Authors: Fareeha Siddiqui, MD and David E. Weissman, MD
Up to 30 percent of patients with cancer develop hypercalcemia. Approximately 50% of these patients will die within 30 days of a hypercalcemia diagnosis. The most common cancers leading to hypercalcemia are squamous cell cancers of lung, head and neck, and esophagus, breast cancer, renal cell carcinoma, lymphomas and multiple myeloma.
Symptoms /Signs
Symptoms roughly correlate with the degree of hypercalcemia (corrected) and the rapidity of rise: Mild (10.5-11.9 mg/dl); Moderate (12-13.9 mg/dl) Severe( >14mg/dl)
Anti-Tumor Therapy Treatment of the underlying malignancy with systemic therapy (e.g. chemotherapy) is essential for long-term management. In cases where further anti-neoplastic therapy is not feasible, the decision to treat or not treat hypercalcemia should be made by careful exploration of the patient’s goals of care. In advanced untreatable cancer, the decision to not treat hypercalcemia may be very appropriate.
Bisphosphonates: The drug class of choice for most patients; blocks osteoclastic bone resorption. Pamidronate and Zoledronic acid are used in the US with full efficacy noted 2-4 days after administration; responses last 1-3 weeks. May lead to hypocalcemia or azotemia; use with caution in renal dysfunction.
Pamidronate = 60-90 mg. Repeat only after 7 days have elapsed after 1 st dose. Repeat infusions every 2-3 weeks or longer according to the degree and of severity of hypercalcemia.
Zoledronate = 4 mg (maximum). Wait at least 7 days before considering retreatment.
Other Agents: Glucocorticoids are useful in lymphoid malignancies that secrete 1,25(OH)2 Vitamin D. Calcitonin may lead to acute reductions in serum calcium (12-24 hours) but reductions are small and transient.(Dose = I.M., SQ: Initial: 4 units/kg every 12 hours; may increase up to 8 units/kg every 12 hours to a maximum of every 6 hours) Mithramycin was the standard agent prior to bisphosphonates--now used only rarely due to a higher side effect profile. Gallium Nitrate is usually impractical due to the need for a 5 day IV infusion. Renal Dialysis can be used in cases of acute/chronic renal failure.
Hypercalcemia is a common oncologic complication that often portends a very short prognosis. The decision to attempt reversal should be made after first exploring the goals of care and assessing the feasibility of future systemic anti-cancer treatments. Vigorous hydration and bisphosphonates are the cornerstones of short-term hypercalcemia therapy.
Copyright/Referencing Information: Users are free to d ownload and distribute Fast Facts for educational purposes only. Citation for referencing: Siddiqui F and Weissman DE. Fast Facts and Concepts #151; Hypercalcemia of Malignancy. February 2006. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.
Fast Facts were edited by David Weissman MD,
Purpose: Self-Study Guide, Teaching
Audience(s)
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Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice |
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Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery |
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Non-Physician: Nurses |
ACGME Competencies: Medical Knowledge and Patient Care
Keyword(s): cancer