Basics to cancer Flashcards
Describe the typical clinical features that might suggest malignant spinal cord compression (MSCC) in a patient with a known history of cancer.
Persistent and progressive back pain
Pain worse on lying down, coughing, or straining
Radicular pain radiating to the buttocks or legs
Motor weakness in the lower limbs
Sensory changes, including diminished pinprick sensation and paraesthesia
Bladder and bowel dysfunction
Reduced power and reflexes in the lower limbs
What are the immediate management steps for a patient suspected of having malignant spinal cord compression (MSCC)?
16mg of Dexamethasone STAT followed by 8mg TDS with PPI cover. IV prednisolone
Arrange urgent imaging, typically MRI of the whole spine, to confirm the diagnosis and identify the level of compression
Consult with oncology and neurosurgery or spinal surgery teams for further management
Provide pain relief and support for any motor or sensory deficits
Consider radiotherapy or surgical decompression depending on the tumour type, extent of disease, and patient’s overall condition
What are the potential long-term complications if malignant spinal cord compression (MSCC) is not treated promptly?
Permanent paraplegia or quadriplegia, depending on the level of compression
Chronic pain and sensory deficits
Bladder and bowel incontinence
Pressure ulcers due to immobility
Deep vein thrombosis (DVT) and pulmonary embolism (PE) secondary to prolonged immobility
Psychological impact, including depression and anxiety related to loss of function and independence
Define and provide examples of modifiable and non-modifiable risk factors for cancer development.
Modifiable Risk Factors: These are risk factors that can be altered or controlled by an individual to reduce their risk of developing cancer. Examples include:
Lifestyle Factors: Smoking and diet.
Environmental Factors: Exposure to UV radiation and asbestos.
Niche Example: Chronic Inflammation: Conditions such as chronic pancreatitis and chronic inflammatory bowel diseases (e.g., Crohn’s disease) can increase cancer risk.
Niche Example: Occupational Exposures: Exposure to certain chemicals in the workplace, such as benzene or formaldehyde, can increase the risk of cancers like leukaemia.
Non-Modifiable Risk Factors: These are risk factors that cannot be changed. Examples include:
Genetic Factors: Family history of cancer and inherited genetic mutations (e.g., BRCA1 and BRCA2).
Demographic Factors: Age and sex.
Niche Example: Ethnicity: Certain ethnic groups have higher risks for specific cancers, such as Ashkenazi Jews with a higher prevalence of BRCA mutations.
Niche Example: Congenital Syndromes: Conditions like Li-Fraumeni syndrome, which predispose individuals to multiple early-onset cancers.
Explain the role of genetic factors in cancer development and provide examples of genetic conditions that predispose individuals to cancer.
Examples of Genetic Conditions:
BRCA1 and BRCA2 Mutations: These mutations are associated with an increased risk of breast and ovarian cancers.
Lynch Syndrome: Increases the risk of colorectal cancer and other cancers like endometrial and stomach cancers.
Niche Example: Retinoblastoma: Caused by mutations in the RB1 gene, leading to a high risk of developing eye cancer in early childhood.
Niche Example: Multiple Endocrine Neoplasia (MEN): Genetic mutations leading to tumours in multiple endocrine glands, such as parathyroid, pancreatic, and pituitary glands.
Discuss how lifestyle factors can influence the risk of developing cancer.
Smoking: Increases the risk of lung cancer and cancers of the mouth, throat, and oesophagus.
Diet: High consumption of processed meats and low intake of fruits and vegetables can raise the risk of colorectal cancer.
Niche Example: Shift Work: Working night shifts can disrupt circadian rhythms and has been linked to an increased risk of breast cancer.
Niche Example: Human Papillomavirus (HPV) Infection: Engaging in unprotected sex can lead to HPV infection, which increases the risk of cervical and oropharyngeal cancers.
List the recommended cervical cancer screening tests and specify the target populations and frequencies for each.
A smear test is offered to all women between the ages of 25-64 years
25-49 years: 3-yearly screening
50-64 years: 5-yearly screening
cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self-refer once past screening age)Pap Smear (Cervical Cytology):
Outline the management steps for a patient who has had a suspicious finding on a mammogram.
Further Diagnostic Imaging:
Procedure: Perform a targeted breast ultrasound to evaluate the suspicious area.
Biopsy:
Type: Core needle biopsy is typically performed to obtain a sample of the abnormal tissue for histopathological analysis.
Referral:
Specialist: Refer to a breast surgeon for a comprehensive evaluation, including potential surgical options if the biopsy confirms malignancy.
Niche Answers:
Genetic Testing:
Consideration: For patients with a strong family history of breast cancer or those who test positive for high-risk lesions, BRCA1/2 testing should be considered to assess hereditary cancer risk.
State the primary and secondary prevention strategies for lung cancer.
Primary Prevention:
Smoking Cessation:
Action: Advise cessation through behavioural therapy, pharmacotherapy (e.g., nicotine replacement therapy), and support programmes.
Occupational Safety:
Action: Implement safety measures and personal protective equipment for workers exposed to asbestos.
Secondary Prevention:
Screening:
Criteria: Annual low-dose computed tomography (LDCT) for high-risk individuals, specifically those aged 55-74 with a smoking history of 30 pack-years or more.
Niche Answers:
Primary Prevention:
Air Quality Improvements:
Action: Support initiatives to reduce ambient air pollution through environmental regulations and public health policies.
Secondary Prevention:
Risk-Based Screening:
Additional Criteria: Consider screening for individuals with a history of significant exposure to radon or those with a diagnosis of chronic obstructive pulmonary disease (COPD) who meet smoking history criteria.
State the primary aims of cancer screening programmes.
Common Answers:
Early Detection: Identifies cancer before symptoms appear.
Reduction in Mortality: Aims to decrease deaths from cancer by catching it early.
Niche Answers:
Identification of Pre-cancerous Lesions: Detects and treats conditions like polyps in colorectal cancer to prevent progression.
Cost-Effective Resource Allocation: Uses resources efficiently by targeting high-risk populations to optimise healthcare delivery.
List the major cancer screening programmes provided by the NHS in the UK and their target populations.
Common Answers:
Breast Cancer Screening:
Target Population: Women aged 50-71
Frequency: Every 3 years
Cervical Cancer Screening:
Target Population: Women aged 25-64
Frequency: Every 3 years (25-49 years), every 5 years (50-64 years)
Colorectal Cancer Screening:
Target Population: Individuals aged 60-74
Frequency: Every 2 years
Niche Answers:
Breast Cancer Screening:
Additional Note: Includes digital mammography and, where available, tomosynthesis (3D mammography) for improved detection.
Cervical Cancer Screening:
Additional Note: Incorporates HPV testing, which may replace cytology in some regions to improve detection of high-risk HPV types.
Colorectal Cancer Screening:
Additional Note: Uses Faecal Immunochemical Test (FIT) and, in some cases, flexible sigmoidoscopy for higher-risk individuals.
Prostate Cancer Screening:
Current Status: No national screening programme, but research is ongoing in using PSA tests and imaging techniques.
Identify one contentious issue associated with cancer screening programmes and mention one new screening programme currently under evaluation.
Contentious issue: Overdiagnosis is a key contentious issue in cancer screening programmes. Screening may detect cancers that are slow-growing and would not have caused harm during the patient’s lifetime. This can lead to unnecessary treatments, anxiety, and overtreatment, including surgery, chemotherapy, or radiation therapy for cancers that may never have progressed or caused symptoms.
New screening programme under evaluation: A lung cancer screening programme using low-dose computed tomography (LDCT) is currently being evaluated in the UK. The programme aims to detect early-stage lung cancer in high-risk populations, such as long-term smokers. Trials, such as the UK Lung Cancer Screening (UKLS) trial, have shown promising results in reducing mortality from lung cancer. However, further evaluation is ongoing to assess the balance of benefits and risks, such as overdiagnosis and false positives.
First step after you find a lung cancer on a CXR
Staging CT Chest/Abdo/Pelvis
What is not a common site for metastasis with lung cancer?
Adrenal
Bone
Liver
Lung
Renal
Brain
Renal
After a staging CT with lung cancer, what is the next investigation?
CT biopsy, bronchoscopy +/- endobronchial ultrasound
Thoracoscopy if pleural effusion
Histology needed to find out the type of lung cancer
What do you measure in US guided aspirate with malignant pleural effusion?
Protein
LDH
Cytology (large volume of fluid the better)
Microbiology
What bloods do you do when initially investigation lung cancer?
FBC
U/E
CRP
INR
LFT
Are nodules in the lungs normal?
100 people from the street, some will have spots in their lungs
Yes if the nodule is <5mm= minimal risk of lung cancer
Screening tools for nodules?
One CT= BROCK
PET= HERDER
Two CT= Volume doubling time
How to treat patients with hypercalcemia?
IV Fluids and bisphosphonates (Pamidronate)
SVCO and types of lung cancer?
Biopsy- small cell?- radiotherapy and chemotherapy
Non small cell- intraluminal stenting
Why should you not give people Dexamethasone after 2pm?
Keeps you awake, hyperactive and confused
What medication is given to prevent seizures with brain mets?
Levertiracetam (Keppra)
What does the WHO performance status measure?
How active you are in the day
Lower the status, more likely you are to do well from treatment and be offered treatment.
Why is there a specific pathway for small cell lung cancer?
Spreads the quickest
Very responsive to chemotherapy
Prioritized
Diagnosed in out of hours
How is mesothelioma classified?
Pleural and peritoneal
Mesothelioma is also grouped according to how the cells look under a microscope. These are 3 main types:
epithelioid – the most common type
biphasic
sarcomatoid
Who is part of the MDT team vs multi-professional team in oncology?
MDT
Primary care
Specialist surgeons
Specialist medics
Medical Oncologists
Clinical oncologists
Histopathologists
Pathologists
Radiologists
Multi-professional team
- Clinical nurse specialists
- Dieticians
- Physiotherapists
- Occupational therapists
- Psychologists
What are the five pillars of cancer care?
- Surgery
- Radiotherapy
- Traditional chemotherapy
- Precision therapy
- Immunotherapy
Give examples of acute toxicity vs late toxicity after radiotherapy (
go head to toe)
Acute (within 3 weeks)
- Fatigue
- Erythema
- Lymphoedema
- Low blood counts
- Hair loss
- Dysphagia
Late (after 3 weeks)
Skin
- Pigmentation, necrosis, telangiectasia, ulceration
Bone
- Necrosis, fracture, impaired growth
Mouth
- Ulceration, dry mouth
Eyes
- Cataracts
Lymphoedema
Lung
- Fibrosis
Heart
- Cardiomyopathy, pericardial fibrosis
Gonads
- Infertility, menopause
Bowel
- Strictures
- Adhesions
- Fistulas
Or… Secondary malignancy
Examples of late toxicities for chemotherapy
- Pleuritis
- Pericarditis
- Cardiovascular complications
- Neuropathy
- Arthritis
- Myalgia
- Chemobrain
- Anxiety
- Depression
- Insomnia
- Dizziness
- Fatigue
Examples of acute toxicities of chemotherapy
(Think about it in body systems)
- Mucositis
- Dry mouth
- N/V
- Dyspnoea
- Pneumonitis
- VTE
- Hand-foot syndrome
- Paronychia (infection of the nail bed)
- Rash
- Skin sensitivity
- Hearing loss
- Tinnitus
- Renal insufficiency
- TLS
- Diarrhoea
- Constipation
- Colitis
- Mucositis
- Cystitis
- Myelosuppression
- Febrile neutropenia
- Infection
- Anaemia
- Bleeding risk
If neutropenic sepsis is suspected, when should antibiotics be given?
Within one hour
IV antibiotics may be given before a full history is taken or the FBC is known
Action for neutropenic sepsis
Action:
URGENT FULL BLOOD COUNT (if suspected neutropenic sepsis DO NOT wait for results before IV antibiotics), U&E, LFT, CRP, glucose, lactate
CULTURES: Blood cultures - peripheral and central line, MRSA screen, MSSU/CSU if symptomatic, sputum if available, stool culture if diarrhoea, wound swabs
CXR if clinically indicated eg if hypoxic or clinical signs in chest
What is Extravasation?
Extravasation refers to the accidental leakage of intravenously (IV) infused drugs or fluids into the surrounding tissues, rather than into the intended vein
What are vesicants?
Certain medications (e.g., chemotherapy drugs, certain antibiotics, and vasopressors) are known as vesicants, meaning they can cause severe tissue damage if they extravasate.
Types of immunotherapy
- Checkpoint inhibitors
- Adoptive cell therapy
- Cancer vaccines
- Monoclonal antibodies
- Immune system modulators
What is the difference between medical and clinical oncologists?
Medical oncologists give systemic anti-cancer treatments- main focus is research and trials. Work in teaching hospitals. Patients who are on a trial
Clinical- main focus is radiotherapy or combined radiotherapy with chemotherapy.
Explain all the stages in a clinical trial
Phase 0
- Early discovery and ongoing preclinical research
Phase 1
- Safety and best dosage levels are determined (12-24 participants)
Phase 2
- Response to new treatment is recorded and analysed (<100 participants)
Phase 3
- Results studied submit to regulatory agency for approval (> than 100 participants)
Phase 4
- Treatment is marketed (> than 1000 involved)
Explain what a bucket trial is
Disease Focus: Tests the same drug in patients with different types of cancer (or other diseases), but all cancers share a common mutation or biomarker.
Example: A drug is tested in patients with lung, breast, and colon cancers, but all have a specific genetic mutation that the drug targets.
Purpose: To see if a single drug works across multiple diseases with the same mutation.
Explain what an umbrella trial is
Multiple Treatments, One Disease: Focuses on one type of cancer or disease but tests different treatments based on the specific genetic mutations or characteristics of that disease in each patient.
Example: Patients with lung cancer are divided into groups based on their mutations, and each group gets a different treatment tailored to their mutation.
Purpose: To personalise treatment for patients with the same type of disease but different genetic profiles.
Describe the difference in endpoints between Phase II and Phase III cancer clinical trials.
Phase II trials primarily focus on evaluating the efficacy of the drug (e.g., tumour response rate or progression-free survival) and continue assessing safety. Phase III trials aim to compare the new treatment against the current standard of care, using endpoints like overall survival, quality of life, and large-scale efficacy.
What are some performance status tools?
WHO performance status
MRC dyspnoea scale
NYHA
Rockwood clinical frailty score
What is the difference between induction and neo-adjuvant therapy?
Induction can make un-resectable disease to resectable disease.
Neo-adjuvant= we can take it out, but taking drugs upfront can optimise the treatment.
What is the mechanism of action of immunotherapy in cancer treatment?
Immunotherapy activates the immune system to target tumour cells by blocking inhibitory immune checkpoints (e.g., PD-1, CTLA-4) on T cells, thereby promoting tumour cell destruction.
The rationale is to reverse tumour-induced immune evasion, enabling the immune system to recognise and attack cancer cells.
