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RCPSC > Medical oncology and palliative care > Flashcards

Medical oncology and palliative care Flashcards

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1
Q

Who is considered average risk for breast Ca

A

Anyone not high risk

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2
Q

In average-risk women, what are the breast cancer screening recommendations?

A

Mamogram q2-3 years age 50-74

*recommend against self-breast exam, clinical breast exam, US/CT/MR

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3
Q

Who is considered high risk for breast cancer?

A
  1. ≥25% lifetime risk
  2. 1 of
    1. Known hereditary gene mutation
      1. BRCA 1/2, TP53, PTEN, CDH1, PALB 1/2
    2. 1st degree relative has known hereditary gene mutation
    3. Personal or family history of at least one of:
      1. ≥2 cases of breast-ovarian cancer in parent, sibling, grandparent, aunt-uncle, niece/nephiew
      2. Bilateral breast Ca
      3. Breast Ca≤age 35
      4. Invasive serous ovarian Ca
      5. Breast/ovarian Ca in Ashkenazi Jewish female
      6. Male breast Ca
    4. Radiation to the chest before age 30 and at least 8 years ago
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4
Q

In high-risk women, what are the recommendations for breast cancer screening

A
  1. Mamogram + MRI breast annually from age 30-69
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5
Q

Who should be screened for lung cancer?

A
  1. Adults over 18 NOT suspected of having lung cancer that meet all 3 of:
    1. 55-74 years old
    2. ≥30 pack-year smoking history
    3. Current smoker or quit within the last 15 years
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6
Q

For patients who meet criteria for screening, how should screening for lung cancer be performed?

A
  1. Annual low dose CT for 3 consecutive years
  2. After 3 years no guidelines
    1. US says continue until quit smoking >15 years
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7
Q

Who is considered average risk for Colon Ca

A

Everyone not at increased risk

No previous CRC, polyps, IBD

No family Hx CRC

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8
Q

How should screening for colorectal cancer be performed in average risk patients

A
  1. FIT or gFOBT q2years OR flex sig q10years between age 50-74
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9
Q

Who is considered at increased risk for CRC

A

≥1 first degree relative with colon cancer or advanced adenoma

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10
Q

How should patients at increased risk for CRC be screened?

A
  1. Colonoscopy q5-10 years starting at age 40-50 10 years before the age of earliest relative’s diagnosis (whatever is younger)
  2. FIT q1-2 years is alternative second line
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11
Q

Who should be screened for HCC

A
  1. High risk population:
    1. All patients with cirrhosis regardless of age or etiology
    2. Hep B carriers AND
      1. Asian males over 40, females over 50
      2. Africans or north American blacks over 20
      3. FHx of HCC in 1st degree relative (start at age 40)
      4. CASL=ALL HIV coinfected patients (start at age 40)
      5. AASLD= All hep D coinfected patients
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12
Q

How is screening preformed for HCC in patients where it is indicated?

A
  1. U/S q 6 months
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13
Q

When should you stop screening for HCC

A

Child C cirrhosis unless patient is awaiting a liver transplant

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14
Q

Who should be screened for cervical cancer?

A
  1. Women aged 25-69
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15
Q

How is screening for cerrvical cancer performed?

A
  1. Pap-cervical cytology q3 years
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16
Q

When should you stop screening for cervical cancer

A

at age 70 AND ≥3 negative tests over the last 10 years

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17
Q

To whom do the cervical cancer screening guidelines not apply?

A
  1. Never sexually active
  2. previous abnormal pap test
  3. immunocompromized
  4. symptomatic cervical cancer
  5. limited life expectancy
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18
Q

Who should be screened for esophageal cancer

A
  1. Patients with alarm symptoms
    1. Dysphagia
    2. Odynophagia
    3. recurrent vomiting
    4. unexplained weight loss
    5. anemia
    6. loss of apetite
    7. GI bleed
  2. Patients with barretts esophagus
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19
Q

Should PSA be used to screen for prostate Ca

A

No

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20
Q

Should average risk women be screened for ovarian Ca

A

No

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21
Q

What are the screening guidelines for testicular cancer

A

No screening

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22
Q

What are the recommendations regarding population-based skin screening for melanoma

A

No screening

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23
Q

How should patients with HNPCC be screened for colon cancer

A

Colonoscopy q1-2 years starting at age 20 or 10 years before relative’s diagnosis

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24
Q

How should patients with FAP be screened for colon cancer

A

Sigmoidoscopy q1year starting at age 10

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25
How should patients with IBD be screened for colon Ca
In left sided colitis: colonoscopy q1-3 years starting 10-12 years post-Dx In pan-colitis: Colonoscopy q1-3 years starting 8 years post-Dx
26
What is the workup for suspected breast Cancer
1. Imaging 1. Bilateral mamogram and breast U/S 2. Axilary US 2. Biopsy (US guided core needle) 1. Receptor status testing 1. ER PR HER2
27
How shoould mastitis not responding to ABx be investigated
Rule out paget's with Bx
28
Describe the staging for breast Cancer
29
How is early stage breast cancer managed
1. Surgery 1. Mastectomy + SLN Bx 1. If SLN +, ALN dissection 2. OR Lumpectomy + SLN Bx + radiation 1. If SLN +, ALN dissection 2. Chemo + endocrine therapy if indicated
30
When should further imaging be done following surgery in breast Cancer?
1. If LN negative=stage1. no further imaging 2. If ≤3 SLN positive= Stage II. No further imaging unless symptoms present 3. If ≥4 SLN +/- ALN positive = stage III: get bone scan + CT CAP
31
What are the indications for adjuvant chemotherapy in breast Ca
1. ER/PR + stage II/III 2. HER-2 + stage II/III 3. Tripple negative I-III
32
What are the indications for adjuvant endocrine therapy in breast Ca. Which agent should be used?
1. ER/PR positive breast Ca, all stages 1. Pre-menopausal 1. Tamoxifen x 5-10 years 2. Post-menopausal 1. Aromatase inhibitor or tamoxifen x 5-10 years
33
What is the typical chemo regiment for breast Ca
Anthracycline (doxorubicin, epirubicin) + Taxane (docetaxel, paclitaxel)
34
How is metastatic ER/PR+ breast Ca managed?
1. Endocrine therapy + CDK 4/6 inhibitor (eg letrozole + palbociclib) 2. Endocrine therapy alone 3. Chemo upfront if present with "visceral crisis" (symptomatic/organ compromise)
35
How is metastatic HER2+ breast Ca managed?
Double HER2 blockade (trastuzumab + pertuzumab) and chemotherapy (taxane)
36
How is metastatic tripple negative breast Ca managed?
1. Chemotherapy (Paclitaxel) 2. Immunotherapy (for PD-L1 positive disease)
37
How is metastatic tripple + breast Ca managed?
Combine taxane, double HER2 blockade AND endocrine therapy
38
What are the side effects of breast cancer endocrine therapy
39
What are the side effects of trastuzumab
* Reversible cardiomyopathy * Diarrhea * Infusion reactions
40
What are the side effects of anthracyclines
1. Irreversible cardiomyopathy 2. Secondary leukemia 3. Alopecia 4. Extravasation reactions (tissue necrosis)
41
Whart are the side effects of taxanes
1. Peripheral neuropathy 2. Infusion reactions 1. Fever 2. Dyspnea 3. Rash 3. Myalgias/arthralgias 4. Alopecia 5. Febrile neutropenia
42
What are the indications for anti-resorptive therapies in breast Cancer and why do we use them?
1. _Adjuvant setting:_ Post menopausal women "deemed candidates for adjuvant systemic therapy" 1. Decreased recurrence and increased survival 2. _Metastatic setting:_ Pre and post menopausal women 1. Improves pain and QOL 2. Decreases skeletal related events 3. Prolongs time to first skeletal event 4. **no mortality benefit** \*Purpose of antiresorptives: 1. Decreased spread to bone 2. Protects against AI induced osteoporosis 3. Decreased risk of skeletal related events
43
What antiresorrptives can be used in the setting of breast cancer
Bisphosphonates or Denosumab
44
What surveillance is recommended after breast cancer remission
Annual mamogram, H/P, breast exam NO surveillance bloodwork, bone scan, CT
45
What lifestyle modifications should be implemented after breast cancer remission?
1. Prevent weight gain 2. **Exercise 150 min/week (reduces breast Ca mortality)** 3. Quit smoking 4. Minimize EtOH 5. Limit saturated fats and high-fat dairy products 6. No need to avoid soy 7. Questionnable benefit of vitamin C/D/E
46
What malignancies does BRCA 1 increase your risk for?
1. Breast Ca (70%) 2. Ovarian Ca (45%)
47
What malignancies does BRCA 2 increase your risk for?
1. Breast Ca (70%) 2. Ovarian Ca (20%) 3. Prostate Ca 4. Pancreatic Ca 5. Gastric Ca
48
What are the criteria for genetic testing for BRCA 1 and 2
1. Ashkenazi jewish + breast Ca at age \<50 2. Breast Ca age\<35 3. Male breast Ca 4. Tripple negative breast Ca \<60 5. Serous ovarian Ca at any age 6. Breast + Ovarian Ca in same patient 7. Gastric, prostate, pancreatic Ca in patients with significant family history of other BRCA2 associated malignancies
49
What are prophylactic therapeutic considerations in patients with BRCA1 or 2?
Prophylactic mastectomy Oophorectomy
50
What are the types of lung Ca
51
What workup should be sent after diagnosing lung cancer
1. In all patients 1. CT C/A/P, CT/MRI brain 2. If no obvious metastatic disease 1. PET scan, look for occult mets 2. Mediastinal staging (mediastinoscopy or EBUS) 3. Biopsy/markers 1. In NSCLC 1. Send path for EGFR, ALK, PD-L1 IHC
52
What is the staging of NSCLC?
53
How are stage I and II NSCLC managed?
1. Fit for surgery 1. Surgery +/- adjuvant chemo 1. Platinum doublet 2. Unfit 1. Radiation (SBRT) +/- chemo 1. Comparable survival to surgery
54
How is stage III (locally advanced) NSCLC managed?
1. Resectible 1. Surgery + adjuvant chemo 2. Unresectible 1. Concurrent chemorad + immunotherapy (Durvalumab) x1 year
55
How is stage IV NSCLC managed?
1. According to molecular subtype 1. EGFR +: EGFR inhibitor (Osimertinib, gefitinib, erlotinib 2. ALK +: ALK inhibitor (crizotinib, alectinib) 3. No driver mutation: Chemo + immunotherapy (PD-L1\<50%) or immunotherapy alone (PD-L1≥50%) 2. Early palliative care referral =**mortality benefit**
56
What is the typical EGFR+ phenotype in lung Ca
1. Elderly 2. Female 3. Asian 4. Non-smoker 5. Adenocarcinoma
57
Describe the staging of SCLC
1. Limited: 1. Confined to 1 hemithorax or 1 radiation field 2. Extensive 1. Not confined to 1 radiation field (i.e. mets) or presence of a malignant effusion
58
How is Limited stage SCLC treated?
1. Chemoradiation + prophylactic cranial irrradiation 2. Curative intent
59
How is extensive stage SCLC treated?
Chemotherapy alone palliative intent
60
What paraneoplastic syndromes are associated with SCLC. Briefly describe each one
1. SIADH 2. Lambert-Eaton myasthenic syndrome 1. Anti-VGCC Ab: reduces presynaptic ACh release 2. Absent/decreased reflexes 3. Encephalomyelitis and sensory neuropathy 1. Anti hu Ab: Cross reacts with both SCLC antigens and neuron-specific RNA-binding nuclear proteins 4. Cushing syndrome 1. Ectopic ACTH production
61
What paraneoplastic syndromes are associated with NSCLC. Briefly describe each one
1. Hypertrophic osteoarthropathy 1. Clubbing + periosteal new bone formation of tubular bones 2. Symmetrical, painfully arthropathies (ankles, knees, wrists, elbows) 2. Hypercalcemia (Squamous cell) 1. PTHrP production
62
What workup should be done following the diagnosis of colon Ca
1. **Full colonoscopy** 2. **CT C/A/P** 3. CEA
63
What are the stages of Colorectal cancer
1. Stage 1: invades **into** the muscle wall 2. Stage 2: Invades **through** the muscle wall 3. Stage 3: **Lymph node** involvement 4. Stage 4: Distant mets
64
What is the tumor marker for Colon Ca
CEA
65
How is stage 1 colon cancer treated
surgery alone
66
How is stage 2 colon cancer treated?
Surgery +/- adjuvant chemo (if perf or obstruction)
67
How is stage 3 colon cancer treated
Surgery + chemo
68
How is stage 4 colon cancer treated
1. **Oligometastatic (isolated liver or lung lesions, undefined # of mets)** 1. **Metastatectomy + Chemotherapy (curative intent)** 2. Non-operable 1. Palliative chemo
69
What are the typical chemo agents in colorectal Ca
1. Adjuvant: FOLFOX, CAPOX 2. Metastatic: FOLFOX, FOLFIRI +/- Bevacizumab, panitumumab, cetuximab
70
What are the surveillance guidelines after a diagnosis of colorectal cancer
1. Stage 1 1. Colonoscopy 1 year post resection (or within 6 months if a complete scope was not node pre-op) 2. Subsequent colonoscopies based on findings of previous scope, if negative do q5 years 2. Stage 2-3 1. Colonoscopy 1 year post resection 2. Years 1-3: q6mo H/P, CEA, CT C/A/P 3. Years 4-5: Annual H/P, CEA, CT C/A/P
71
When should a PET scan be performed in the context of surveillance post colon Ca
Only if rising CEA with no evidence of disease on CT
72
What are the risk factors for SCC of the esophagus
1. EtOH 2. Smoking 3. Caustic injurry
73
Where are SCCs usually located within the esophagus
upper-mid esophagus
74
Where are adenocarcinomas usually located within the esophagus?
1. Distal
75
What are the risk factors for esophageal adenoCa
1. Barrett's esophagus 2. GERD 3. Obesity 4. Smoking
76
How is esophageal cancer treated
1. Localized 1. Neoadjuvant chemo +/- radiation 2. THEN surgery 3. THEN +/- adjuvant chemo 2. Metastatic 1. Chemotherapy 2. +/- Trastuzumab if (HER2 +)
77
How is prostate Ca Diagnosed
DRE Prostate Biopsy, calculation of the gleason score
78
What is the tumor marker in prostate Ca
PSA
79
When should imaging be pursued in prostate cancer and what imaging should be done?
1. Image if *High Risk* 1. *​*Gleason ≥8 2. PSA \>20 3. Tumor extent over T3 2. Get CT C/A/P and bone scan
80
How is localized prostate Ca managed
1. 3 options 1. Active surveillance (PSA monitoring intervene if progression) 1. Should be discussed before starting any therapy as per choosing wisely 2. Radical prostatectomy +/- LN dissection 3. Radiation
81
How is metastatic prostate Ca managed
1. Prostate Ca in hormonally driven and androgen sensitive thus androgen deprivation therapy is the backbone of treatment 1. GnRH agonist (lupron) or antagonist (degarelix) 2. Standard of care is 1st line ADT + second agent 1. ADT + Chemo (docetaxel) 2. ADT + Non-steroidal antiandrogen (abiraterone)
82
List the side effects of ADT
1. Osteoporosis 2. Decreased libido 3. Gynecomastia 4. Hot flushes 5. Fatigue
83
List the side effects of non-steroidal antiandrogens
1. Abiraterone 1. HTN 2. Hyperglycemia 3. Hypokalemia 4. CV disease 2. Enzalutamide 1. Sz 2. Fatigue
84
What 3 meds should all patients on ADT be taking?
1. Calcium (if needed) 2. Vitamin D 3. Bisphosphonate
85
How should Testicular cancer be worked up?
1. Imaging: 1. Scrotal US 2. CT C/A/P 2. Diagnosis 1. Made on radical orchiectomy 1. \**never biopsy a testicular mass. risk of seeding* 3. Tumor markers 1. Beta-HCG 2. AFP
86
How can seminomas and non-seminomas be differentiated based on tumor markers
87
How is testicular cancer managed?
1. Localized 1. Surgical resection 2. Metastatic 1. Chemotherapy (highly curable)
88
What is the typical chemotherapy regimen for testicular cancer
BEP (Bleomycin, etoposide, Cisplatin)
89
List a side effect of bleomycin
Pulmonary fibrosis
90
How should a localized renal mass be managed
1. \<1 cm 1. Active surveillance 2. 1-4cm 1. Renal CT/MRI to better caracterize 1. Good surgical candidate: partial nephrectomy 2. Poor surgical candidate: consider Bx and ablation 3. \>4cm 1. Nephrectomy
91
How is a patient classified as *favorable, intermediate,*or *poor* risk in metastatic RCC?
IMDC score risk calculator
92
How should metastatic RCC be managed
1. Favorable risk 1. Oral TKI (Axitinib) + Immunotherapy (pembrolizumab) 2. Intermediate/poor risk 1. Dual imunotherapy (ipilimumab+Nivolumab)
93
What imaging should be obtained when suspecting/diagnosing Ovarian Ca
1. Abdomina + TV US AND CT CAP
94
What tumor marker is associated with ovarian Ca
Ca-125
95
How is Ovarian Cancer managed?
1. Localized 1. Surgery (TAH+BSO+ LN dissection +peritoneal washing) 2. Do not biopsy adnexial mass. Risk of seeding. Do upfront surgery 2. Stage III (visible peritoneal deposits +/- malignant ascites) 1. Cytoreduction (debulk) then adjuvant chemo 3. Stage IV (mets beyond pelvis, malignant pleural effusion) 1. Palliative chemo (+/- debulking) 2. +/- VEGF inhibitor (Bevacizumab) or PARP inhibitor (Olaparib if BRCA +)
96
What is the typical adjuvant chemotherapy regimen in adjuvant setting of ovarian cancer
Carboplatinum + Paclitaxel
97
List 2 PD-1 inhibitors
1. Pembrolizumab 2. Nivolumab
98
Name a CTLA-4 inhibitor
Ipilimumab
99
List side effects of immunotherapy (checkpoint inhibitors i.e. PD-1 inhibitors and CTLA-4 inhibitors)
1. **Rash** (most common) 2. Endocrine 1. **Hypo T4** 2. **Panhypopituitarianism** 3. **Adrenal insufficiency** 4. DM 3. GI 1. Colitis 2. Hepatitis 4. **Pneumonitis** 5. Uveitis 6. Myocarditis 7. Nephritis 8. MSK 1. Synovitis 2. Arthritis 9. Hematologic 10. Encephalitis
100
How is immunotherapy toxicity managed?
1. ALWAYS R/O infection 2. "mild' symptoms 1. HOLD treatment (**Unless asymptomatic hypoT4, then just start levothyroxine**) 2. Supportive management 3. COnsider re-challenge 3. "Moderate-severe" symptoms 1. HOLD treatment 2. **IV methylprednisolone 1mg/kg** or prednisone 0.5-1mg/kg 3. GI toxicity 1. Refer for scope 2. R/O infection 3. If no reasonable response after 72hrs or symptoms are worstening, give infliximab (can repeat after 2 weeks)
101
What further workup should be done in a cancer of unknown primary?
102
What is the stage of a prostate or bladder cancer with any positive LN
Automatically stage 4
103
Describe stage 4 testicular Ca
There is no such thing
104
What is the DDx of Osteoblastic bone mets
1. **Prostate** 2. SCLC 3. Carcinoid 4. Hodgkins lymphoma
105
What is the DDx of osteolytic bone mets
1. **MM** 2. NSCLC 3. RCC 4. Melanoma 5. Thyroid 6. NHL
106
What is the DDx of mixed bone mets?
1. **Breast** 2. GI 3. SCC 1. NSCLC 2. H&N 3. Cervical
107
List 3 radio-resistant tumors When can radiation _still_ be used in the setting of these cancers
1. RCC 2. Melanoma 3. Osteosarcoma \*Radiation may still be used to alleviate pain or cord compression
108
What are the side effects of anthracyclines (Doxorubicin, epirubicin)
1. Irreversible cardiomyopathy 2. Secondary leukemia
109
List a side effect of Topoisomerase inhibitors
1. Diarrhea
110
List side effects of cisplatin
1. Highly emetogenic 2. Nephrotoxicity 3. Peripheral neuropathy 4. Ototoxicity
111
List side effects of cyclophosphamide
1. Secondary malignancies 1. MDS 2. AML 3. bladder Ca
112
List side effects of anti-angiogenesis/VEGf inhibitors (Bevacizumab)
1. Bleeding 2. Bowel perf
113
List side effects of Trastuzumab
Reversible cardiomyopathy
114
List a side ffect of EGFR TKIs (Gefitinib, erlotinib, osimerrtinib)
Rash
115
How is chemo induced N/V managed
1. Highly emetogenic regiment (cisplatin) 1. NK1-receptor antagonist (aprepiant) 2. 5-HT antagonists (Ondansetron) 3. Steroids (dexamethasone) 4. +/- 5-HT2/D2 antagonists (Olanzapine) 2. Moderately emetogenic (carboplatin) 1. 5-HT antagonists (Ondansetron) 2. Steroids (dexamethasone) 3. +/- 5-HT2/D2 antagonists (Olanzapine) 3. Mildly emetogenic (Etoposide, paclitaxel) 1. 5-HT antagonists (Ondansetron) OR Steroids (dexamethasone) 4. Anticipatory nausea 1. Refer to psychiatry (behavioral Tx) 2. May use benzos
116
Is there evidence for canabioids, marijuana, ginger, acupuncture or accupressure for management of chemotherapy induced nausea
Insufficient evidence to recommend
117
What is the DDx of diarrhea in patients with cancer on chemotherapy
1. Chemo induced Diarrhea 2. 2/2 immunotherapy (colitis) 3. 2/2 other meds 4. Infectious (R/O C. diff) 5. Partial SBO 6. Malabsorption
118
How is chemotherapy (not immunotherapy) induced diarrhea treated?
1. Loperamide → Lomotil → Codein syrop 2. Octreotide if all else fails
119
How is chemotherapy related mucositis treated (Oral ulcers, dysphagia, odynophagia)
1. Baking soda rinses 2. Viscous Lidocaine 3. Magic mouthwash
120
How is anthracycline induced heart failure treated
As any other HFrEF
121
How long after treatment do patients usually develop anthracyclin induced cardiomyoopathy
Delayed onset, sometimes 20 years later!!
122
How long after treatment do patients usually develop Trastuzumab induced cardiomyopathy
1. Early onset, during treatment
123
How is trastuzumab-induced cardiomyopathy treated?
1. STOP Rx 2. Routine HFrEF management 3. Repeat TTE in 1 month to ensure recovery 4. Likely OK to stop HFrEF therapy once resolved 5. Do not rechallenge with Trastuzumab
124
When can EPO be used to treat anemia in the context of cancerr
1. Factors to considerr before/when starting 1. R/O non-chemo/cancerr associated causes 2. Discuss risk of VTE 3. No firm Hb Target, target avoiding transfusions 4. D/C ESA if not working after 6-8 weeks 5. CAN add iron to ESA to increase efficacy, even in no iron deficiency! 2. Chemo associated anemia 1. Curative treatment - Do not use ESA 2. Palliative treatment - may use ESA 3. Cancer associated anemia, NOT on therapy 1. Do not use ESA
125
List symptoms of a malignant bowel obstruction
1. Crampy abdo pain 2. N/V 3. inability to pass BM or gas
126
How is a malignant bowel occlusion diagnosed
1. H/P 2. Flat plate 3. CT abdo
127
How should a malignant bowel occlusion be managed
1. Consult gen surg (even in palliative setting) 2. Supportive care (IVF, lytes, NG decompression) 3. Metoclopramide (for partial, not complete occlusion) 4. Octreotide (reduce secretions, motility, splanchnic blood flow) 5. +/- corticosteroids (reduce peritumor edema, increase mobility) 1. Benefit is questionable
128
What interventions can be considered in malignant bowel obstruction other than definitive surgical management
1. Depending on location, Consider intraluminal stent 2. If not responsive to pharmacotherapy, consider venting G-tube
129
What is the definition of febrile neutropenia
1. Temp ≥38.3 x1 or ≥38.0 for ≥1hr 2. AND ANC \<0.5 or \<1 and predicted nadir \<0.5
130
What are the most common bacterial etiologies in febrile neutropenia
1. ˜25% is infectious bacteremia (only 25-30% have identified source of infection) 1. ˜70% Gram positives -- S. Aureus, S. Epi, S. Pneumo 2. ˜20% gram negatives -- Pseudomonas, klebsiella, E. Coli 3. Fungal infections occur in prolonged neutropenia \>7d and/or prolonged ABx use
131
What investigations should be done in febrile neutropenia
1. Blood cultures x2 1. peripheral + line 2. Urine cultures 3. Skin exam 4. Sputum cultures if present 5. Stool culture + C. Diff 6. CXR, other imaging as indicated
132
How is febrile neutropenia treated
Broad spectrum ABx immediately
133
When should G-CSF be used in febrile neutropenia
For secondary **prophylaxis**
134
How can you decide whether a patient with febrile neutropenia requires admission?
1. MASCC score 1. If low risk and live within 1 hour of medical care, have a caregiver at home and are able to return to ED for follow-up, reasonable to send home
135
What febrile neutropenia patients automatically require inpatient management?
1. Anticipated neutropenia ≥7 days 2. Heme malignancy 3. SCT
136
What is the outpatient antibiotic regiment of choice for febrile neutropenia?
1. Cipro + Clavulin (clinda if PNC allergy)
137
What are the 3 malignancies with the biggest risk for hyperrcalcemia
1. Breast 2. Lung 3. MM
138
what are the 3 most common mechanisms involved in hypercalcemia of malignancy
1. Lytic bone destruction 1. Breast Ca 2. MM 2. PTHrP production 1. H&N 2. squamous cell NSCLC 3. vit D/calcitriol production 1. Lymphoma
139
How is hypercalcemia of malignancy managed?
1. IV hydration (most effective short term) 2. Bisphosphonates 1. Pamidronate or zolendronic acid IV 2. Max effect 4-7 days post-infusion 3. Monitor for hypocalcemia post Tx 3. Treat the underlying malignancy
140
What are the most commonly implied malignancies in spinal cord compression
1. Breast 2. Lung 3. Prostate 4. MM
141
What are the symptoms of malignant spinal cord compression
1. Back pain (often 1st sign, most sensitive) 2. Spinal cord compression =UMN symptoms 3. Cauda equina = LMN symptoms, saddle anesthesia 4. Leg weakness, sensory loss 5. urinary retention, bowel incontinence
142
How should a malignant spinal cord compression be managed?
1. Urgent MRI, whole spine 2. Steroids -- Dex 3. Pain control 4. Consult surgical spine service AND rad onc
143
What are the diagnostic criteria for TLS
1. Requires ≥2 lab abnormalities within 7 days of chemo 1. HyperK 2. Hyper P 3. Hyperuricemia -- causes AKI 4. HypoCa
144
What types of cancer are most prone to TLS
1. Highly proliferative malignancies, large tumor burdens, highly sensitive to Tx 1. Leukemia 2. Lymphoma 3. Testicular Ca 4. SCLC
145
How is TLS treated
1. IVF 1. Target urine output 2cc/kg/hr 2. Rasburicase 1. If G6PD deficiency, use allopurinol 3. Treat lyte abnormalities
146
What can be given for TLS prophylaxis
1. IVF AND 2. Allopurinol or rasburicase
147
Which malignancies are most likely to cause SVC syndrome
1. NSCLC (50%) 2. SCLC 3. Lymphoma 4. metastatic lesion
148
List one "non malignant" cause of SVC syndrome
VTE
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What are the symptoms of SVC syndrome
1. Face and arm edema 2. distended neck + chest veins 3. Dyspnea 4. Cough 5. facial plethora 6. hoarseness 7. stridor 8. confusion/LOC changes
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What symptoms are associated with grade 4 (life-threatening) SVC syndrome
1. Confusioon/obtundation 2. stridor 3. HD compromise/hypotension 1. syncope with no other cause 4. renal insufficiency
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What workup should be ordered in SVC syndrome
1. CXR, CT chest head and neck 2. If unstable, venography and immediate intervention
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How is SVC syndrome managed?
1. Life threatening 1. Immediate stenting 2. Consider lytics if thrombus 2. Non-life threatening 1. Get tissue 2. For chemo-sensitive tumors, give chemo 3. Stents +/- radiation if non-chemo sensitive 4. Steroids for steroid-sensitive malignancy or if obstruction is not amendable to stenting
153
Describe the ECOG scale
154
Which ECOG levels should generally not be getting chemotherapy?
3-4
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Describe the palliative performance scale
100% perrfectly well -- 0% death PPS 50% (Sit/lie throughout the days=0nly 10% survive to 6mon
156
List options for cancer pain control
1. Non-opioids - acetaminophen, nsaids 2. Opioids 3. Adjuvants -- Gabapentin, Pregabalin, TCAs 1. For neuropathic pain
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How should opioids be titrated?
1. Start with immediate release formulations q1-4, q4 PRN for opioid naive 2. Increase dose to effect/ side effect 3. Allow steady-state (approx 24hrs) 4. Calculate dose over 24hrs 5. Divide this dose into long acting formulation 6. Order 10% TDD in breakthrough
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What is the evidence for cannabinoids in cancer related pain
1. Nabilone\>Placebo, benefits compared to other meds not proven
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Which opioids should be used preferentially in renal dysfunction, which should be avoided
1. USE: Hydromorphone, Methadone, fentanyl 2. AVOID: Morphine, codeine, tramadol, Demerol
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Which opioids should be used preferentially in hepatic dysfunction, which should be avoided
1. USE: Hydromorphone, morphine, fentanyl 2. AVOID: Codeine, methadone
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What opioid should be used preferentially in patients with opioid induced itching/urticaria
1. Fentanyl
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List the common and rare opioid side effects
1. Common 1. Constipation 2. Nausea 3. Vomiting 4. Sedation 2. Rare 1. Confusion 2. hallucinations 3. Myoclonus
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List side effects specific to methadone
1. QT prolongation 2. Drug-drug interactions
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How would you manage an opioid rotation
1. Calculate TDD of the drug 2. Convert TDD to morphine equivalent 3. COnvert TDD to drug of choice 4. Calculate interval dosing 5. Calculate breakthrough dose 1. 10% TDD or 50% q4 dose 6. If switching meds due to toxicity, consider 25-30% dose reduction to allow for cross-tolerance. If pain is not well controlled, don't decrease the dose
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What is the equianalgeic dose of morphine for: * Oxycodone * hydromorphone * Transdermal fentanyl
166
How is dyspnea managed in palliative care
1. Stepwise approach 1. Non-pharm 1. Open windows 2. fan 2. If hypoxic 1. Oxygen 3. Opioids \*Oxygen can be effective for noon hypoxemic dyspnea in COPD, butt not in cancer or heart failure
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How is N/V managed in palliative care
1. Treat etiology 2. Unknown etiology: 1. Dopamine agonists or agents used for chemo nausea
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How is Delirium managed in palliative care
1. Risperidone/haldol do not alleviate distress at end of life, tend towards harm 1. May worsten delirium 2. May increase side effects
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How is Cachexia managed in palliative care
1. Refer for councilling + assessment regarding high protein, nutrient dense food. Advise against extreme/fad diets 2. NO enteral or parenteral feeding is cancer cachexia 3. No evidence to endorse pharmacological agent
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How is constipation managed in palliative care
1. Before treating consider: 1. Disease and drug effects 2. Calcium + TSH 3. Council on bowel regimen if starting opioids 2. Treatment: 1. Stimulant laxatives (Give alongside opioids as Px) 2. Osmotic laxatives 3. Enema 4. Selective opioid antagonists 1. MethylNaltrexone 2. Naldemidine 5. Chloride channel agonist (Lubiprostone) 6. Do not use stool softeners (Colace) Alone
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Name a medication that should be discontinued at end of life
Statin
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What is the transfusion cutoff in palliative care
No such thing, dont transfuse _unless symptomatic_
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What are the eligibility criteria for MAID
1. Must meet all criteria 1. Be eligible for health services funded by the government (i.e. have a health card) 2. Be ≥18 years old and have **decision making capacity** 3. Have a **Grevious and irremediable** medical condition 1. Does not need to be fatal or terminal 2. Must be a serious illness, disease, disability in an advanced, **irreversible state** 3. 2 track approach depending on wether death is reasonably foreseeable or not 4. Excludes mental illness for now but not neurocognitive or neurodevelopmental disoorders 4. Patient must make a voluntary request for MAID, free from outside pressure or influence 5. Provide informed consent
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How is a MAID request processed when a patient's death is reasonably foreseeable?
1. Request in writing, signed by independent witness 2. 2 Independent MDs/NPs must confirm all eligibility criteria are met 3. Person must be given the opportunity to withdraw consent, and confirm consent expressly before receiving MAID \*10 day reflexion period removed
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How is a MAID request processed when a patient's death is not reasonably foreseeable?
1. Request in writing signed by an independent witness 2. 2 independent MDs/NPs must confirm all eligibility criteria are met AND _consult with expert in the medical condition (if MD/NP not familiar with it)_ 3. The person must be informed of means to alleviate suffering and be offered consults with experts in this (councilling, palliative care) 4. **The eligibility assessment must take at least 90 days,** this period can be shortened if the patient is about to lose capacity 5. The patient must be given the opportunity to withdraw consent and confirm consent expressly before receiving MAID
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In what circumstance does a patient NOT have to provide consent immediately before the provision of MAID
1. Patient assessed and approved for MAID 2. Patient was at risk of losing decision making capacity prior to receiving MAID and was made aware of that risk 3. Patient makes arrangements in writing with their practitioners to waive final consent, and according to which their practitioner will provide MAID on their preferred date iif they have lost capacity
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RCPSC (14 decks)

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