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Cancer Care Flashcards

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1
Q

What are the risk factors for breast cancer?

A 
Female
Increasing age
Family history
High alcohol consumption
Previous history
Oestrogen exposure: obesity post-menopause, early menarche/late menopause, nulliparity
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2
Q

What are the symptoms of breast cancer?

A 
Lump or thickening in breast
Change in size or contours
Discharge/bleeding from nipple
Change in colour of areola
Redness or rash
Peau d'orange
Pulled in nipple
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3
Q

What is the UK screening programme for breast cancer?

A

47-73 yo women
Every 3 years
Mammogram

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4
Q

How is breast cancer diagnosed?

A

Triple assessment:
Clinical - inspection and palpation
Radiological - mammograms & USS
Pathological - FNA / core biopsy

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5
Q

Who should have mammograms and why?

A

Older than 40

More adipose tissue than younger women, whose breast tissue is more dense

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6
Q

What should you look for on mammography?

A

Irregular, speculated radiopaque mass

Microcalcification

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7
Q

What are the advantages of FNA over core biopsy?

A

Quick

Less uncomfortable

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8
Q

What is the most common type of breast carcinoma?

A

Invasive ductal carcinoma

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9
Q

What types of surgery are used for breast cancer?

A

Breast conserving surgery
Mastectomy
Oncoplastic

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10
Q

When is breast conserving surgery used?

A

Smaller tumour size relative to breast
Usually peripheral tumour
Requires adjuvant radiotherapy to remaining breast

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11
Q

What are the different types of Oncoplastic breast surgery?

A

Volume replacement

Volume displacement

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12
Q

What is sentinel node biopsy?

A

Taking a sample from the 1st lymph node in the direct drainage pathway of the primary tumour

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13
Q

What are the complications of axillary clearance surgery?

A

Lymphoedema
Shoulder stiffness
Numbness

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14
Q

Which patients require radiotherapy for breast cancer?

A

All patients who have breast conserving surgery
Chest wall in high-risk mastectomy patients
To axilla and supraclavicular fossa in certain cases

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15
Q

What is the mechanism of action of tamoxifen?

A

Mixed agonist and antagonist at the oestrogen receptor

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16
Q

What are the risks of tamoxifen?

A

Increased risk of DVT and endometrial cancer

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17
Q

When is chemotherapy used in breast cancer?

A 
Grade 3
Younger than 50
Tumour bigger than 5cm
Triple negative
Lymph node positive
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18
Q

What are the poor prognostic factors for breast cancer?

A 
Young age
Large tumour size
High grade
Oestrogen receptor negative
Positive lymph nodes
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19
Q

What is the lifetime risk for breast cancer in UK females?

A

1 in 8

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20
Q

What is the principle of the mechanism of action of chemotherapy agents?

A

Interferes with an essential step required for the 6 properties of cancer cells
Damaged cell unable to repair the damage and will apoptose

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21
Q

What are anthracyclines?

A

Topoisomerase inhibitors

Prevents the enzyme from replicating cleaved DNA

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22
Q

What are alkylation agents?

A

Form cross links in DNA to interfere with cellular replication

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23
Q

What are anti metabolites?

A

Disrupt synthesis of essential compounds required for cell synthesis
Eg methotrexate inhibits DHFR

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24
Q

What are vinca alkaloids?

A

Bind to tubulin to prevent formation of the mitosis spindle

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25
What are the general side effects of chemotherapy?
``` Myelosuppression GI effects Skin damage inc alopecia Organ damage Gonadal failure Teratogenicity Neurotoxicity Nausea and vomiting Tumour lysis syndrome ```
26
What are the clinical consequences of myelosuppression?
Infection Anaemia Bleeding
27
At what stages of chemotherapy can nausea and vomiting occur?
Acute Delayed Anticipatory
28
Why can cancer recur after apparent complete remission?
Technical inability to measure fewer than 10^3 cells
29
How does radiotherapy work in cancer?
Ionises chemicals within cells Causes DNA strand breakage Leads to apoptotic or mitotic cell death
30
What is the main difference between palliative and radical radiotherapy?
Palliative uses lower doses to minimise side effects
31
Why is radiotherapy given in fractions?
Allows normal tissues to recover between treatment, but malignant cells don't recover
32
What are the side effects of radiotherapy?
``` Mucositis Hair loss and desquamation of skin Dysphagia Nausea and vomiting Radiation cystitis and dysuria Fatigue Late: second cancers eg leukaemia ```
33
How is neutropenic sepsis diagnosed?
Patients having anti-cancer treatment with neutrophils 38
34
Which patients are particularly high risk for neutropenic sepsis?
Chemotherapy Extensive field radiotherapy Haem conditions eg leukaemia, lymphoma, MDS
35
What are the common causative organisms for neutropenic sepsis?
Staph aureus Staph epidermidis Enterococcus Streptococcus
36
What is the management of neutropenic sepsis?
High-flow O2 Blood cultures / urine culture / wound swabs / line cultures IV Tazocin 4.5g IV fluids FBC, UEs, LFTs, clotting, lactate (ABG), CRP
37
What is used for prophylaxis for neutropenic sepsis?
GCSF - granulocyte stimulating factor
38
What do you need to tell patients about neutropenic sepsis?
Warn of signs | Give details of 24hr number to call if they develop an infection or become unwell
39
What is MSCC?
Compression of the dural sac and its contents (spinal cord or cauda equina) by an extra dural tumour mass
40
What tumours commonly metastasise to the spine?
``` Bronchus Breast Prostate Kidney Haem: myeloma and NHL ```
41
What is the commonest tumour site in the spine?
Vertebral body
42
What are the symptoms of MSCC?
Back pain Weakness Sensory deficit Autonomic dysfunction
43
What is the investigation of choice for MSCC?
MRI whole spine
44
What is the management for MSCC?
Dexamethasone 16mg stat then 8mg BD Radiotherapy Surgery
45
When is surgery used to treat MSCC?
``` Single vertebral involvement No evidence of widespread disease Patient will live longer than 3 months Tissue needed for histology Tumour type not radio sensitive ```
46
What is the median survival following cord compression?
3-6 months
47
What are the common malignant causes of SVCO?
Lung cancer | Lymphoma
48
What are the symptoms of SVCO?
``` Swelling of face neck and 1/both arms Distended neck and chest wall veins Shortness of breath Headache Lethargy ```
49
What are the investigations for SVCO?
CXR CT with contrast Angiography
50
What is the treatment for SVCO?
Prednisolone Chemo or radiotherapy depending on tumour type Stenting - rapid relief of symptoms
51
How does malignancy cause hypercalcaemia?
Production of PTHrP Osteolytic metastases Calcitriol production
52
What are the symptoms of hypercalcaemia?
``` Moans, stones, groans Nausea, anorexia, thirst Polydipsia and polyuria Constipation Confused, poor concentration, drowsy ```
53
What investigations would you do if you suspect hypercalcaemia?
``` Calcium - normal range 2.1-2.6 Albumin - to calculate corrected calcium U&Es PTH/PTHrP Phosphate Myeloma screen if no known malignancy ```
54
How do you manage hypercalcaemia?
IV normal saline | Bisphosphonates - 60-90mg pamidronate IV
55
What are the biochemical abnormalities seen in tumour lysis syndrome?
``` Hypeuricaemia Hyperkalaemia Hyperphosphataemia AKI HypOcalcaemia ```
56
Why does tumour lysis syndrome require rapid treatment?
Can progress to life-threatening metabolic disorders or renal failure
57
Which tumour types are particularly susceptible to tumour lysis syndrome?
``` High-grade lymphoma Acute lymphoblastic leukaemia Myeloma Germ cell tumours Small cell lung cancer Inflammatory breast cancer ```
58
What are the patient risk factors for tumour lysis syndrome?
Pre-existing renal dysfunction Hypovolaemia Pre-treatment LDH high Urinary tract obstruction from tumour
59
When does tumour lysis syndrome commonly present?
Day 3-7 post-chemotherapy
60
What is the management for prevention/treatment of tumour lysis syndrome?
Hydration before and during treatment Allopurinol Rasburicase Haemodialysis
61
How does allopurinol work?
Xanthine oxidase inhibitor - reduces uric acid
62
How does rasburicase work?
Synthetic uricase. Converts uric acid to allantoin
63
What is the amber care bundle?
``` Assessment Management Best practice Engagement Recovery uncertain ```
64
Give some physical clues to recognise a dying patient
``` Profoundly weak Gaunt Drowsy, disorientated, poor concentration Diminished oral intake Abnormal breathing patterns Skin colour or temperature changes ```
65
What are the main symptoms to address in anticipatory prescribing in palliative care?
``` Pain Nausea and vomiting Breathlessness Restlessness and agitation Respiratory tract secretions ```
66
What would you prescribe for noisy respiratory secretions?
Glycopyronium 200mcg SC PRN
67
What would you prescribe PRN for breathlessness?
2.5 - 5mg morphine SC
68
What would you prescribe for agitation?
Midazolam 2.5-5mg SC PRN
69
What should the dose of morphine be for a breathless patient already taking morphine for pain?
Half of their PRN dose
70
Other than morphine, what other drugs can be used to treat breathlessness?
Benzodiazepines eg lorazepam 0.5-1mg SL PRN
71
Define nausea
Subjective, unpleasant feeling of the need to vomit
72
What are the consequences of nausea?
Physical: dehydration, malnutrition, anorexia, weight loss, insomnia Psychological: anxiety, depression, anger
73
What are the most common causes of vomiting in palliative care?
Impaired gastric emptying Chemical and metabolic disturbances GI: bowel obstruction and constipation
74
What are the characteristics of vomiting caused by impaired gastric emptying?
Intermittent vomiting that relieves the nausea Reduced appetite and early satiety Post-prandial fullness/bloating Small vomits that may contain food
75
What are the causes of impaired gastric emptying?
Locally advanced cancer, lymph nodes, liver mets Morphine, anticholinergics Gastroenterostomy Autonomic neuropathy
76
What are the characteristics of vomiting caused by chemical and metabolic disturbances?
Persistent nausea Aggravated by the sight or smell of food Nausea unrelieved by vomiting
77
What chemical and metabolic disturbances can cause N & V?
``` Drugs: opioids, antibiotics, SSRIs Renal/hepatic failure Hypercalcaemia Hyponatraemia Sepsis Tumour toxins ```
78
What are the characteristics of vomiting caused by bowel obstruction/constipation?
Intermittent vomits that may relieve nausea Abdo cramps Altered bowel habit Abdo distension
79
What is the mechanism of action of haloperidol?
Dopamine antagonist
80
What is the dose of haloperidol?
1.5-5mg/d
81
What are the side effects of haloperidol?
Restlessness Sedation Parkinsonism
82
What types of N&V is haloperidol used to treat?
Metabolic or drug causes
83
What is the mechanism of action of metoclopramide?
Dopamine antagonist
84
What is the dose of metoclopramide?
10-20mg TDS
85
What are the side effects of metoclopramide?
Restlessness | Parkinsonism
86
What is the mechanism of action of domperidone?
Dopamine antagonist
87
Where are D2 receptors found in the brain?
Chemoreceptor trigger zone
88
What is the mechanism of action of cyclizine?
Antagonist at ACh and H1 receptors
89
What is the dose of cyclizine?
50mg TDS
90
What are the side effects of cyclizine?
Hypotension Urinary retention Dry mouth Constipation
91
What is the mechanism of action of ondansetron?
5HT3 receptor antagonist at vagus afferent nerve
92
What is the dose of ondansetron?
4-8mg BD/TDS
93
What are the side effects of ondansetron?
Constipation | Headache
94
What are the indications for ondansetron?
Chemo-induced | Bowel obstruction
95
Where is the vomiting centre?
Medulla
96
What receptors are found in the vomiting centre?
ACh H1 5HT3
97
Where is the chemoreceptors trigger zone?
Area prostrema - 4th ventricle
98
What drugs would you chose for vomiting caused by gastric stasis?
Metoclopramide | Domperidone
99
What drugs would you chose for vomiting caused by intestinal obstruction?
Dexamethasone | Cyclizine
100
Give 3 examples of weak opioids
Codeine Tramadol Dihydrocodeine
101
Give 4 examples of strong opioids
Morphine Fentanyl Oxycodone Pet hiding
102
What is an adjuvant analgesic?
Drugs whose primary indication is not pain
103
What are the common side effects of opioids?
Constipation Nausea and vomiting Drowsiness/sedation
104
How do you calculate the standard release dose of morphine a patient requires?
Total daily dose divided by 2 This is the total amount of morphine they have had in the last 24hrs Given as BD
105
How do you calculate the PRN (breakthrough) dose of morphine a patient needs?
Total daily dose divided by 6
106
What is the most common preparation of oramorph?
Liquid, 10mg/5ml
107
How long does oramorph take to work, and how long do its effects last?
30-40mins to work | Lasts 2-3hrs
108
What is the ceiling dose of codeine?
240mg/day
109
How does a dose of codeine equate to morphine?
1:10 morphine:codeine | So 240mg codeine = 24mg morphine
110
How does OxyContin relate to morphine?
OxyContin is twice as strong as morphine
111
What is important about opioid prescribing in renal impairment?
No standard release morphine, as this builds up Longer lock-out time for oramorph PRNs Consider fentanyl rather than morphine
112
How do you write a controlled drug prescription?
Name + Form + Strength + Total amount of drug in words AND figures Eg supply 56 (fifty six) 10mg tablets zomorph
113
What are oncogenes?
Increase activity in the absence of a relevant signal | Dominant manner - mutation to one allele results in continuous unchecked activation
114
What are tumour suppressor genes?
Inhibitors of cellular growth | Mutation to both alleles must occur before cellular effects are evident: 2-hit hypothesis
115
What percentage of breast cancers are due to mutated BRCA genes?
5-10%
116
What type of genes are BRCA?
Tumour suppressor genes
117
What is the lifetime risk of developing breast cancer for a carrier of the mutated BRCA1 gene?
65%
118
What is the lifetime risk of breast cancer for a carrier of the mutated BRCA2 gene?
45%
119
What is the lifetime risk of developing ovarian cancer for a carrier of the mutated BRCA1 gene?
40%
120
What is the lifetime risk of ovarian cancer for a carrier of the mutated BRCA2 gene?
11%
121
What are the different types of familial colorectal cancer?
Familial adenomatous polyposis Peutz-Jeghers syndrome Hereditary non-polyposis colorectal cancer
122
What cancers are involved in HNPCC?
``` Colorectal Uterine Ovarian Stomach Renal pelvis Small bowel Pancreas ```
123
What gene is involved in FAP?
APC gene
124
What type of radiation causes direct DNA damage?
UV-B Rays
125
What should you look for on examination of a mole?
``` Asymmetrical shape Irregular border Changes in colour Diameter - new growth >6mm Evolution ```
126
What is the Breslow depth?
For melanoma, the distance the lesion goes below the basement membrane
127
How does Breslow depth relate to prognosis?
4mm - 4y survival 50%
128
What is lentigo maligna?
Melanoma in situ
129
What conditions are pre-malignant for squamous cell carcinoma?
Actinic keratosis | Bowens disease
130
How does squamous cell carcinoma present?
Ulcerated lesion Hard, raised edges In sun-exposed sites
131
How is SCC treated?
Excision and local radiotherapy
132
How is basal cell carcinoma managed?
Excision and radiotherapy if >60y Doesn't metastasise but can cause problems due to local erosion No 2ww, normal referral is fine as they won't change in this time

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