Flashcards in Oncology Deck (100):
Cancer is a disease of the West, people with low SES & poor lifestyles.
What percentage of cancers are avoidable?
List risk factors for cancer
Lack of exercise
Infections - HPV, H.Pylori, Hep, EBV
Autoimmune D - Pernicious anaemia, IBD
Occupational - asbestos
What are the most common cancers in men and women in order of incidence?
Women - Breast (30%), Lung, Bowel, Endometrial
Men - Prostate (26%), Lung, Bowel, Bladder
Which cancers have screening programs in place?
List red flag symptoms of cancer of different symptoms.
Breast - lump
Lung/mets - SOB, chronic cough, hamoptysis
Bowel - Unexplained anaemia, change in bowel habit, rectal bleeding
General: weight loss, fatigue, bone pain
Any male with unexplained Hb < ____ triggers URGENT ENDOSCOPY
Hb < 110
Increase plasma viscosity increase platelets & leucocytosis could all indicate _____
What tool can patients use online to see their % risk of cancer?
If you suspect a patient may have cancer, how long should they wait to see an oncology specialist?
( 2 week wait/ Fast track, Urgent referral)
History format for suspected cancer:
- Hx of system
- Cancer red flags
- Rule out oncological emergencies
- ICE/ biopsychosocial impact
- Explore risk factors in PMH/ SH
How many consultations do cancer patients often have with GPs before a formal diagnosis?
Name the Big 4 cancers of the UK
A 67 y/o lorry driver with IBD comes into the GP complaining of weight loss without trying in the last 3 months. He has no other symptoms. What investigation should this trigger?
CT chest, abdo, pelvis
80% of lung cancer cases are caused by smoking. What are other causes?
What is the peak incidence?
60-85yrs (mostly stage III-IV)
List risk factors for lung cancer.
PMH of cancer - esp head/neck
The presentation of lung cancer can be categorised into:
- Respiratory symptoms
- Systemic symptoms
- General signs
- Chest signs
- Met signs
List the presentation in each category
Resp - chronic cough, haemoptysis, SOB, chest pain, recurrent pneumonia
Systemic - weight loss, anorexia, fatigue
General signs - clubbing, lymphadenopathy, anaemia
Chest signs - consolidation, collapse, creps from pleural effusion, pneumothorax, SVC ob
Mets - delirium, focal neurology, bone pain, RUQ pain
Differentials of lung cancer based on coin lesion on CXR?
I - Pneumonia, TB, Abscess, cyst, bronchial adenoma
T - foreign body
Fill in the gaps for presentations that would trigger an urgent referral to oncology:
1. Normal CXR but ___________
2. Persistent haemoptysis in ________ or _______
3. If _______ exposure + symptomatic
1. High index of suspicion
2. Smoker or Ex-smokers
A 78 y/o lady with chronic COPD comes into the GP complaining of worsening of her cough in the last month and haemoptysis. It could be an infective exacerbation but you want to rule out malignancy. What investigations are ordered to explore this?
Contrast CT/ PET scan
Bronchoscopy +/- Biopsy
Lung cancer is staged using ____
Bronchial carcinomas make up 95% of lung cancers.
What are the two types and which is most common
Non-small cell lung carcinoma (NSCLC) 85%
Small cell lung carcinoma (SCLC) 15%
Within NSCLC, which type of cancer is the most common, often presenting peripherally > central
Adenocarcinomas (50% of NSCLC)
Which NSCLC is often central > peripheral + can secrete PTH to cause a metabolic complication called ______?
Squamous carcinoma (30% of NSCLC)
Which type of lung cancer is a neuroendocrine tumour secreting ACTH & ADH?
What is the prognosis?
Poor prognosis - no in-situ detected, rapidly progressive & invasive (hence chemo +/-RT)
How would you treat the following lung cancers?
1. NSCLC with no mets
2. NSCLC advanced in 60 y/o performance status 0
3. NSLC advanced in 78 y/o with performance status 3 from chronic COPD
4. Locally advanced NSCLC/met
1. Surgical resection
2. Chemo +/- RT
3. Palliative RT
4. Gefitinib (anti-VEGF)/ Immunotherapy
5. Chemo +/- RT
2yr survival for NSCLC with no mets is 50%, 10% if mets.
What tool is used to assess the patients overall well-being and activity level to guide treatment & care?
0 = independent, can do all activities with no restrictions
1 = limited activities if physically demanding, ambulatory
2 = able to self-care but unable to carry out activities, ambulatory
3 = confined to bed/ chair >50% of the day, limited self-care
4 = completed disabled, bed-bound
5 = dead
Breast carcinoma is the most common cancer in the UK. What is the lifetime risk in women?
What is the incidence peak ?
1 in 8
List risk factors of breast cancer.
> 50 yrs
Uninterrupted oestrogen exposure (obesity, early menarche, late menopause, nulliparity, OCP, HRT)
Alcohol > 14U
Chest wall RT
Protective factors of breast factors are _________ & having children at a ___________ age
How can breast cancer present?
2. Screening program
3. Distant mets: bone, liver, liver, (brain)
A 56 y/o lady comes into the GP saying that she felt a lump in her left breast the shower.
You take a breast history, what other symptoms would you like to ask her?
Lumps - breast, axilla, neck
Skin changes - peau orange, dimpling, tethering, rashes, colour changes
Nipple changes - inversion, blood, serous fluid
Mets: bone pain (back)
You suspect that the 56 y/o lady should be fast tracked to oncology as on examination the lump is hard, irregular, ~2cm, non-mobile and located in the tail of spence.
Name the assessment that they do that is specific for breast?
Clinical - examination
Pathology - FNAC/ Core Biopsy*
Radiology - Mammogram
After the triple assessment for breast cancer, the 56 y/o lady was diagnosed with a Stage 2 Ductal carcinoma of the left breast with ER +ve, HER -ve & PR -ve.
What treatments would she be eligible for?
Wide local surgical excision (lumpectomy) + RT
Sentinel node biopsy
Hormone therapy: Aromatase inhibitors (Anastrazole - blocks extra-ovarian oestrogen production from e.g fat)
A 49 y/o secretary lady has been diagnosed with an early-invasive ductal carcinoma. She is due to have breast wide local excision surgery and a sentinel node biopsy.
What other treatment should she have post-surgery?
Chemotherapy (adjunct - eliminate microscopic mets)
Anti-oestrogen - Tamoxifen (pre-menopausal women - blocks oestrogen production of ovaries)
In which cases would a mastectomy be appropriate?
Wish to avoid adjunctive RT
The 56 y/o lady with the let ductal carcinoma stage 2 has had her surgery.
What tool would you use to help decide her prognosis +/- adjuvant therapies would be improve survival?
Differentials of breast lumps are ____________
Fibrocystic change (<55yrs)
Ductal papilloma (under nipple)
The most common malignancy in men is prostate cancer.
What is the lifetime risk?
What are the risk factors?
1 in 8
Age (80% >80yrs)
Prostate cancer tends to arise in the peripheral zone.
It can present in 5 main ways which are....
-PSA elevated (request if >50yrs)
-LUTS: Nocturia, haematuria, Frequency, Urgency, Incomplete emptying, dribbling, hesistancy, poor stream
-Signs of dysfunction:
recurrent UTI, Stones, Sexual dysfunction, Urinary rention, Mass on PR, Lymphadenopathy
Pelvic/ back pain, Weight loss, Tenesmus
A 78 y/o Afro-Caribbean man comes into fast track urology clinic complaining of a 1 month history of nocturia, frequency and often have UTIs.
What investigations would you order?
BEDSIDE: PR, Urinalysis
BLOODS: U&Es, PSA
IMAGING: Transrectal USS +/- biopsy, CT (XR if had bone pain)
List the differentials of the 78 y/o Afro-Caribbean man with a 1 month history of nocturia, frequency and often have UTIs.
Bladder - neurogenic bladder, detrusor instability, trauma
Prostate - BPH, chronic prostatitis, prostate cancer
Ureter - stricture
What grading system is used in prostate cancer?
What staging system is used?
Gleason grading system
The 78 y/o Afro-Caribbean man with a 1 month history of nocturia, frequency and UTIs has had his investigations.
He has been diagnosed with a high grade prostate carcinoma with no mets. You decide that he is high risk and therefore should start treatment.
He has a performance status of 1 and also has diabetes. What is the most appropriate treatment?.
Radical RT (not fit for surgery)
Hormone therapy (anti-adrenergic)
What are the side effects of anti-adrenergic hormone therapy in prostate cancer?
(increased risk of CVD)
If a patient had prostate cancer but was low risk or intermediate risk then how would you manage them?
Low risk - active surveillance
Intermediate risk - active surveillance +/- Rx
High risk - Rx
A 56 y/o with a family with BRCA mutations complains of haematuria, nocturia, incomplete empyting . He has an appointment at fast track and is diagnosed with prostate cancer. What is the best treatment option for him?
(younger patients with expected longer LE)
Besides radical protacteomy, radical RT & hormone therapy. What is another treatment option for prostate cancer?
(RT directly given to provide via needles, done under GA.
Complications of prostate cancer include sexual dysfunction, ________
Obstruction - UTI, stones, hydronephrosis --> AKI/ CKD
Mets: pelvic/ back bones, liver, lung, (brain)
The most most common cancer in the UK is ________ which is usually an adenocarcinoma.
What is the peak incidence?
Colorectal cancer (CRC)
List the risk factors of CRC
Low fibre diet, red meat
FH, FAP, HNPCC
30% of presentations of CRC present in the GP, 25% in A&E & 10% from screening.
What sign/symptoms of CRC may lead to someone going to A&E
Bowel obstruction - constipation, abdo distention/pain, no wind, anorexia, N/V
Bowel perforation - abdo pain, peritonitis
Rectal bleeding --> Anaemia - SOB, dizzy, faint
A 62 y/o lady comes into the GP complaining of a 3 month history of change of bowel habit. What other questions would you ask to exclude malignancy?
Constipation or diarrhoea
Anorexia, weight loss
Abdo ain/ distention
Anaemia - SOB, tired, faint, pale
Differentials: with certain foods? gluten? lactose? tenesmus? abdo cramps? recent travel? dodgy food? new medication?
A 70 y/o man comes into the GP complaining of 3 weeks of new rectal bleeding. He doesn't have haemorrhoids or constipation as he takes regular Lactulose 30ml bd.
You send him for fast track to Oncology. What investigations do they order?
BLOODS: FBC (anaemia), LFTs (mets)
IMAGING: Endoscopy +/- biopsy, CT/ PET/ MRI, Liver USS (mets)
Treatment for CRC is _______________
Surgical excision +/- Adjuvant Chemo/ RT
What staging is used for CRC?
A - confined to submucosa
B - infiltration through muscle
C - lymph node involvement
D - mets
Also used TNM
A 67 y/o man with a long-standing diagnosis of CRC has had surgery and adjuvant RT as he was unfit for chemo with a performance status of 3 from COPD. He now has abnormal LFTs and you decide to order a Liver USS. there are 2cm lesions.
Where else can bowel mets go to?
5yr survival of CRC is ~50%. There is a screening program to catch it early.
Who is the screening program for & how does it work?
Offer every 2 yrs.
Request 3 home stool samples to be sent in post. Test for faecal occult blood.
The biggest predictor of survival in CRC is the patient's comorbidities.
True or False
(Think performance status)
What other GI cancers are important to be aware of?
What are the key features in their presentation?
Oesophageal - dysphagia, haematemesis, weight loss
Gastric - dyspepsia, dysphagia, N/V, weight loss
Pancreatic - painless obstructed jaundice, epigastric pain+/- radiation to back, weight loss
Liver - fatigue, anorexia, weight loss, RUQ pain, jaundice, ascites
The 4 oncological emergencies are __________________
Neutropenic sepsis is defined as:
- A neutrophil count of less than ______
- A sustained temp > _____ degrees
Neutrophils < 1
Sustained temp >38
(suspect if systemically unwell in patient receiving chemo)
What is the critical window after chemo where neutropenic sepsis is most likely to present?
1st 7 days --> 14 days post-chemo
What is the mechanism behind neutropenic sepsis?
Chemo causes bone marrow suppression as it targets rapidly dividing cells.
Less WBC to fight of bacterial infections
A 56 y/o female with breast cancer comes into the GP after her 10th day of chemotherapy. She complains of feeling hot, lacking appetite, is developing a cough and looks pale.
You take her temperature, which is 37.9. What do you do next?
Send her to hospital in ambulance - suspect neutropenic sepsis
How is neutropenic sepsis managed?
IV EMPIRICAL ANTIBITOICS (Tazocin) within 1hr
Assessment: ABCDE, find source of infection,
Investigations: Full septic screen, BUFALO
Hx of chemo regime, MASCC risk score
What is a MASCC risk score?
= Multinational Association of Supportive Care in Cancer patients
Score uesd in neutropenic sepsis to determine risk of complications from this episode
Where is a possible source of infection often forgotten about in cancer patients?
Mortality in neutropenic sepsis in 5% so must be recognised and treated quickly. What are the common pathogens that cause it?
Gram +ve (70%) - S.aurea, Coag -ve Staph, Group A & B Strep
Gram -ve - E.coli, Psuedomonas, K. pneumonia
Fungi - Candida, asperigillus
50% of fevers during neutropenia have no underlying cause.
True or False?
70% have no underlying cause
20% of patients with neutropenic sepsis grow bacteria in the blood culture.
As a last line resort if the neutrophil count is close to 0 with signs of organ failure from sepsis. What treatment could you give?
G-CSF = boosts bone marrow to produce blood cells.
(Not given routinely due to SE)
Spinal cord compression (SCC) can be caused by a crush #, extension of tumour from vertebral body or __________ ______
(most common in cancer)
Which cancers are associated with Spinal cord compression?
The most common presentation of Spinal cord compression is ________.
How else does it present?
Back pain (2/3 thoracic)
Leg weakness, change in gait
Change in sensation, incl saddle anaesthesia
Urinary incontinence/ retention
Bowel incontinence/constipation, loss of anal tone
Which sign of Spinal cord compression is a late sign?
Therefore what examomation is important to do if someone presents with back pain?
Bowel incontinence/constipation, loss of anal tone
PR (+ Peripheral Neuro exam)
A 76 y/o man with a 1 year history of prostate cancer, comes into A&E with severe back pain and a floppy left leg. He has chronic urinary retention rom the prostate cancer but has recent been incontinent of urine.
What red flag symptoms of his back pain would you ask?
PMH Cancer/ weight loss
Changes in sensation, saddle anaesthesia
Urinary retention/ incontinence
Bowel incontinence/ constipation
You want to treat the 76 y/o man with prostate cancer and back pain as you suspect Spinal cord compression.
How would you treat him?
1. Dexamethasone 16mg OD + PPI (monitor [glucose])
2. Urgent MRI within 24hrs
3. Speak to neurosurgery (if MRI +ve) OR Clinical Oncologist (Palliative RT)
Spinal Cord compression may be the first presentation of malignancy in GP.
If they receive treatment within 24hrs, what % of patients will walk again?
90% of Superior Vena Cava obstructions (SVCO) are caused by _______
Malignancy (75% are lung cancers)
SVCO is often due to external compression from lung cancer.
How may it present?
Headache (worse when cough)
Swollen red face/arm
Distended neck/chest veins
If you suspect SVC what test can you do to confirm this?
(Ask patient to lift hands above head for 1 min. Face will go blue as cyanosed, raised JVP & inspiratory stridor
A 70 y/o lady who was a 30 pack year smoking history, has a diagnosis of lung cancer. She presents to A&E with SOB, looking blue and a swollen face.
What investigations would you order?
IMAGING - CXR, Contrast CT thorax
How would you treat SVCO?
Dexamethasone 16mg OD + PPI (monitor [glucose])
Treat SOB, Give VTE prophylaxis
Interventions: vascular stent, Chemo/ RT
The most common cause of hypercalcaemia is 1" hyperparathyroidism..
The 2nd most common cause is _____________
Some cancers release PTH-like peptide (Lung SCC) + TGFa secretonoid
Which cancers are associated with hypercalcaemia?
Lung - NSCLC
Typically hypercalcaemia presents with "bones, stones, moans & groans".
How may it present according to the different systems?
General: dehydration, weakness, fatigue, thirst, N/V, bone pain
CS: Delirium, Seizure, Depression, proximal neuropathy, coma
CV: bradycardia, arrthymias, cardiac arrest
GI: N/V, dyspepsia, pancreatitis, abdo pain, constipation
Genitourinary: polydipsia, polyuria
A 79 y/o man with breast cancer presents with N/V, abdo pain, feeling thirsty and generally week.
You suspect hypercalcaemia. What investigations would you order?
BLOODS: PTH, Ca-adjusted, Myeloma screen (CRAB), U&Es, glucose
How do you manage hypercalcaemia in malignancy?
1. IV FLUIDS (saline) - 1L/4hrly for 24hrs then 1L/6hrly for next few days + K+
2. +/- IV Pamidronate (bisphosphonates)
(If arrhythmias/ seizures --> IM Calcitonin + Prednisolone)
Hypercalcemia is a poor prognostic factors in itself and a sign of cancer progression,
True or False
Besides oncological emergencies, there are acute oncological presentations. These include ________________
SOB (primary/mets, lung collapse, pleural effusion, anaemia)
Radiology is used in Oncology for diagnostics, inventions, breast screening etc.
What is a PET-scan used for?
What is a bone scan used for?
PET-scan - inject 18F-FDG which is absorbed in tissues with high glucose demand incl CANCERS, brain, kidney etc
Bone scan - swallow/inject radioisotope which you later trace to see if it shows bone mets
Define the following terms in cancer treatments:
Radical = curative intent
Primary = sole Rx for cure
Adjuvant = Rx post-surgery (chemo/RT)
Neo-adjuvant = Rx pre-surgery (chemo/RT)
Palliative = incurable advanced D where now managing symptoms
Chemotherapy is an IV systemic cytotoxic anti-cancer treatment. What other systemic treatments are available?
Chemo - kills rapidly dividing cells
Hormone therapy - breast, prostate
Biologics - Monoclonal ab "-imab", Tyrosine kinase In "-nib"
Chemo is given in cycles (patterns of treatment with a break).
What is the purpose of chemo?
Radical treatment - cure
Adjuvant/Neo-adjuvant - eliminate microscopic mets or shrink cancer pre-op
Palliative - symptom control, prolong life
Chemo has a narrow therapeutic window and is cytotoxic. What are the common SE?
Nail/skin changes - beau lines
Neutropenia, anaemia, thrombocytopenia
Hormone therapy side effects for prostate cancer include: gynaecomastia, reduced libido, sexual dysfunction, penis shrinkage.
What are SE of immunotherapy?
Lung - pneumonitis*
Liver - transamintis
GI - colitis, dairrhoea
Renal - glomerulonephritss
Endocrine - thyroid D
Skin- rash, itch
Symptoms can present late in Rx or after Rx stopped
Radiotherapy (RT) is a visible silent pain-fee bream treatment using ionisation radiation.
True or False?
What intent can RT be used for?
1. Where is RT given?
2. What is given to target cancer cells?
3. What is the dose measured in?
4. What safety measures do staff have in place for radiation exposure?
1. Tertiary hospitals - outpatient
2. Photons - high nery X-rays to damage DNA, cancer poor at DNA repair)
3. Gray (Gy). Series of Grays = Fraction
4. Staff where safety device to detect radiation expsoure
Outline for process of Radiotherapy from consent to treatment
Consent --> Immobilise --> CT simulation --> skin tattoo --> Volume margin margin for resp --> RT --> Follow-up
Radiotherapy can cause transient damage to normal cells.
What are the most common toxicity symptoms?
When do they often occur?
Skin reactions - redness, desquamation
Days/ weeks post-treatment