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Y4 Cancer Care > Key Topic Lectures > Flashcards

Key Topic Lectures Flashcards

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1
Q

What do you need to assess in a cancer pain hx?

A

Need to assess the impact of pain on the patient day to day, their understanding of the cause of the sxs (do they assume that escalating pain means that their cancer is spreading?), what management has been tried, do they have any concerns about proposed tx

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2
Q

How does cancer pain present?

A

Usually persistent
Impairs function and threatens independence
Often multiple aetiologies

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3
Q

Give some causes of chest pain in a patient with lung cancer

A

Cancer itself: chest wall invasion, bone mets, MSCC
Tx: oesophagitis, local reaction to RT
Unrelated to cancer: CAP, PE, Pneumothorax, MI, MSK, Anxiety

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4
Q

What different types of pain may patients present with?

A

Nociceptive pain = normal nervous system with identifiable lesion causing tissue damage
- Can be somatic (well localised) or visceral (diffuse)

Neuropathic pain = due to malfunctioning nervous system, nerve structure itself is damaged
- Stabbing, shooting, burning, stinging, allodynia, electric shocks, numbness

40% of pain is mixed – prolonged poorly controlled nociceptive pain may damage nervous system

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5
Q

What is breakthrough pain?

A

transient exacerbation of pain, spontaneous or secondary to trigger

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6
Q

Outline the cancer pain tx stepladder

A

Non opioid (+/- adjuvant) – often start with paracetamol (be careful giving full dose in cachexic patients) and ibuprofen!
Weak opioid (+/- adjuvant, +/- non-opioid)
Strong opioid (+/- adjuvant, +/- non-opioid)

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7
Q

Give some examples of non-opioids that may be used for cancer pain. What do you need to remember about these drugs?

A

NSAIDs
COX2 (lower risk of GI problems, doesn’t affect bleeding time)

Always prescribe a PPI alongside
These drugs may exacerbate heart failure

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8
Q

What are adjuvants? What may they be used for?

A

Primary indication is not analgesia – patients may not be compliant for this reason (e.g. if box says it is an epilepsy medication)

Can be considered for pain that is only partially responsive to opioids
Can be used synergistically – opioid sparing effect
Can help with CNS sxs

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9
Q

Give some examples of adjuvants

A

Antidepressants, Anticonvulsants, Benzodiazepines, Steroids, Bisphosphonates

Key doses to remember:
Amitriptyline start 10-25mg (S/E confusion, hypotension)
Gabapentin 300mg TD

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10
Q

Give some examples of weak opioids. Key facts to remember?

A

Codeine, dihydrocodeine, tramadol

Not recommended in kids
Tramadol is less constipating than codeine but causes more N&V and anorexia

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11
Q

Give some examples of strong opioids

A

Morphine, diamorphine, oxycodone, fentanyl

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12
Q

Give some key opioid side effects

A

Constipation – on-going, prescribe with laxatives

Nausea and Vomiting – only in 1/3 of patients, usually transient, lasts up to a week, can prescribe an antiemetic PRN alongside

Dry mouth – on-going, can be managed with ice-lollies, sugar free sweets, chewing gum

Sedation – usually at the start of new dose, lasts 2/3 days

Drowsiness / cognitive impairment / light-headedness

Respiratory depression – suddenly giving a very high dose increases risk, AKI may precipitate
- No increased risk at end of life, relatively rare

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13
Q

How would you address patient concerns about opioid use including addiction, tolerance and hastening of death?

A

Many patients are concerned about becoming addicted to opioids: if it is taken as prescribed for pain there is a low risk of becoming dependent, if they are using it for other reasons for example to sedate themselves at night then risk of addiction increases

Patients also worry about tolerance: giving opioids early to get on top of pain does not increase risk of worse pain down the line

No evidence that opioids shorten life: Good pain relief can lengthen life- allows to stay active for longer, keep eating and drinking

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14
Q

What tx does bone pain often respond well to?

A

NSAIDs, radiotherapy and bisphosphonates

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15
Q

What pain relief is best suited to liver capsule pain?

A

steroids / NSAIDs

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16
Q

What is the common dose for codeine?

A

Codeine phosphate 30mg is commonly used, ceiling dose is 240mg/24hours

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17
Q

What types of morphine are available?

A

Oramorph – immediate release, lasts 3-4 hours
Zomorph – slow release, lasts 12 hours
Parenteral (morphine sulphate for injection)

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18
Q

Give some general rules to remember when starting a patient on opioids

A

When starting opioids add laxative and anti-emetics
- Metoclopramide is a good anti-emetic because is a prokinetic and acts at CNS
- Movicol is a good laxative

Don’t start too high, titrate too quickly, or make them wait 4 hours for PRN dose
No strict ceiling for PRN dose – just ensure its an opiate responsive pain

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19
Q

Give some signs of opioid toxicity. What may precipitate this?

A

Pinpoint pupils, hallucinations, drowsiness, vomiting, confusion, myoclonic jerks, respiratory depression

Causes: prescribing errors, quick dose escalation, AKI – always check renal function!

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20
Q

What is required for controlled drug prescriptions?

A

Requires name and ID of patient, exact instructions for pharmacist, drug, form, strength, total number of tablets/patches in words and figures

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21
Q

Give some causes of N+V in cancer patients

A

Gastric stasis- feel full after a couple of mouthfuls, belching, reflux symptoms, vomiting after eating, after vomiting feel better

Bowel obstruction- abdominal distension and colicky pain, absolute constipation, potentially faecal vomit

Cerebral mets / raised ICP– worse on movement, worse in the mornings, vomiting often projectile, may also complain of headaches and visual disturbance

Chemotherapy – comes alongside doses of chemotherapy, first 24 hours usually the worst

Medication side effects – digoxin, citalopram

Infection – gastroenteritis, pneumonia (severe coughing), thrush

Anxiety- nausea without vomiting, sweating, tremor, palpitations

Biochemical causes – alcohol, low sodium, high calcium, significant renal impairment, tumour toxins

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22
Q

What receptors are found in the CTZ?

A

dopamine, serotonin (5HT3)

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23
Q

Give some causes of constipation in cancer patients

A
  • Disease related: immobility, reduced intake, abdominal disease, obstruction
  • Fluid depletion
  • Weakness
  • Medication side effect
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24
Q

How can you manage malignant bowel obstruction?

A

Can use drip and suck – may not be appropriate for all patients because only a holding measure until surgery and they may not be candidate for surgery (e.g. multi-level disease, last weeks of life) – conservative management is more appropriate

Can use a syringe driver with cyclizine, opiates and buscopan (to reduce colic and secretions)

May use octreotide – somatostatin analogue used to reduce secretions

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25
When should you be concerned about hypercalcaemia? How should you treat?
anything over 2.5! tx with aggressive fluid resus and bisphosphonates e.g. Pamidronate
26
What clinical scoring systems can be used in palliative care?
SPICT: used to identify patients at risk of deteriorating or dying Clinical frailty scale – 9 phenotypes
27
What 5 common symptoms should you prescribe for in anticipation in an end of life patient?
Pain – morphine 2.5-5mg Breathlessness / changes in breathing (e.g. Cheynes-Stokes irregular breathing) – morphine 2.5-5mg Nausea and vomiting – levomepromazine 2.5-5mg Terminal agitation – midazolam 2.5-5mg, consider haloperidol if hallucinating Respiratory secretions – glycoperronium 200-400mcg (less sedating and doesn’t cross BBB)
28
What types of radiotherapy are available?
External Beam: most common Brachytherapy: internal localised radiation (e.g. through seed or capsule implanted in body cavity) Systemic Treatment
29
Chemotherapy describes the use of cytotoxic drugs to destroy cancer cells. What routes of administration are available?
* PO * IV * IM * Intralesional - directly into a cancerous area * Intrathecal - into the CSF – by lumbar puncture * Topical - medication will be applied onto the skin
30
Define neoadjuvant, adjuvant and palliative treatment
Neoadjuvant: administration of a therapeutic agent before definitive treatment (surgery or radiotherapy) to shrink tumour and optimize outcomes Adjuvant: treatment given after treatment to reduce the risk of disease recurrence (chemotherapy or radiotherapy) Palliative: treatment designed to relieve symptoms and improve quality of life (chemotherapy, radiotherapy, sometimes surgery)
31
Give some examples of acute toxicity of radiotherapy
* Hair loss * Fatigue * Dysphagia * Nausea and vomiting * Diarrhoea * Erythema * Lymphoedema * Dysuria / radiation cystitis * Sterility
32
Give some examples of long term toxicity of radiotherapy
Skin: Pigmentation, necrosis, telangiectasia, ulceration Bone: Necrosis, fracture, impaired growth (children) Mouth: Ulceration, xerostomia (dry mouth) Eyes: Cataracts, loss of sight Lymphoedema Lung Fibrosis Heart: Cardiomyopathy, pericardial fibrosis Gonads: Infertility, menopause Bowel: strictures, adhesions, fistulas Secondary malignancy
33
What is extravasation? How should you approach this?
the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue Check whether agent is: *vesicant: DNA-binding/non-DNA-binding *irritant *non-vesicant Arrange plastics review if concerned
34
What supportive mx is available for acute toxicity of chemotherapy and radiotherapy?
Cold cap for alopecia– cooling reduces blood flow (and therefore chemo flow) to hair follicles Prophylactic anti-emetics for N+V Flamigel cream to protect skin
35
What are the risks to haematology patients undergoing tx?
* Infection * Difficulties with IV access * Renal failure and bulky disease (high WCC) * Tumour lysis syndrome * Impact on fertility
36
How should you manage neutropenic sepsis?
Sepsis Six – give abx, IV fluids and oxygen, take urine output, lactate and blood culture Tazocin first line antibiotic unless obvious contraindication (Meropenem if Penicillin allergy) Can also give GCSF Don’t automatically put catheter in neutropenic patient unless renal injury due to risk of UTI and ascending infections Take cultures from peripheral vein and indwelling lines If not responding to abx consider fungal infection
37
What can you give patients with haem malignancies to reduce risk of infection?
* Aciclovir – prevent varicella and herpes reactivation * Posaconazole – antifungal * Co-trimoxazole – prevent PCP * G-CSF (granulocyte colony stimulating factor)
38
What is GCSF? Who should never receive it? Side effects?
sub cut injection, stimulates bone marrow, used for patients with healthy bone marrow that has been wiped out by chemo DON’T give to leukaemia patients as will just stimulate their bone marrow to make more blast cells Side effects include bone pain, fatigue, and nausea
39
What are the options for obtaining IV access?
Cannula Tunnelled central line – into jugular vein PICC Line – into subclavian vein Portacath – nothing externally, reduced infection risk, harder to access
40
Complications of IV lines?
Infection Thrombosis Bleeding Failure
41
What are the fertility considerations when treating patients with haem malignancies?
Consider fertility preservation e.g. egg preservation (only an option for slow growing cancers that don’t require urgent tx) and sperm banking Patients need to avoid pregnancy whilst on chemo (men and women) Avoid COCP Give norethisterone to stop periods
42
How can you manage mucositis in patients undergoing anti cancer treatments?
Can impair ability to eat Can give mouthwashes e.g chlorhexidine (antiseptic) and difflam (anaesthetic) Can use mucane lozenges and a syringe driver for analgesic if severe If significant diarrhoea – measure fluid losses, consider loperamide
43
how may haematological cancers present?
Sxs of bone marrow failure – anaemia, thrombocytopenia, neutropenia Sxs of disease involvement – lumps, organomegaly (due to extramedullary haemopoiesis, invasion by cancer) B sxs – weight loss, fever, night sweats Sxs of hypercalcaemia - mostly in myeloma and lymphoma Sxs of hyperviscosity – headache, somnolence, visual disturbance
44
How should suspected haematological cancer be investigated?
* FBC, U&Es, LFTs, CRP, Ca * Blood film, reticulocytes * LDH, urate (TLS- need urate baseline, start allopurinol early) * Immunophenotyping (certain proteins are fluorescent, flow cytometry = immunophenotyping in peripheral blood FLOW) * BM aspirate * CT scan * PET scan (lymphoma/myeloma) * MRI spine/pelvis (myeloma)
45
Younger child with high WCC and blasts =
almost always ALL
46
Older adult with high WCC and blasts =
more likely to be AML
47
Dry tap (no liquid aspirated on BMB) may =
myelofibrosis
48
Unexplained cough for longer than 3 weeks =
urgent CXR
49
Erythema nodosum + unexplained cough =
think sarcoidosis (not lung cancer)
50
What are the 4 commonest presenting sxs of lung cancer?
* Unexplained cough * Haemoptysis * Weight loss * SOB
51
Lung cancer rarely causes mets where?
the kidneys
52
Nobody leaves lung cancer clinic without having what measured?
calcium levels - risk of hypercalcemia
53
What are the next steps after lung cancer is detected on CXR?
Next perform a Staging CT (CT CAP) After staging CT, explain to patient the dx and need to biopsy (can do a CT guided lung biopsy) to plan specific tx Can use SPIKES mnemonic to help with breaking bad news
54
How should you investigate and manage malignant pleural effusion?
Bloods- FBC, U&Es, LFTs, CRP, INR US guided aspirate – protein, LDH, cytology, microbiology o If cytology +ve = cancer o If -ve = medical thoracoscopy Pleural effusion = usually non curative tx for cancer
55
Nodules (mass in the lung 5mm – 3cm) may progress to lung cancer. How high is the risk?
Nodules > 2cm have a 50% chance of becoming lung cancer BROCK score and HERDER score to calculate risk
56
How should you approach a patient with MSCC?
Ix: MRI Spine Mx: High dose steroids IV or PO dexamethasone (don’t give at night as will keep awake) +PPI Radiotherapy +/- surgical decompression Urinary catheterisation
57
Lung Cancer + confusion, nausea and weakness =
likely hypercalcaemia Ix: measure serum calcium!!! Mx: IV fluids + Pamidronate (bisphosphonate) infusion over 30-60 mins
58
How should you approach a patient with SVCO?
Ix: Urgent CT Mx: Admit, give oxygen and analgesia, sit upright to reduce venous pressure Urgent steroids Radiotherapy, intraluminal stenting or chemotherapy
59
Give some of the key paraneoplastic syndromes associated with lung cancer
Cushing’s syndrome – most common with SCLC, manage with metyrapone Lambert-Eaton Syndrome SIADH – common, presents with hypernatremia, measure serum and urine osmolality to dx, has a very poor prognosis, manage with fluid restriction and tolvaptan
60
How should you manage a patient with headache due to brain mets?
* CT and MRI brain * Start Dexamethasone 4mg BD with weaning plan * Give Keppra for seizures * Patients cannot drive
61
What surgery is available for lung cancer?
* Wedge resection * Lobectomy * Pneumonectomy
62
What are the options for palliative lung cancer intervention?
* YAG Laser * Cryotherapy * Diathermy * Intraluminal brachytherapy * Bronchial stents
63
Biggest occupational exposure to asbestos =
plumbing!
64
>1/2 of new cases of cancer in men are what?
prostate, lung or bowel
65
What diagnoses should you consider if you see lytic bone lesions?
think myeloma first, but consider other causes e.g. prostate and breast
66
What would be the issues with PSA screening for prostate cancer?
PSA can be raised for multiple reasons –poor specificity, low positive predicted value Lead time bias – appears patients are surviving longer but there is actually just a longer time between diagnosis and death because diagnosis is earlier Length time bias – screening picks up slow growing indolent cancer Over diagnosis Over-treatment Poor cost-effectiveness
67
Give some urological DDx for haematuria (could also be glomerular):
Cancer * Renal cell carcinoma (RCC) * Upper tract TCC * Bladder carcinoma * Advanced prostate carcinoma Other * Stones * Infection, Inflammation * Benign prostatic hyperplasia (large)
68
How should you investigate a painless testicular lump?
Refer via cancer pathway to Urology! Urgent ultrasound of scrotum to confirm diagnosis Check testis tumour markers if testicular mass on ultrasound (aFP, hCG, LDH)
69
How should you approach a patient with a penile lump?
Suspect penile cancer if a sexually transmitted infection has been excluded or lump/ulcer/lesion is persistent despite treatment Beware the male with recurrent balanitis and phimosis

Y4 Cancer Care (13 decks)

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