Flashcards in Cancer Deck (181):
Name 6 aetiologies of cancer?
H.pylori associated with what cancer/
HPV associated with which cancers?
Oral, anal and cervical
Non hodgkin and other Lymphoma is associated with which infection?
EBV nuclear antigens
100 fold increase of hepatocellular carcinoma from what?
How do retroviruses increase chances of cancer?
Overexpression of oncogenes, can lead to T cell lymphoma
which commonly prescribed drugs can increase the chances of cancer?
Most commonly used staging measure in cancer?
What does grade refer to in cancer ?
How far or not does the tissue resemble normal GX-G3
What is the definition of a partial response to cancer treatment?
Radiologically shrinking of at least 30% but disease still present.
Stable disease in cancer is defined how?
Less than 20% increase in size, or a less than 30% decrease in size.
Progressive disease is defined how?
>20% increase in new lesion size
MRI is gold standard for imaging which tumour types?
Neurospinal, rectal, MSK, some head and neck sub types and prostate
CEA is used as a marker for which disease?
What may give false positive raised CEA?
Smoking, IBD, pancreatitis, and hepatitis
CA125 raise associated with which cancer?
86% of ovarian tumours have this
Tumour marker produced by hepatocelluar carcinoma, some teratomas, prognosis?
Alpha fetoprotein++ = poor prognosis
HCG raised in which tumours?
Hydatiform mole and choriocarcinoma, elevation of specific B units in non seminomatous testicular cancer.
What is the value of PSA tyesting?
Can be raised from prostate exam, UTI or BPH, useful in assessing response however.
Immunoglobulins role in cancer diagnoses?
Can be present with myelomas, also bence jones proteins in urine. Occasionally raised in non hodgkins.
% patients curative with surgical resection?
Which metastatic sites may be resected curatively in metastasis?
Solitary lung masses from sarcomas, localises liver mets from colorectal.
What is neoadjuvant chemo, and why?
Chemo before a surgery, shrink tumour, better margins- established in osteosarcomas, being tested elsewhere.
Primary chemo uses?
Inoperable, uncertainty, may make surgery with curative intent feasible
Adjuvant chemo uses?
Treatment of micromets after surgery = higher survival
Curative chemo in which diseases?
Often childhood, germ cells or lymphomas... often more intensive treatments.
Principles of multi drug chemo regimes?
significant single agent activities, non overlapping toxicity, different mechanisms.
What is high dose chemo, problems and treats what?
Chemo requiring bone marrow support, often through transplantation of bone marrow or stem cells. Can be curative in disease such as lymphoma, myeloma and leukaemias also germ cell tumours. Significant morbidity and mortality- 1-2%
After how many days post chemo does bone marrow suppression often occur and what is lowest point known as?
10-14 days - lowest point of drop know as nadir
Neutrophil count significant infection
Recovery of bone marrow occurs how long after?
3-4 weeks, matches with cycles of chemotherapy
Paralytic ileus may occur with which drugs?
Vinca alkaloids, and platinum based
What may be used to reduce hair loss in chemo?
Platinum, vincas ands taxanes often cause which neuro complications?
Residual defect of the peripheral sensory nerves, sometimes recovers but often doesnt.
Ifosamide and 5fu may be associated with CNS toxicity such as?
Encephalopathy and cerebellartoxicity.
High tone hearing loss may be associated with which chemo?
Cisplastin, pre-existing damage precludes use
Bladder toxicity caused by?
cyclophosphamide and isofamide
Cisplatin and isofamide
Cardiac toxicity associated with which chemos?
Doxirubicin and paclitaxel = arrhythmia
Coronary artery spasm can be a complication of which chemo?
Chemo causing photosensitivity?
Pulmonary fibrosis and pigmentation caused by which chemo abx?
Most common type of chemo to cause secondary malignancies?
Infertility is caused by which agents?
Pneumonitis associated with which type of chemo?
Haemoglobin below what level prompts consideration for transfusion in cancer patients?
10g/dl, can be associated with lower quality of life
Thrombocytopaenia levels and when to take action?
Below 10= take action significant risk of spontaneous bleed
10-20 usually supported with transfusion especially when infections are present
20+ not routinely requiring transfusions
Most frequent complication of myelosuppression?
Total white cell count below what with fever requires in patient management?
Trastuzumab (herceptin) used for what?
Her2+ disease in breast cancer
Ipilimumab used in what metastatic disease?
CLL and non hodgkin can use what monoclonal antibody?
What do tyrosine kinase inhibitors end with (drug name) ?
"ib" eg Sunitinib
What do Mtor inhibitors end in (drug name)
"us" eg everolimus, useful in renacl cell and metastatic breast disease
Goserelin, what does it do, useful for what?
Block sex hormones, useful in some breast and prostate cancers
How does tamoxifen work?
Blocks the action of oestrogen
Example of a steroidal anti androgen?
Cyroterone acetate, inhibit andrgoen in tumour and substitute for testosterone in hypothalamus = negative feedback.
Approx what % of patients are cured with radiotherapy?
How does radiotherapy work v briefly?
Electrons fired with a linac, secondary electrons in body made "free radicals" destroys DNA growth stops. Normal cells can repair usually cancer cells defective
What is the small dose of radiotherapy called?
The full dose of radiation to be delivered is measured in what unit?
What is concurrent chemotherapy thought to do ?
Act as a radiosensitiser and enhance the response to radiotherapy.
Acute effects of radiotherapy treatment?
Diarrhoea, mucositis and local skin irritation
Late effects of radiotherapy when ?
3 months plus, effects can last years, include lung fibrosis, infertility and skin atrophy
What are the 3 phases of clinical trials?
phase 1 -establish toxicity and maximum dose, disease response not an end point
phase 2- assess anti tumour activity, no control, tumour shrinkage is outcome usually
phase 3- comparing new with conventional treatments, randomised
A screening test for cancer ideally would...?
Detect early, sensitive and specific, tolerated, easy to administer, inexpensive, and publicised.
What is the most effective screening program?
When are womern invited for smears?
25-49 every 3 years and 49+ every 5 years (in england)
When and to whom is mammography offered?
47-70 years every 3 years although over 70 can request still
Bowel screening takes place what ages? what does it do?
Faecal occult blood, every 2 years, ages 60-69 (extended to 74 in england.
What % of cancer patients have pain?
Describe bone pain and management in cancer?
dull, widespread ache or tenderness over bone. NSAIDS, radiotherapy and bisphosphonates
Describe visceral cancer pain, treatments too?
Dull, deep seated, poorly localised. Can be spasmodic or over organ areas,colicky pain = anticholinergic (buscopan), capsule pain = steroids other pain = opiates usually.
Raised ICP headache features and treatment?
Worse on coughing, when waking, bending forward sneezing nausea and vomiting also. often treated with steroids, NSAIDs and paracetamol.
Describe neuropathic pain?
Altered sensation, less defined areas, numbness, pallor sweating tingling burning. Anti convulsants help gabapentin etc also TCA amitryptiline... steroids helpful for compression
Side effects of opiates?
Constipation, drowsiness (on dose change), confusion (rarely hallucination), resp depression, addicition and dependance, nausea and vomiting
Two forms of morphine? how long acting? examples?
Immediate release- 4hrs relief, extended up to 12hrs relief. Immediate- sevredol and oramorph
extended- zomorph MST continus
Max strength codeine switching to morphine extended approx dose?
Renal impairment alternatives to morphine?
What fraction of total dose should breakthrough dose be in morphine?
Converting oral morphine to diamorphine subcut would require dividing by what?
3 as diamorphine is 3 times as potent
Subcut morphine is how much as potent as oral morphine?
Twice so divide oral by 2 to get sc dose
Megestrol acetate and dexamethasone may be used to promote what?
Eating though effects often wear off
4 main causes of vomiting?
Cerebral, Gastric, Toxic, indeterminate
Gastric stasis anti emetic?
Toxic nausea causes?
drugs, infection, uraemia, hypercalcaemia
Treatment for toxic vomiting?
Haloperidol 1.5-5mg nocte (sedative effect)
Cerebral causes of vomiting?
raised ICP, tumour, morning headache, vomiting without nausea
Cerebral vomiting treatment?
Dexamethasone 8-16, and or cyclizine 50mg tds
Anticipatory nausea treatments?
Benzos, CBT and therapy
Intractable or unknown cause vomiting consider?
Levopromazine 6.25-12mg (very sedating)
How often should laxatives be reviewed in palliative care?
Stool softener examples?
Docusate and lactulose
Bulk forming laxatives use in palliative?
Senna and dantron
Combination laxatives used in palliative?
Movicol + co-danthramer
What is co-danthrusate?
Danthramer + docusate
What may ocreotide be used for in cancer patients?
Causes of sudden onset dyspnoea in cancer patients?
Asthma, Pulmonary oedema, PE
SOB arising over days in cancer pts?
COPD exacerbation or pneumonia, bronchial obstruction, SVC obstruction
Gradual on SOB in cancer pts?
Anaemia, pleural effusions, ascites, Lymphangitis
Common cancers causing spinal compression?
Breast, prostate and bronchus
Where do 2/3 of metastatic spinal lesions occur?
Signs and symptoms of spinal compression?
Back or nerve root pain, weakness, bladder and bowel dysfunction (late sign insidious), "walking on cotton wool"
Painless bladder distention, increased reflexes below lesion.
How soon should MRi be done if suspecting compression? What given?
Within 24hrs, give dex (16mg)
Definitive management of compression of cord?
Radiotherapy, surgery, combination
Symptoms and signs of SVC obstruction? Causes?
usually bronchial/lymphoma tumour but any solid tumour can cause it.
Headache, fullness in head, facial swelling, SOB, hoarseness, engorged vessels neck and chest
SVC obstruction treatment?
Commence high dose dex, stenting treatment of choice often chemo and radio also given
Hypeercalcaemia associated with what?
Usually breast, lung myeloma and scc's but any tumour can cause it. Do not need bone mets to have hypercalcaemia
Symptoms of hypercalcaemia?
Malaise, anorexia, polyuria, polydipsia, N&V, constipation, confusion, fits, coma.
Initial management of hypercalcaemia?
Rehydrate with IV fluids.
Definitive management of hypercalcaemia?
IV bisphosphonates zolendronic acid, 70% respond to treatment
Most common female cancer?
Breast- 19% of all female cancers.
Risk factors for breast cancer?
Increased age, (more oestrogen)> null parity, early menarche, late menopause obesity
HRT, radiation, BRCA,
Most common breast cancer type/
How are breast cancers graded?
Due to differentiation - 1 being good 3 being poor
Common presentation of breast cancer?
Lump- less commonly nipple changes and discharge or metastatic disease.
What is triple assessment?
history imaging and then biopsy if needed (USS best in <35years)
Primary management of localised breast cancer?
Surgery, mastectomy or conservative wide local exision, assessment of local nodes
When is radiotherapy offered with breast cancer?
After surgery and sometimes in mastectomy pts if large mass was found, if full axillary node clearance has occurred should not use radiotherapy. Sentinel node biopsy increasing use
Factors to consider for systemic therapy of breast cancer?
Hormone status receptors, menopause, previous response, performance status.
What is tamoxifens roles?
Blocks oestrogen provides benefit to recurrence in oestrogen positive cancers. Reduced contralateral cancer seen regardless of ER Status.
Tamoxifen side effects/risks?
Increased endometrial cancer, and thrombotic problems.
Aromatose inhibitors useful when and how/
Block oestrogen, superior to tamoxifen in post menopausal women, can be used after 2-5years of tamoxifen to continue the effects. Can cause osteoporosis
HER 2 treatment?
Trastuzamab (herceptin helpful)
Ovarian ablation why and how?
Chemo induced menopause or oopherectomy to reduce the oestrogen
Metastatic patients who responds best to endocrine treatments?
ER positive 50-60%
Poor prognosis factors for breast cancer?
ER negative HER2 positive, higher grades >5cm size lymph involvement
How common lung cancer?
2nd most common after the most common breast and prostate in men and women.
Risk factors for lung cancers?
Smoking (80-90% cases) Age, occupational exposures
Most common lung cancer type?
Small cell cancers often associated with what ?
Neuroendocrine secretion, acth or adh
% lung cancer seen on xray? % sputum cytology?
95% and 80%
Chance of metastasis in SCLC?
very high early on
Management of Small cell?
Chemo 99% response with combined chemo but often relapse after 12 months with resistant disease. rarely surgical
Radiotherapy value in small cell?
Adjuvant primary treatments, cranial to avoid mets and palliative
Prognosis of small cell?
2-4 months or 11 with treatment
Management of non small cell?
Most die within a year, although stage 1 and 2 resections have good prognosis over 5 years(80%)
Surgery useful in what % of non small?
30% mediastinal involvement usually precludes surgery
Use of radio in nsclc?
Can help but only 20% survival in stage 1/2
Chemo for non small cell?
Limited effectiveness up to 30% response but duration is short.
Risk factors for colorectal cancer?
Diet, rich in animal fats and meat, poor in fibre common in western world.Inflammatory diseases, Familial conditions.
% cancers in rectum?
Majority of colon cancer what type?
How many rectal tumours can be felt?
Tumour marker for colorectal?
CEA, but not diagnostic
A-wall confined, B- invading through C-lymph node involvement D-Metastases
Usual treatment for colon cancer?
Radical resection, early stage usually achieves cure
Radiotherapy value colorectal?
Usually used in rectal tumours
Chemo for colorectal?
Yes role in dukes stage C not great evidence to suggest dukes B benefit. 5 FU most active agent.
Prognostic factors for colorectal?
Lower age <40 possible more aggressive tumour
Screening for colorectal?
60-74 year old faecal occult blood 10% detected 44% in early stages
Incidence of testicular cancer what ages?
15-45 years 20/million population
Risks for testicular cancer?
Non descended testicles, family history or atrophy of testicle
What type of tumour most testicular and cure rate?
Germ cells 95% high cure rate divided in to non semitous 60% and seminomas 40%
Investigations for testicular cancer?
USS, bHCg raised in seminomas and non seminomas up to 75% patients. Alpha fetoprotein only if non seminomatous present. LDH can be helpful to monitor progress.
Main treatment for testicular cancer?
Orchidectomy through inguinal canal for treatment and biopsy
Chemo for testicular cancer?
Can use one dose carboplatin for seminoma
Non seminoma 2 cycles (BEP bleo etop and cisplatin) very intense
Value of radiotherapy testicular?
Para aortic nodes, but one dose carboplatin has been show to be just as effective and less complications.
Prognostic factors testicular?
Highly raised markers seminos >4cm Pulmonary metastases not affecting prognosis
Incidence of prostate cancer in white and black males?
Most common cancer in men 1/8 white males 1/4 black males.
Aetiology of prostate cancer?
No clear links, diet, BRCA2 and steroid use may be linked
Type of cancer prostate and where?
Adenocarcinoma usually posterior of the prostate- BPH often central
Gleason grading scale?
T1- no palpable mass T2 cancer within, T3 cancer breaching capsule T4 cancer extending out of capsule(rectum/bladder)
Symptoms of prostate cancer?
Usually asymptomatic, poor stream, dribbling, nocturia, frequency or metastatic features
Main treatment for prostate cancer?
Observation is best if confined to prostate, raised psa but no clinical signs is unknown evidence
Surgery options for prostate cancer?
Can resect but significant mortality, trans urethral resection palliatively used or to help urinary symptoms.
Radiotherapy in prostate cancer uses?
Can be used as adjuvant, can be alternative to surgery should be at least 6/52 after TURP to avoid strictures.
Hormonal treatment for prostate cancer?
Can be effective in reducing androgens and work in up to 80%. May be used to downsize/grade tumour prior to surgery. Eamples goserelin. Anti androgens cyproterone acetate.
Chemo for prostate cancer?
Docitaxel and carbazitaxel improves quality of life in metastatic disease.
Prognosis prostate cancer?
good usually if not advanced, serum psa high correlates with worse prognosis.
% pts with unknown primary, what needs to be thought about?
10% holistic approach, fitness, co-morbidities, probable sites and patient wishes need to be thought about.
Most likely site of unknown adenocarcinoma?
GI breast ovary lung
Squamous unknown primary could be?
Lung head and neck
Young men midline disease think what cancers?
possible germ cell tumour which may be cured!
Women with axillary or thoracic nodes but no known primary?
Treat as breast cancer
Women with abdominal carinamatosis?
Treat as ovarian
men with bony mets treat?
Multiple medium sized nodal areas no known primary?
Treat as lymphoma
Treatment basis of unknown cancers?
Epirubicina nd platinum based cover msot solid tumours and 5fu for GI. Radiotherapy may be given for palliation