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Cancer care Flashcards

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1
Q

How is breast cancer classified?

A

ductal v lobular

in situ v invasive

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2
Q

What are the risk factors for breast cancer?

A

age
BRCA genes - 40% lifetime risk of breast/ovarian cancer
1st degree relative premenopausal relative with breast cancer (e.g. mother)
nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
early menarche, late menopause
hormone replacement therapy,, combined oral contraceptive use
past breast cancer
not breast feeding
ionising radiation
p53 gene mutations
obesity

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3
Q

Define carcinoma in situ

A

contained within the basement membrane of the tissue

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4
Q

What is the most common type of breast cancer

A

invasive ductal carcinoma

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5
Q

Describe the breast cancer screening programme

A

women aged 47-73 years f
offered a mammogram every 3 years.

After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.

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6
Q

What features make it more likely that a person is at high risk of a familial breast cancer?

A

Family history of:

age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative younger than age 45 years
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal history of breast cancer (two or more relatives on the father’s side of the family)

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7
Q

What are the common presentations of breast cancer?

A 
lump
erythema - not high temp
nipple retraction
change in shape
dimpling
axillary lymphadenopathy
discharge
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8
Q

What is triple assesssment

A

hospital-based assessment clinic that allows for the early and rapid detection of breast cancer.

referred by their GP if they have signs or symptoms that meet the breast cancer “2 week wait” referral criteria, or if there has been a suspicious finding on their routine breast cancer screening mammography.

clinical
imaging
pathological

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9
Q

Describe the clinical aspect of the triple assessment

A

history - presenting complaint, any potential risk factors, family history and current medications.
examination -

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10
Q

Describe the imaging aspect of the triple assessment

A

Mammography
or
Ultrasound scanning

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11
Q

What are the benefits of USS assessment of the breast

A

more useful in women <35 years and in men, due to the density of the breast tissue in identifying anomalies.

routinely used during core biopsies.

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12
Q

How is mammography undertaken?

A

involves compression views of the breast across two views (oblique and craniocaudal),

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13
Q

How is a cancer seen on mammography?

A

mass lesions

microcalcifications.

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14
Q

Describe the pathological aspect of the triple assessment

A

biopsy!

core or FNA

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15
Q

What are the differences between core and FNA biospy

A

A core biopsy provides full histology wheras fine needle aspiration (FNA) only provides cytology - allowing differentiation between invasive and in-situ carcinoma.

A core biopsy also gives tumour grading and staging,

Core biopsy has higher sensitivity and specificity than FNA for detecting breast cancer.

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16
Q

How is the triple assessment graded and used?

A

Each part is given a score out of five.

P = examination, M = mammography, U = USS, B = biopsy

P1 – Normal	
P2 – Benign	
P3 – Uncertain/likely benign	
P4 – Suspicious of malignancy
P5 – Malignant etc

Aim is to establish whether this is likely a benign lesion or whether the patient should go onto have more definitive biopsy and further intervention.

Cases suspicious for breast cancer are discussed by the MDT to create a suitable treatment plan

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17
Q

What are the treatment options for breast cancer?

A

Surgery

  • breast conserving
  • mastectomy
  • sentinel node biopsy
  • axillary clearance

Hormonal

  • tamoxifen
  • aromatase inhibitors
  • immunotherapy
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18
Q

Describe breast conserving surgery for breast cancer and who it is suitable for

A

A Wide Local Excision (WLE) involves excision of the tumour, ensuring a 1cm margin of macroscopically normal tissue is taken along with the malignancy.

This option is only suitable for:
single cancers <4cm in diameter with no metastatic disease
peripheral tumour

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19
Q

Describe mastectomy for breast cancer and who it is suitable for

A

mastectomy removes all the tissue of the affected breast, along with a significant portion of the overlying skin, with the muscles of the chest wall left intact.

Mastectomies are indicated when:
multifocal tumour
central tumour
large lesion in small breast
>4cm
patient choice.
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20
Q

Describe sentinel node biopsy for breast cancer and who it is suitable for

A

A sentinel node biopsy involves removing the nodes responsible for draining the tumour; the nodes are identified by injecting a blue dye with associated radioisotope into the skin overlying the malignancy.

A radioactivity detection or visual assessment (for the nodes which become blue) is then carried out to establish the location of the sentinel nodes. Once identified the nodes are removed and sent for histological analysis.

Performed alongside WLE and mastectomies, in order to assess the sentinel lymph node, as this indicates prognosis of the disease.

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21
Q

Describe axillary clearance for breast cancer and who it is suitable for

A

Axillary node clearance involves removing all nodes in the axilla, being careful not to damage many important structures located in the axilla.

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22
Q

What are the complications of axillary clearance for breast cancer?

A

Common complications from this operation include paresthesia, seroma formation, and lymphedema in the upper limb.

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23
Q

Explain the use and mechanism of tamoxifen

A

used typically if an aromatase inhibitor is not appropriate. and can be used pre-menopausally or peri-menopausally

It acts through blockade of oestrogen receptors at the cell nucleus, preventing the cancer cell proliferation and growth.

However, it is known to increase the risk of thromboembolism during and after surgery or periods of immobility.

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24
Q

What are the risks of tamoxifen use?

A

increased risk VTE, endometrial cancer and menopausal symptoms.

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25
Explain the use and mechanism of aromatase inhibitors in breast cancer
Used in post menopausal women Prevent conversion androgens made in peripheral tissues into oestrogen. Therefore inhibits further malignant growth of the tumour. NOT for use in pre menopausal women
26
Explain the use and mechanism of immunological therapy in breast cancer
block HER2 receptor - human epidermal growth factor receptor. stops them from receiving growth signals. By blocking the signals, Herceptin can slow or stop the growth of the breast cancer. given IV or SC and forms part of adjuvant therapy, or can be administered as monotherapy in patients who have received at least two chemotherapy regimens for metastatic breast cancer
27
How many tumours are HER2 postitive?
20-25%
28
What factors determine the prognosis of breast cancer
extent of nodal involvement is best prognostic indicator NPI = nottingham prognostic indicator. takes into account size, grade and number of nodes involved.
29
How is breast cancer followed up?
surveillance imaging - yearly mammogram for 5 years
30
What are some differentials for breast cancer?
``` breast cysts fibroadenoma and other benign cysts firbocystic changes mastitis breast abscess gynaecomastia in males ```
31
What is Paget's disease?
Paget’s disease of the nipple is roughening, reddening, and slight ulceration of the nipple related to ductal carcinoma of the breast. Microscopically there is involvement of the epidermis by malignant ductal carcinoma cells.
32
What are the signs and symptoms of paget's disease?
itching or redness in the nipple and/or areola, flaking and thickened skin flattened nipple, yellowish or bloody discharge
33
How can Paget's disease and Eczema be differentiated?
Paget’s disease always affects the nipple and only involves the areola as a secondary event, Eczema nearly always only involves the areola and spares the nipple.
34
Define febrile neutropenia
oral temperature ≥38.5°C or two consecutive readings of ≥38.0°C for two hours and an absolute neutrophil count ≤0.5 x 109/L.
35
When is neutropenic sepsis most common
5-10days after chemo
36
What is the immediate management of neutropenic sepsis
``` A B - 15L oxygen if sats low C - insert cannulae, bloods, fluids, ABX D - catheterise E - check for rashes ``` Urgent consultant/registrar review
37
What investigations should be done in neutropenic sepsis
urine dip, FBC, U+E, ABG, LFT, CRP, lactate blood cultures, urine culture, sputum culture, line and wound swab culture, stool culture CXR, AXR
38
Which antibiotic is used empirically in neutropenic sepsis
Tazocin meropenem if penicillin allergic
39
What can be added to management of neutropenic sepsis if the patient has not improved after 3-7days on antibiotic therapy?
start antifungal if high risk and no identified cause of organism
40
What are the risk factors for neutripenic sepsis
``` >7 days of neutropenia severity of neutropenia comorbidities aggressive cancer central lines mucositis inpatient ```
41
When is GCSF used
in the management of neutropenic sepsis Granulocyte-colony stimulating factor (G-CSF or GCSF) stimulates the bone marrow to produce granulocytes and stem cells and release them into the bloodstream
42
Which cancers most commonly metastasise to the spine
prostate lung breast kidney, thyroid,
43
What are the symptoms and signs of spinal cord compression
back pain - worse on lying down and coughing lower limb weakness sensory loss and numbness neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
44
Why does spinal cord compression occur in cancer patients?
extradural spread from a vertebral body metastasis direct metastases vertebral crush fracture
45
Describe the immediate management of spinal cord compression
Nurse flat dexamethasone 16mg PO within 24 hours MRI within 24 hours Insert a catheter to manage bladder dysfunction. If definitive treatment of the cord compression is appropriate, it should be started before patients lose the ability to walk or before other neurological deterioration occurs, and ideally within 24 hours. Definitive treatment may be using surgery (eg, laminectomy, posterior decompression ± internal fixation) or using radiotherapy. Discharge should be fully planned and community-based rehabilitation and support should be available when the patient returns home. This includes support and any necessary training of carers and familie
46
What is the definitive management of spinal cord compression and who are these treatments suitable for?
radiotherapy - for those with extensive disease and poor physiological reserve surgery - laminectomy, posterior decompression ± internal fixation - for those with good prognosis, good performance status and good motor function
47
What are the benefits of giving radiotherapy for spinal cord compression
relieves compression! relieves pain stabilises (but does not improve) neurological deficit
48
What supportive care measures need to be given in spinal cord compression
``` analgesia laxatives bladder care VTE prophylaxos physio/OT monitor BMs - can rise after dexamethasone ```
49
Define hypercalcaemia
Corrected calcium >2.6
50
What can cause malignant hypercalcaemia
bone metastases - osteolytic myeloma, PTHrP from squamous cell lung cancer
51
What are the symptoms of hypercalcaemia
``` polydipsia polyuria dehydration thirst nausea and vomiting, anorexia, lethargy, bone pain, abdominal pain, constipation, confusion weakness ``` symptoms of renal stones!
52
How should hypercalcaemia be investigated?
ECG corrected calcium, albumin, PTH, alkaline phosphatase, U+E X-ray, bone scan
53
How can hypercalcaemia be seen on ECG
Cardiac arrhythmias, shortened QT interval
54
How is hypercalcaemia treated?
IV fluids - 0.9% sodium chloride IV bisphosphonates after rehydration (can cause renal failure) consider loop diuretic if fluid overload
55
Define tumour lysis syndrome
hyperuricaemia, hyperkalaemia, hyperphosphataemia and hypocalcaemia caused by the abrupt release of large quantities of cellular components into the blood following the rapid lysis of malignant cells.
56
When is tumour lysis syndrome most common?
within 1-5 days of starting chemotherapy (but can be delayed by days or weeks in patients with a solid tumour).
57
Which cancers are most at risk of tumour lysis syndrom
haematological - high grade lymphoma and leukaemia
58
What are the risk factors for tumour lysis syndrome
``` CKD gout treatment sensitive tumours dehydration High pre-treatment urate, lactate and lactate dehydrogenase (LDH) ```
59
What are the signs/symptoms of tumour lysis syndrome
seizures, acute kidney injury cardiac arrhythmias.
60
How can tumour lysis syndrome be prevented
Low-risk patients: vigilant monitoring of electrolyte levels and fluid status. Intermediate-risk patients: seven days of oral allopurinol along with increased hydration. High-risk patients: prophylaxis, usually with a fixed single dose of 3 mg rasburicase (recombinant urate oxidase), along with increased hydration.
61
What is the mechanism of action of rasburicase
Rasburicase is a recombinant version of urate oxidase, an enzyme that metabolises uric acid to allantoin. Allantoin is much more water soluble than uric acid and is therefore more easily excreted by the kidneys
62
What is the managenet of tumour lysis syndrome
``` admit to ITU/HDU IV fluids (without potassium). Daily rasburicase infusion. Intravenous calcium gluconate for symptomatic hypocalcaemia . Cardiac monitoring Dialysis may be needed in severe cases. ```
63
What are the causes of SVCO
``` Lung cancer (~85% of cases), lymphoma metastatic tumours ```
64
What are the signs and symptoms of SVCO
``` dyspnoea cough chest pain at rest swelling of the face, neck and arms conjunctival and periorbital oedema headache: often worse in the mornings visual disturbance pulseless jugular venous distension ```
65
What are the treatment options for SVCO
stenting chemotherapy Radiotherapy
66
Describe the pathophysiology of SVCO
external pressure from a tumour involvement of the vessel by tumour tissue, a blood clot obstructing the lumen
67
What investigations should be done for SVCO and what would be seen
CXR: this may reveal a widened mediastinum or a mass on the right side of the chest. CT scan
68
Which cancer most commonly causes hyponatraemia?
small cell lung cancer due to SIADH
69
What are the signs and symptoms of SIADH
Depression and lethargy. Irritability and other behavioural changes. Muscle cramps. Seizures. Depressed consciousness leading to coma. Neurological signs (such as impaired deep tendon reflexes and pseudobulbar palsy). Hyponatraemia
70
How is SIADH managed?
treat the lung cancer! | fluid restriction
71
State the TNM staging of bowel cancer
``` T1 = in submucosa T2 = through muscularis mucosa T3 = through subserosa T4 = into adjacent tissues ``` ``` N1 = 1-3 nodes N2 = >=4 ``` M1 = metastasis present
72
State Duke's staging colorectal cancer
A no deeper than submucosa B through muscle C nodes D mets
73
State the difference between adjuvant and neoadjuvant chemotherapy
adjuvant = after curative treatment to decrease risk recurrence neoadjuvant = given before treatment to decrease risk recurrence and shrink tumour to make it more operable
74
What is hte diffference between palliative and curative treatment
palliative = no intention to cure, but intention to treat symptoms curative = with intention of completely curing the cancer
75
What are the risk factors for skin cancer?
``` sun exposure skin type 1 age smoking multiple atypical moles organ transplant recipient ```
76
What are the worrying signs in a mole suggestiv eof malignant melanoma
``` Asymmetrical Borders - irregular, notched, scalloped Changes in colour Diameter >6mm Evolution - change in shape/size/colour ```
77
What is a prognostic indicatior in malignant melanoma
Breslow depth
78
What is the treatment for malignant melanoma
complete excision biopsy
79
What are the features of basal cell carcinoma
``` on sun-exposed sites pearly, flesh-coloured papule telangiectasia central destructive ulceration slow progression ```
80
What are the treatment options are there for basal cell carcinoma
``` compete excision biopsy curettage cryotherapy topical cream: imiquimod, fluorouracil radiotherapy ```
81
What are the features of squamous cell carcinoma
``` indurated ulcer/hard lump rapid growth large on sun exposed areas can metastasise ```
82
What are the risk factors for squamous cell carcinoma
excessive exposure to sunlight actinic keratoses and Bowen's disease immunosuppression e.g. following renal transplant, HIV smoking genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism
83
What is Moh's micrographic excision
removal of the skin layer by layer with staged mapping procedures
84
What are the features of actinic keratoses
premalignant skin lesion that develops as a consequence of chronic sun exposure small, crusty or scaly, lesions may be pink, red, brown or the same colour as the skin typically on sun-exposed areas e.g. temples of head multiple lesions may be present
85
What are the treatment options for actinic keratoses
prevention of further risk: e.g. sun avoidance, sun cream fluorouracil cream: typically a 2 to 3 week course. topical imiquimod: trials have shown good efficacy cryotherapy curettage and cautery
86
What are the side effects of fluorouracil cream
The skin will become red and inflamed
87
Which receptors are present at the chemoreceptor trigger zone?
D2 also NK1 and 5HT3
88
Which receptors are present at the vomiting centre?
H1, ACh also 5HT2 and NK1
89
Metaclopramide: Which receptors does it act on Where does it act When is it useful
D2 (5HT2) CTZ, gut. Gastric stasis (prokinetic), chemical N+V
90
Cyclizine Which receptors does it act on Where does it act When is it useful
ACh, H1 vomiting centre functional obstruction, opioid
91
Levomepromazine Which receptors does it act on Where does it act When is it useful
D2, 5HT2, ACh, H1 VC and CTZ broad spectrum
92
Ondanstron Which receptors does it act on Where does it act When is it useful
5HT3 CTZ post operative, opioid
93
Haloperidol Which receptors does it act on Where does it act When is it useful
D2 CTZ chemical
94
Domperidone
D2 CTZ chemical, also gastric stasis as prokinetic`
95
Which antiemetics are prokinetic
domperidone | metoclopramide
96
Which antiemetics are good for chemical N+V
haloperidol | metaclopramide
97
Which antiemetics are good for N+V caused by gastric stasis
domperidone | metoclopramide
98
Which antiemetics are good for N+V caused by functional bowel obstruction
cyclizine | dexamethasone
99
Which antiemetics are good for N+V caused by raised ICP
cyclizine | dexamethasone
100
What can cause nausea and vomitng
infection metabolic - renal or hepatic impairment, low sodium, hypercalcaemia, tumour toxins drug related - opioids, chemo, SSRI, gastric stasis - ascites, opioids, anticholinergics, GI disturbance - constipation, obstruction organ damage - distension, obstruction, radiotherapy neurological - raised ICP, motion sickness psychological - anxiety, fear
101
State the meaning of the PS grading
0= no symptoms from cancer. 1= minimal symptoms from cancer, patient able to complete light work without symptoms. 2= resting in bed/chair less than 50% of the day. 3= resting in bed/chair more than 50% of the day, able to mobilise to independently manage limited self care. 4= patient bed bound.
102
Give a atrategy for breaking bad news
Rapport - how are you doing today? Check they're okay to speak to you? Setting - anyone they'd like with them? Perception - what do they understand? Maybe give warning shots Invitation - Would the patient like to know the result now? Knowledge - explain in small chunks, checking understanding Emotions and empathy Strategy and Summary - next steps, reassurance of care, check understanding. Any questions Help with telling relatives Clinical nurse specialist, written info, online support groups
103
How can you try and communicate with an angry person
acknowledge anger!!! - "from my perspective, it seems that you're feeling quite frustrated by this whole situation" don't be threatening Tell me more! thank you for explaining that to me i can see why you'd feel that way i'm sorry that this situation has made you feel that way Anything I can do to help this situation? Explain Thank patient Plan going forwards
104
What medications can be prescribed for pain in the last few days of life?
Morphine 2.5-5mg s/c PRN or equivalent to oral PRN
105
What medications can be prescribed for dyspnoea in the last few days of life?
Midazolam 2.5-5mg s/c PRN | Morphine 2.5-5mg s/c PRN
106
What medications can be prescribed for secretions in the last few days of life?
Glycopyrronium 200mcg s/c PRN
107
What medications can be prescribed for agitation in the last few days of life?
Midazolam 2.5-5mg s/c PRN Haloperidol 1.5-2.5mg s/c PRN Levomepromazine6.25-12.5 mg s/c PRN
108
What medications can be prescribed for nausea in the last few days of life?
Haloperidol 0.5-1.5mg s/c PRN | Levomepromazine2.5-6.25mg s/c PRN
109
In summary, what should you prescribe for someone in the last few days of life
Midazolam 2.5-5mg s/c PRN for dyspnoea and agitation Morphine 2.5-5mg s/c PRN for pain and dyspnoea Glycopyrronium 200mcg s/c PRN Haloperidol 1.5-2.5mg s/c PRN for agitation Levomepromazine6.25-12.5 mg s/c PRN for agitation and nausea
110
What can be expected in the last few hours/days of life
``` more drowsy reduced appetite changes in breathing - Cheyne-Stokes breathing, noisy from secretion confusion and hallucinations loss of bladder and bowel control ```
111
Do DNACPR decisions need to be discussed with patients? How?
YES! | and write it in the notes!!!
112
What are the key points about DNACPR decisions that a patient should understand
Only 3% of over-80s survive CPR and 1.9% of secondary cancer patients. A decision about CPR will not affect the rest of your treatment. it is ultimately a medical decision, but we want to know your opinion
113
How might you explain what CPR is to a patient
Cardiopulmonary arrest means that a person’s heart and breathing has stopped. When this happens it is sometimes possible to restart their heart and breathing with an emergency treatment called CPR. CPR can include: • repeatedly pushing down very firmly on the chest • using electric shocks to try to restart the heart • artificially inflating the lungs through a mask over the nose and mouth or a tube inserted into the windpipe.
114
What are the risks of CPR
bruising, fractured ribs and punctured lungs. that it won't work That you will have long term health problems if it does work
115
Which drugs can be useful as adjuncts in pain relief?
``` Antidepressants; amitriptyline, duloxetine Anti-convulsants; gabapentin, pregabalin Benzodiazepines; diazepam, clonazepam Steroids; dexamethasone Bisphosphonates for bony pain ```
116
Which drugs can be prescribed for neuropathic pain relief
Amitriptyline start 10-25mg nocte Gabapentin 300mg TDS over 3/7 Pregabalin 75mg BD
117
Which drugs are in step 2 of the analgesic ladder
Dihydrocodeine Codeine phosphate Tramadol Co-codamol
118
Which drugs are in step 3 of the analgesic ladder
Oxycodone Morphine Fentanyl Diamorphine
119
How are a patients total daily dose of morphine and PRN requirements calculated
total using = total daily dose. divide by 2 and give SR PRN = TDD/6 given as oramorph for breakthrough pain
120
What do you need on a controlled drug prescription
Then write SUPPLY and give the pharmacist EXACT instructions  Drug name and formulation (be explicit re tablets/capsules/patches) - NAME, FORM and STRENGTH  Total number of tablets or amount of drugs in words and figures
121
How do you convert oral morphine to SC, keeping it at the same dose
need half the amount 20mg oral morphine = 10mg SC morphine

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