Oncology/Palliative Care

Question 1

Breaking bad news

Answer 1

1) Quiet place where not going to be disturbed. Make sure family present if wanted
2) Find out what patient already knows
3) Ask how much pt wants to know - if anything were amiss, would you want to know all the details
4) Warning shot
5) Specific info about diagnosis and tx, specifically listing supporting people (CNS) and institutions (Hospices)
- Chunk & Check
6) ‘cancer has negative connotations for many people - 50% of cancers are cured in the developed world’
7) Summarise, make a plan and offer availability. Record details of conversation in the notes (including language uesd)

Question 2

BRCA 1 mutation?

Answer 2

65% lifetime risk of breast cancer
40% ovarian cancer

• 40-60% risk of developing a second breast cancer
• Bilateral prophylactic mastectomy in BRCA1/2 reduces risk of breast cancer by 90%, and may be offered in conjunction with oophorectomy.

Question 3

BRCA2

Answer 3

45% Breast cancer risk (6% in males)

11% ovarian cancer

Question 4

Familial adenomatous polyposis

Answer 4

Dominant
Germline mutations in APC (5q)
- offspring 50% risk for being a gene carrier, with gene penetrance almost 100% for colorectal cancer by age 50
–> Total colectomy prevents inevitable development

Question 5

Peutz-Jegher’s

Answer 5

Auto-dommutation of serine threonine kinase LKB1 or STIK11

Numerous hamaratomatous polyps in GI tract + orofacial/palm/sole pigmentation

Intestinal obstruction eg. intussusception

GI bleeding

Question 6

HNPCC

Answer 6

Auto-Dom with incomplete penetrance

Colorectal (HNPCC1)
+ cancer of uterus, ovary, stomach, renal pelvis , small gut or pancreas (HNPCC2)

Mutations in 1 of 5 DNA mismatch repair genes

Lifetime risk of CRC: 60%
Women with mutation = 40% endometrial cancer

Question 7

MEN I

Answer 7

3 P’s
Parathyroid hyperplasia/adenoma (95%, most present with increased Ca2+)

Pancreas endocrine tumours eg. gastrinoma/insulinoma,somatostatinoma, VIPoma, glucangonomas

Pituitary prolactinoma

Question 8

Men2a?

Answer 8

Ret-proto-oncogene

2Ps + T

Phaeochromocytoma (50%, usually benign and bilateral)

Parathyroid hyperplasia (80%, but less than 20% have increased Ca2+)

T: Medullary thyroid carcinoma (seen in 100%)

Question 9

Men 2b

Answer 9

Ret proto-oncogene

Similar features to men2a (phaeo, parathyroid hyperplasia + medullary thyroid carcinoma) + mucosal neuromas & Marfanoid appearance

NO hyperparathyroidism

Question 10

Neutropenic sepsis?

Answer 10

Neutrophil 38 or 37.5 on 2 occasions, > 1 hr apart, or pt toxic, assume sepsis and start
blind combination therapy: Piperacillin-tazobactam (+ vancomycin if gram +ve suspected or isolated eg. Hickman line sepsis)
- Continue until afebrile for 72, or 5d course and until neutrophils > 0.5x10^9

If fever persists despite abx, think CMV, fungi (Candida, aspergillus) & Central line infection
- Consider Tx for pneumocystis eg. co-trimoxazole

Question 11

Tumour lysis syndrome?

Answer 11

Particularly in haematological malignancies/ Burkitt’s
- Massive destruction of cells leading to increased K+, Urate and renal injury

Prevention: High fluid intake + allopurinol (300mg/12h PO started 24 hrs before chemo) pre-cytotoxics
- If high risk of cell lysis, rasburicase may be given

Complications:

• Hyperviscosity (if WCC >100, wbc thrombi may form in brain, lung and heart (Leukostasis)
• DIC - widespread activation of coagulation from release of procoagulants into the circulation, with consumption of clotting factors and platelets, with increased risk of bleeding

Question 12

Spinal cord compression

Causes

Signs and symptoms

Investigations

Mx

Answer 12

Causes:

• Extradural mets normally
• extension of tumour from a vertebral body
• Direct extension of tumour
• Crush fracture

Sx:
Back pain, weakness or sensory loss with a root distribution (or sensory level), bowel and bladder dysfunction

Ix: Whole spine MRI

Mx: Dexamethasone 16mg/24 PO (8mg BD)
Discuss with neurosurgeon/clinical oncologist immediately for palliative chemo or decompressive surgery
- IF vertebral involvement from myeloma/breast cancer - start Bisphosphonates - helps pain and stability

Question 13

SVC obstruction

Causes?

Sx?

Ix?

Mx?

Answer 13

Not emergency unless tracheal compression with airway compromise

Causes:
- Malignancy (>90%), 75% are lung cancer

Rare:

• Mediastinal enlargement (germ cell tumour), thymus malignancy, mediastinal lymphadenopathy (lymphoma)
• Thrombotic disorders (eg. Behcets or nephrotic syndromes)

Sx:
Dyspnoea, orthopnoea, plethora/cyanosis, swllen face & arms, cough, headache, engorged veins, Pemberton’s sign

Ix:
- Urgent contrast enhanced CT

Mx:

• Tissue biopsy if cause unknown
• Oral dex 8-16mg
• Consider balloon venoplasty + SVC stenting (provides most rapid relief) prior to radical or palliative chemo/radio

Question 14

Malignancy associated Hypercalcaemia

Answer 14

10-20% of cancer pts, 40% of myeloma
Poor prognostic sign - 75% dead within 2mo

Causes:

• Lytic bone mets
• Myeloma
• Production of osteoclast activating factor or PTH like hormones by the tumour

Sx:
Lethargy, anorexia, nausea, polydipsia, polyuria, constipation, dehydration, confusion, weakness

Stones (renal/biliary), bones (bone pain), groans (Abdo pain, N+V), thrones (Polyuria & Polydipsia) & Psychic moans (Depression, confusion , anxiety)

Mx:
Acutely: Rehydration + IV bisphosphonate (or calcitonin if resistant)

Best tx = control of underlying malignancy

Question 15

Oncology: raised ICP

Answer 15

CNS tumour or metastatic disease

Sx:
Headache - worse in morning, when coughing or bending over
N+V
Papilloedema
Fits, focal neuro

Ix: Urgent CT/MRI to diagnose expanding mass, cystic degeneration, haemorrhage within a tumour, cerebral oedema or hydrocephalus due to tumour or blocked shunt, since Mx of each scnario very different

Mx:

• Dexamethasone 8-16mg, radiotherapy & surgery as appropriate depending on cause.
• Mannitol may be tried for sx relief for cerebral oedema (Not evidence based)

Question 16

Extravasation of chemotherapeutic agents?

Answer 16

• Can cause severe tissue necrosis, suspet if there is pain, burning or swelling at the infusion site

Mx:

• Stop infusion & disconnect drip
• Attempt to aspirate any residual drug from cannula before removing
• Take advice & follow local policies if available (many cancer wards have extravasation kits)
• Apply a cold pack (if extravasation of DNA binding drug) to vasoconstrict & mimise drug spread, or heat pack (if non-dna binding) to vasodilate and increase drug distribution.
• Liase with plastics early to discuss flush out

Question 17

Radiotherapy basics?

Types:

Answer 17

uses ionising radiation to produce free radicals which dmg DNA
- Normal cells better at repair this than cancer cells,s o able to recover before next dose

Radical - curative intent
- 40-70 Gy in 15-35 daily fractions

Palliation:

• 80-30Gy, given in 1,2,5,10 fractions
• Bone pain, haemoptysis, cough, dyspnoea and bleeding helped in >50% of pts

Question 18

Radiotherapy sideeffects?

Answer 18

Early:

• Tiredness (can last wks-mths)
• Skin reaction (from erythema to dry/moist desquamation + ulceration
• Mucositis (treat oral thrush eg. with Nystatin oral solution (1ml Swill + swallow every 6h) +- fluconazaole)
• N+V
• Diarrhoea
• Dysphagia
• Cystitis
• Bone marrow suppression

Late reactions:

• CNS: Somnolence, myelopathy, brachial plexopathy, reduced IQ in kids
• Lung: pneumonitis
• GI: Xerostomia , benign strictures, fistulae, radiation proctitis
• GU: urinary frequency, fertility, vaginal stenosis, dyspareunia, ED
• Other; Pit fossa –> panhypopituatitarism

Question 19

Methods of delivering radiotherapy?

Answer 19

Conventional external beam radiotherapy

Stereotactic radiotherapy - Highly accurate from of EBRT used to target small lesions with great precision: Gamma knife

Brachytherapy

Radioisotope therapy: uses tumour seeking radionuclides to target specific tissues eg. Radioiodine 131 to ablate remaining thyroid tissue after thyroidectomy for thyroid cancer

Question 20

Fertility issues in cancer pts

Answer 20

Semen cryopreservation from men and older boys with cancer must be offered before therapy
- If pt is infertile male post Tx, refer to specialist - Testicular sperm extraction with intracytoplasmic sperm injection could still yield normal pregnncies

Cryopreservation of embryos and ovarian tissue banking are harder options in women.
- Ovarian stimulation + oocyte collection which may result in unacceptable delays to Tx

Question 21

Breast cancer 2 week referral?

Answer 21

• Discrete, hard lump with fixation; • Over 30 with a discrete lump persisting after a period or presenting post-menopause; • Under 30 with an enlarging lump, fixed and hard lump, or family history; • Previous breast cancer with a new lump or suspicious symptoms; • Unilateral eczematous skin or nipple change unresponsive to topical treatment; • Recent nipple distortion; • Spontaneous bloody unilateral nipple discharge; • Men over 50 with a unilateral firm subareolar mass; • Consider referral if under 30 with a lump or persistent breast pain.

Question 22

Tumour markers: 
Germ cell/testicular
HCC
Ovarian
Pancreatic
Breast
Colorectal
B cell proliferative disorders (eg. myeloma)
Thyroid cancers

Answer 22

GCC/ Testicular: AFP/ HCG

HCC: AFP

Medullary thyroid: Calcitonin

Ovarian: Ca125

Pancreatic: Ca19-9

Breast: Ca15-3

Colorectal: CEA

Gestational trophoblastic: B-HCG

B cell - Paraproteins

Thyroid; Thyroglobulins

Question 23

Palliative care: N+V mx

Answer 23

• Treat reversible causes eg. with laxatives, fluconazole (thrust), analgeis or antibiotics. Change/reduce drugs/routse
• Pt starting strong optiiods should be prescribed regular antiemetic for first week, then PRN

Oral:

• Cyclizine 50mg/8H (antihistamine/anticholinergic with central action)
• Domperidone 10-20mg/8h(peripheral antidopaminergic, no acute dystonic SEs
• Metoclopramide 10mg/8h - blocks central chemoreceptor trigger zon + peripheral PROKINETIC EFFECTS - good in gastric stasis

Question 24

Anti-emetic for drug/metabolic induced nausea?

Answer 24

Haloperidol (0.5-1.5mg/12)

Dopamine antagonist

Useful if chemical causes eg. drugs, renal failure, hypercalcaemia.

Avoid if risk of fitting, as it can decrease seizure threshold

Question 25

Anti-emetic for chemo/radiotherapy related nausea?

Answer 25

Ondansetron 4-8mg/8h Serotonin antagonist Good for chemo/radiotherapy related nausea Causes constipation

Question 26

Anti-emetic for gastric stasis?

Answer 26

Metroclopramide 10mg/8h Blocks central chemoreceptor trigger zone + Peripheral prokinetic effects

Question 27

Palliative care: Constipation Mx?

Answer 27

Common with opiates, Ca2+ and dehydration : better to prevent than treat All pts on opiods should be prescribed regular oral laxative (faecal softener + stimulant) unless CI Softener: Sodium Docusate 100-200mg BD/TDS Osmotic laxative: - Lactulose 10-20ml OD/PO Movicol: Start 1-2 sachets OD PO, up to 2 BD - 1 sachet in 125ml water ``` Stimulant: Senna - 1-4 tablets OD/BD 5-20ml syrup BD - Glycerine suppositories - Phosphate enema ``` Combination: Softener + stimulant Co-danthramer 1-4 capsules OD/BD PO

Question 28

WHO analgesic ladder?

Answer 28

1) Paracetamol 2) Paracetamol + codeine +- ibuprofen 3) Paracetamol + Opiod +- Ibuprofen

Question 29

Palliative care: minimising SE general advice?

Answer 29

o Opioids→ Give antiemetics prn and laxatives regularly o NSAIDs/Steroids→ Consider gastric protection, e.g. lansoprazole 30mg od o Steroids→ Prescribe early in the day (before 2pm) to avoid insomnia

Question 30

Breakthrough pain dose if on 30mg MST continus BD?

Answer 30

= 60mg MST Daily 1/6 of 60mg = 10mg Oramorph PRN (4hrly)

Question 31

Visceral pain mx?

Answer 31

- Usually opioid responsive - Consider cause + treat where possible: - Constipation - laxatives/suppositories - Abdo colic: Anticholinergeic - Hyoscine butylbromide (Buscopan) 20mg QDS PO or SC - Gastric irritation: PPI/antacid - Liver capsular pain: NSAID/ Dexamethasone 4-6mg with PPI - Ascites : Consider drainage, diuretics, chemo if malignant - Bladder spasm: Oxybutynin 2.5-5mg BD-QDS PO - Rectal pain/tenesmus: GTN ointment, nifedipine

Question 32

Palliative Care; Bone pain

Answer 32

- Partially opioid responsive - NSAID (ibuprofen 400mg TDS with PPI) - Consider radiotherapy, corticosteroids and IV pamidronate for metastatic pain Consider orthopaedic referral for prophylactic fixation if risk of fracture

Question 33

Palliative care; Neuropathic pain

Answer 33

Partially opiod responsive Other drugs: - TCA eg. amitrptilline - Anticonvulsants eg. Gabapentin Consider also nerve block/radio as adjuvant treatments if appropriate

Question 34

Palliative care; Muscular pain

Answer 34

NSAID: Ibuprofen 400mg TDS + PPI Muscle relaxanteg. diazepam 2-5mb BD/TDS Consider physiotherapy, massage, heat pad

Question 35

Palliative care; non medical approaches to pain relief?

Answer 35

For pressure areas: appropriate mattress,barrier cream/spray, regular repositioning Relaxation exercises TENs machine Acupuncture Psychological support + counselling Complementary tx: massage, reflexology

Question 36

Palliative care: Dose conversion to oramorph 1) Codeine Phosphate (60mg) 2) Tramadol 100mg 3) Oral Oxycodone 5mg

Answer 36

1) Codeine = 10:1 therefore 6mg 2) Tramadol = 5:1 therefore 20mg 3) Oral oxycodone 1:2 therefore 10mg

Question 37

Palliative dose conversion: 1) Morphine sulphate 5mg IV/SC 2) Diamorphine 5mg IV/SC 3) Oxycodone 5mg IV/SC 4) Alfentanil 1mg IV/SC 5) Pethidine 100mg SC/IV/IM

Answer 37

1) Morphine sulphate IV = 1:2 therefore 10mg 2) Diamorphine IV = 1:3 therefore 15mg 3) Oxycodone 5mg IV = 1:4 therefore 20mg 4) Alfentanil 1mg IV/SC = 1:30 therefore 40mg 5) Pethidine 100mg IV = 4:1 therefore 25mg

Question 38

Opioid brand names actual names? Oramorph Sevredol Oxycontin Oxynorm Durogesic Dtrans Abstral BuTrans Transtec

Answer 38

Oramorph® =morphine sulphate immediate release solution Sevredol® = morphine sulphate immediate release tablets Oxycontin® = oxycodone slow release (12-hrly) tablets or Oxynorm® = oxycodone immediate release capsules or liquid Durogesic DTrans® fentanyl transdermal patch (every 72 hours) Abstral® = sublingual fentanyl (short-acting) BuTrans® = buprenorphine 7-day patch Transtec® = buprenorphine 3-day patch

Question 39

Tramadol + SSRI risk?

Answer 39

Can potentially lower seizure threshold and also carry a risk of serotonin syndrome, especially when used together

Question 40

Opioid toxicity: Signs?

Answer 40

Common: - Mild: V, increased drowsiness, pinpoint pupils ``` Moderate: Confusion Muscle twitching/myoclonus Vivid dreams/hallucinations Agitation ``` Severe: - Resp depression ( RR

Question 41

Potential causes of opioid toxicity?

Answer 41

Pt received unintentionally high dose - Pt develops hepatic/renal impairment - Pain responded to adjuvant therapies, leading to loewr opiod requirement - Paid not opiod responsive - Concomitant drugs that may dress CNS eg. Benzo/ TCAs - Change in opioid/route administered

Question 42

Opioid Toxicity Mx?

Answer 42

Look up local trust guidelines + seek specialist advice from palliative care team Mild: Reduce dose by 1/3 Moderate: Omit next dose + restart lower dose eg. decrease 1/3 Severe: If RR

Question 43

Resp secretions Mx?

Answer 43

1) Reposition pt 2) If on IV fluid, r/v to see if this is exacerbating 3) Anticholinergic will help reduce production of secretions, but not increase absorption, so use early - -> Hyoscine hydrobromide 400ug PRN SC - Hyoscine butlbromide (Buscopan; use in conscious pts as does not cross BBB so less sedating) 20mg PRN SC (MAx 100mg/24hr)

Question 44

Dyspnoea Mx?

Answer 44

1) Consider reversible causes eg. Pleural effusion, PE, airway obstruction, infection 2) Fan, position upright, breathing/relaxation exercises/ reassurance 3) Nebulisers, chest physsio and O2 as appropriate 4) Meds: - To alleviate sensation: Oramorph 2.5-5mg PO PRN To alleviate anxiety: Midazolam 2.5-5mg SC PRN

Question 45

Terminal agitation/restlessness Mx?

Answer 45

1) Consider reversible causes eg. Pain, retention, constipation, drugs , deranged U+Es 2) Quiet safe environment, consider pillows, cot sides and 1:! nursing as appropriate Midazolam 2.5-5mg SC PR - Can also use levomepromazine Consider use of CSCI for more continuous symptom control

Question 46

Palliative care: Troublesome cough? Hiccups Anorexia Dry mouth Pruritis

Answer 46

Cough - Codeine linctus 5-10ml QDS PRN Hiccups: Metoclopramide 10mg TDS PO for gastric distention Anorexia - consider dex 2-4mg if needed for short bursts Dry mouth: Treat candida, regular sips of water, ice chips , pineapple chunks, chewing gum Pruritis: emollients, antihistamines, chlorphenamine

Question 47

When is a CSCI useful?

Answer 47

when a pt: - Has difficulty swallowing/ taking oral meds safely - Is N/V - in bowel obstruction - Too drowsy to swallow tablets or is unconscious - Requires multiple SC injections Nb. If skin intact/healthy, needle can be left in situ for 3-4 days before changing - Up to 4 drugs can be combined in a CSCI over 24 hrs, depending on compatibility

Question 48

CSCI morphine dose if on 80mg MST continus BD PO? Breakthrough dose?

Answer 48

80 x 2 = 160mg oramorph IV:PO = 1:2 therefore 80mg Morphine sulphate over 24 hrs via CSCI Breakthrough dose = 24hr oral dose SC Morphine sulphate/6 (hourly max)

Question 49

Advanced care planning?

Answer 49

ACP is a process of discussions between a patient and professionals regarding their future care. There are different ways of documenting and formalising the outcome of these discussions, which should then be circulated to other clinicians involved in their care: • An advance statement is documentation of a patient’s preferences and wishes, e.g. that they would only wish to receive antibiotics for a future chest infection, or that they would like to be cared for at home and not return to hospital even if less well, or that they would like certain people to be involved in discussions about their care. • An Advance Decision to Refuse Treatment (ADRT) – previously known as a living will or advance directive – is legally binding,drawn up when the patient has capacity, then to be used if they are no longer competent to make decisions, and documents refusal of specific treatments in a given situation. • Lasting Power of Attorney (LPA) may be given by the patient to a nominated person (the attorney) so that they are legally responsible for making decisions on their behalf regarding their health or welfare

Question 50

Personalised End of Life care plans?

Answer 50

These have replace the Liverpool care pathway and should be developed when: • Patient is bedbound/semi-comatose/can only take sips/unable to take tablets and • multidisciplinary team members agree that the patient is dying (last days of life), including consultant/registrar. • Guidelines on how to develop these will be found on local hospital/ hospice intranet.