Treatments Flashcards
(160 cards)
1
Q
List some common adverse effects of chemotherapy
A
Dyspnoea Diarrhoea/constipation Dysuria Infection Nausea and vomiting Oral mucositis Dysphagia Anorexia Pain Weight loss/gain Fatigue Peripheral neuropathy Alopecia - temporary
2
Q
Traditional chemotherapy typically targets which cell types
A
Rapidly dividing cells
This means the cancer cells are targeted but also healthy cells which happen to divide rapidly
3
Q
In which tissues do chemo side effects typically occur in
A
GI tract, bone marrow and hair matrix
This is because the cells here are rapidly dividing
4
Q
How does chemotherapy attack cells
A
Disrupting cell division
Attacking DNA
Disrupting essential metabolism for DNA replication
Can also affect cytoplasmic signalling, cell membrane receptor synthesis, expression and function and the cellular environment
5
Q
Chemotherapy doses are typically calculated in relation to which factor
A
The patient’s body surface area
Also consider renal excretion
6
Q
Why are breaks given between chemotherapy cycles
A
To maximise tumour cell death whilst minimising normal cell death
This is because normal cells have greater propensity for recovery than
malignant cells, therefore rest between cycles allows normal cell
recovery.
7
Q
What is the difference between neo-adjuvant and adjuvant chemotherapy
A
Neo-adjuvant - to shrink tumour prior to surgery/
radiotherapy and treat micro-metastases
Adjuvant - given after surgery/radiotherapy to destroy
any remnant cancer cells
8
Q
Chemotherapy induced nausea &
vomiting affects which proportion of patients
A
70-80%
One of the most common side effects
9
Q
What is the most common treatment for chemotherapy induced nausea and vomiting
A
Give ondasentron prior to chemo dose
Given in combination with dexamethasone
10
Q
List non-pharmacological treatments for chemo induced nausea and vomiting
A
Stay hydrated - sip on cool drinks
Small meals staggered throughout the day
Easy to swallow food
Food/drink with minimal smells
11
Q
What is the major adverse effect of ondansetron to consider when prescribing
A
QT prolongation
More common ones include constipation and headache
12
Q
What should always be considered in a cancer patient with back pain
A
Metastatic spinal cord compression
Usually the result of bony mets which are most commonly seen in lung, breast and prostate
13
Q
When prescribing an opiate, you should always co-prescribe
A
A laxative and an antiemetic
14
Q
Which chemotherapy drugs can cause peripheral neuropathy
A
carboplatin and paclitaxel
Many other can as well
15
Q
Describe the typical distribution of peripheral neuropathy caused by chemo
A
Symmetrical ‘glove and stocking’ distribution
16
Q
What effect of chemo leads to the life threatening side effects such as neutropenic sepsis
A
Myelosuppression - bone marrow suppression
Can lead to infection
(neutropenic sepsis), bleeding (thrombocytopenia) and
anaemia.
17
Q
How can you reduce the amount of hair loss during chemo
A
Cold caps
These lower the temperature of the scalp, which reduces
the amount of chemotherapy drug reaching the hair
follicles
Don’t work for everyone
18
Q
A fever in a chemo patient should make you suspect what
A
Neutropenic sepsis
19
Q
What are the diagnostic features of neutropenic sepsis
A
A temperature >38C + neutrophils 0.5×10^9
20
Q
How do you manage neutropenic sepsis
A
- Initiate Sepsis 6 protocol
- Start empirical antibiotic therapy - NICE recommends
Piperacillin with Tazobactam. Gentamicin, vancomycin and
ciprofloxacin can be used if penicillin allergic. - Confirm diagnosis with blood results
- Senior review
21
Q
How does targeted cancer therapy work
A
These drugs have specific molecular targets they work on - can be an individual gene from patient or tumour or specific proteins expressed by the tumor
22
Q
List some examples of targeted cancer therapy
A
Hormonal therapies
Angiogenesis
inhibitors
Apoptosis inhibitors
Common targets include
BRAF in melanoma
HER2 in breast - Herceptin
BRCA1/2 in ovarian/breast
23
Q
What is the major issue with targeted cancer drugs
A
Cancer cells will eventually develop
resistance.
This may either be due to finding an alternative
pathway that doesn’t require the targeted molecule, or mutation
of the target itself
24
Q
Targeted cancer drugs are often used on their own - true or false
A
False
They are often
used in combination and alongside traditional chemotherapy
Due to resistance risk
25
If a patient is taking 30mg of slow release morphine bd for pain control, what should their breakthrough dose of oramorph be
10mg
| The breakthrough dose should be 1/6 of the daily dose
26
Radiotherapy is prescribed in what units?
Gray (Gy)
one joule deposited per kilogram
Delivered in fractions over several treatments
27
Which breast cancer patients can be treated with Tamoxifen
Pre or post menopausal
Those who have had children
Those with metastatic disease
28
How do radiologists make sure they target the same area with radiotherapy each time
Patients have dots tattooed on them which line up with the machine
Also line up bony landmarks on CT images
In head and neck cancers a fitted mask is made
29
Patients are required to stay in hospital following radiotherapy - true or false
False
| Most can go straight home
30
Patients are required to stay in hospital following radiotherapy - true or false
False
| Most can go straight home
31
Cisplatin chemo can be toxic to which organ
Kidney
32
Vincristine chemo can be toxic to which organ
Nerves
33
What is the most common side-effect of radiotherapy
Tiredness
| Also the only major non-local effect
34
Radiotherapy side effects tend to only affect the area being irradiated - true or false
True
| This means side effects will differ based on the tumour site being treated
35
List some common side effects of radiotherapy
Skin reactions- erythema to moist desquamation
Telangectasia/ vasculitis
Tiredness (especially after radical treatments)
Nausea, vomiting (stomach/liver/brain radiation)
Diarrhoea/cystitis (abdominal/pelvic radiation)
Mucositis (head and neck radiation)
Dysphagia (thoracic radiation)
Pneumonitis (acute/chronic)
Cardiac damage
Bone marrow suppression (more likely with chemotherapy)
36
Which guideline is used to prescribe pain management
WHO analgesic ladder
37
Paracetamol and/or NSAIDs at all steps of the pain ladder unless contraindicated - true or false
True
38
What is the 1st line subcutaneous treatment for severe pain in cancer patients
Diamorphine
39
What is the strong opiate of choice in the pain ladder
Morphine
40
List signs of opiate toxicity
```
Drowsiness
Nausea and vomiting
Confusion
Myoclonic jerks
Hallucinations
Pupils
Respiratory depression
```
41
How often do you take modified release morphine
12- hourly
| It is long acting
42
What is the drug of choice for breakthrough pain
Oramorph - quick acting liquid
1/6th of total 24 hour dose
Given PRN up to hourly if needed
43
Subcut morphine is weaker than oral so you double the dose - true or false
False
| Subcut morphine is twice as strong as oral morphine, so half the oral dose
44
Which drugs can be used as adjuvant treatment for metastatic bone pain
Bisphosphonates
45
Which drugs can be used as adjuvant treatment for neuropathic pain
```
Tricyclic antidepressant (e.g. amitriptyline)
Anticonvulsant (e.g. gabapentin, pregabalin)
```
Must monitor for side-effects
46
Which drug is used as adjuvant treatment for raised ICP in cancer
Dexamethasone 16mg/day
47
What is the drug of choice for treating chemo induced nausea and vomiting
Ondasentron
48
What is the drug of choice for treating anticipatory/anxiety related nausea and vomiting
Lorazepam
49
What is the drug of choice for treating nausea and vomiting caused by impaired gastric emptying/ bowel issues
metoclopramide/ domperidone
50
What is the drug of choice for treating nausea and vomiting caused by obstruction of the oesophagus
Dexa
51
What is the drug of choice for treating nausea and vomiting caused by cerebral disease/ raised ICP
Cyclizine and dexamethasone
52
Which anti-emetic causes anticholinergic side effects
Cyclizine
53
Which anti emetic causes extrapyramidal side effects
Metoclopramide
54
Which anti-emetic causes constipation
5HT3 antagonists
55
What can cause constipation in cancer patients
immobility, drugs, altered gut function, pain, altered habit
56
Which types of laxatives can be used in cancer care
Stimulant laxatives (senna, bisacodyl), osmotic laxatives Macrogol (Movicol®), stool softeners
Rectal treatment may be needed if faecal impaction/bed-bound (e.g. phosphate enema/ glycerol suppository/arachis oil enema)
57
Oral laxatives should be co-prescribed with analgesia - true or false
True
58
How does radiation damage cancer cells
Direct DNA/RNA damage
- Protons work via this method
- They cause a double strand break in the DNA
Accumulations of these breaks should make it hard for the cancer to repair
Indirect DNA damage (more commonly)
The radiation contacts water molecules and creates free radicals which damage the DNA
Can also bind with O2 to make superoxidisers which also damage
59
Which types of radiation are used in radiotherapy
It is ionising radiation - particles or rays
Most commonly photons are released in a beam to the target
Electrons and protons can also be used but are less common
60
What stage of the cell cycle is radiotherapy most effective in
M phase
| As this is when the chromosome is dividing
61
Why is radiotherapy given in fractions
It distributes the damage among all tumour cells
A single dose will not catch all cells in the tumour at their most vulnerable (in m phase of the cell cycle) so by spreading the dose over time you kill more of the cells
Also leads to irreversible damage as one dose may only cause incomplete damage where the cell can still repopulate
Indirect damage requires O2 but the cells in the tumour centre are often hypoxic. Using fractions kills off the O2 rich cells first and then allows the centre cells to re-oxygenate, making them more sensitive to the next treatment fraction
Also allows normal cells to recover in between sessions
62
What is the main mechanism of DNA damage caused by radiotherapy?
Free radical formation causing double strand breaks
63
What is the most common delivery mechanism for radiotherapy
External beam radiotherapy - radiation delivered from outside the body
Generated by linear accelerators
64
How can the radiotherapy beam be targeted to the tumour rather than surrounding tissues
The beam can be shaped to the tumour shape by multi-leaf
collimators (movable metal leaves).
This allows a higher dose to be given to the target
tissue, whilst minimising radiation to surrounding tissue.
Intensity Modulated Radiotherapy (IMRT) is an even more precise version of this
This reduces dose to organs at risk and long term toxicities
65
What is brachytherapy
A type of radiotherapy where radioactive pellets are inserted into the tumour
Gives high dose to the tumour whilst sparing normal tissue (rapid dose fall off)
66
Brachytherapy is most commonly used in which type of cancer
Prostate
Cervical
Endometrial
67
Which factors are taken into account when planning the radiotherapy target
Gross tumour volume - area where it is
Clinical target volumes - adds a margin for microscopic cells not seen on CT
Can also plan which nodes you want to irradiate
Organs at risk (OAR) are identified- allows planning to minimise radiation to important structures
All done based on the patient's CT
68
Radiotherapy comes with a risk of secondary malignancy - true or false
True
Can occur many years later at the irradiated sight
More common if someone had radiotherapy as a child
Less common these days due to better targeting of treatment
69
How is the skin typically affected by radiotherapy
It may be erythematous and pruritic
(sun-burn type lesion)
Dry, peeling or weeping.
Rarely patients may develop ulcers and bleeding
70
What causes radiation pneumonitis
Irradiation of the lungs
71
How does radiation pneumonitis present
Cough
Fever
Hypoxia
Dyspnoea
72
List common side effects of radiotherapy for head and neck cancer
```
mucositis
xerostomia
dysphagia
taste alteration
pain
thrush infections
weight loss from
poor nutritional intake
```
73
List common side effects of radiotherapy to the bowel
Nausea and vomiting
Diarrhoea - also seen in pelvic raditaion
Bowel erosions, ulceration and inflammation
74
List common side effects of radiotherapy to the bones
Marrow suppression
75
List common side effects of radiotherapy to the brain
Raised ICP
Headaches
Seizures
76
What is the most common type of immunotherapy used in the treatment of cancer
Immune Checkpoint Inhibitors
77
How doe Immune Checkpoint Inhibitors work
They block the cancer cell signalling pathways which switch off T cells
This effectively
switches back on the body's natural immune surveillance, allowing T cells to kill cancer cells
78
List types of cancer that can be treated with immunotherapy
```
Melanoma
NSCLC
Renal Cell Carcinoma (RCC)
Bladder
Head and neck
MSI Colorectal – e.g. Lynch syndrome
```
79
What are the main side effects of immunotherapy
Can cause inflammation at many sites throughout the body
Pneumonitis, thyroiditis and colitis are particular risks
An erythematous, vesicular rash is another common one
80
Physical activity can reduce your risk of which cancers
Convincing - Colon
Probable - Breast (post-meno), endometrial
Limited but suggestive - lung, pancreas, breast (pre-meno)
81
How might physical activity directly protect against cancer
Through several biologic mechanisms, including promoting healthier levels of circulating hormones, decreasing inflammation and maintaining a healthy body weight.
82
How can physical activity benefit cancer patients
Fitter individuals tolerate treatment better
Slowed decline in quality of life
Preserved functional outcomes
Decrease in fatigue - excessive rest = deconditioning
Less severe symptoms
Reduces risk of secondary health issues following treatment
83
What causes visceral pain in cancer
Pain caused by infiltration,
compression, extension or stretching of the
thoracic, abdominal or pelvic viscera
eg. liver capsule pain
84
What causes somatic pain in cancer
Activation of pain receptors in either
cutaneous or deep tissues (muscoloskeletal)
Cutaneous – sharp, burning, pricking
Deep – dull, aching (eg. bone mets)
85
What causes neuropathic pain in cancer
Damage to the nervous system:
Compression of nerves/spinal cord
Infiltration of nerves/spinal cord
Chemical damage – chemotherapy/XRT
86
Which factors can affect the perception of pain
Mood – depression, anxiety
| Context – expectation, pain beliefs, placebo
87
How long must pain last to be defined as chronic
At least 3 month duration
88
List the steps of the WHO pain ladder
MILD: Paracetamol
MILD to MODERATE: Co-codamol 30/500, dihydrocodeine, tramadol
MODERATE to SEVERE: Morphine, diamorphine, oxycodone, hydromorphone,
Methadone
ADJUVANT: NSAID’s, TCA’s, anticonvulsants, corticosteroids, anxiolytics, muscle
relaxants, antimuscarinics
89
List some of the side effects of opioids
Initially - N&V, drowsiness, unsteadiness, confusion
On-going - constipation
Occasional - dry mouth, sweating, pruritus, hallucinations, myoclonus
Rare - respiratory depression, psychological dependence
90
How potent is codiene in relation to morphine
Codeine is 1/10th as potent as morphine
91
How potent is oxycodone in relation to morphine
Oxy is 2x as potent as morphine
92
How potent is methadone in relation to morphine
Methadone is 10x as potent as morphine
93
How do you convert oral morphine to subcut
Divide oral dose by 2
94
If morphine is not suitable which other opiods can be used
```
Oxycodone/Hydromorphone – less CNS
side-effects
Fentanyl – less constipation
Fentanyl/Alfentanil – good in renal
Impairment (shorter half-life)
```
95
Which other drugs should be started at the same time as opioids
Antiemetic for first few days
| Regular laxative
96
How should you manage drowsiness caused by opioids
Reduce dose or switch
97
How should you manage hallucinations caused by opioids
Haloperidol or switch
98
How should you manage myoclonus caused by opioids
reduce dose, switch or benzodiazepine
99
How should you manage pruritus caused by opioids
antihistamine or switch if does not settle
100
How should you manage respiratory depression caused by opioids
Give naloxone
101
NSAIDs are good as an adjuvant for which type of cancer pain
Bone pain
102
NSAIDs are good as an adjuvant for which type of cancer pain
Bone pain
103
How can corticosteroids help in the management of cancer pain
Reduce inflammation (cerebral mets, spinal cord
compression, liver capsule pain)
Stimulate appetite
Antitumour effect (lymphoma etc)
104
Which drugs are good for neuropathic cancer pain
TCA - amitriptyline
| Anti-convulsants - carbamazepine, gabapentin etc
105
How can benzos be used in the treatment of cancer
Can help reduce agitation, dyspnoea
| Diazepam also works as a muscle relaxant - reduces muscle spasm pain
106
How do antimuscarinics help with cancer pain
Can reduce colicky bowel pain
107
How is ketamine used as adjuvant therapy for cancer pain
Reduces opioid requirement
Good for neuropathic pain
Given oral or subcut
108
What are some of the complications of chemo induced N&V
Dehydration
Electrolyte imbalance
Risk of aspiration pneumonia
109
List risk factors for developing chemo-induced N&V
Age <50 years
Female
Alcohol intake
Prone to N +V
110
What are the 2 categories of chemo-induced N&V
Acute - within 24 hours of chemotherapy
| Delayed - 24 hours to 7 days post chemo
111
What is the most effective was to control chemo-induced N&V
To prevent symptoms of acute and delayed CINV by using a combination of an NK1 antagonist, 5HT3 antagonist and dexamethasone
112
Why does chemotherapy cause N&V
Causes cell damage which may Increased afferent input to the chemoreceptor trigger zone and vomiting center
May also directly activates the CTZ which activates the vomiting centre
113
5HT3 receptor pathway antagonists are most effective for which type of chemo-induced N&V
Effective in acute vomiting
Very limited efficacy for delayed events
They block the release of serotonin from enterochromaffin cells in GI tract
114
Which treatment is effective for delayed chemo-induced nausea and vomiting
NK1 receptor blockade
| This receptor responds to substance P whichrelays noxious sensory information to the brain
115
Which treatment is effective for nausea specifically in chemo-induced nausea and vomiting
Dexamethasone
Its also good for both acute and delayed vomiting
M.O.A not fully understood
116
List side effects of 5HT3 anatagonists
constipation, abdominal spasms, headaches
117
Give an example of a 5HT3 anatagonist used in chemo-induced N&V
Ondasentron
| Granisentron
118
How are 5HT3 anatagonists administered for chemo-induced N&V
Best given as a stat dose pre-chemo
| Oral and IV equally effective
119
List side effects of dexamethasone
heartburn/indigestion, agitation, hiccups, abnormal BM’s (all manageable in most instances)
120
How is dexa administered for chemo-induced N&V
Acute: pre-dose before chemo
Delayed: 2-4 days after
121
How do you treat anticipatory nausea and vomiting
Lorazepam is an effective treatment
122
What is anticipatory nausea and vomiting
A conditional response - often to sights and smells
Involves higher cortical centres of brain
Occurs in 30% of chemo patients
123
What is meant by breakthrough symptoms in relation to chemo-induced N&V
N + V in spite of optimal preventative treatment
| Add in another anti-emetic - choice guided by the cause
124
What is meant by concomitant treatment
Combined modality treatment (Chemo/radiotherapy)
125
What is the aim of palliative treatment
To reduce cancer load thereby improving symptoms and prognosis
126
How can chemotherapy be delivered
```
Oral
Intravenous
- Bolus / Infusional
- Central / Peripheral
Locally
- Intratheccal
- Intraperitoneal / Intravesical
- Topical
- Intra-arterial (limb perfusion)
Subcutaneous or Intramuscular
```
127
List the 4 traditional chemotherapy classes
Antimetabolites - Interfere with DNA/RNA growth
Antimicrotubule agents -prevent microtubule function therefore preventing the separation of chromatids
Alkylating agents - add an alkyl group to DNA and cause cross-linking, includes platinum
Antitumour antibiotics - interferes with both transcription and replication of DNA by upsetting proper DNA supercoiling.
128
Which hormone based treatments can be used as chemo
Prednisolone / Dexamethasone
```
Tamoxifen - breast
Aromatase Inhibitors (Letrozole, Anastrozole) - breast
```
Gonadotropin releasing hormone agonists (Zoladex)
129
Which cytokine based treatments can be used as chemo
Interferon alpha
130
How are monoclonal antibodies used in the treatment of cancer
Designed to target highly expressed tumour specific antigens thereby increasing the immune response to the tumour cell
131
What effect does chemo toxicity have on the skin/hair
```
Palmar plantar erythodysthesia
Sun sensitivity
Extravasation
Rashes
Alopecia
```
Often worse if tumour is superficial or on skin itself as skin gets a higher dose
132
Radiotherapy side effects tend to be in the target ares for treatment - true or false
True
| Localsied to the area being irradiated and the surrounding tissues
133
List common side effects of radiotherapy to the pelvis
```
Diarrhoea
Reduced lubrication
Narrowing of passages
Less flexibility of tissues
Impotence or difficulties with erection
```
134
The side effects of radiotherapy can continue after the treatment is finished - true or false
True
Cell destruction can continue for up to 10-14 days post treatment end
94% patients were still experiencing at least one symptom 14-21 days after completion of therapy .
135
What is the difference between hypo and hyperfraction in relation to radiotherapy
Hypofractionation – greater than 2Gy per fraction
Hyperfractionation – less than 1.8Gy per fraction
136
Radiotherapy can be used as curative treatment for which types of cancer
```
Head and neck
Lung
Bladder
Prostate
Anal
Cervical
```
137
How is radiotherapy used palliatively
Local control
Symptom control
Lower doses than radical treatment
138
What determines the toxicity of radiotherapy
Dependent on tissue irradiated, dose, dose per fractionation, duration of treatment
139
Radiotherapy can cause long term/permanent effects in which tissues
```
Occur in slowly proliferating tissues
Kidney
Heart
Central nervous system
Lens
```
Will depend if these were in the area getting treatment
Can occur months – years after treatment
140
Radiotherapy can cause short term/temporary effects in which tissues
```
Occur in rapidly proliferating tissues
GI tract
Skin
Bladder
Haematopoetic system
```
Will depend if these were in the area getting treatment
Often peak at end of treatment but resolve over weeks
141
What is Stereotactic ablative body radiotherapy (SABR)
More accurate delivery of external beam radiotherapy
Uses higher doses per fraction
Generally better tolerated (good for elderly populations where surgery would not be appropriate)
142
Which cancers is Stereotactic ablative body radiotherapy (SABR) typically used for
Used mainly in lung cancer (particularly small cancers) but also has uses in CNS and liver
143
Which treatments are available for head and neck cancer
Surgery
Radiotherapy +/- SACT
Systemic Anti-Cancer Therapy (SACT) - conventional chemo and immunotherapy
Supportive Care
144
What are the advantages of radiotherapy
Preserves tissue function
Treats microscopic disease
Fewer systemic side effects
145
What are the disadvantages of radiotherapy
4-6 weeks treatment - have to come in every day
acute side effects
late sequelae
146
What are the advantages of Systemic Anti-Cancer Therapy (SACT)
Improved local control
Decreasing incidence distant metastases
Relief of symptoms - reduces tumour size
147
What are the disadvantages of Systemic Anti-Cancer Therapy (SACT)
Increased toxicity
May increase rate of treatment related deaths
148
Which head and neck cancers are treated with Systemic Anti-Cancer Therapy (SACT)
Squamous cancers
Locally Advanced Disease
Those who need palliation of symptoms
149
List common platinum based chemo agents
Cisplatin, Carboplatin
150
List common monoclonal antibodies used in the treatment of cancer
Cetuximab - target EGFR
Nivolumab - targets a checkpoint inhibitor
Pembrolizumab
151
Platinum based chemos commonly cause which side effects
Vomiting, tinnitus, deafness, paraesthesia, renal impairment
152
Taxane chemos commonly cause which side effects
alopoecia, nail dystrophy, hypersensitivity
153
5FU chemos typically cause which side effects
mouth ulcers, diarrhoea
154
What is performance status used to predict
Prognosis and toxicity
More important than age
Can change over time/during treatment
155
What is the typical length of a chemotherapy regime
Most chemotherapy regimes are 4-8 cycles
Cycles can vary in length – typically 2-4 week
Will have small gaps between cycles to allow normal tissue to recover
156
How long does a schedule of radical radiotherapy typically last
Usually 25-30 fractions (4-6 weeks) - will come in 5/7 days a week
Palliative is shorter and a lower dose
157
List some radiotherapy toxicities that can last months/years after treatment
```
Skin fibrosis/ulceration
Dysphagia
Bowel dysfunction
Incontinence
Bladder instability
Pneumonitis (cough, dyspnoea)
Menopause
Infertility
Secondary cancer
```
158
Describe the 4 different phases of a clinical trial
* Phase 1 – Is the drug safe?
* Phase 2 – Does the drug work?
* Phase 3 – Is the drug better than current standard of care?
* Phase 4 – Is the trial representative of real world?
159
Which treatments come under systemic anti-cancer therapy
Chemo
Immunotherapy (Immune checkpoint inhibitors)
Targeted agents
Hormones
160
How do you manage the side effects of immunotherapy in cancer treatment
* Supportive care
* STEROIDS
* Hormone replacement
* Specialist input
