By adhering to evidence-based guidelines, leveraging the expertise of specialists, and staying vigilant for drug-drug interactions, oncologists can navigate these complexities while maintaining patient-centered care.— M. Edie Brucker, DNP, MPH, ARNP, AGPCNP-BC, AOCNP, CENP
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Cancer care is increasingly complicated by the presence of comorbidities, which affect nearly two-thirds of patients at the time of diagnosis and can influence treatment decisions, participation in clinical trials, and overall outcomes. During 2024 JADPRO Live, M. Edie Brucker, DNP, MPH, ARNP, AGPCNP-BC, AOCNP, CENP, discussed the identification and management of common comorbidities encountered in patients with cancer entering treatment.
“Hypertension, pulmonary conditions, and diabetes each present unique challenges that require nuanced, multidisciplinary care,” said Dr. Brucker, Director, Advanced Practice Providers, Fred Hutchinson Cancer Center, Seattle. “By adhering to evidence-based guidelines, leveraging the expertise of specialists, and staying vigilant for drug-drug interactions, oncologists can navigate these complexities while maintaining patient-centered care.”
Hypertension in Patients With Cancer
Hypertension is the most prevalent comorbidity among cancer survivors, with 64% experiencing elevated blood pressure during or after treatment. “It’s not just about managing blood pressure; it’s about managing it in a way that doesn’t compromise the cancer treatment,” explained Dr. Brucker. This dual challenge requires oncologists to balance controlling hypertension with avoiding adverse interactions with oncology therapies.
According to Dr. Brucker, hypertension guidelines provide different thresholds for management, but the key is consistent monitoring and early intervention. The American Academy of Family Physicians recommends a target blood pressure of less than 140/90 mm Hg, whereas international guidelines suggest less than 130/80 mm Hg for patients older than age 65. “It’s less about the specific numbers and more about ensuring that hypertension is being addressed before it complicates cancer treatment or other comorbidities,” Dr. Brucker emphasized.
Angiotensin-converting enzyme inhibitors and thiazide diuretics are common first-line therapies, said Dr. Brucker, but kidney function and potential drug interactions should guide decision-making. For example, amlodipine is frequently preferred in oncology because of its minimal renal impact.
Accurate blood pressure monitoring is also essential, both in the clinic and at home. Dr. Brucker recommended using cuff-based monitors and encouraging patients to keep a blood pressure log. This is especially important for detecting issues like white coat syndrome.
“I always want patients to monitor their blood pressure at home and bring me a log,” Dr. Brucker explained. “We’ve all seen patients come in at 160/90 after fighting rush-hour traffic. That’s not a true baseline.”
In addition, certain cancer treatments, such as tyrosine kinase inhibitors and platinum-based chemotherapies, can exacerbate hypertension. Proactive monitoring is critical, and oncologists should adjust antihypertensive doses gradually, adhering to the principle of “start low, go slow.” Dr. Brucker emphasized that collaborative care with cardiologists or primary care providers is often necessary when hypertension proves difficult to control or requires multiple medications.
“By identifying and addressing hypertension early, oncologists can help patients stay on track with their cancer treatment while reducing risks to cardiovascular health,” said Dr. Brucker. “It’s about giving patients the best possible chance for a good outcome—both for their cancer and their overall health.”
Pulmonary Comorbidities and Cancer Treatment
Pulmonary comorbidities, such as asthma, chronic obstructive pulmonary disease (COPD), and tuberculosis, frequently complicate cancer care, particularly in patients with lung cancer. These conditions not only increase the risk of cancer but also impact treatment decisions and outcomes. “Asthma and COPD often show up in our lung cancer population, and they can really complicate treatment, especially when you’re weighing options like radiation or immunotherapy,” explained Dr. Brucker.
Asthma, the most common pulmonary comorbidity, is often diagnosed long before cancer treatment begins. Most patients manage their condition well, but it’s essential to ensure they have appropriate medications before initiating oncology treatments.
“Make sure they have a rescue inhaler,” Dr. Brucker emphasized. “If they haven’t needed one in years, it’s okay to prescribe a new one to ensure they’re covered.”
Immunotherapy, which is widely used in treating lung cancer, is generally well tolerated in patients with asthma, but exacerbations can occur. Increasing the dose of inhaled corticosteroids or adding a long-acting bronchodilator may improve lung function and reduce inflammation. Collaboration with a pulmonologist or primary care provider is invaluable for managing asthma in complex oncology cases, Dr. Brucker added.
Chronic obstructive pulmonary disease presents a more significant challenge because of its structural impact on the lungs and its frequent presence in patients with lung cancer. The disease can manifest as emphysema, chronic bronchitis, or both, further compromising lung function. “COPD makes everything harder,” Dr. Brucker said. “Radiation might be the best option for their cancer, but with compromised lungs, it’s not always feasible.”
In cases where chronic obstructive pulmonary disease limits treatment options, short-acting bronchodilators or combination inhalers such as fluticasone furoate plus vilanterol can provide symptom relief. Oxygen therapy may also be necessary for severe cases, particularly in older patients.
“Education is critical here—make sure patients know how to use their inhalers properly,” Dr. Brucker added. “You’d be surprised how many older patients underuse or misuse them.”
Ultimately, pulmonary comorbidities require a patient-centered approach that balances effective cancer treatment with maintaining the highest possible quality of life. “It’s all about finding the right balance,” Dr. Brucker noted. “Our patients are already fighting cancer, so we do everything we can to avoid making their breathing any harder than it already is.”
Diabetes and Cancer Treatment
Diabetes is a common and impactful comorbidity in patients with cancer, affecting 18% to 20% at diagnosis. Poorly managed diabetes not only complicates treatment but also increases cancer-related mortality.
“Diabetes is one of those silent contributors,” Dr. Brucker emphasized. “If it’s not well controlled, it can derail even the best cancer treatment plans.”
Before initiating treatment, it is essential to assess a patient’s diabetes status through fasting glucose levels and HbA1c measurements. Many patients misunderstand the severity of their condition or rely on suboptimal regimens. “I’ve had patients tell me, ‘My HbA1c is 7.5%—it’s fine.’ No, it’s not fine,” Dr. Brucker said. “We need to ensure their diabetes is managed effectively, or they’ll face even greater risks during treatment.”
For patients already on medications such as metformin or insulin, oncologists should verify adherence and assess for potential treatment adjustments. Multidisciplinary collaboration with endocrinologists or primary care providers may help to ensure diabetes management aligns with the demands of cancer therapy.
Certain cancer treatments, including corticosteroids such as dexamethasone, can significantly exacerbate hyperglycemia. Adjusting premedication protocols to minimize these effects is critical. “In my practice, I often halve the dexamethasone dose,” Dr. Brucker explained. “It’s about finding the right balance—controlling nausea without sending blood sugar through the roof.”
Chemotherapy and its side effects, such as appetite loss and weight fluctuations, can further destabilize glucose control. Introducing basal insulin with a short-acting sliding scale before meals may be necessary, especially during intensive regimens such as FOLFOX (leucovorin, fluorouracil, oxaliplatin) for colorectal cancer. Dietitian consultations can also support patients struggling with diet-related challenges during treatment.
According to Dr. Brucker, effective diabetes management requires close monitoring of blood sugar levels, liver function, and kidney function throughout cancer treatment. Oncologists should remain vigilant for signs of uncontrolled hyperglycemia or complications such as delayed wound healing after surgery. Dr. Brucker underscored the importance of collaboration: “I’m not here to manage diabetes—I’m here to treat cancer. If I’m unsure, I’m calling the endocrinologist or primary care physician to ensure the patient gets the care needed.”
When diabetes is well controlled, patients are better positioned to tolerate cancer treatments and achieve improved outcomes. “It’s all about giving patients the tools they need to keep going,” Dr. Brucker concluded. “Whether that’s adjusting their medication, helping them track their blood sugar, or just listening to their concerns, it all makes a difference.”
DISCLOSURE: Dr. Brucker reported no conflicts of interest.
REFERENCE
1. Brucker E: Cancer complexities: Balancing your patients’ comorbidities with their treatment. 2024 JADPRO Live. Presented November 14, 2024.
