Respiratory - Tobacco Smoking and Lung Cancer Flashcards
(152 cards)
1
Q
When do most people start smoking
A
While still children and become addicted to nicotine
2
Q
How much more likely are those whose parents smoke to start smoking than those w/ non-smoking parents
A
3x
3
Q
Which group of people finds it harder to give up smoking
A
Children who start smoking at younger ages
4
Q
Why has the prevalence of smoking decreased in the 21st century
A
Smoking is no longer associated w/ Hollywood glamour and its social acceptability has decreased
5
Q
Habitus
A
The body of tacit knowledge that we each carry with us that either enables us to feel comfortable on certain social settings or out of place
6
Q
Models explaining mechanisms of health inequality
A
Behavioural
Material
Psychosocial
Life-course
7
Q
Behavioural model of health inequality
A
Involve class differences in behaviour that are damaging or health promoting which are subject to individual choice
8
Q
Material model of health inequality
A
Involve hazards that are inherent in the present form of social organisation and to which some people have no choice but to be exposed
9
Q
Which model of health inequality is most important in accounting for social class differences in health
A
Material model
10
Q
Psychosocial model of health inequality
A
Feeling affect behaviours
Incl helath-related stigma
Feelings that arise because of inequality, subordination and lack of social support may directly affect biological processes
11
Q
Life-course model of health inequality
A
Disadvantages in their various forms are likely to accumulate through childhood and adulthood and into old age
12
Q
Lifestype drift
A
The idea that govts start w/ policies designed to address the social of health e.g. poverty but due to complexity of this work they end up, endorsing narrow lifestyle interventions or individuals
13
Q
What will habitus influence
A
The social acceptability of certain health practices
Social and cultural context plays a role in whether we smoke, drink, what food we eat
14
Q
The rise of surveillance medicine
A
The idea that med has become much more about monitoring healthy bodies that it used to be
15
Q
How common is lung cancer on the UK
A
130 dx daily
3rd most common cancer in UK
16
Q
Lung cancer risk factors
A
Cigarette smoking Occupational exposure Genetics Low level radiation Smoking and low intake of beta carotene Lung disease hx Fhx
17
Q
Symptoms seen in lung cancer
A
Persistent cough Change in cough SOB Haemoptysis Ache/ pain in chest or shoulder Unexplained wt loss Hoarse voice Swollen face
18
Q
Signs seen in lung cancer
A
Pyrexia Recurring infections e..g bronchitis snd pneumonia Clubbing Swollen lymph nodes in neck Pleural effusion Dysphasia
19
Q
Where do lung cancer pts px initially
A
76% in primary care
24% in secondary care
20
Q
Why do we need a timely dx in lung cancer
A
To detect disease at an asymotomatic stage
In really stages, treatment is most successful
Earlier dx can increase survival
21
Q
Why don’t we screen for lung cancer
A
High no. pts needed to screen
Cost effectiveness uncertain
Risk of over dx and invasive tests for benign sounds
22
Q
What is likely to be more cost effective then screening for lung cancer
A
Smoking cessation snd tobacco control
23
Q
Profile of a pt that should be referred urgently for a CXR (suspected lung cancer)
A
Unexplained haemoptysis or persistent lung cancer symptoms (>3/52) or <3/52 in pts w/ known risk factors
24
Q
Profile of a pt that should be referred urgently to a lung cancer specialist
A
Persistent haemoptysis and are smokers or ex smoker 40+ CXR suggestive of lung cancer Finger clubbing Severe wt loss SVC obstruction - medical emergency Neck nodes - smokers
25
CXR suggestive of lung cancer
Lung nodules
| Inca pleural effusion and slowly resolving consolidation
26
Why do we stage cancers
Treatment decision
Prognosis refinement
Communication between Drs
Stratification for clinical trials
27
Types of cancer staging
Clinical
Surgical
Pathological
28
What modalities are involved in clinical staging of lung cancer
```
CXR
CT scan +/- bx
MRI
PET csan
Bone scan
```
29
What is involved in surgical staging of lung cancer
```
Bronchoscopy
EBUS-TBNA - best dx accuracy
Mediastinoscopy
Thoracoscopy (VATS)
Thoracotomy
```
30
Pathological staging of lung cancer
After complete resection and LN (lymph node) staging
31
VATS in lung cancer
Can identify +ve or -ve LN stations
32
Staging lung cancer in metastatic disease
When the disease is metastatic the biopsy is obtained from the easiest site
CT/ USA guided needle aspiration - thoracocentTesis, cervical lymph node, liver bx
EBUS - L adrenal metastasis
33
TMN system of staging
T - tumour (0, 1A - 1C, 2A - 2B, 3, 4)
N - regional lymph nodes (0 - 3)
M - distant metastasis (0, 1A, 1B, 1C)
34
Pathological stating in the TMN system - T
Clinical size - size of solid component
| Pathological size - size of invasive component
35
Implications of T component - TMN staging
Every cm counts; careful follow-up
Worse prognosis of larger tumours
Better prognosis for endobronchial location and total atelectasis and pneumonitis
36
Implications of N component - TMN staging
Amount of +ve LN has prognostic impact
Treatment decision regarding surgery
Prognosis refinement
37
Staging cancers w/ metastatic lesions
Multiple primary tumours - 1 TMN for each tumour
38
Implication of M component
No. metastasis is more important than their location
o M1a: pleural effusion, nodules in the unilateral or contralateral lung
o M1b: baseline definition of oligometastases and oligoprogression
39
Types of cancer cells (in order from highest to lowest frequency)
```
Adenocarcinoma
Squamous cell carcinoma
Small cell
Large cell (undifferentiated)
Carcinoid
```
40
What are the two manor classes of lung cancer
Small cell
| Non small cell
41
Traits of NSCLC
Most common lung cancer
| Gross more slowly than SCLC
42
Traits of SCLC
Usually begin in bronchi and nearly always caused by smoking
Spread more quickly than that of NSCLC
Frequently metastasises to mediastinal lymph nodes or distant sites at px
43
Main types of NSCLC
Adenocarcinoma - 40%
Squamous - 25-30%
Large cell - 10-15%
44
Features of adenocarcinomas
Slow growing cancers that can take years to develop into invasive cancer
Tend to be located in the periphery of the lung
Most common type of lung cancer among women and in non-smokers
45
Features of squamous cell carcinoma
Commonly starts in the bronchi and may not spread as rapidly as other lung cancers
Treatment is typically more difficult than other types
Dx in its initial state is v important
46
Features of large cell carcinoma
Named for the large, round cells seen in this cancer
| Grow quickly and spread so usually are diagnosed in later stages
47
Good prognostic factors in NSCLC
Early stage disease at dx
Good performance status (ECOG 0, 1, 2)
No significant wt loss (5% or less)
Female gender
48
Biomarkers in lung cancer
Pts w/ spp gene mutations or rearrangements had better prognosis - lived longer and improved therapeutic efficacy
49
Common biomarkers in lung cancer
EGFR
K-ras oncogene
EML4-ALK fusion oncogene
PDL1
50
Immunohistochemical staining in SCC
TTF-1 -ve
P63 +ve
Cytokeratin 5/6 +ve
51
Immunohistochemical staining in adenocarcinoma
TTF-1 +ve
52
What does SCLC typically present with
Large hilar mass - bulky mediastinal lymphadenopathy that causes cough and dyspnoea
Paraneoplastic syndromes
53
What type of lung cancer has earlier development of widespread metastases
SCLC
54
Paraneoplastic syndromes in SCLC
```
SIADH
Ectopic ACTH production - cushingoid
Eaton-Lambert myasthenic syndrome
Hypercalcaemia
Peripheral neuropathy
Increases risk of DVT/ PE
```
55
SIADH
Secretion of Inappropriate ADH
| Causes hyponatraemia
56
Eaton-Lambert myasthenic syndrome
Proximal muscle weakness that improves on repetition
57
Signs and symptoms in SCLC
```
Smokers (almost exclusively)
Cough
Haemoptysis
Dyspnoea and chest pain
Clubbing
Pneumonia
Wt loss and constitutional symptoms
```
58
Best ix for SCLC
```
Labs - FBC, LFTs, LDH
CT chest/abdo/pelvis
Brain imaging (CT or MRI) - esp if symptomatic
```
59
Why do we image the brain in SCLC ix
Up to 30% have brain metastases at px
60
Common SCLC metastasis
BALLS
```
Brain (30%)
Adrenal (20-40%)
Liver (25%)
Lung
Skeletons (bones)
```
61
What kind of factors strongly influence whether or not someone smokes
Psychological
Micro social
Macro social
62
Psychological factors affecting whether or not people smoke
Beliefs
Coping resources
Risk factors e.g. stress
63
Micro social factors affecting whether or not people smoke
Background
School and area - peer group initiation
Culture, identity
64
Macro social factors affecting whether or not people smoke
Advertising
| Wider society
65
In which groups do >75% people smoke
Homeless
Severe mental illness
Substance misuse
Criminal justice system
66
Public health interventions for smoking
Solution must be wider than individual smoking cessation
```
Plain packaging
Harm reduction - E-cigarette
Tax
Advertising
Smoke-free space
```
67
Why do we need smoke free public spaces
Importance of passive smoking
Increased risk of IHD and lung cancer by 25%
Increased risk of stroke >40%
WW estimation of 600,000 lives lost to 2nd hand smoke
68
NHS Stop Smoking services
Offers effective combined behavioural and pharmacological support to stop smoking
69
Lung cancer avg 5 year survival
5-10% survival
70
What % of lung cancer pts are dead within 12/12 of dx
80%
71
Mean time from dx to death in lung cancer pts
6/12
72
Bone pain in lung cancer
HPOA - hypertrophic pulmonary osteoarthropathy
73
Types of large cell cancers
Adenocarcinoma
SCC
Undifferentiated large cell
Bronchoalveolar
74
What do all lung cancer pts for radical therapy need
PET-CT
75
How do we dx lung cancer
```
Hx and examination
CXR
Bronschoscopy
CT chest
Lung function tests
Biopsy
MDT discussion
```
76
The role of surgery in lung cancer
Dx
Staging
Treatment
77
What do you need to consider in treatment of NSCLC
Is the disease localised?
| Is the ot well enough to have potentially, curative treatment?
78
What should ideally be considered for treatment of NSCLC
Surgery - more likely to kill all tumour cells
| If surgery is not feasible - radiotherapy
79
What can be considered in localised NSCLC
Surgery or radiotherapy
80
When is surgery not feasible for NSCLC
Tumour to closer to other structures of pt not well enough
81
What influences selection for surgery in NSCLC
```
Disease features (resectability)
Pt features (operability)
```
82
Disease features affecting selection for lung cancer surgery
Histology (NSCLC)
| Stage (I/ II/ IIA)
83
Pt features affecting selection of surgery for lung cancer
PMH/ co-morbidities
| Pulmonary function
84
Contraindications to surgery for lung cancer
```
Malignant pleural effusion
SVC obstruction
Horner’s syndrome
Vocal cord paralysis
Phrenic nerve paralysis
```
85
Surgical resection procedures for lung cancer
Wedge excision
Segmentectomy
Lobectomy - chest wall excision
Pneumonectomy - intra/ extra pericardial, chest wall excision
86
When is chemotherapy indicated in lung cancer
To improve results of RT
| SCLC
87
When are biological agents used in lung cancer
Advanced or metastatic disease
88
What extra modalities can be used in lung cancer in infancy
Immunotherapy
| Gene therapy
89
How is RT given
Radically - curative intent, given daily over 4-6 weeks
| Palliatively - relief of symptoms in shorter courses
90
Purpose of palliative RT for lung cancer
```
To relieve symptoms:
Haemoptysis
Breathlessness due to obstruction
Pain
Short term fatigue
```
91
Post-operative RT
Given only when tumour is known to extended to the surgical margins
92
Endobronchial RT
Placing radioactive isotope in the bronchus
Placed via a bronchoscope
Effective palliative for symptom relief
93
Overcoming tumour motion in NSCLC
Resp gating is a way of reducing the amount of normal lung irradiated
The RT is given in one Lhasa of breathing cycle
94
Gating in RT
Linking the treatments witch to the breathing cycles
95
Chemotherapy for lung cancer
Systemic treatment
Not curative except in lymphoma or leukaemia
Can reduce bulk of tumour by killing dividing cells
Difficult side effects
96
Chemo drugs for lung cancer
Cisplatin and carboplatin
| Gemcitabine and vinorelbine
97
In which cancers can biological agents be very effective
NSCLC, eso if they have an EGFR mutation
| Works well in non-smokers, Asians, females and BAC pts
98
BAC
Bronchiolo-alveolar cell carcinoma
99
How is the risk of post-operative dyspnoea after lung cancer surgery assessed
By spiro
| Predicted post-op FEV1 or TLCO <40% predicted is considered moderate-high risk of dyspnoea
100
General stages of operation in lung cancer surgery
Inspection to confirm no disease progression
Define anatomy
Divide vein, artery, bronchus (typically)
Lymphadenectomy
101
When would adjuvant chemo be considered after lung cancer surgery
Unexpected higher staging
Confirmed nodal involvement
Large tumour size
102
A/c side effects of radiotherapy
Oesophagitis
Pneumonitis
N & V
Bone marrow suppression
103
Longer term side effects of radiotherapy
Pneumonitis and pulmonary fibrosis
Rib fractures
Cardiac fibrosis and dysfunction
Hypothyroidism
104
Stigma (Monaghan & Williams)
Meaning imposed on an attribute via -ve images, stereotypes and attitudes that potentially discredits a member of a particular category
105
‘Virtual social identity’
What a person ‘ought’ to be according to social norms
| Linked to the idea of stereotype
106
‘Actual social identity’
The attributes the person actually possesses
107
‘Discredited’ - stigma
Stigmatised attribute is known by others
108
‘Discreditable’ - stigma
Concealed attribute that could be a source of stigma
109
Graham Scrambler’s theories of stigma
Felt stigma - fear of discrimination
| Enacted stigma - enactments of discrimination
110
Possible reasons why condns are stigmatised
Perception of infection/ contamination e.g, HIV
Perception that the condn devalues QoL e.g. wheelchair users
Perception that condn is ‘self inflicted’ e.g. obesity, lung cancer
Sense of social embarrassment e.g. speech impediment
Perception that someone living w/ a condn cannot live independently
111
Why is haemoptysis seen in lung cancer
Bronchial tissue is friable
| Sign of infection
112
Why is SOB seen in lung cancer
Space occupying lesion affecting alveoli
| Pleural effusion
113
Why is chest pain seen in lung cancer
Invasion of pleura
| Rib metastasis
114
Why is hypercalcaemia seen in lung cancer
PTHrP or metastatic bone cancer
115
What is HPOA
Triad of periostitis, digital clubbing and painful arthropathy of large joints
116
Lung cancer referral pathway
Urgent referral in 2/52
117
Which cancers cause thrombocytosis
LEGO
Lung
Oesophageal
Gastric
Ovarian
Clotting screen must be performed
118
Pharmacological smoking cessation agents
Bupropion
Varenicline
NRT
119
How is SVCO obstruction treated
Stent and radiotherapy
120
Where does the oblique fissure begin
At level of T3 spinous process and lies anteriorly at 6th costal cartilage
121
Course of horizontal fissure
Comes from meeting point with oblique and runs anteriorly to follow line of 4th rib
122
Which lobe of the lung is above 4th rib
Upper
123
Which lobe of the lung is found between 4th to 6th rib
Middle
124
Which lobe of the lung is found below the 6th lung
Lower
125
Surfaces of the lungs
Anterior (costal)
Posterior (costal)
Diaphragmatic
126
Where is the lingula found
L lung
127
Where does the primary bronchus enter the hilum
Posteriorly
| Most posterior element in hilum
128
Structure of L hilum
Pulmonary artery is most superior structure
| Below and posterior is airway, then pulmonary veins
129
Structure of R hilum
Pulmonary artery enters R lung anteriorly at same level as airway
Pulmonary veins enter inferiorly and anteriorly
130
Pulmonary ligament
Found inferiorly
| Fold of mediastinal pleura
131
Specific features on L lung
Lingula
| Cardiac notch
132
Function of sympathetic chain
Carries sympathetic outflow from CNS
133
Where is the sympathetic chain
T1 to L2 in thorax
134
Where does the sympathetic chain run
On lateral aspect of vertebral bodies
135
Where are ventral rami of the sympathetic chain found
IC spaces
136
Where are the ganglions in the sympathetic chain found
At each vertebral level
137
Largest ganglion in the sympathetic chain
Stellate ganglion - goes to head and neck, part of upper L8IQMY
138
Rami communicantes
Connections between rami
139
White rami of sympathetic chain
Delivers signal from spinal nerve into sympathetic chain
140
Splanchnic nerves
Pre synaptic fibres (myelinated - go through diaphragm into abdominal cavity to innervate abdominal viscera
141
Common places for space occupying lesions in lung
Hilum (adenocarcinoma)
| Apex (small cell, Pancoast’s)
142
Which lesions may compromise the azygous vein
Lesion in R main bronchus - hilum tumour
143
What structures may be compressed by apical tumours
Sympathetic chain - Horner’s syndrome
| Vagus nerve
144
What might a hilar tumour affect on the L lung
Recurrent branch of vagus nerve
145
Why can lung tumours cause a hoarse voice
Apical tumours may compress recurrent laryngeal nerve around R lung ——> unilateral vocal cord paralysis ——> hoarse voice
146
Divisions of the Bronchial tree
Trachea - both lungs
Main bronchus - single lung
Secondary bronchus - lobe
Tertiary bronchus - bronchopulmonary segment
147
Bronchopulmonary segment
Discrete portion of the lung that has its own individual bronchus, arterial supply and venous drainage
Contain alveoli - site of gaseous exchange
148
What are bronchopulmonary segments separated by
Connective tissues
149
What property allows the resection of bronchopulmonary segments without affecting each other
Having its own bronchus, arterial supply and venous drainage allows each segment to function semi-independently
150
What is the main difference in the layout of structures in the L and R hilum
On the L, the artery is superior to the bronchus
| On the R, the bronchus is superior to the artery
151
If someone stops breathing after inhaling a foreign object, where is the item most likely to be
Trachea - obstructing whole airway
152
Where is an inhaled foreign body most likely to be
R main bronchus or R lower 2’ bronchus
| R main is wider, shorter & more vertically orientated. May continue to lower 2’ bronchus if small enough
