicin dose of 450 to 550 mg/m2, while trastuzumab cardiotoxicity is not dose-dependent and is often reversible with interruption.

Live vaccines are contraindicated during active chemotherapy, but inactivated and recombinant vaccines including recombinant zoster vaccine are indicated, and resuming routine screening for other cancers is the most commonly missed element of survivorship care.

Last updated: September 2026

The Family Physician's Two Oncology Roles

The blueprint activity "disease management related to cancer treatment" sits in Chronic Care Management, and it captures two distinct jobs that family physicians perform far more often than they perform cancer diagnosis:

Caring for the patient who is currently on treatment — recognizing the handful of true oncologic emergencies, managing common toxicities, and knowing what must be escalated the same day.

Caring for the survivor — surveillance for recurrence and second primaries, management of long-term and late effects, and reintegration of routine preventive care that was suspended during treatment.

Neither job requires prescribing chemotherapy. Both require knowing exactly where the primary care threshold for urgency sits.

• Emergencies in the Patient on Active Treatment
• Febrile neutropenia — the highest-stakes recognition on the blueprint

Definition : a single oral temperature ≥ 38.3 °C (101 °F) , or a temperature ≥ 38.0 °C (100.4 °F) sustained for at least 1 hour , in a patient with an absolute neutrophil count (ANC) below 500 cells/µL , or an ANC expected to fall below 500 within the next 48 hours.

The nadir typically occurs 7 to 14 days after a cytotoxic cycle.

Fever may be the only sign. Neutropenic patients cannot mount the erythema, fluctuance, or infiltrate that normally localize infection, so a normal chest radiograph and a benign examination do not reassure.

Empiric broad-spectrum antibiotics with antipseudomonal coverage must be given within 1 hour of presentation — cefepime, piperacillin-tazobactam, or a carbapenem. Cultures should be drawn but must not delay the first dose.

Add vancomycin for hemodynamic instability, suspected catheter-related infection, skin or soft-tissue infection, pneumonia, or known MRSA colonization — it is not part of routine initial coverage.

The MASCC risk index identifies low-risk patients (score ≥ 21 ) who may be candidates for oral therapy (ciprofloxacin plus amoxicillin-clavulanate) and outpatient management, but this decision belongs with oncology, not with an unsupported office triage.

Do not administer antipyretics and observe, and do not defer antibiotics pending culture results or an oncology callback. Sending a febrile neutropenic patient home from clinic is a recurring wrong answer.

Other must-not-miss presentations

Emergency Classic presentation Immediate action

Malignant spinal cord compression New or worsening back pain, worse when supine or with Valsalva; later leg weakness, sensory level, bowel/bladder dysfunction Dexamethasone immediately plus urgent MRI of the entire spine ; do not wait for neurologic deficit to image

Hypercalcemia of malignancy Confusion, constipation, polyuria, dehydration, shortened QT Isotonic saline volume repletion plus IV bisphosphonate (zoledronic acid); calcitonin for rapid short-term lowering; avoid loop diuretics as a primary strategy

Tumor lysis syndrome Within days of treating a bulky or highly proliferative tumor: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia , acute kidney injury Aggressive IV fluids, allopurinol for prophylaxis or rasburicase for established/high-risk disease, urgent electrolyte management

Superior vena cava syndrome Facial and upper-extremity swelling, distended neck veins, dyspnea worse when supine Urgent imaging and oncology referral; airway compromise or cerebral edema makes it emergent

Immune-related adverse events (irAEs) Any new colitis, hepatitis, pneumonitis, thyroiditis, hypophysitis, nephritis, or rash in a patient on a checkpoint inhibitor Grade ≥ 2: hold the drug and start corticosteroids after urgent discussion with oncology

Important

Checkpoint inhibitor diarrhea is not gastroenteritis. New diarrhea in a patient on pembrolizumab, nivolumab, or ipilimumab is immune-mediated colitis until proved otherwise. Treating it with loperamide alone and waiting delays corticosteroids and risks perforation. Similarly, fatigue plus hyponatremia in a checkpoint-inhibitor patient should raise hypophysitis (most classically with ipilimumab) and prompt evaluation of the pituitary–adrenal axis.

Common Toxicities Managed in Primary Care

Toxicity Typical agents Practical management

Chemotherapy-induced nausea and vomiting Cisplatin, anthracycline–cyclophosphamide Prophylaxis, not rescue: 5-HT3 antagonist + dexamethasone + NK1 antagonist ± olanzapine for highly emetogenic regimens

Chemotherapy-induced peripheral neuropathy Platinums, taxanes, vinca alkaloids, bortezomib Duloxetine is the only agent with meaningful supporting evidence; there is no effective preventive agent

Mucositis 5-fluorouracil, methotrexate, radiation Bland oral rinses, analgesia, nutrition support; assess for candidiasis and HSV

Anthracycline cardiotoxicity Doxorubicin ( cumulative dose limit approximately 450–550 mg/m² ) Dose-dependent and largely irreversible ; serial LVEF assessment

Trastuzumab cardiotoxicity HER2-directed therapy Not dose-dependent and often reversible with interruption; LVEF monitoring roughly every 3 months

Cancer-related fatigue Nearly all modalities The most prevalent symptom of treatment; exercise has the strongest evidence , ahead of any pharmacologic option

Vaccination during treatment

Live vaccines are contraindicated during active chemotherapy and other significant immunosuppression (MMR, varicella, live attenuated influenza, and the older live zoster vaccine). Inactivated and recombinant vaccines are indicated and encouraged , including inactivated influenza, COVID-19, and recombinant zoster vaccine. Timing is best coordinated with the treatment cycle so that vaccination does not fall at the neutrophil nadir. Household contacts should be fully vaccinated.

Survivorship Care

More than 18 million cancer survivors live in the United States, and most of their long-term care is delivered in primary care. A survivorship care plan should be obtained or reconstructed at the first post-treatment visit and contains two parts: a treatment summary (diagnosis, stage, surgery, cumulative chemotherapy doses, radiation fields and dose, and biologic agents) and a follow-up plan (surveillance schedule, expected late effects, and division of responsibility between oncology and primary care).

Long-term and late effects worth memorizing

• Exposure Late effect to anticipate
• Anthracyclines Cardiomyopathy and heart failure, often years later

Chest radiation Premature coronary disease, valvular disease, hypothyroidism, second primary breast cancer — breast MRI surveillance is added for chest irradiation received between roughly ages 10 and 30

• Neck radiation Hypothyroidism (check TSH periodically), carotid disease
• Aromatase inhibitors Arthralgia and accelerated bone loss — bone density monitoring and calcium/vitamin D

Tamoxifen Endometrial carcinoma and venous thromboembolism risk; abnormal uterine bleeding requires prompt evaluation, but routine endometrial surveillance of asymptomatic users is not recommended

• Androgen deprivation therapy Osteoporosis, metabolic syndrome, hot flashes, sexual dysfunction
• Platinum agents Persistent peripheral neuropathy, ototoxicity, nephrotoxicity
• Alkylating agents Premature ovarian insufficiency, infertility, secondary hematologic malignancy
• Axillary or inguinal node dissection Lymphedema — early referral to lymphedema therapy improves outcomes
• Any curative treatment Cognitive changes, fatigue, sexual dysfunction, fear of recurrence, financial toxicity
• The primary care survivorship checklist

Resume and complete routine preventive care. Screening for cancers other than the treated one, immunizations, blood pressure, lipids, and diabetes screening are frequently abandoned during treatment years and are the most common survivorship care gap.

Surveillance per the plan , not by symptom-driven scanning. For most solid tumors, intensive imaging surveillance of asymptomatic survivors does not improve survival, and tumor-marker testing outside guideline indications generates anxiety and false alarms.

Manage cardiovascular risk aggressively — cardiovascular disease, not recurrence, is a leading cause of death in long-term survivors of several common cancers.

Address psychosocial and sexual health explicitly; both are under-asked and highly prevalent.

Discuss family risk. A survivor with early-onset disease or a suggestive family history warrants genetic counseling referral, which also affects relatives.

Board Exam Traps

Fever 10 days after chemotherapy, benign examination, normal chest film → this is febrile neutropenia until the ANC proves otherwise; give antipseudomonal antibiotics within an hour and admit, rather than reassuring and rechecking.

Diarrhea on a checkpoint inhibitor → immune-mediated colitis; hold the drug and start corticosteroids for grade 2 or higher, not loperamide alone.

New back pain in a patient with metastatic prostate or breast cancer → dexamethasone and urgent whole-spine MRI before deficits appear.

Zoster vaccination request during active chemotherapy → recombinant zoster vaccine is not live and is appropriate; the live attenuated products are contraindicated.

A breast cancer survivor 4 years out asking about "the scan that catches recurrence" → guideline-concordant surveillance is history, examination, and mammography; routine PET or tumor markers in asymptomatic survivors are not recommended.

A 5-year survivor overdue for colorectal and cervical screening → resuming standard preventive care is the intervention with the clearest survival benefit at this visit.