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Oncology and Palliative Care Flashcards

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1
Q

Requirements for urgent referral for lung cancer

A

> 40 with unexplained haemoptysis, CXR suggestive of cancer.

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2
Q

Requirements for urgent CXR for lung cancer

A 
>40 and have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 of the following unexplained symptoms:
Cough
Fatigue
Shortness of breath
Chest pain
Weight loss
Appetite loss
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3
Q

Requirements for urgent endoscopy

A

Dysphagia OR

>55 with weight loss and either upper abdominal pain, reflux or dyspepsia.

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4
Q

Requirements for urgent referral for upper GI cancer

A

> 40 and jaundice (?pancreas), or people with signs of an upper abdominal mass (?gall bladder, ?liver)

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5
Q

Requirements for urgent CT of pancreas for pancreatic cancer

A 
>60 plus weight loss plus any of:
Diarrhoea
Back pain
Abdo pain
Nausea
Constipation
New-onset DM
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6
Q

Requirements for Non-urgent endoscopy for Upper GI cancer

A 
>55 and one of:
Treatment-resistant dyspepsia
Upper abdo pain with low Hb
Raised platelet count
Nausea or vomiting
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7
Q

Requirements for urgent referral for lower GI cancer

A

> 40 with unexplained weight loss & abdominal pain
50 with unexplained rectal bleeding
60 with iron def. anaemia OR change in bowel habit
Test positive faecal occult blood

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8
Q

Requirements to consider urgent referral for lower GI cancer

A

Rectal or abdominal mass
Unexplained anal mass or anal ulceration

<50 years with rectal bleeding AND any of:
Abdo pain
Change in bowel habit
Weight loss
Iron def. anaemia
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9
Q

Faecal occult blood test should be offered to:

A

> 50 and unexplained abdominal pain or weight loss
<60 with change in bowel habit or iron def. anaemia
60 with anaemia even in absence of iron def.

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10
Q

What is the screening programme for colorectal cancer

A

Men and women aged 60-74 every 2 years.

Patients aged >74 may request screening.

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11
Q

What are the requirements for urgent referral for gynaecological cancer

A

Ascites, pelvic mass (fibroid excluded), >55 with post-menopausal bleeding

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12
Q

Requirements for urgent referral for breast cancer

A

> 30 with unexplained breast lump with or without pain

>50 with unilateral nipple discharge, retraction or other changes of concern.

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13
Q

Requirements for consideration of breast cancer urgent referral

A

Skin changes that suggest breast cancer

Aged 30 and over with unexplained lump in axilla

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14
Q

Requirements for urgent urological cancer referral

A

Irregular prostate on PR, abnormal age-specific PSA
>40 with unexplained visible haematuria
>60 with unexplained non-visible haematuria + dysuria or increased WCC
Non-painful enlargement or change in shape/texture of testicle.

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15
Q

Give an example of an alkylating agent, mechanism of action and adverse effects

A

Cyclophosphamide

Causes cross-linking in DNA

Haemorrhagic cystitis, myelosuppresion, transitional cell carcinoma

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16
Q

Give 2 examples of cytotoxic antibiotics, mechanism of action and adverse effects

A

Bleomycin - degrades preformed DNA - lung fibrosis

Doxorubicin - stabilises DNA-topoisomerase II complex inhibits DNA and RNA synthesis - cardiomyopathy

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17
Q

Give 3 examples of antimetabolites, mechanism of action and adverse effects

A

Methotrexate - inhibits dihydrofolate reductase and thymidylate synthesis - myelosuppresion, mucositis, liver fibrosis, lung fibrosis

Fluorouracil (5-FU) - pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase - myelosuppresion, mucositis, dermatitis

6-MP - purine analogue, decreases purine synthesis - myelosuppresion

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18
Q

Give 2 examples of spindle poisons, mechanism of action and adverse effects

A

Vincristine/Vinblastine - inhibits formation of microtubules
Vincristine - peripheral neuropathy (reversible), paralytic ileus
Vinblastine - myelosuppresion

Docetaxel - prevents microtubule depolymerisation and disassembly, decreasing free tubular - neutropenia.

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19
Q

Give an example of a topoisomerase inhibitor, mechanism of action and adverse effects

A

Irinotecan - inhibits topoisomerase I which prevents relaxation of supercoiled DNA - myelosuppresion

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20
Q

Cisplatin mechanism of action and adverse effects

A

Causes cross-linking in DNA

Ototoxicity, peripheral neuropathy, hypomagnesaemia

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21
Q

Hydroxyurea mechanism of action and adverse effects

A

Inhibits ribonucleotide reductase, decreasing DNA synthesis

Myelosuppresion

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22
Q

Early reactions of radiotherapy (2-4 weeks into treatment)

A

Tiredness
Skin reactions - dry desquamation, erythema, moist desquamation, ulceration
Mucositis
Nausea and vomiting (treat with either metoclopramide, ondansetron or domperidone)
Diarrhoea (treat with loperamide)
Dysphagia
Cystitis

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23
Q

Late reactions of radiotherapy (months-years)

A

CNS/PNS - somnolence, spinal cord myelopathy, brachial plexopathy
Lung - pneumonitis
GI - xerostomia, benign strictures of oesophagus or bowel, radiation proctitis
GU - urinary frequency, vaginal stenosis, dyspareunia, erectile dysfunction
Endocrine - panhypopituitarism

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24
Q

What are the different methods of radiotherapy

A

Conventional external beam radiotherapy (EBRT)

Stereotactic radiotherapy - targets small lesions with great precision (eg gamma knife therapy)

Brachytherapy - radiation source placed within or close to tumour, allowing high local radiation dose.

Radioisotope therapy - eg radioiodine to ablate remaining thyroid tissue after thyroidectomy for thyroid cancer.

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25
What is neutropenic sepsis
Consequence of chemotherapy 7-14 days after chemo. Neutrophil count <0.5 and one of the following: Temperature >38 Signs or symptoms consistent with clinically significant sepsis: Chills and shivering, tachycardia, tachypnoea, clammy, cold, mottled skin, dizziness, confusion, disorientation, slurred speech, diarrhoea, nausea and vomiting
26
Management of neutropenic sepsis
Prophylaxis - fluoroquinolone Tazocin first-line If patients still febrile and unwell after 48 hours, switch to meropenem +/- vancomycin If still not improving after 4-6 days - order investigations for fungal infections Role of G-CSF for selected patients.
27
Which cancers are most likely to have spinal cord compression
Lung, prostate, breast, myeloma, melanoma
28
Signs and symptoms of spinal cord compression
Back pain (earliest and most common), worse on lying down and coughing Lower limb weakness Sensory changes - sensory loss and numbness Neurological signs depend on level of lesion - lesion above L1 usually result in UMN signs in legs and a sensory level. Lesions below L1 cause LMN signs in legs and perianal numbness Tendon reflexes tend to be increased below level of lesion and absent at level of lesion.
29
Management of spinal cord compression
Admit for bed rest and arrange urgent MRI whole spine within 24 hours. Dexamethasone 16mg/24 hours PO with PPI Radiotherapy is most common treatment and should be given within 24 hours of MRI diagnosis. Decompressive surgery +/- radiotherapy may be appropriate depending on prognosis. Patients with loss of motor function after 48 hours are unlikely to recover function.
30
Most common cancers causing brain mets
Lung, breast, colorectal, melanoma
31
Signs and symptoms of brain mets
Headache, focal neurological signs, ataxia, fits, nausea, vomiting, papilloedema
32
Management of brain mets Prognosis of brain mets
Urgent CT/MRI depending on underlying diagnosis, disease staging, performance status. Dexamethasone 16mg/24 hours to reduce cerebral oedema. Stereotactic radiotherapy Prognosis - 1-2 months survival. Better prognosis with single lesion, breast cancer.
33
Features of superior vena cava obstruction
``` Most common with lung cancer Dyspnoea Swelling of face, neck and arms Headache - often worse in mornings Visual disturbance Pulseless jugular venous distension ```
34
Causes of superior vena cava obstruction
NSCLC, lymphoma, Kaposi's sarcoma, breast cancer, aortic aneurysm, mediastinal fibrosis, goitre, SVC thrombosis
35
Management of superior vena cava obstruction
Dexamethasone, balloon venoplasty, stenting Chemo or radiotherapy depending on sensitivity of underlying cancer.
36
Causes of malignancy associated hypercalcaemia
PTH-related protein produced by tumour (eg squamous cell carcinoma of lung)
37
Signs and symptoms of malignancy associated hypercalcaemia
Weight loss, anorexia, nausea, polydipsia, polyuria, constipation, abdominal pain, dehydration, weakness, confusion, seizure, coma
38
Treatment of malignancy associated hypercalcaemia
Aggressive rehydration - 3-4 litres/day Bisphosphonates eg zolendronic acid IV normalises calcium within 3 days. Can repeat infusion. Calcitonin has quicker effect than bisphosphonates.
39
What is tumour lysis syndrome
Related to treatment of high grade lymphomas and leukaemia. Can occur in absence of chemotherapy, but usually triggered by introduction of combination chemotherapy. Occurs from breakdown of tumour cells and subsequent release of chemicals from cell.
40
Features of tumour lysis syndrome
``` High potassium High phosphate High uric acid Low calcium AKI (increased serum creatinine) Cardiac arrhythmia or sudden death Seizure ```
41
Prophylaxis of tumour lysis syndrome
Prophylaxis IV allopurinol or IV rasburicase Lower risk groups - oral allopurinol
42
What tumour marker is raised in testicular and hebatocellular cancer
Alpha-fetoprotein
43
What tumour marker is raised in medullary thyroid
Calcitonin
44
What tumour marker is raised in ovarian cancer
CA 125
45
What tumour marker is raised in pancreatic cancer
CA 19-9
46
What tumour marker is raised in Breast cancer
CA 15-3
47
What tumour marker is raised in colorectal cancer
Carcinoembryonic antigen (CEA)
48
What tumour marker is raised in testicular cancer/germ cell cancer
hCG
49
What is the screening programme for breast cancer
47-73 years of age | Mammogram every 3 years.
50
What dose of morphine do you start with patients for palliative care
20-30mg of MR morphine with 5mg morphine for breakthrough pain
51
What medication should prescribed alongside strong opioids
Laxatives and anti-emetics
52
How do you calculate daily breakthrough dose of morphine
1/6th of TDD
53
How do you calculate modified release morphine dose
1/2 of TDD
54
What opioids are preferred in renal failure
alfentanil, buprenorphine, fentanyl
55
Side effects of opioids
Nausea, drowsiness, constipation, dry mouth
56
How do you treat opioid toxicity
Naloxone indicated for life-threatening respiratory depression
57
How do you convert oral morphine dose to transdermal fentanyl patch
12 microgram patch equates to 30mg oral morphine daily.
58
What anti-emetic is good for intracranial disorders?
Cyclizine
59
Where does metoclopramide act on and what is it good for?
Central chemoreceptor trigger zone, peripheral pro kinetic effects Good for gastroparesis Monitor for extra-pyramidal side-effects
60
Which anti-emetic is a D2 antagonist and does not have extra-pyramidal side-effects
Domperidone
61
Which anti-emetic is good for drug induced nausea?
Haloperidol
62
Which anti-emetic is used first line for chemotherapy induced nausea and vomiting?
Ondansetron Aprepitant second line
63
Treatment of constipation in palliative care
Good fluid intake, treat reversible causes. Stimulant (senna) at night +/- stool softener (docusate) Osmotic laxative (lactulose, movicol) Rectal treatments (bisacodyl suppositories, phosphate enema)
64
What treatment types are used for N+V in Bowel Obstruction
``` Endoscopic stenting Venting gastrostomy to decompress Centrally acting anti-emetic Antispasmodic and anti-secretory agents (hyoscine butylbromide or octreotide) Somatostatin analogue ```
65
How to treat intractable breathlessness in palliative care
Airflow across face Position patient so using gravity to aid diaphragm Trial of oxygen if hypoxic Consider trial of low dose opioids Consider lorazepam for anxiety.
66
What are the anticipatory end of life medication and what are they used for?
``` Pain - morphine Agitation + N&V - Haloperidol Agitation + anxiety - Midazolam N&V - levomepromazine Respiratory secretions - glycopyrronium ```
67
What are the conservative and medical management options for excessive secretions in palliative care?
Conservative - avoid fluid overload. Educate family that patient is likely not troubled by secretions Medical - first line: hyoscine butyl bromide. Second line: glycopyrronium bromide
68
What are the management options for agitation and confusion in palliative care?
1st line - haloperidol Other options - chlorpromazine, levomepromazine Terminal phase of illness - midazolam
69
What is the management of hiccups?
Chlorpromazine for intractable hiccups Haloperidol and gabapentin also used Dexamethasone used if hepatic lesions.

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