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Yr 5 - cancer care > palliative and Tx > Flashcards

palliative and Tx Flashcards

(100 cards)

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1
Q

what are the ways in which a cancer can metastasise

A

1) local invasion/ direct extension –> this normally happens in locally invasive tumours like those of the head and neck
2) haeamtogenous spread (common in lung, prostate, melanoma - the secondary sites look like the primary cancer)
3) lymphatic
4) transcoelomic
5) seeding - where cancer c ells spread by direct implantation into body cavities such as the pleural or pericardial cavity

-NOTE cancers can metastasise in more than one way

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2
Q

what antiemetic is used firstline in cancer is cause of the sickness is unknown

A

metoclopramide - D2 antagonist (this is pro kinetic and does cross the BBB)

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3
Q

what SE can you get from metoclopramide

A

extrapyramidal - oculogyric crisis, hyperprolactinaemia, tar dive dyskinesia, Parkinsonism

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4
Q

what is haloperidol used for

A

D2 antagonist (cross BBB) which can be used to treat sickness caused by metabolic disturbance or agitation

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5
Q

MOA of ondansetron

A

5HT3 antagonist

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6
Q

MAO of cyclizine

A

H1 antagonist

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7
Q

what antiemetic is used as an anticipatory drug

A

levomepromazine

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8
Q

what drug can be used for large volume vomitign cause by BO

A

hyoscine butyl bromide (ACH antagonist) / ocreotide (somatostatin analogue)

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9
Q

what are some causes for N+V in cancer

A

1) reduced gastric motility –> this may be due to compression or can be due to the use of opioids
2) chemically mediated –> from chemo or from electrolyte imbalances like hypercalcaemia
3) visceral - if constipated
4) raised ICP
5) vestibular - may be due to cerebral mets or opioids
6) cortical - anxiety (in this case would treat with benzos)

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10
Q

causes of constipation in palliative care

A

1) opioids
2) bowel obstruction
3) hypercalcaemia, inadequate intake, dehydration

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11
Q

if laxatives are not sufficient to treat constipation, what an be used next?

A

Rectal treatments:
1) soft loading - bisacodyl suppository
2) hard loading - glycerol suppository
3) arachis oil enema

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12
Q

what are the 5 principles of pain management for cancer

A

1) oral administration where possible
2) prescribe based on the pain the patient says they are in, not what you think
3) start low
4) administer consistently

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13
Q

3 examples of weak opioids

A

codeine, dihydrocodeine and tramadol

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14
Q

what other considerations can be given to pain Tx, if the pain ladder does not work

A

nerve blocks, epidurals, PCA pumps

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15
Q

what is the opioid dose recommended for opioid naive patients

A

20-30mg a day

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16
Q

what would you prescribe alongside opioids

A

always a stimulant laxative, sometimes an antiemetic like metocloprmaide

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17
Q

what opioid can be used in mild renal impairment

A

oxycodone

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18
Q

what opioid can be used in severe renal impairment

A

buprenorphine patch or fentanyl

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19
Q

what can be said to the patient about how long their side effects will last with opioids

A

drowsiness and nausea are transient but constiaption will last

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20
Q

for metastatic bone pain, what should be considered

A

opioids, bisphosphonates and radiotherapy

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21
Q

what adjuvant can you not use in a Hx of heart problems

A

amitriptyline

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22
Q

what can be used for a painful mouth at the end of life

A

benzydamine hydrochloride

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23
Q

what is the difference between nociceptive and neuropathic pain

A

nociceptive pain is when there is a stimulus and the nerves are in tact where as neuropathic pain is when the stimulus has gone. Causes allodynia, hyperkalaemia and parasthesia.

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24
Q

what’s a key difference between incident pain and neuropathic pain

A

incident pain is predictable

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25
conservation management of secretions
avoid fluid overload, advise family that the patient is not troubled by it, reposition the patient and leave their upper body elevated to allow for postural drainage
26
which secretion med is sedating
hyoscine hydrobromide
27
simple measures for a cough
humidify room air if cough is dry, sit person up
28
what are the causes of dyspnoea in cancer patient
1) direct causes of the cancer - lung cancer/mets 2) indirect effects of the cancer like pleural effusion of SVCO 3) non malignant - COPD, heart failure, anxiety
29
what is used for agitation in terminal phase
midazolam
30
as part of the gold standards framework, what are three trigger questions
1) surprise Q 2) general indicators of decline (weight loss, increased admission, low albumin, reduced activity) 3) specific indicators of decline
31
what are some specific indicators that someone is at the end of their life with COPD
MRC grade 4/5, FEV1<30% predictive, cor pulmonale
32
what is good about the gold standard framework
promotes better coordination and collaboration between HCP, hospital and community services and prevent hospital admissions and give people choices over their death
33
which med is used for ANTICIPATORY secretions
glycopyrronium (this doesn't cross BBB so is not sedating)
34
when is someone considered for a syringe driver in their terminal phase
when they need 2+ anticipatory meds in 24 hours
35
for end of life, what is it important to make
LPoA
36
signs someone is dying
agitation, mottled skin, noisy secretion, weight loss, someone might express that they are dying, cheyne stokes breathing, sleeping more, no oral intake
37
what must be on a controlled drug prescription
address of patient
38
definition of hospice based care
specialist palliative care for people with terminal illnesses and their families
39
what is adjuvant treatment
treatment after surgery to prevent cancer reoccurrence
40
what is maintenance treatment
treatment which is given o helps he primary treatment succeed
41
what determines the cancer treatment given
type of cancer, stage of cancer, performance status of patient, patient wishes, comordbities, genetics
42
what are the challenges of survivorship (which means anyone who has received a cancer diagnosis at some point)
long term toxicities from treatment, survivor guilty, uncertainty about future, effects on family / friends, trouble getting health and life insurance
43
benefits of MDT
reduces variation in access to treatments and improves continuity to cancer
44
problems with MDT (members - oncologist, CNS, histopathologist, pharmacy, PT/OT, surgeons)
-resource intensive -logistics -lose patient centeredness as focus too much on clinical considerations rather than on holistic care
45
what is CAR-T therapy
remove T cell from patients blood by aphaeresis, genetically programme them to fight the cancer by making them produce the chimeric antigen receptor which then binds to cancer cells and labels them for destruction, multiple the cells and infuse back to patient, CAR-T cells can then destroy the patients cancer cells
46
cytokine release syndrome is one problem of CAR-T therapy, what is this?
huge T cell response which causes an overwhelming cytokine release --> can cause symptoms ranging from flu to sepsis
47
how do you treat cytokine release syndrome
antihistamines, some people will need an ITU admission
48
what are some complications of CAR-T therapy?
1) cytokine release syndrome 2) neurological complications 3) infections - CAR-T cells kill normal B cells as well as cancer cells
49
how do immune checkpoint inhibitors work
some cancers produce proteins which turn T cells off. Checkpoint inhibitors stop this happening. Eg Nivolumab.
50
what are side effects of immune checkpoint inhibitors
all immune cells are activated by the drugs so get rashes, dry and itchy skin. -can also get N+V -endocrine disturbance -pneumonitis if activated T cells attack healthy cells
51
Mx of side effects from immunotherapy
steroids
52
what are the four types of immunotherapy
1) immune checkpoint inhibitors 2) monoclonal antibodies 3) CAR-T 4) cancer vaccines
53
what is the big SE with rituximab
allergic reaction
54
what is radiotherapy
high energy ionising radiation used to treat malignant disease (the ionising radiation can kill cells directly by damaging the cells and triggering apoptosis or indirectly by making free radicals)
55
what are the aims of radiotherapy treatment
deliver calculated doses of radiotherapy to cancer cells whilst minimising exposure to surrounding tissues to achieve a high grade of tumour control and low risk of complications
56
the energy absorbed in radiotherapy is measured in what
grays
57
why is the energy in radiotherapy delivered in fractions
limit damage to normal cells
58
what happens in simulation before radiotherapy
patient is placed in a reproducible position, may make tattoos on patient so they know where to put the beams
59
what are the different types of radiotherapy
1) external beam radiation 2) brachytherapy - internal radiation where a radioactive source in a catheter or seed is used to deliver radiation from the body directly to the tumour site 3) systemic - where the radioactive source is injected or swallowed
60
early side effects of radio, which normally resolve in a few weeks
skin reactions, fatigue, mucositis
61
when do late side effects of radiotherapy occur and why
months to years after a course of radiation due tot he excessive extracellular matrix and deposition of collagen and fibrogenesis (these are irreversible and progressive)
62
what is a site specific side effect of radiotherapy to the chest
radiation pneumonitis (which if untreated becomes radiation fibrosis) -this presents a few weeks after radiotherapy with a cough, dyspnoea, low grade fever, pleuritic chest pain -do IX to rule out infective course -CXR - see changes around radiation port -Tx with steroids!
63
SE of tamoxifen
hot flush, vaginal irritation, loss of libido, VTE, endometrial cancer
64
what hormonal Tx is given to post menopausal women who are ER+
anastrozole (cause - hot flushes, joint pain and osteoporosis)
65
SE of GnRH agonists
hot flushes, erection problems and low libido
66
MOA of GnRH agonists
overstimulate --> downregulation of receptors (takes 2/3 weeks and have to use antiandrogens in the interim to stop tumour flare(
67
what do phase 1 clinical trials assess
safety
68
what do phase 2 clinical trials affect
efficacy - does it work?
69
what do phase 3 clinical trials assess
effectiveness - how do they work compared to other preexisting treatments. CONTROLLED TRIALS
70
what do phase 4 clinical trials do
post market surveillance - look at effectiveness and side effects
71
what's an umbrella trial
look at one treatment for one type of cancer with different mutations
72
what's a bucket trials
look at one treatment on lots of different cancers with the same mutation
73
what is immune related colitis
new onset diarrhoea after starting immunotherapy, get abdominal pain, nausea, vomit, bleeding
74
Ix for immune related colitis
rule out infective cause and IBD
75
what is grade 1 immune related colitis, and how do we treat it
asymptomatic and treat with loperamide
76
what is grade 2 IRC and how do we treat
abdo pain, mucous, blood in stool. Tx with oral steroids
77
what is grade 3 IRC
severe abdo pain and peritoneal signs, this needs a scope or Ct if signs of peritonitis. Need IV steroids and infliximab if steroids not working -will not be able to carry on with immunotherapy
78
what is grade 4 IRC
life threatening complications and need IV steroids and infliximab
79
RF of getting radiation mucositis
smoking, poor oral hygiene having chemo and radio together
80
complications of radiation mucositis
reduced oral intake, dehydration, pain, susceptibility to infection
81
what is the WHO grading of radiation mucositis
0 1 - soreness and erythema 2- erythema, ulcers, can eat solids 3 - ulcers, can only eat liquid 4 alimentation not possible
82
MX of radiation mucositis
good oral hygiene, soft bland diet, no smoking or alcohol, benzydamine mouthwash, may need antibiotics
83
if someone is on cancer tx and they present with nose bleeds, what should you consider
thrombocytopenia
84
what class of chemo is cisplatin
platinum agent which cross links DNA
85
SE of cisplatin
ototoxic, peripheral neuropathy, hypomagnesium, seizures, highly emetic
86
class of chemo is 5-FU
antimetabolite - these replace the buidling blocks need to DNA replication so cell cannot replicate (can cause myelosuppression and mucositis)
87
what class of chemo is cyclophosphamide
alkylating agent
88
why is chemo often giving as a combination
stops resistance, maximise therapeutic effect without toxicity,
89
chemo drug resistance mechanisms
increased drug efflux, increased DNA damage repair, drug compartmentalisation
90
performance statuses
0 - no limitation 1 - able to do light work 2 - able to do all self care but no light work, up and about 50% of time 3 - capable of limited self care, sat for >50% waking hours 4 - completely disabled 5 - dead
91
what are some acute toxicities of chemo
mucositis, rash, alopecia, myelosuppression, TLS
92
example of a protooncogene
RAS (gain of function)
93
example of TSG
BRCA
94
what is it important to check in extravasation
vesicant? - blistering non vesicant - no inflammation but pain -irritant - pain and inflammation
95
Mx of extravasation
stop infusion, leave cannula in, classify agent, extravasation kit, cold pack, aspirate out, mark with pen, can use hydrocortisone cream
96
Mx of hiccups
chlorpromazine / haloperidol
97
if isolated tumour cells are found in the sentinel lymph node, what needs to happen
nothing ! only do axillary clearance if actual tumours found
98
topoisomerase inhibitor example
irinotecan
99
mitotic inhibitor example
vinca alkaloid
100
Mx of diabetic drugs at end of life
stop oral glycemic and considered stopping insulin but want to avoid hyperglycaemia as this is unpleasant

Yr 5 - cancer care (6 decks)

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