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Evaluating the Medically Complex Patient > Cancer / Cancer and Immunocompromised > Flashcards

Cancer / Cancer and Immunocompromised Flashcards

1
Q

When to consult oncologist when seeing a pt who is undergoing cancer tx:

A

every pt, every time

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2
Q

What is important for px of pts with cancer:

A

HPV status

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3
Q

TNM system:

A

T - tumor size, N - cervical LD metastases, m - distant metasases

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4
Q

T1:

A

less than or equal to 2cm –> up to diameter of a nickel

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5
Q

T2:

A

greater than 2cm, less than or equal to 4cm

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6
Q

T3:

A

greater than 4cm

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7
Q

T4:

A

greater than 4cm with invasion of adjacent structures

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8
Q

N:

A

cervical LD metastases “regional)

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9
Q

N0

A

no node

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10
Q

N1:

A

single ipsilateral node less than or equal to 3cm “small”

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11
Q

N2a:

A

single ipsilateral node, larger than 3cm, less than or equal to 6cm

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12
Q

2b:

A

multiple ispisliateral nodes, larger than 3cm, less than or equal to 6cm

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13
Q

N2c:

A

bilateral or contralateral nodes less than or equal to 6cm

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14
Q

N3a:

A

ipsilateral node greater than 6cm

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15
Q

N3b:

A

bilateral nodes greater than 6cm

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16
Q

N2 a-b N3 a-b:

A

progrtssively bigger and /or contralateral

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17
Q

M0:

A

no known metastases:

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18
Q

M1:

A

metastases

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19
Q

Staging is from:

A

1-4

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20
Q

Stage 1:

A

T1N0Mo

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21
Q

Stage 2:

A

T2N0M0

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22
Q

Stage 3:

A

T3N0M0 or T1,2, or 3N1M0, any lymph node metastases is at least Stage 3

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23
Q

Any lymph node metastases is at least Stage:

A

3

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24
Q

Stage 4:

A

T4 and NM0, any TN2 or N3M0, ant T or NM1

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25
Q

New cases of cancer in US for oc and pharynx:

A

48,330

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26
Q

Deaths due to cancer in the oc and pharynx per year:

A

9,570

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27
Q

5 yr relative survival rate f cancer of the oral cavity or pharynx:

A

64% (2009-2013)

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28
Q

% of oral and pharyngeal cancer cases that are localized:

A

30%

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29
Q

% of oral and pharyngeal cancers that are regional:

A

47%

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30
Q

% of oral and pharyngeal cancers that are distant:

A

18%

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31
Q

% of oral and pharyngeal cancers that are at an unknown stage:

A

5%

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32
Q

5yr relative survival rate of localized oral and pharyngeal cancer:

A

83.3%

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33
Q

5yr relative survival rate of regional oral and pharyngeal cancer:

A

63.3%

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34
Q

5yr relative survival rate of distant oral and pharyngeal cancer:

A

38%

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35
Q

5yr relative survival rate of oral and pharyngeal cancer that is at an unknown stage:

A

47.2%

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36
Q

Risk factors for oral and pharyngeal cancer:

A

tobacco, alcohol, combined, HPV, Betel-quid chewing, any immunocompromised condition, history of radiation therapy, history of cancer

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37
Q

Risk of smokers in relation o non”

A

10 times greater risk, dose related

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38
Q

What are most oral cancers attributable to?

A

smoking

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39
Q

Risk of oral cancer for those who drink 3-4 drinks per day in relation to those who don’t:

A

2 times

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40
Q

Is the risk of oral cancer from drinking alcohol dose dependant?

A

yes

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41
Q

The risk of oral cancer for those who both smoke and drink heavily is how many times greater than that for ppl who never smoke or drink?

A

35 times

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42
Q

Oral infection w HPV 16 confers about a___ -fold increase in risk relative to individuals without oral HPV 16 infection:

A

15 fold

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43
Q

Relative risk of oral cavity cancer s greater for which, betel quid chewing alone or gutka?

A

gutka, oral pharyngeal cancer

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44
Q

These can lead to immunocompromised conditions:

A

steroids, transplants, immune modulation medications

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45
Q

Reasons why pts may have had radiation therapy in the in the past:

A

acne, benign conditions, previous cancers

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46
Q

Why a history of cancer may be a risk factor for oral cancer:

A

filed cancerization, genetic predisposisiton

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47
Q

Colors of suspicious lesions:

A

red, white, red and white, blue, brown, mixed

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48
Q

Surface descriptors of suspicious lesions:

A

ulcerated, exophytic, macules, papules

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49
Q

Consistency descriptors for suspicious lesions:

A

soft, firm, hard

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50
Q

Longest duration to watch a suspicious lesion:

A

2wk BIOPSY!!

51
Q

Initial tx for suspicious lesion:

A

remove potential source of irritation

52
Q

What does the accuracy of biopsy results depend upon?

A

skill of the practitioner and pathologist, site selected

53
Q

TF? If biopsy results com back negative, you don’t’ need to continue to monitor the lesion

A

F. must continue, take photos, repeat biopsy by linical appearance

54
Q

Types of dysplasia:

A

mile, moderate, severe

55
Q

TF? Dysplasia can become into cancer.

A

T, if the pt lives long enough

56
Q

Purpose of pretreatment for dyplasia (?):

A

reduce morbidity during and after tx, treat any potential source of o=infection, id potential problems for closer follow-up

57
Q

How to pretreat for patients with dysplasia:

A

remove teeth with poor prognosis, severe perio, unrestorable caries, large pa lesions, optimally 21 d prior to radiation

58
Q

How many days prior to radiation should pre-treatment in the dental office be done?

A

21 d

59
Q

Surgical pretreatment concerns of pts w dysplasia:

A

sufficient teeth for the pt to continue to function, which teeth are vital to help retain post-op function?

60
Q

Radiation concerns of pretreatment for dysplasia (OLD SCHOOL):

A

which teeth will be in the port, can the teeth in the port remain for the lifetime of the pt, are any teeth in danger of requiring emergency care during radiation?

61
Q

Radiation concerns of pretreatment for dysplasia (NEW SCHOOL):

A

Intensity modulated radiaiton therapy, no longer as clear cut what the dose is to a give tooth, however new computer modeling programs can help

62
Q

Pretreatment concerns for pts who will undergo chemo

A

Are any teeth abscesseed or at risk of local infection during chemo?., is there a risk of septicemia from any current oral conditions

63
Q

OH counseling to give as pretreatment for pts about to get treated for cancer:

A

nutrition and diet, complications of therapy, prevention via freq recalls, F therapy (every day/ varnish?), chlorhexidine rinses

64
Q

Fluoride to Rx for pts about to get treated for cancer:

A

neutral sodum fluoride, neutral pH is less irritating

65
Q

Directions to give for pts that are Rx’ed F for pretretment for cancer tx:

A

Brush for 5m, expectorate, DO NOT RINSE, EAT OR DRINK FOR 30m

66
Q

What to treat before radiation or chemo?

A

mucositis, fungal infection, bacterial infection, viral infection, oral pain

67
Q

Mucositis, how to treat in pts with cancer who are getting tx:

A

basic oral care, , use oral mouthwashes not containing alcohol wo intense flavor, no superiority of one mouthwash over saline or bicarbonate rinses, oral prostheses should be kept clean w an antimicrobial solution and their use should be discouraged during night time and in presence of overt oral mucositis

68
Q

Post-surgical tx:

A

rehabilitation potential (implant, prosthesis), hypomobility concerns

69
Q

Post-radiation therapy:

A

salivary gland dysfunction, hypomobility concerns, less potential with IMRT, but not absent!, osteoraidonecrosis ptential

70
Q

Salivary gland dysfunction can lead to:

A

dysphagia, dental caries potential

71
Q

Post-radiation tx:

A

recall every 3mo, Rx F therapy, chlorhexidine possible, osteoradionecrosis potential

72
Q

Hyperbaric oxygen concerns of osteoradionecrosis:

A

cost, time, access to chambers, risk/benefit

73
Q

Indications for hyperbaric oxygen:

A

prevention of osteoradionecrosis

74
Q

Osteoradionecrosis i more likely to occur in man or max?

A

man, does >6000 cGy

75
Q

Osteoradionecrosis is likely in these sites:

A

ites of extraction of teeth in previously irradiated site

76
Q

How many exposures and at how much oxygen is hyperbaric oxygen tx:

A

30 preop exposures at .4 absolute oxygen for 90m each time, followed by 10 additional exposures post-op

77
Q

Tx concerns of osteoradionecrosis:

A

soft tissue breakdown that heals spontaneously, reports of poor long-term resolution (healing s/p HBO w recurrence of osteoradionecrosis within 2y), cost/ benefit ratio unknown, availability of chambers

78
Q

Medical risks of tx w HBO:

A

if residual tumor cells are present, risk of seizures (oxygen toxicity), barotrauma, middle ear injuries, temporary myopia

79
Q

Drugs used for bisphosphonate IV therapy:

A

zoledronic (Zometa), pamidronate (Aredia)

80
Q

How to dec risk once bisphosphonate therapy is started:

A

no known way

81
Q

Risk of ON after oral bisphosphonates after IV:

A

1-10%

82
Q

Risk of ON after ofal bisphosphonates:

A

0.001-0.01%

83
Q

TF? There is an increased risk of ON if taking oral bisphosphonates for longer than 3y.

A

T? not sure

84
Q

How to prevent occurence?

A

no way

85
Q

Is the absolute risk of ON from oral bisphosphonates therapy low or high?

A

low

86
Q

TF? Morbidity and mortality of hip fracture is significant in relation to MRONH.

A

T

87
Q

What are IV bisphosphonates used for?

A

metastatic bone disease

88
Q

Result of stopping IV bisphosphonates:

A

may limit quality of remaining life by increasing pain and tumor size

89
Q

TF? Surgery is the best option after diagnosis of ON:

A

F. Surgery may exacerbate ON

90
Q

TF? Debridement is the best option after diagnosis of ON:

A

F/ all areas of the jaw are at risk, debridement may only increase the area exposed

91
Q

Consequence of bone marrow suppression by chemotherapy:

A

thrombocytopenia

92
Q

How often to take PrEP:

A

daily

93
Q

Trade name for PrEP:

A

truvada

94
Q

Truvada is a combo of these 2 meds:

A

tenofovir and emtricitabine

95
Q

HIV- CDC Stage 1:

A

Early HIV infection: acute phase of HIB infection and recent HIV infection

96
Q

acute phase HIV infection:

A

immediately after HIV infection and before seroconversion

97
Q

Recent infection:

A

within first 6mo of HIV infection

98
Q

Initial testing for HIV:

A

CD-4 count; plasma HIV-1 RNA levels; resistance assays

99
Q

HIV, clinical latency:

A

With ART can live decades; wo ART avg period 10 yr

100
Q

Goals in tx for HIV pts:

A

CD-4 count >500 (continue in CDC Stage 1), plasma HIV-1 RNA levels < 200

101
Q

CDC Stage 2:

A

CD-4 count bw 200-499

102
Q

CDC Stage 3:

A

CD-4 plus HIV+, HIV+ and pulm TB, recurrent pneumonia, invasive cervical carcinoma, Karposi’s sarcoma, P. carinii pneumonia, opportunistic infections, Wasting syndrome, CNS syndrome

103
Q

PEP must start within:

A

72h, continue for 4wk, 3+ drugs

104
Q

ART sf:

A

Antiretroviral therapy

105
Q

Concerns regarding tx with ART for HIV:

A

Cost (AIDS Drug Assistance Programs), drug toxicities, non-sdherence, potential eariier development of resistnace

106
Q

Oral signs of the immunocompromised:

A

candidiasis, viral associated: Hairy leukoplakia, Cancers: Karposi’s sarcoma, Non-Hodgkins lymphoma, PDD

107
Q

Tx for oral candidiasis;

A

antifungals - topical or systemic

108
Q

Topical rinse used for candidiasis:

A

nystatin, clotrimazole

109
Q

Systemic pill for candidiasis:

A

Fluconazole (Diflucan)

110
Q

Disadv to Nystatin and clotrimazole:

A

sugar containing, may have resistance, prosthesis concerns

111
Q

Disadv to systemic antifungal:

A

arrhythmias, hepatotoxicity

112
Q

Oral signs of the immunocompromised:

A

salivary gland enlargement, xerostomia

113
Q

Tx for the immunocompromised with xerostomia:

A

biotene products, artificial saliva

114
Q

Drug tx for xerostomia in immunocompromised pt:

A

Salagen (pilocarpine), Evoxav (cevimeline)

115
Q

Other oral manifestations of immunocomp=romisd pts:

A

bac infections, NUG, biral infections: Herpes complex, HPV, Herpes zoster, CMV

116
Q

TF? All organ transplants require immunosuppression.

A

F. not if identical

117
Q

What is req for dental “clearance”

A

FMS, exam, follow-up

118
Q

What happens immediately after Bm transplant?

A

severe immunosuppression initially

119
Q

Long term result of organ transplant;

A

raft vs. host disease

120
Q

% of pts that are long term survivors of allogenic stem cell transplants that graft vs. host disease occurs in:

A

25-40%

121
Q

Oral signs of graft vs. host disease:

A

erythema, lichenoid lesions, pain

122
Q

How much more of an increase risk of developing oral cancer is there for pts with graft vs host disease?

A

10 fold

123
Q

% of incidence of malignant tumors after 10y:

A

15-20%

124
Q

Up to ___% increased risk after 20yr:

A

40%

Evaluating the Medically Complex Patient (4 decks)

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