Week 8 Oncology in Primary Care Flashcards
(62 cards)
1
Q
What does it mean to be cured of cancer?
In remission?
A
Means when the patient hasn’t had cancer in 5 year time span
2
Q
Top 6 cancer deaths in 2023 (combined M+W)
A
- Lung and bronchus (top for M+W)
- Colorectum
- Pancreas
- Breast
- Prostate
- Liver and intrahepatic bile duct
Lung and bronchus d/t smoking boom in 1960s-1980s
3
Q
Top 3 Estimated new cancer cases (women)
A
- Breast
- Lung
- Colon and rectum
4
Q
Top 3 estimated cancer cases (Male)
A
- Prostate
- Lung and bronchus
- Colon and rectum
5
Q
Most people diagnosed with cancer are above how old?
A
55
6
Q
SDOH in context of cancer care
Factors
7 L’s
A
- Low income
- Low health literacy
- Long travel distance to screening sites
- Lack health insurance
- Lack of good transportation to facility
- Leave (no medical leave)
- Lack of access to clean water/air
7 L’s
7
Q
Optimal Cancer Care across continuum
Steps of Cancer care (6 steps)
A
- Prevention and risk reduction
- Screening
- Diagnosis
- Treatment
- Survivorship
- EoL care
8
Q
Which level of prevention is most optimal for cancer?
A
Primary prevention
- aka prevent the problem from happening in the 1st place
- Reduce modifiable risk factors
9
Q
Which level of prevention is cancer screening?
A
Secondary
- You are detecting disease in early, asymptomatic, or preclinical state to eliminate potential impact
10
Q
Risks of screening
A
- Bleeding from invasive tests (colonoscopy)
- False (+)
- False (-)
- DX cancer not treatable or treatment not improve QoL
- SDOH in screening
11
Q
Other components in screening appointment
what else do you gather from pt/give to pt
A
- Complete health history (FMHx + PMHx)
- Genetic testing
- Provide evidence-based + age-appropriate screening
- PE - look for s/s
12
Q
Signs/symptoms of cancer presence
TEST QUESTION
A
- May be asymptomatic
- Mass or lesion, skin changes
- Lymphadenopathy
- Bone pain
- Bowel/Bladder changes
- Unintentional weight loss
- Fever
- Cough, SOB
- Fatigue
- Abnormal bleeding
13
Q
Special considerations of screening in older adults
A
- Clinical trails usually don’t include older adults
- Use individualized approach when using recommendations/guidelines
- Consider life expectancy, comorbidities, functional status, + pt’s goals/values
- Underscreening vs overscreening (don’t do mammograms on dementia pts)
- Consider lag time between cancer screening and its benefits; harms of screening are more immediate
- Life expectancy of at least 10 yrs is necesary to derive a survival benefit for breast or colorectal cancers
14
Q
Choosing wisely recommendation in cancer screening
A
15
Q
Cancer pathology descriptors
A
- Histological info
- to tailor txs; need to know cancer type
- Biomarker testing/genomic profiling
- Unique pattern of biomarkers/tumor markers - also to tailor prognostic info + tx
- Biopsy to assess malignant cells: Needle, endoscopic, surgical
- Tissue exam vs. Cytologic exam
- Timing: frozen section (udring surgery) vs pathology (more accurate - takes longer)
16
Q
Purpose of biomarker testing
A
Looks for genes, proteins to help ID cancer type + tx options
surveillance cancer with these too
17
Q
Types of Cancer biomarkers
A
- Circulating tumor markers (not diagnostic)
- Tumor tissue markers (usually from tumor tissue itself)
18
Q
Purposes of circulating tumor markers
Frequency of measurement?
A
- Estimate prognosis
- Determine stage of cancer
- Detect cancer that remains after tx or that has returned
- Assess how well tx is working
- Monitor whether treatment has stopped working
- Measured serially during cancer tx
- Checked to retect possible recurrence
19
Q
Cancer Grading system
A
Description of a tumor based on how abnormal the tumor cells and tumor tissues appear microscopically
GX: Grade cannot be assessed
G1: Well differentiated (low grade)
G2: Moderately differentiated (intermediate)
G3: Poorly differentiated (high)
G4: Undifferentiated (high)
20
Q
Cancel cell
Differentiated vs undifferentiated
A
Well-differentiated: close to normal cells
Undifferentiated: abnormal looking cells
21
Q
Cancer staging system
A
Helps to describe the extent of the cancer
TNM staging
T = size and extent of primary tumor
N = number of regional lymph nodes w/cancer
M = metastasis
22
Q
Curative treatment for which cancer stage(s)?
A
Stage 3 or below
23
Q
Standard tissue biopsies (GOLD STANDARD) involving…
A
Generally involve invasive procedures to detect a tumor
24
Q
Local cancer treatment modalities
A
Surgery
Radiation therapy
Interventional procedures
25
Systemic cancer treatment modalities
Chemotherapy: attacks different phases of cell cycle
- Neoadjuvant - given before surgery
- Adjuvant - given after surgery
Hormonal therapy
Targeted therapy
Immunotherapy/biotherapy
- Cytokines
Vaccines
26
Why offer complementary/alternative medicine in oncology
Helps pt cope w/stress of cancer
27
Roles of PC NP during oncology treatment
| there are many
* Be a case manager
* Maintain regular contact
* Be available - for any other issues
* Have knowledge of community resources + covered services
* Address ongoing health maintenance needs
* Provide appropriate pain management
* Assess for pathologic depression and other psychiatric pathology
* Be aware of therapeutic options
* Communicate w/ and support patient
28
What labs should the PC NP monitor?
Lab surveillance - mostly determined by cancer team
- CBC w/diff- anemia, neutropenia, thrombocytopenia
- CMP - renal + liver function
- Circulating tumor markers - serially
29
How often and When should the NP perform cardiac monitoring
0, 3, 6, 9, and 18 mos (more frequent if (+)Cardiac Hx)
Frequent monitoring for deteriorating LVEF
Radiation to the chest
Bone marrow/stem cell transplant or certain types of chemo
30
Which cardiac condition would an NP permanently discontinue cancer treatment?
S/S of CHF
31
Chemo tx AEs
* Hair loss (Rx for wig)
* Diarrhea
* Anemia
* Skin changes
* N/V
32
Radiation therapy AEs
Often dependent on site of radiation
* Mucositis
* Thrush
* Fibrosis
* Diarrhea, proctitis
33
Dangers of Chemo-related Diarrhea (CRD)
What to R/O 1st?
- Serious and potentially life-threatening complication of wide variety of chemo drugs, hospital admission frequently needed for adequate care
- Can result in treatment delays and diminished compliance → compromise long-term outcomes
- **R/o infectious cause** before tx w/anti-diarrheals
- Refractory CRD → supportive care/discontinuation of tx
34
General principles of N/V s/s
* Consider emetogenicity of the chemotherapy regimen
* Consider timing: acute, delayed, anticipatory, breakthrough
* Consider severity: mild, mod, severe, refractory
* Consider options of route administration
* Cost and insurance coverage
35
Timing:
Acute
Delayed
Anticipatory
Breakthrough
Acute: < 24hrs
Delayed: > 24hrs
Anticipatory: take meds on the way to treatment center
Breakthrough: s/s occuring despite meds
36
Diarrhea non-pharm measures
Avoid triggering foods that might aggravate diarrhea and aggressive oral rehydration w/fluids containing salt, water, and sugar
Foods to avoid:
* Milk + dairy products
* Spicy foods
* High fiber and high fat foods
* Some fruit juices: prune, orange
37
Neutropenic fever
| Definition
A single oral temp of ≥ 101F (38.3C) OR
temp of ≥ 100.4F (38C) sustained over a 1hr period
38
Neutropenia
| Definition
ANC < 1500 or 1000
Severe neutropenia: ANC < 500
39
Neutropenia fever treatment
Med used
* Empiric abx therapy initiated immediately → infectious workup
* Admission as needed then diagnostic reassessment
* MED used: LEVAQUIN
40
Hisk risk pts of Neutropenic fever
Inpatient management
* Cr > 2; LFTs > 3x normal limit
* Uncontrolled/progressive disease
* PNA risk
* Comorbidities: age, social/home status
* ANC < 1000
* Fever 101F
41
Low risk pts of Neutropenic fever
Outpatient management
* Tx w/Levaquin
* Cr < 2; LFTs < 3x normal limit
* No co-morbid conditions
* Limited duration of neutropenia
* Active and independent
42
Mucositis
| Definition
Acute/short term oral toxicity realted to chemotherapy self-limited AE of either radiation or chemotherapy
- Can affect entire GI tract
43
When does mucositits usually occur in cancer treatment
After chemo
~7 days peak, usually healed w/in 10-14d
From radiation, more delayed and cumulative
44
Mucositis staging
G0: None
G1: Erythema and soreness
G2: Ulcers; able to eat solid food
G3: Ulcers; but requires liquid diet d/t mucositis
G4: Ulcers; alimentation not possible d/t mucositis
45
Mucositis complications
Oral candidiasis
HSV infection
Superimposed bacterial infection
46
Mucositis management
Magic mouthwash! (Benadryl + Maalox + Viscous lidocaine)
Mylanta (simethicone)
Many others
47
Fatigue causative factors and treatment in setting of cancer care
Causative factors
* Emotional distress
* Anemia
* Sleep disturbance
* Nutrition imbalance
* Activity level
* Metabolic derangements
Treatment
* Increase exercise as tolerated
* Address anxiety, depression - to help w/sleep
* Stress management
* Support groups
* Steroids, stimulants
48
What not to give if pts on immunotherapy?
STEROIDS
49
Immunotherapy common SEs
Skin: Dermatitis, pruritis
Constitutional: Fevers, chills, fatigue
GI: Diarrhea/colitis
Resp: Pneumonitis
50
Immunotherapy Infrequent SEs
* Hepatitis/liver enzyme abnormalities
* Endocrinopathies: hypophysitis, thyroiditis, adrenal insufficiency
* Vitiligo
51
Treatments for Immunotherapy SEs based on grade
Grade 1-2
- Supportive care
GRade 3-4
- Steroids (except w/endocrinopathies, which are treated w/HRT and not steroids)
Refractory to steroids
- Infliximab (hepatotoxic, not for pts w/liver disease) or mycophenolate mofetil
- Rechallenging with immunotherapy after discontinuataion if possible
52
When do immunotherapy SEs usually show?
10-20wks
53
Spinal cord compression
| What is it, what does it signify, and symptoms
* Spinal column metastasis, local spread intramedullary metastasis
Symptoms
* Back pain (EARLY)
* Neurologic defecits in legs
54
Superior Vena Cava Syndrome
| What is it, what does it signify, and symptoms
Mediastinal tumors
Venous catheters
Symptoms: Think everything head stuffiness
* Neck
* Facial, periocular swelling
* Dyspnea
* Cough
* Head pressure
* Hoarseness
* Nasal congestion
* Syncope
55
Pericardial tamponade
| What is it, what does it signify, and symptoms
Lymphatic obstruction
Pericardial metastasis
Symptoms:
* Dyspnea
* Orthopnea
* Chest pain
* Weakness
56
Hypercalcemia (in cancer SEs)
| What is it, what does it signify, symptoms
Bone metastasis
PTH - related protein production
Calcitriol excretion
Symptoms:
* Confusion
* Lethargy
* Sleepiness
Bisphosphonates as prophylactic treatment
57
Tumor Lysis Syndrome (TLS)
| What is it, what does it signify, and symptoms
Rapid tumor cell destruction from chemo - chemo working too well
Multiple electrolyte abnormalities - acute renal failure
Hyperuricemia
Symptoms:
* Nausea
* Weakness
* Myalgia
* Dark urine
* Arrythmias
58
When to contact oncology team?
| AKA REFER
* Difficult symptom management
* Critical lab values
* New suspicious findings
* Oncologic emergencies
59
Cancer survivorship
| Definition
Any individual who has had cancer from time of DX through reminder of their life
60
Risk factors of cancer survivorship
Physical and Psychological effects
* Recurrence of primary cancer or through risks for a second primary cancer - chemotherapy related cancers
* Late effects of treatment
* Chronic complications
* Radiation post-effects
* Premature menopause
* Preipheral neuropathy
* Cognitive slowing
* Lymphedema
* Urinary or bowel problems
61
Late or long term effects of chemotherapy
* Cardiac dysfunction
* Pulmonary fibrosis
* Neuropathy
* Hearing loss
* Premature menopause, infertility
62
Late or long term effects of Hormonal Therapy
* Tamoxifen - clotting, uterine cancer, hot flashes, vaginal dryness
* Aromatase inhibitors - Osteoporosis, MSK pain
* Androgen deprivation (LHRH agonists, anti-androgens GnRH agonists) - hot flashes, osteoporosis, metabolic syndrome breast tenderness, reduced libido/ED, fatigue
