Managing Cancer Symptoms Overnight and on Weekends

Oncology clinics have a number that reaches a nurse or doctor at night and at weekends. It exists because some problems truly cannot wait until Monday.

The National Cancer Institute's patient booklet Chemotherapy and You puts it plainly: "Call your doctor right away if you think you have an infection. Even if it's on the weekend or in the middle of the night, you still need to call."

Under medical review. This page describes urgent decisions and is held back from public search until a clinician has checked the wording.

Any sign of infection. The instruction is to call when you have chills or sweats or if you have a fever of 100.4 degrees F (38 degrees C) or higher — CDC's chemotherapy threshold — or whatever temperature your doctor or nurse tells you. That last part matters, because the published thresholds differ slightly:

• National Cancer Institute: a "fever of 100.5 °F (38 °C) or higher" — its printed 100.5 °F is a conversion slip, since 38 °C is 100.4 °F; act at 100.4 °F (38 °C) — listed as a sign of infection to report to your health care team.
• American Cancer Society: "For people with cancer, a fever is defined as a temperature of 100.4 °F (38 °C) or higher for at least one hour."
• MedlinePlus (NIH), on preventing infection during cancer treatment: "a fever of 100.4°F (38°C) or higher."
• The clinical definition of febrile neutropenia: "a single oral temperature greater than or equal to 101 F (38.3 C) or a temperature greater than or equal to 100.4 F (38 C) for at least an hour, with an absolute neutrophilic count (ANC) of less than 1500 cells/microliter." IDSA's guideline sets the bar lower still for high-risk febrile neutropenia, at an ANC below 500 cells/microliter or expected to drop below it. Either way, the count comes from a blood test taken after you are assessed, so this is a lab definition rather than a number to act on at home.

These describe close to the same body temperature, but they are not identical: 38.0 °C converts to 100.4 °F, so 100.4 °F is the lower of the figures and the safer one to act on if your team has not given you their own. ACS says to "ask your cancer care team what temperature they consider to be a fever. It might be different depending on your situation, but 100.4 °F (38 °C) is often used." Use your team's number whenever you take a reading, and if your reading sits just below your team's number and you are unsure, call anyway — no oncology service minds being called.

NCI also lists these signs of infection: cough or sore throat; diarrhea; ear pain, headache or sinus pain, or a stiff or sore neck; skin rash; sores or white coating in your mouth or on your tongue; swelling or redness, especially where a catheter enters your body; and urine that is bloody or cloudy, or pain when you urinate. Infections during cancer treatment can be life threatening and require urgent medical attention.

NCI's advice is to talk with your doctor or nurse before taking medicine, even aspirin, acetaminophen (such as Tylenol) or ibuprofen (such as Advil), for a fever. Do not bring a temperature down before you call.

Fluids not staying in. MedlinePlus tells people to call their provider if they cannot keep any food or liquid down, vomit three or more times in one day, have nausea for more than 48 hours, or have not urinated for 8 hours or more.

Bleeding or bruising. NCI asks you to call about bruises, especially if you did not bump into anything; small, red spots on your skin; red- or pink-colored urine; black or bloody bowel movements; bleeding from your gums or nose; heavy or unusually long menstrual bleeding; vaginal bleeding not caused by your period; headaches or changes in your vision; a warm or hot feeling in your arm or leg; and feeling very sleepy or confused.

Breathlessness, faintness, or a racing heart. Call if you feel dizzy or like you are going to faint, feel short of breath, or it feels like your heart is pounding or beating very fast.

New nerve or thinking changes. NCI says to let your doctor or nurse know right away if you notice any nervous system changes.

No published patient source grades urgency by the hour of the day. NCI, ACS and MedlinePlus set their thresholds by the symptom and by how long it has lasted, not by whether the clinic is open. This page cannot tell you what will keep until Monday, and neither can they.

Some of those thresholds are measured in days. NCI asks you to let your doctor or nurse know if diarrhea lasts more than 24 hours, or comes with pain and cramping. The same goes for two days without a bowel movement, or vomiting that lasts more than a day or starts right after you drink. Report all of those. How soon is a question for your own plan.

Your own team's after-hours instructions are the authority here. If they wrote nothing down, ask them to, and use the after-hours line in the meantime.

Name and date of birth. Cancer type, current treatment, and date of the last dose. The temperature you just took, and how. When the symptom started and whether it is getting worse. What has been eaten and drunk today, and when they last urinated. The medicine list, including anything taken in the last 24 hours. The pharmacy that is open now.

NCI's instruction is to find out how to contact your doctor or nurse in an emergency, including who to call and where to go, and to enter important phone numbers in your phone so they are there when you need them. Ask what happens when you dial the main number after hours, whether an answering service picks up, and how long a callback takes.

The American Cancer Society advises asking your cancer care team if and how often you need to check your temperature, and when to call or get medical help. Ask in advance and write the answer down.

ACS warns that sepsis can turn into septic shock quickly, and lists a fast heart rate, low blood pressure, confusion, pale, cold, or clammy skin, nausea, and breathing problems as its signs. For signs of infection, its guidance is to call your cancer care team, or get medical attention right away. Confusion, trouble breathing, or cold clammy skin are reasons to seek emergency care rather than wait for a callback.

• National Cancer Institute, Chemotherapy and You: Support for People With Cancer: https://www.cancer.gov/publications/patient-education/chemo-and-you
• National Cancer Institute, Infection and Neutropenia During Cancer Treatment: https://www.cancer.gov/about-cancer/treatment/side-effects/infection
• MedlinePlus, When you have nausea and vomiting: https://medlineplus.gov/ency/patientinstructions/000122.htm
• American Cancer Society, Managing Infections and Sepsis: https://www.cancer.org/cancer/side-effects/infections/managing-infections-and-sepsis.html
• American Cancer Society, Fevers: https://www.cancer.org/cancer/managing-cancer/side-effects/infections/fever.html
• MedlinePlus, Cancer treatment - preventing infection: https://medlineplus.gov/ency/patientinstructions/000913.htm
• StatPearls (NCBI Bookshelf), Febrile Neutropenia: https://www.ncbi.nlm.nih.gov/books/NBK541102/