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OPB Flashcards

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1
Q

Incidence of breast cancer

A

1 in 8 women

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2
Q

Most common cancer in women

A

Breast cancer

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3
Q

2 most common cancers overall

A

1) Lung

2) Breast

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4
Q

Risk factors for breast cancer

A
  • Age >50
  • Benign breast disease
  • Proliferative types of hyperplasia
  • Exposure to ionising radiation
  • Later first child birth
  • History of breast cancer
  • Family history of breast or ovarian cancer in a 1st degree relative
  • Hormone therapy use
  • Nulliparity
  • Obesity
  • Alcohol
  • No breast-feeding
  • Elevated endogenous oestrogen levels
  • Hormonal contraceptive use
  • Increased mammography density of breast tissue
  • Menarche <12
  • Menopause >45
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5
Q

Features which may make you suspect inflammatory breast cancer

A
  • Erythema
  • Oedema
  • Peau d’orange
  • Nipple retraction
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6
Q

Clinical features of breast cancer

A
  • Breast lump
  • Change in shape of breast
  • Nipple discharge
  • Skin changes
  • Pain
  • Ulceration
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7
Q

Most common sites of metastasis for breast cancer

A
  • Bone
  • Lung
  • Liver
  • Pleura
  • Adrenal glands
  • Skin
  • Brain
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8
Q

Investigations to consider in a patient with ?breast cancer

A
  • Mammogram (>40 years old)
  • US (<40 years old)
  • MRI
  • FNA/core biopsy/vacuum assisted biopsy
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9
Q

Factors influencing choice of surgical management option in breast cancer patients

A
  • Patient age
  • Comorbidities
  • Patient preference
  • Tumour stage (size, lymphovascular invasion, nodal involvement, location)
  • Tumour biomarkers
  • Tumour: breast size ratio
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10
Q

Contra-indications for breast conservation surgery/wide local incision/lumpectomy in breast cancer patients?

A
  • Large primary tumour
  • Central primary tumour
  • Small breast size
  • Patient unfit for surgery/follow up radiotherapy
  • Severe lung/heart disease
  • Pes excavatum
  • Chronic lack of mobility at ipsilateral shoulder
  • Kyphoscoliosis
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11
Q

Indications for mastectomy (rather than WLE) in breast cancer patients

A
  • Multifocal disease
  • Bilateral disease where it is not possible to conserve the breasts
  • Extensive DCIS
  • Patients unsuitable for breast radiotherapy
  • Significant family history of risk regarding procedures
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12
Q

Indications for axillary sampling (rather than axillary clearance)

A
  • Negative findings on US of the axilla +/- biopsy

- High upper quadrant tumour (avoid irradiation of ‘cleared’ axilla)

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13
Q

Indications for axillary clearance (rather than axillary sampling)

A
  • Histologically confirmed invasive breast cancer/ >1 node axilla biopsy confirmed malignant
  • Patient preference
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14
Q

Main complication of axillary clearance

A

Lymphoedema

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15
Q

Aim of adjuvant therapy in breast cancer patients

A

Aim to reduce risk of recurrence locally or systemically

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16
Q

Indications for breast adjuvant radiotherapy in breast cancer patients

A
  • No lymph node metastases in an adequate axillary node sample (4 nodes)
  • <4 nodes involved in an adequate axillary node clearance (10 nodes)
  • Invasive disease with inadequate excision margins unsuitable for re-excision
  • Conserved breast unsuitable for excision
  • T4 disease at presentation
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17
Q

Indications for chest wall radiotherapy after mastectomy in breast cancer patients

A
  • Tumour size >5cm
  • 4 or more involved nodes
  • Involved resection margins
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18
Q

Indications for adjuvant chemotherapy after surgery in breast cancer patients

A
  • High-risk early breast cancer
  • Grade 3
  • LVI
  • Nodal involvement
  • Triple negative
  • HER2+
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19
Q

Main hormonal treatment of breast cancer in pre-menopausal women

A
  • 5 years Tamoxifen

OR

  • 5 years tamoxifen + another 5 years (if still pre-menopausal) or 5 years of letrozole (if post-menopausal)
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20
Q

Main hormonal treatments of breast cancer in post-menopausal women

A
  • 5 years tamoxifen

OR

  • 5 years tamoxifen + 5 years letrozole

OR

  • 5 years letrozole
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21
Q

Indications for 5 years of tamoxifen treatment in pre-menopausal women with breast cancer

A
  • Grade 1-2
  • T1 <2cm
  • Node -
  • ER+
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22
Q

Indications for 10 years of tamoxifen or 5 years or tamoxifen + 5 years letrozole in pre-menopausal women with breast cancer

A
  • T2-4
  • Grade 3
  • Node +
  • HER2+
  • ER poor
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23
Q

Indications for 5 years of treatment with tamoxifen in post-menopausal women with breast cancer

A
  • Grade 1-2
  • T1 <2cm
  • Node -
  • ER+
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24
Q

Indications for 5 years of treatment with tamoxifen + 5 years with letrozole in post-menopausal women with breast cancer

A
  • Grade 2
  • T2 >2cm
  • Node -
  • ER+
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25
Indications for 5 years of treatment with letrozole in post-menopausal women with breast cancer
- Grade 3 - T3-4 - Node + - HER2+ - ER poor - Response to neo-adjuvant aromatase inhibitors - Tamoxifen contra-indicated
26
What scan needs to be done before starting a breast cancer patient on letrozole
DEXA scan
27
How would you check menopausal status in patients on tamoxifen?
Check hormone levels after 6 weeks off tamoxifen
28
How would you confirm menopause in a women <50 on tamoxifen?
- FSH >30 on 2 occasions >6 weeks apart AND - Amenorrhoeic for 24 months
29
How would you confirm menopause in a women 50-54 on tamoxifen?
- FSH >30 on 2 occasions >6 weeks apart AND - Amenorrhoeic for 12 months
30
Which group of breast cancer patients should be offered immunotherapy, and what treatment would you offer?
- HER2 + patients | - Herceptin for 6-12 months
31
Features that increase risk of breast cancer recurrence
- Tumour size >1cm - ER- - Involvement of lymph nodes
32
Long-term follow up of 'cured' breast cancer patients
YEAR 1 - Clinical examination and mammogram - Check family history and consider genetic testing YEAR 2-4 - Mammogram - Clinical examination if bilateral mastectomy performed YEAR 5 - Clinical examination and mammogram - Consider changing endocrine therapy YEAR 6-10 - Mammogram Year 10 - Mammogram with clinical examination - Stop endocrine therapy as appropriate - Discharge to breast screening programme - Contact genetics if high risk patient - Reassess family history and consider genetic referral
33
Define neutropenic sepsis
WCC <1 + pyrexia as a potential complication of systemic anti-cancer treatment
34
When are patients on SACT at risk of neutropenic sepsis?
Days 7-21 post-treatment
35
Risk factors for neutropenic sepsis
- Age >65 - Poor performance status - Previous neutropenic sepsis - Combined chemotherapy + radiotherapy - Poor nutrition - Advanced disease - Co-morbidities - Active infection - Central venous catheters - Surgical wounds - Previous MRSA colonisation - Unwell contacts
36
Clinical features of neutropenic sepsis
- Pyrexia (temp >37.5 or <36) - Malaise - Infective symptoms e.g. cough
37
What scoring assessment is used for initial assessment of patients with ?neutropenic sepsis
Formal risk assessment - combines NEWS score and MASCC score (maximum score is 26 - patients <21 or with NEWS Score >6 are high risk)
38
What investigations would you carry out in a patient with ?neutropenic sepsis?
- Clinical examination (including mouth and perineum) for signs of infection - Daily bloods (CRP, FBC, U&Es, LFTs) while on antibiotics - must be requested URGENTLY on admission and following day - Peripheral (and central) blood cultures - Viral throat swabs - Urine dipstick and MSU - CXR - Consider abdominal x-ray and CT or stool cultures for C. diff
39
Antibiotic choice in patients with standard risk neutropenic sepsis
1) IV piperacillin/tazobactam 4.5g qds
40
Antibiotic choice in patients with high risk neutropenic sepsis
1) IV piperacillin/tazobactam 4.5g qds + IV gentamicin
41
Side effects of Tazocin
- GI upset - Rash, pruritis - Phlebitis - Insomnia
42
Side effects of Gentamicin
- Neurotoxicity (vertigo, gait instability) - Ototoxicity - Nephrotoxicity - Oedema - Rash, pruritis
43
What does dose regime of Tazocin depend on
Renal function - creatinine clearance determines if Tazocin is given bd, td or qds
44
Antibiotic management of a patient with neutropenic sepsis with previous MRSA or presumed central line infection
1) IV Tazocin + Vancomycin
45
Antibiotic management of a patient with neutropenic sepsis with suspected atypical pneumonia
1) IV Tazocin + Clarithromycin
46
Side effects of Vancomycin
- Anaphylactic reaction - 'Red man' syndrome - Back pain - Bradycardia - Chest pain - Dyspnoea - Hearing loss - Hypotension - Muscle pain
47
Side effects of clarithromycin
- Decreased appetite - GI upset - Dizziness - Headache - Insomnia - Pancreatitis - Skin reactions - Vasodilation - Vision disorders
48
What would you recommend in regards to chemotherapy treatment in a patient recovering from neutropenic sepsis?
- Reduce dose of chemotherapy OR - Delay chemotherapy cycle by a week
49
Clinical features of malignant spinal cord compression
- Pain (most commonly in the back, exaggerated by coughing and straining, and in a radicular pattern) - Weakness - Bowel problems - Altered sensation - Urinary incontinence - Faecal incontinence - Bilateral sciatica - Saddle anaesthesia
50
Radicular pain in a patient with previous/current malignancy is ??? until proven otherwise
malignant spinal cord compression
51
What is the 1st line investigation in a patient with ?malignant spinal cord compression
URGENT MRI of the WHOLE spine (within 24 hours)
52
Management options for a patient with malignant spinal cord compression
1) 16mg PO dexamethasone (as a 'holding measure') followed by 8mg bd dexamethasone + PPI cover (given in the daytime) 2) Radiotherapy (20Gy in 5 fractions) to the affected area and 1-2 vertebrae above and below OR Surgery (fixation of the affected vertebrae) (1st line in indicated patients) Or OR Chemotherapy (for sensitive tumours) OR Hormone treatment (in metastatic prostate cancer)
53
Side effects of lumbar spine radiotherapy
- Skin reaction - Fatigue - Cystitis - Diarrhoea
54
Indications for surgery in patients with malignant spinal cord compression
- Single vertebral region of involvement - No evidence of widespread metastasis - Radio-resistant primary tumour (e.g. renal, sarcoma) - Previous radiotherapy to a affected site) - Unknown primary (allows us to get tissue for histology)
55
Causes of SVC obstruction
- Bronchus cancer - Lung cancer (SCLC) - Lymphoma - Other malignancy - Aneurysms - Goitre - Fibrosis - Infection - Central line in situ - Thrombosis
56
Clinical features of SVC obstruction
- Swelling of face, neck, one/both arms - Distended veins - Shortness of breath - Lethargy - Headache - Nasal congestion - Epistaxis - Dizziness - Syncope Symptoms are often worse on bending forward or lying down - Neck veins don't collapse on compression - Visible veins - Raised JVP - Arm oedema - Plethora
57
Investigations to consider in a patient with SVC obstruction
1) CXR (looking for a mass) 2) CT chest with contrast (provides 3D information about the cause - contrast will accumulate in the area before the obstruction) 3) Venogram 4) Routine bloods and coagulation screen
58
Management of a patient with malignant SVC obstruction
Dexamethasone is often given first line (although there is limited evidence for this) 1) Radiological stenting 2) Chemotherapy (in SCLC, lymphoma, teratoma) OR Radiotherapy (in other malignant causes)
59
Define malignant hypercalcemia
Corrected serum calcium >2.65 mmol/L on two occasions in patients with malignancy
60
3 most common causes of malignant hypercalcemia
- Lung cancer - Breast cancer - Multiple myeloma
61
Differentials for malignant hypercalcemia
- Brain/bony metastasis - Delirium - Paraneoplastic syndrome - Electrolyte imbalances - Infection
62
Clinical features of malignant hypercalcemia
May be asymptomatic (particularly in mild cases) - Bone pain, pathological fractures - Delirium, drowsiness, coma - Fatigue - Muscle weakness - Impaired concentration and memory - Depression - GI upset - Polyuria, polydipsia and dehydration - Renal colic, renal stones, renal impairment - Hypertension - Shortened QT on ECG - Pruritus - Eye infections, corneal calcifications
63
Investigations to consider in a patient with ?malignant hypercalcemia
- General infection screen e.g. MSU - Routine bloods including calcium and PTH - CT head (rule out brain metastasis)
64
Management of a patient with malignant hypercalcemia
1) Adequate rehydration to correct dehydration - Oral rehydration if appropriate - 3L of 0.9% NaCl over 24 hours 2) IV zolendronate 4mg over 15 mins in 100ml 0.9% NaCl (if eGFR >30) OR Pamidronate (if eGFR <30) 3) Review medications affecting renal function (e.g. NSAIDs, diuretics, ACE inhibitors) 4) Check U&Es in 3-4 days
65
Management of a patient with neutropenic sepsis with a penicillin allergy
1) IV Vancomycin + Metronidazole + PO Ciprofloxacin
66
Side effects of metronidazole
- Dry mouth - Myalgia - GI upset - Metallic taste
67
Side effects of ciprofloxacin
- Tendon damage - Arthralgia, myalgia - GI upset - Dizziness - Dyspnoea - Fever - Headache - QT prolongation - Skin reactions - Sleep disorders - Altered taste - Tinnitus - Vision disorders
68
Oral antibiotic stepdown in patients with neutropenic sepsis
Co-amoxiclav + ciprofloxacin
69
Indications for GCS-F in patients with neutropenic sepsis
- Profound neutropenia (<0.1) - Prolonged neutropenia (> 10 days) - Pneumonia - Hypotension - Multi-organ dysfunction - Uncontrolled primary disease - Invasive fungal infection - Age >65 - Hospital inpatient at time of developing fever
70
Most common malignant causes of spinal cord compression
- Breast - Lung - Prostate - Multiple myeloma
71
What is the scoring system used to consider surgery in patients with malignant spinal cord compression, and what factors does it take into account?
Tokuhasi score: - Patient's general condition - Number of extra-spinal bone metastasis - Number of spinal bone metastasis - Metastasis in major organs - Primary site of cancer - Neurological deficit
72
What blood tests should you request to monitor a patient on bisphosphonates
- Renal function - Calcium - Phosphate - Potassium
73
Side effects of bisphosphonates
- GI upset - Flu-like symptoms - Osteonecrosis of the jaw
74
Mechanism of action of Tamoxifen
Oestrogen receptor antagonist
75
Route of administration of Tamoxifen
Oral
76
Indications for Tamoxifen
- ER+ breast cancer (as adjuvant or neb-adjuvant therapy) post-surgery/radiotherapy in pre- or peri-menopausal women - Breast cancer patients for 5 years after tumour removal - Primary prevention of breast cancer (in women >30 with moderate/high risk) - Gynaecomastia in males
77
Contraindications for tamoxifen
- Family/personal history of idiopathic VTE - Pregnancy - Concurrent anastrozole therapy
78
Side effects of tamoxifen
MOST IMPORTANT: 1) endometrial changes (hyperplasia, polyps, cancer, uterine sarcoma) 2) Increased risk of thromboembolism - Alopecia - Anaemia - Cataracts - Cerebral ischaemia - Fatigue - Fluid retention - Headache - Hot flushes - Nausea - Retinopathy Tamoxifen DOES NOT affect bone mineral density
79
Route of administration of aromatase inhibitors
Oral
80
Indications for letrozole
- Adjuvant treatment of ER+ invasive early breast cancer in post-menopausal women - 1st line treatment in ER/PR+ or ER/PR status unknown locally advanced or metastatic breast cancer in post-menopausal women - Extended adjuvant therapy of early breast cancer in post-menopausal women who have received 5 years of adjuvant tamoxifen - Treatment of advanced breast cancer in post-menopausal women where other anti-oestrogen therapy has failed
81
Indications for exemestane
- Adjuvant treatment of ER+ early breast cancer in post-menopausal women following 2-3 years of tamoxifen - Advanced breast cancer in post-menopausal women where anti-oestrogen therapy has failure
82
Indications for anastrozole
- Adjuvant treatment of ER+ early invasive breast cancer in post-menopausal women - Adjuvant treatment of ER+ early breast cancer in post-menopausal women following 2-3 years of tamoxifen - Advanced breast cancer in post-menopausal women which is ER+ or responsive to Tamoxifen
83
Contra-indications for aromatase inhibitors
- Pre-menopausal women | - Pregnancy and breast feeding
84
Side effects of aromatase inhibitors
MOST IMPORTANT: 1) Decreased bone mineral density/osteoporosis - Alopecia - Arthralgia - Hot flushes - Vaginal dryness - Oedema - Bone pain - Headache - GI upset - Carpal tunnel syndrome - Insomnia - Leucopenia - Thrombocytopenia - Skin reactions
85
Monitoring required during aromatase inhibitor treatment
- Bone mineral density
86
Mechanism of action of Goserelin
GnRH receptor antagonist
87
Route of administration of Goserelin
SC injection into anterior abdominal wall
88
Indications for Goserelin
- Locally advanced prostate cancer (as an alternative to surgery) - Adjuvant/neoadjuvant treatment to radiotherapy/radical prostatectomy in patients with high-risk localised or locally advanced prostate cancer - Metastatic prostate cancer - Advanced breast cancer - ER+ early breast cancer
89
Contra-indications for Goserelin
- Undiagnosed vaginal bleeding | - Use for >6 months in endometriosis
90
Side effects of Goserelin
- Alopecia - Pain - Breast abnormalities - Altered mood, depression - Impaired glucose tolerance - Gynaecomastia - Headache - Heart failure - Hot flushes - Hyperhidrosis - MI - Neoplasm complications - Parasthesia - Sexual dysfunction - Skin reactions - Spinal cord compression - Vulvovaginal disorders - Weight gain
91
Monitoring required on Goserelin
- Men at risk of 'tumour flare' (temporary worsening of disease) should be closely monitored during first month of treatment for prostate cancer - Monitor for QT-prolongation and ventricular arrhythmia (in patients on QT-prolonging agents)
92
Drug interactions of Goserelin
Goserelin interacts with QT-prolonging agents
93
Mechanism of action of Herceptin
Monoclonal antibody which down-regulates HER2
94
Route of administration of Herceptin
SC injection or IV infusion
95
Indications for Herceptin
- Early HER2+ breast cancer - Metastatic HER2+ breast cancer in patients who have not received chemotherapy and where Anthracyclines treatment is inappropriate (given in combination with paclitaxel or docetexal) - Monotherapy for metastatic breast cancer patients who have previously received at least 2 chemotherapy agents - Metastatic HER2+, ER/PR+ breast cancer in post-menopausal women not previously treated with Herceptin - Metastatic HER2+ gastric cancer
96
Contra-indications for Herceptin
- Severe dyspnoea at rest | - Pregnancy, breast-feeding
97
Side effects of Herceptin
MOST IMPORTANT: 1) Decreased ejection fraction and congestive heart failure - Headache - GI upset - Insomnia - Cough - Rash - Cardiac disorders - Infection (including neutropenic sepsis) - Pancytopenia - Fatigue, malaise, pain - Tremor - Dizziness - Parasthesia - Altered sense of taste - Hot flushes - Respiratory symptoms - Swollen face - Alopecia - Nail disorders - Hand-foot syndrome - Peripheral oedema
98
Monitoring required when on Herceptin
Regular echocardiograms to assess ejection fraction
99
Mechanism of action of Imatinib
Tyrosine kinase inhibitor - inhibits BCR-ABL in the Philadelphia chromosome and c-Kit
100
Route of administration of Imatinib
Orally with food
101
Indications for Imatinib
- Philadelphia+ CML - Philadelphia+ ALL - C-KIT+ GIST
102
Side effects of Imatinib
MOST IMPORTANT: 1) Hepatotoxicity 2) Cardiac toxicity - Pancytopenia - Fluid retention - GI upset - Photosensitivity - Alopecia - Myalgia, arthralgia - Blurred vision - Taste alteration - Skin changes
103
Monitoring required when on Imatinib
- FBC - LFTs - Monitor for GI haemorrhage - Monitor for fluid retention - Monitor for growth retardation (in children)
104
Drug interactions with Imatinib
- CYPA34 inhibitors (erythromycin) and inducers (carbamazepine, St JOhn's wort) - Warfarin
105
Mechanism of action of Capecitabine
Anti-metabolite - converted into fluorouracil in the tumour to inhibit DNA synthesis and slow tumour growth
106
Route of administration of Capecitabine
Orally after a meal, bi-daily | Given for 14 days followed by a 7 day interval (course of 6 months)
107
Indications for Capecitabine
- Monotherapy is first line treatment of advanced colorectal cancer - Adjuvant therapy of patients with stage III colon cancer - Advanced gastric cancer - In combination with Docetexal in locally advanced or metastatic breast cancer - Monotherapy in advanced breast cancer after failure or taxmen and anthracyclines chemotherapy
108
Contra-indications for Capecitabine
- Dihydropyrimidine dehydrogenase deficiency - Severe liver dysfunction - Severe renal impairment - Thrombocytopenia - Neutropenia - Pregnancy/breast feeding
109
Side effects of Capecitabine
- GI upset and appetite suppression - Eye irritation - Fever - Alopecia - Stomatitis - Myelosuppression - Headache - Fatigue - Shortness of breath - Hand-foot syndrome - Weakness - Dermatitis - Pain - Peripheral oedema
110
Monitoring required when on Capecitabine
- Serum calcium - Monitoring for eye disorders - Monitoring for severe skin reactions e.g. Stevens-Johnson syndrome and toxic epidermal necrosis - discontinue permanently if these occur
111
Mechanism of action of Rituximab
Anti-lymphocytic monoclonal antibody - causes apoptosis of B lymphocytes
112
Route of administration of Rituximab
IV (or SC for non-Hodgkin's lymphoma)
113
Indications for Rituximab
- Non-Hodgkin's lymphoma - CLL - Autoimmune disease e.g. RA, SLE
114
Contra-indications for Rituximab
- Severe infection | - Severe heart failure, severe uncontrolled heart disease (when used for autoimmune disease)
115
Side effects of Rituximab
MOST IMPORTANT: 1) Reactivation of Hepatitis B and TB infection 2) Induced serum sickness (triad of arthralgia, fever and rash) 3) Cytokine-releasing syndrome Transient hypotension occurs frequently during infusion. - Angioedema - Anxiety - GI upset - Arrhythmia - Bone marrow disorders - Bursitis - Cancer pain - Cardiac disorders - Chest pain - Infection - Dizziness - Dysphagia, throat pain - Ear pain - Electrolyte imbalance - Hypercholesterolaemia - Hyperglycaemia - Hyperhidrosis - Insomnia - Lacrimation disorders - Malaise - Migraine - Multi-organ failure - Myalgia - Increased muscle tone - Nerve disorders - Oedema - Oral disorders - OA - Respiratory disorders - Abnormal sensation - Skin reactions - Tinnitus
116
Screening required before starting Rituximab
Hepatitis B and TB screen
117
Management steps for pain
1) Mild pain - Paracetamol 1g qds OR - NSAID (Reduce dose of paracetamol in poor nutritional status, low body weight, hepatic impairment, chronic alcohol abuse) 2) Mild-moderate pain - ADD a weak opioid (codeine or dihydrocodeine 30-60mg qds) OR - Switch to a combined paracetamol codeine preparation (co-codamol 30/500, 2 tablets qds) (Consider prescribing a laxative or anti-emetic) 3) Moderate-severe pain - Switch from a weak to a strong opioid (24mg oral morphine in 24 hours)
118
Adjuvant therapies available for pain management in palliative care
- NSAID (bone pain, liver pain, soft tissue infiltration inflammatory pain) - Anti-depressants/anti-convulsants (nerve pain) - should be started at a low dose and titrated slowly - Dexamethasone (raised ICP, neuropathic or liver capsule pain) - TENS - Nerve block - Radiotherapy - Surgery - Bisphosphonates - Ketamine - Smooth/skeletal muscle relaxants
119
NSAID side effects
- GI ulcers/bleeding - Renal impairment - Fluid retention - Adverse cardiac events
120
Amitryptilline side effects
- Confusion - Hypotension - Dry mouth - Use with caution in CVD or risk of seizures
121
Gabapentin side effects
- Sedation - Tremor - Confusion - Use with caution in renal impairment
122
Dexamethasone side effects
- Insomnia - GI ulcer - Hyperglycaemia - Fluid retention - Infection e.g. candida - Myopathy
123
Dose of breakthrough pain relief (compared to daily pain relief)
1/6th-1/10th (given as immediate release form)
124
When should you seek specialist advice regarding pain control in palliative care patients
- >3 doses breakthrough pain relief given but patient still in pain - >6 doses breakthrough pain relief in 24 hours
125
Opioid management ladder
1) Mild-moderate pain: - Codeine - Dihydrocodeine - Tramadol - Buprenorphine patches 2) Moderate-severe pain: - Morphine - Diamorphine - Oxycodone - Fentanyl patch - Alfentanil - Fentanyl sublingual/buccal/intra-nasal - Hydromorphone - Methadone
126
Analgesics to avoid in stage 4/5 CKD
- Codeine - Dihydrocodeine - Morphine (titrate slowly and monitor in stages 1-3) - Diamorphine (titrate slowly and monitor in stages 1-3 and liver impairment) - Modified release Oxycodone
127
Contra-indications/cautions for using Tramadol
- Caution in stage 4/5 CKD - Caution in severe liver failure - CI with Monoamine oxidase inhibitors - CI in epilepsy - Avoid/use with caution in those on SSRIs or tricyclic antidepressants (risk of serotonin syndrome and lower seizure threshold)
128
Drug of choice for high-dose SC breakthrough pain control injections
Diamorphine
129
CIs for oxycodone
- Severe liver impairment - Titrate slowly and minter in stages 1-3 CKD - CI in stage 4/5 CKD (for modified release form)
130
Indications for fentanyl patch
Tolerant to opioids and chronic/stable pain
131
Contra-indications/cautions for fentanyl patch
- Monitor carefully in renal impairment - Reduce dose in liver impairment - Don't initiate at end of life if oral route unavailable (can take too long to reach a steady state)
132
Drug of choice for pain control in palliative care if eGFR <30 and a syringe driver is indicated
Alfentanil
133
How would you convert a patient from immediate release morphine to modified release morphine?
Divide dose of 24 hour morphine by 2 and prescribe 12 hourly
134
How would you convert a dose of an oral weak opioid to oral morphine?
Oral codeine/dihydrocodeine/tramadol --> oral morphine: divide dose by 10
135
How would you convert a dose of an oral morphine to SC morphine?
Divide dose by 2
136
How would you convert a dose of an oral morphine to SC Diamorphine?
Divide dose by 3
137
How would you convert a dose of an oral morphine to oral oxycodone?
Divide dose by 2
138
How would you convert a dose of an oral morphine to SC oxycodone?
Divide dose by 4
139
How would you convert a dose of an oral oxycodone to SC oxycodone?
Divide by 2
140
Precipitating factors for opioid toxicity
- Rapid dose escalation - Renal impairment - Sepsis - Electrolyte abnormalities - Drug interactions
141
Symptoms of opioid toxicity
- Persistant sedation - Vivid dreams/hallucinations - Shadows at edge of visual fields - Delirium - Muscle twitching/myoclonus/jerking - Abnormal skin sensitivity to touch
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How to manage a patient with opioid toxicity
- Reduce opioid dose by 1/3rd | - Ensure patient is well hydrated
143
4 types of medication that can be prescribed using anticipatory care planning?
1) Opioids (for pain or breathlessness) e.g. morphine sulphate 2) Anxiolytic sedative (for anxiety, agitation or breathlessness) e.g. midazolam 3) Anti-secretory (for respiratory secretions) e.g. hyoscine butylbromide 4) Anti-emetic (for nausea and vomiting) e.g. levomepromazine
144
Most common malignant causes of cachexia
- Gastric - Pancreatice - NSCLC - SCLC - Prostate - Colon - NHL - Sarcoma - Acute non-lymphocytic leukaemia - Breast
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Reversible causes of anorexia
- Pain - Breathlessness - Depression - Ascites - Nausea and vomiting - Constipation - Dysphagia - Heartburn - Gastritis - Anxiety - Medication - Oral problems - Odours - Delayed gastric emptying - Fatigue
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Symptoms of cachexia
- Weight loss - Anorexia - Fatigue - Muscle wasting - Aesthesia - Anaemia - Oedema
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Pharmacological management of anorexia/cachexia
- Corticosteroids (PO dexamethasone or prednisolone for 1 week then review) - may improve appetite and help nausea, energy levels and malaise. Effect is usually rapid but wears off after a few weeks. - Progestogens (megestrol acetate) - may stimulate appetite and weight gain. Onset of effect is slower but more prolonged than steroids.
148
Side effects of progestogens
- Nausea - Fluid retention - Increased risk of thromboembolism
149
Pharmacological management of breathlessness in palliative care
1) Opioids (morphine) 2) Dexamethasone 8-16mg/daily (indicated in lymphangitis or tumour-associated airway obstruction) 3) Benzodiazepines 4) Oxygen 5) Nebulised saline
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Define delirium
Disturbed consciousness and inattention with cognitive impairment of acute onset and fluctuating course as a consequence of disease or treatment.
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Causes of delirium
- Drugs e.g. opioids, anti-cholinergics, corticosteroids, benzodiazepines, antidepressants, sedatives - Drug withdrawal e.g. alcohol, sedatives, antidepressants, nicotine - Dehydration - Constipation - Urinary retention - Uncontrolled pain - Liver or renal impairment - Electrolyte imbalance - Infection - Hypoxia - Cerebral tumour - Cerebrovascular disease
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Pharmacological management of delirium in palliative care patients
1) Haloperidol PO or SC | 2) Benzodiazepines
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Risk factors for depression in palliative care
- Personal/family history of depression - Concurrent life stresses - Multiple losses - Unfulfilled life aspirations - Absence of social support - History of substance misuse/abuse - Oropharyngeal, pancreatic, breast and lung cancers
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Pharmacological management of depression in palliative care patients
1) SSRIs 2) Mirtazapine (well tolerated in elderly patients and heart failure) 3) Amitryptilline
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Side effects of SSRIs
- GI upset - Risk of GI bleeding - Insomnia - Sweating - Impaired sexual function - Vivid dreams - Agitation - Hyponatremia - Risk of serotonin syndrome
156
Investigations to consider in a palliative patient with nausea and vomiting
- U&Es - LFTs - Calcium - Blood glucose
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Non-pharmacological management of a patient with nausea and vomiting
- Regular mouth care - Regularising bowel habit - Regular, small, palatable meals - Avoid food preparation and cooking meals - Acupressure bands - Acupuncture - Psychological approaches
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Management of nausea/vomiting caused by chemical stimulation (e.g. drugs, malignancy, metabolic upset)
1) Dopamine receptor antagonist (metroclopramide, haloperidol, levomepromazine)
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Management of nausea/vomiting caused by motility disorders (e.g. gastric paresis)
1) Pro kinetic (metroclopramide)
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Management of nausea/vomiting caused by raised ICP or stimulation of the vestibular nerve
1) Cyclizine/hyoscine hydrobromide + dexamethasone 2) Levomepromazine 3) Prochloperazine
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Management of nausea/vomiting caused by cranial nerve irritation (oral, pharyngeal or oesophageal causes)
1) Cyclizine 2) Hyoscine hydrobromide 3) Levomepromazine
162
Dopamine receptor antagonists used to treat nausea
Haloperidol
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5HT3 receptor antagonists used to treat nausea
-Setrons
164
Anti-muscarinics used to treat nausea
Hyoscine hydrobromide
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Histamine 1 receptor antagonists used to treat nausea
Cyclizine
166
5HT2 receptor antagonists used to treat nausea
Levomepromazine
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Factors leading to fatigue in cancer patients
- Anaemia - Cancer treatment - Tumour bulk - Cytokine release - Depression and anxiety - Difficulty sleeping - Low degree of physical functioning
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Non-pharmacological management of fatigue in palliative care patients
- Energy conservation/restoration plans - Exercise regimes - Stress reduction and increased psychological support - Sleep pattern advice - Recombinant EPO (may stimulate tumour progression in head and neck cancer)
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Pancreatic cancer tumour marker
Ca19-9
170
Breast cancer tumour marker
Ca15-3
171
Hepatic cancer tumour marker
AFP
172
Colorectal cancer tumour marker
CEA
173
Ovarian cancer tumour marker
Ca125
174
Testicular cancer tumour markers
AFP | B-HCG
175
Clinical features of a fibroadenoma
- Young woman (18-25) | - Painless, mobile, firm breast lump
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Management of a fibroadenoma
None required usually Surgical removal if >3cm or patient wants it removed
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Clinical features of duct ectasia
- Women >50 - Cheesy/white or thick green nipple discharge from single or multiple ducts - Slit like nipple retraction - Doughy palpable mass
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Risk factors for mastitis
- Breast-feeding - Smoking - Diabetes
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Is lactational or non-lactational mastitis more serious?
Lactational - infection is usually more generalised and the patient is more systemically unwell so requires IV antibiotics
180
Most common bacterial cause of breast abscess
S. Aureus
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Clinical features of mastitis
- Usually affects one breast - Symptoms develop quickly - Red, swollen area/lump on breast - Hot and painful to touch - Area of hardness or tender fluctuating mass - Burning pain - Nipple discharge (white or blood-stained) - Malaise
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Indications for referral of a mastitis patient
- Mastitis or breast inflammation which does not settle after 1 course of antibiotics - Abscess suspected - Breast inflammation in patient >35
183
Management of lactational mastitis
1) Continue breast feeding 2) Antibiotics (if systemically unwell, nipple fissure present or symptoms don't improve after 24-48 hours) - 10-14 days Flucloxacillin 500mg QDS OR - Erythromycin 500mg BD
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Management of non-lactating mastitis
1) Co-amoxiclav 375mg TD OR 2) Erythromycin 500mg WDS + Metronidazole 400mg TD
185
Clinical features of intra-ductal papilloma
- Clear or bloodstained nipple discharge originating from a single duct
186
Clinical features of a breast cyst
- Peri-menopausal women - Soft, fluctuant breast swelling - 'Halo' appearance on mammography
187
Management of symptomatic breast cysts
Aspiration then re-examine the breast to ensure cyst has gone.
188
Most common lung cancer in non-smokers
Adenocarcinoma
189
Clinical features of lung cancer
- Persistent cough - Haemoptysis - Dyspnoea - Chest pain - Weight loss and anorexia - Hoarseness - SVC syndrome - Fixed, monomorphic wheeze - Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy - Finger clubbing
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Paraneoplastic features of SCLC
- ADH - hyponatremia - ACTH - hypertension, hyperglycaemia, hypokalemia, alkalosis, muscle weakness - Lambert-Eaton syndrome
191
Paraneoplastic features of squamous cell lung cancer
- PTHrP - hypercalcemia - Finger clubbing - Hypertrophic pulmonary osteoarthropathy - Hyperthyroidism
192
Paraneoplastic features of adenocarcinoma
- Gynaecomastia | - Hypertrophic pulmonary osteoarthropathy
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Indications for an URGENT CXR in suspected lung cancer
Patients >40 with 2 or more of the following symptoms OR 1 symptom + smoking history: - Cough - Fatigue - Shortness of breath - Chest pain - Weight loss - Appetite loss OR patients >40 with ANY of the following: - Persistent or recurrent chest infections - Finger clubbing - Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy - Chest signs consistent with lung cancer - Thrombocytosis
194
Investigations to consider in a patient with suspected lung cancer
- CXR - CT - Bronchoscopy - PET scanning - FBC
195
Indications for urgent referral for lung cancer work up
- CXR findings that suggest lung cancer | - >40 with unexplained haemoptysis
196
Management of SCLC
Chemotherapy + radiotherapy
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Contra-indications for surgery in NSCLC patients
- Poor general health - Metastatic disease - FEV <1.5L - Malignant pleural effusion - Tumour near hilum - Vocal cord paralysis - SVC obstruction
198
3 'types' of colon cancer
1) Sporadic 2) HNPCC-associated 3) FAP-associated
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Mode of inheritance for HNPCC and FAP
Autosomal dominant
200
Clinical features of colorectal cancer
- Persistant changes in bowel habit - Rectal bleeding - Persistent abdominal discomfort - Tenesmus - Weakness or fatigue - Unexplained weight loss
201
Indications for urgent referral for colorectal cancer work up
- Patients >40 with unexplained weight loss and abdominal pain - Patients >50 with unexplained rectal bleeding - Patients >60 with iron deficiency anaemia OR change in bowel habit Consider referral in: - Rectal or abdominal mass - Unexplained anal mass or anal ulceration - Patients <50 with rectal bleeding AND abdominal pain/change in bowel habit/weight loss/iron deficiency anaemia
202
Screening programme for colorectal cancer
Faecal Immunochemical testing offered every 2 years to men and women 60-74 in England and 50-74 in Scotland
203
Follow up for patients with a positive FOB test
Colonoscopy
204
Indications for FOBT (outside normal screening criteria)
- Patients >50 with unexplained abdominal pain OR weight loss - Patients <60 with changes in bowel habit or iron deficiency anaemia - Patients >60 with anaemia
205
Risk factors for ovarian cancer
- Family history - BRCA1/2 mutations | - Many ovulations e.g. early menarche, late menopause, nulliparity
206
Clinical features of ovarian cancer
- Age >60 - Abdominal distention and bloating - Abdominal and pelvic pain - Urinary symptoms e.g. urgency - Early satiety - Diarrhoea
207
Investigations to consider in a patient with suspected ovarian cancer
1) Ca125 (not to be used to screen asymptomatic women) 2) Urgent abdo/pelvis US (if Ca125 >35) 3) Diagnostic laparotomy
208
Causes of an increased Ca125
- Endometriosis - Menstruation - Benign ovarian cysts
209
Management of ovarian cancer
Combination of surgery and platinum-based chemotherapy

Year 5 (9 decks)

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