Oncology/palliative: General

Question 1

Most commonly causing death

Answer 1

Lung > colorectal > breast > prostate

Question 2

Most likely to metastasise to bone

Answer 2

Prostate > breast > lung

Question 3

Treatment of SCLC

Answer 3

Chemo (usually systemic at presentation
Radiotherapy

Rarely surgery

Question 4

Treatment of NSCLC

Answer 4

Surgery 30%
Radiotherapy
Chemo
Tyrosine kinase inhibitors

Question 5

Management of bone pain

Answer 5

NSAIDs, bisphosphonates, radiotherapy

Question 6

Most common cancers

Answer 6

Breast > lung > colorectal > prostate

Question 7

Terminal drug for bowel colic

Answer 7

Hycosine butylbromide

Question 8

Terminal drug for respirator secretions

Answer 8

Hycosine hydrobromide

Question 9

Terminal drug for nausea and vomiting

Answer 9

Cyclizine
Levopromazine
Haloperidol
Metoclopramide

Question 10

Terminal drug for agitation/restlessness/confusion

Answer 10

Midazolam

Also haloperidol, levopromazine

Question 11

Terminal drug for pain

Answer 11

Diamorphine

Question 12

Best antiemetic for:
GI cause
Toxic cause
Cerebral cause

Answer 12

GI cause - domperidone, metaclopramide, but not in Parkinson’s
Toxic cause - haloperidol
Cerebral cause - antihistamine

Ondansetron - also good for chemo/GI
Benzos - good adjuncts for chemo nausea

Question 13

Para neoplastic syndrones SCLC

Answer 13

Hyponatraemia
Cushing’s (raised cortisol)
Lambert-Eaton syndrome (myasthenia)

Question 14

Laxatives:
Bulk-forming
Softeners
Stimulants
Combination

Answer 14

Bulk forming: fybogel
Softeners: lactulose, docusate
Stimulants: senna
Combination: movicol, co-danthramer

Question 15

Four essential PRN medications all dying patients should be prescribed

Answer 15

1. Anti-emetic - haloperidol/levomepromazine
2. Analgesic - diamorphine
3. Anti-secretory - hycosine hydrobormide
4. Sedative - midazolam

If >2 SC PRN injections required, put in syringe driver and keep PRN

Question 16

Converting oral morphine to SC diamorphine

Answer 16

Divide by 3

Question 17

Neutropenic sepsis management:
ABx
If MRSA positive/line infection
If penicillin allergy
If C.diff suspected
Additional management

Answer 17

Tazocin
MRSA/line infection - add vancomycin
Pen allergy - vancomycin + aztreonam
If C.diff - add metronidazole

O2, IV fluids, caution with antipyretics (mask pyrexia), early senior involvement

Question 18

Colorectal cancer: risk factors (6)

Answer 18

Lots of meat, little fibre
Inflammatory disease (UC, Crohn's)
HNPCC, FAP
Diabetes, obesity
Increasing age
Smoking, alcohol

Question 19

Colorectal cancer - commonest site for mets

Answer 19

Liver

Question 20

Management of colorectal cancer

Answer 20

Surgery - definitive treatment for localised disease
Radiotherapy - rectal only (brachytherapy)
Chemo - adjuvant for high risk

Question 21

Prostate cancer histological type

Answer 21

Adenocarcinoma (95%)

Question 22

Prostate cancer: risk factors (5)

Answer 22

Increasing age
BRCA2
Developed countries
Family history
Afro-caribbean

Question 23

Gleason score

Answer 23

Prostate cancer grading based on 2 most predominant areas of tumour

Question 24

Prostate cancer: prognostic factors (2)

Answer 24

High BPH - poor prognosis

Extent of disease

Question 25

Management of prostate cancer (4)

Answer 25

Surgery for localised disease Radiotherapy/brachytherapy if early Hormonal therapy in advanced disease (LHRH agonists, oestrogen, anti androgens) Chemo (docetaxel

Question 26

Breast cancer: risk factors (4) including in males (2)

Answer 26

``` Increasing age Oestrogen exposure BRCA1/2 Family history In males: gynaecomastia, Kleinfelter's ```

Question 27

Types of breast cancer

Answer 27

Invasive ductal carcinoma (develops from DCIS) 70-80% Invasive lobular carcinoma (devlops from LCIS) 10% Paget's disease = infiltrating carcinoma of nipple epithelium (1%)

Question 28

Investigation of breast cancer

Answer 28

Triple testing 1. Clinical examination 2. Diagnostic radiography (USS/mammogram) 3. Biopsy (core/open/FNA) Also ER+PR status (+ve good because will respond to hormonal treatment) HER2 status (+ve bad) Ca15-3 Search for mets

Question 29

Management of breast cancer

Answer 29

Surgery - initial treatment of choice (mastectomy/WLE) Radiotherapy - post-surgery Chemotherapy - adjuvant Hormone therapy if ER/PR+ (aromatase inhibitors, anti-oestrogens, ovarian ablation)

Question 30

Types of lung cancer

Answer 30

``` Bronchial carcinoma (95%) - SCLC, NSCLC (squamous, adenocarcinoma, large cell, other) Lung mets from: prostate kidney, breast, bone, GI ```

Question 31

Urgent CXR if (6)

Answer 31

``` Hoarseness >3wk Cough >3wk Dyspnoea >3wk Weight loss Chest pain Bone pain/met signs ```

Question 32

Lung cancer: prognostic factors (1 positive, 5 negative)

Answer 32

Positive: stopping smoking Negative: advanced, mets, respiratory complications, weight loss, biochemical abnormalities

Question 33

Diagnosing dying patient

Answer 33

``` Irreversible life-threatening illness Stepwise change Day to day change Bed bound/profound weakness Drowsy Sips/no oral intake No easily reversible cause ```

Question 34

Certifying death (5)

Answer 34

``` Absence of central pulse Absence of pupillary light response Absence of corneal reflex No motor response to supra-orbital pressure Asystole on ACG ``` Observe for 5 minutes

Question 35

When to refer to coroner's office (9)

Answer 35

``` No doctor attended during last illness Not seen by a doctor in last 14 days of life Unknown cause Death udring op/anaesthetic Occupational Medical mistake Suicide/accident In prison custody Suspicious circumstances ```

Question 36

Courvoiser's sign

Answer 36

Painless jaundice and enlarged gall bladder - upper GI cancer

Question 37

Virchov's node

Answer 37

L supraclavicular node - gastric cancer