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Phase 2 > Cancer Care > Flashcards

Cancer Care Flashcards

1
Q

What are the risk factors for breast cancer?

A 
Female
Increasing age
Family history
High alcohol consumption
Previous history
Oestrogen exposure: obesity post-menopause, early menarche/late menopause, nulliparity
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2
Q

What are the symptoms of breast cancer?

A 
Lump or thickening in breast
Change in size or contours
Discharge/bleeding from nipple
Change in colour of areola
Redness or rash
Peau d'orange
Pulled in nipple
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3
Q

What is the UK screening programme for breast cancer?

A

47-73 yo women
Every 3 years
Mammogram

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4
Q

How is breast cancer diagnosed?

A

Triple assessment:
Clinical - inspection and palpation
Radiological - mammograms & USS
Pathological - FNA / core biopsy

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5
Q

Who should have mammograms and why?

A

Older than 40

More adipose tissue than younger women, whose breast tissue is more dense

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6
Q

What should you look for on mammography?

A

Irregular, speculated radiopaque mass

Microcalcification

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7
Q

What are the advantages of FNA over core biopsy?

A

Quick

Less uncomfortable

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8
Q

What is the most common type of breast carcinoma?

A

Invasive ductal carcinoma

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9
Q

What types of surgery are used for breast cancer?

A

Breast conserving surgery
Mastectomy
Oncoplastic

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10
Q

When is breast conserving surgery used?

A

Smaller tumour size relative to breast
Usually peripheral tumour
Requires adjuvant radiotherapy to remaining breast

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11
Q

What are the different types of Oncoplastic breast surgery?

A

Volume replacement

Volume displacement

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12
Q

What is sentinel node biopsy?

A

Taking a sample from the 1st lymph node in the direct drainage pathway of the primary tumour

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13
Q

What are the complications of axillary clearance surgery?

A

Lymphoedema
Shoulder stiffness
Numbness

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14
Q

Which patients require radiotherapy for breast cancer?

A

All patients who have breast conserving surgery
Chest wall in high-risk mastectomy patients
To axilla and supraclavicular fossa in certain cases

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15
Q

What is the mechanism of action of tamoxifen?

A

Mixed agonist and antagonist at the oestrogen receptor

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16
Q

What are the risks of tamoxifen?

A

Increased risk of DVT and endometrial cancer

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17
Q

When is chemotherapy used in breast cancer?

A 
Grade 3
Younger than 50
Tumour bigger than 5cm
Triple negative
Lymph node positive
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18
Q

What are the poor prognostic factors for breast cancer?

A 
Young age
Large tumour size
High grade
Oestrogen receptor negative
Positive lymph nodes
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19
Q

What is the lifetime risk for breast cancer in UK females?

A

1 in 8

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20
Q

What is the principle of the mechanism of action of chemotherapy agents?

A

Interferes with an essential step required for the 6 properties of cancer cells
Damaged cell unable to repair the damage and will apoptose

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21
Q

What are anthracyclines?

A

Topoisomerase inhibitors

Prevents the enzyme from replicating cleaved DNA

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22
Q

What are alkylation agents?

A

Form cross links in DNA to interfere with cellular replication

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23
Q

What are anti metabolites?

A

Disrupt synthesis of essential compounds required for cell synthesis
Eg methotrexate inhibits DHFR

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24
Q

What are vinca alkaloids?

A

Bind to tubulin to prevent formation of the mitosis spindle

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25
Q

What are the general side effects of chemotherapy?

A 
Myelosuppression
GI effects
Skin damage inc alopecia
Organ damage
Gonadal failure
Teratogenicity
Neurotoxicity
Nausea and vomiting
Tumour lysis syndrome
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26
Q

What are the clinical consequences of myelosuppression?

A

Infection
Anaemia
Bleeding

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27
Q

At what stages of chemotherapy can nausea and vomiting occur?

A

Acute
Delayed
Anticipatory

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28
Q

Why can cancer recur after apparent complete remission?

A

Technical inability to measure fewer than 10^3 cells

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29
Q

How does radiotherapy work in cancer?

A

Ionises chemicals within cells
Causes DNA strand breakage
Leads to apoptotic or mitotic cell death

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30
Q

What is the main difference between palliative and radical radiotherapy?

A

Palliative uses lower doses to minimise side effects

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31
Q

Why is radiotherapy given in fractions?

A

Allows normal tissues to recover between treatment, but malignant cells don’t recover

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32
Q

What are the side effects of radiotherapy?

A 
Mucositis
Hair loss and desquamation of skin
Dysphagia
Nausea and vomiting
Radiation cystitis and dysuria
Fatigue
Late: second cancers eg leukaemia
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33
Q

How is neutropenic sepsis diagnosed?

A

Patients having anti-cancer treatment with neutrophils 38

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34
Q

Which patients are particularly high risk for neutropenic sepsis?

A

Chemotherapy
Extensive field radiotherapy
Haem conditions eg leukaemia, lymphoma, MDS

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35
Q

What are the common causative organisms for neutropenic sepsis?

A

Staph aureus
Staph epidermidis
Enterococcus
Streptococcus

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36
Q

What is the management of neutropenic sepsis?

A

High-flow O2
Blood cultures / urine culture / wound swabs / line cultures
IV Tazocin 4.5g
IV fluids
FBC, UEs, LFTs, clotting, lactate (ABG), CRP

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37
Q

What is used for prophylaxis for neutropenic sepsis?

A

GCSF - granulocyte stimulating factor

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38
Q

What do you need to tell patients about neutropenic sepsis?

A

Warn of signs

Give details of 24hr number to call if they develop an infection or become unwell

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39
Q

What is MSCC?

A

Compression of the dural sac and its contents (spinal cord or cauda equina) by an extra dural tumour mass

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40
Q

What tumours commonly metastasise to the spine?

A 
Bronchus
Breast
Prostate
Kidney
Haem: myeloma and NHL
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41
Q

What is the commonest tumour site in the spine?

A

Vertebral body

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42
Q

What are the symptoms of MSCC?

A

Back pain
Weakness
Sensory deficit
Autonomic dysfunction

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43
Q

What is the investigation of choice for MSCC?

A

MRI whole spine

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44
Q

What is the management for MSCC?

A

Dexamethasone 16mg stat then 8mg BD
Radiotherapy
Surgery

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45
Q

When is surgery used to treat MSCC?

A 
Single vertebral involvement
No evidence of widespread disease
Patient will live longer than 3 months
Tissue needed for histology
Tumour type not radio sensitive
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46
Q

What is the median survival following cord compression?

A

3-6 months

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47
Q

What are the common malignant causes of SVCO?

A

Lung cancer

Lymphoma

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48
Q

What are the symptoms of SVCO?

A 
Swelling of face neck and 1/both arms
Distended neck and chest wall veins
Shortness of breath
Headache
Lethargy
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49
Q

What are the investigations for SVCO?

A

CXR
CT with contrast
Angiography

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50
Q

What is the treatment for SVCO?

A

Prednisolone
Chemo or radiotherapy depending on tumour type
Stenting - rapid relief of symptoms

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51
Q

How does malignancy cause hypercalcaemia?

A

Production of PTHrP
Osteolytic metastases
Calcitriol production

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52
Q

What are the symptoms of hypercalcaemia?

A 
Moans, stones, groans
Nausea, anorexia, thirst
Polydipsia and polyuria
Constipation
Confused, poor concentration, drowsy
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53
Q

What investigations would you do if you suspect hypercalcaemia?

A 
Calcium - normal range 2.1-2.6
Albumin - to calculate corrected calcium
U&Es
PTH/PTHrP
Phosphate
Myeloma screen if no known malignancy
54
Q

How do you manage hypercalcaemia?

A

IV normal saline

Bisphosphonates - 60-90mg pamidronate IV

55
Q

What are the biochemical abnormalities seen in tumour lysis syndrome?

A 
Hypeuricaemia
Hyperkalaemia
Hyperphosphataemia
AKI 
HypOcalcaemia
56
Q

Why does tumour lysis syndrome require rapid treatment?

A

Can progress to life-threatening metabolic disorders or renal failure

57
Q

Which tumour types are particularly susceptible to tumour lysis syndrome?

A 
High-grade lymphoma
Acute lymphoblastic leukaemia
Myeloma
Germ cell tumours
Small cell lung cancer
Inflammatory breast cancer
58
Q

What are the patient risk factors for tumour lysis syndrome?

A

Pre-existing renal dysfunction
Hypovolaemia
Pre-treatment LDH high
Urinary tract obstruction from tumour

59
Q

When does tumour lysis syndrome commonly present?

A

Day 3-7 post-chemotherapy

60
Q

What is the management for prevention/treatment of tumour lysis syndrome?

A

Hydration before and during treatment
Allopurinol
Rasburicase
Haemodialysis

61
Q

How does allopurinol work?

A

Xanthine oxidase inhibitor - reduces uric acid

62
Q

How does rasburicase work?

A

Synthetic uricase. Converts uric acid to allantoin

63
Q

What is the amber care bundle?

A 
Assessment
Management
Best practice
Engagement
Recovery uncertain
64
Q

Give some physical clues to recognise a dying patient

A 
Profoundly weak
Gaunt
Drowsy, disorientated, poor concentration
Diminished oral intake
Abnormal breathing patterns
Skin colour or temperature changes
65
Q

What are the main symptoms to address in anticipatory prescribing in palliative care?

A 
Pain
Nausea and vomiting
Breathlessness
Restlessness and agitation
Respiratory tract secretions
66
Q

What would you prescribe for noisy respiratory secretions?

A

Glycopyronium 200mcg SC PRN

67
Q

What would you prescribe PRN for breathlessness?

A

2.5 - 5mg morphine SC

68
Q

What would you prescribe for agitation?

A

Midazolam 2.5-5mg SC PRN

69
Q

What should the dose of morphine be for a breathless patient already taking morphine for pain?

A

Half of their PRN dose

70
Q

Other than morphine, what other drugs can be used to treat breathlessness?

A

Benzodiazepines eg lorazepam 0.5-1mg SL PRN

71
Q

Define nausea

A

Subjective, unpleasant feeling of the need to vomit

72
Q

What are the consequences of nausea?

A

Physical: dehydration, malnutrition, anorexia, weight loss, insomnia
Psychological: anxiety, depression, anger

73
Q

What are the most common causes of vomiting in palliative care?

A

Impaired gastric emptying
Chemical and metabolic disturbances
GI: bowel obstruction and constipation

74
Q

What are the characteristics of vomiting caused by impaired gastric emptying?

A

Intermittent vomiting that relieves the nausea
Reduced appetite and early satiety
Post-prandial fullness/bloating
Small vomits that may contain food

75
Q

What are the causes of impaired gastric emptying?

A

Locally advanced cancer, lymph nodes, liver mets
Morphine, anticholinergics
Gastroenterostomy
Autonomic neuropathy

76
Q

What are the characteristics of vomiting caused by chemical and metabolic disturbances?

A

Persistent nausea
Aggravated by the sight or smell of food
Nausea unrelieved by vomiting

77
Q

What chemical and metabolic disturbances can cause N & V?

A 
Drugs: opioids, antibiotics, SSRIs
Renal/hepatic failure
Hypercalcaemia
Hyponatraemia
Sepsis
Tumour toxins
78
Q

What are the characteristics of vomiting caused by bowel obstruction/constipation?

A

Intermittent vomits that may relieve nausea
Abdo cramps
Altered bowel habit
Abdo distension

79
Q

What is the mechanism of action of haloperidol?

A

Dopamine antagonist

80
Q

What is the dose of haloperidol?

A

1.5-5mg/d

81
Q

What are the side effects of haloperidol?

A

Restlessness
Sedation
Parkinsonism

82
Q

What types of N&V is haloperidol used to treat?

A

Metabolic or drug causes

83
Q

What is the mechanism of action of metoclopramide?

A

Dopamine antagonist

84
Q

What is the dose of metoclopramide?

A

10-20mg TDS

85
Q

What are the side effects of metoclopramide?

A

Restlessness

Parkinsonism

86
Q

What is the mechanism of action of domperidone?

A

Dopamine antagonist

87
Q

Where are D2 receptors found in the brain?

A

Chemoreceptor trigger zone

88
Q

What is the mechanism of action of cyclizine?

A

Antagonist at ACh and H1 receptors

89
Q

What is the dose of cyclizine?

A

50mg TDS

90
Q

What are the side effects of cyclizine?

A

Hypotension
Urinary retention
Dry mouth
Constipation

91
Q

What is the mechanism of action of ondansetron?

A

5HT3 receptor antagonist at vagus afferent nerve

92
Q

What is the dose of ondansetron?

A

4-8mg BD/TDS

93
Q

What are the side effects of ondansetron?

A

Constipation

Headache

94
Q

What are the indications for ondansetron?

A

Chemo-induced

Bowel obstruction

95
Q

Where is the vomiting centre?

A

Medulla

96
Q

What receptors are found in the vomiting centre?

A

ACh
H1
5HT3

97
Q

Where is the chemoreceptors trigger zone?

A

Area prostrema - 4th ventricle

98
Q

What drugs would you chose for vomiting caused by gastric stasis?

A

Metoclopramide

Domperidone

99
Q

What drugs would you chose for vomiting caused by intestinal obstruction?

A

Dexamethasone

Cyclizine

100
Q

Give 3 examples of weak opioids

A

Codeine
Tramadol
Dihydrocodeine

101
Q

Give 4 examples of strong opioids

A

Morphine
Fentanyl
Oxycodone
Pet hiding

102
Q

What is an adjuvant analgesic?

A

Drugs whose primary indication is not pain

103
Q

What are the common side effects of opioids?

A

Constipation
Nausea and vomiting
Drowsiness/sedation

104
Q

How do you calculate the standard release dose of morphine a patient requires?

A

Total daily dose divided by 2
This is the total amount of morphine they have had in the last 24hrs
Given as BD

105
Q

How do you calculate the PRN (breakthrough) dose of morphine a patient needs?

A

Total daily dose divided by 6

106
Q

What is the most common preparation of oramorph?

A

Liquid, 10mg/5ml

107
Q

How long does oramorph take to work, and how long do its effects last?

A

30-40mins to work

Lasts 2-3hrs

108
Q

What is the ceiling dose of codeine?

A

240mg/day

109
Q

How does a dose of codeine equate to morphine?

A

1:10 morphine:codeine

So 240mg codeine = 24mg morphine

110
Q

How does OxyContin relate to morphine?

A

OxyContin is twice as strong as morphine

111
Q

What is important about opioid prescribing in renal impairment?

A

No standard release morphine, as this builds up
Longer lock-out time for oramorph PRNs
Consider fentanyl rather than morphine

112
Q

How do you write a controlled drug prescription?

A

Name + Form + Strength + Total amount of drug in words AND figures
Eg supply 56 (fifty six) 10mg tablets zomorph

113
Q

What are oncogenes?

A

Increase activity in the absence of a relevant signal

Dominant manner - mutation to one allele results in continuous unchecked activation

114
Q

What are tumour suppressor genes?

A

Inhibitors of cellular growth

Mutation to both alleles must occur before cellular effects are evident: 2-hit hypothesis

115
Q

What percentage of breast cancers are due to mutated BRCA genes?

A

5-10%

116
Q

What type of genes are BRCA?

A

Tumour suppressor genes

117
Q

What is the lifetime risk of developing breast cancer for a carrier of the mutated BRCA1 gene?

A

65%

118
Q

What is the lifetime risk of breast cancer for a carrier of the mutated BRCA2 gene?

A

45%

119
Q

What is the lifetime risk of developing ovarian cancer for a carrier of the mutated BRCA1 gene?

A

40%

120
Q

What is the lifetime risk of ovarian cancer for a carrier of the mutated BRCA2 gene?

A

11%

121
Q

What are the different types of familial colorectal cancer?

A

Familial adenomatous polyposis
Peutz-Jeghers syndrome
Hereditary non-polyposis colorectal cancer

122
Q

What cancers are involved in HNPCC?

A 
Colorectal
Uterine
Ovarian
Stomach
Renal pelvis
Small bowel
Pancreas
123
Q

What gene is involved in FAP?

A

APC gene

124
Q

What type of radiation causes direct DNA damage?

A

UV-B Rays

125
Q

What should you look for on examination of a mole?

A 
Asymmetrical shape
Irregular border
Changes in colour
Diameter - new growth >6mm
Evolution
126
Q

What is the Breslow depth?

A

For melanoma, the distance the lesion goes below the basement membrane

127
Q

How does Breslow depth relate to prognosis?

A

4mm - 4y survival 50%

128
Q

What is lentigo maligna?

A

Melanoma in situ

129
Q

What conditions are pre-malignant for squamous cell carcinoma?

A

Actinic keratosis

Bowens disease

130
Q

How does squamous cell carcinoma present?

A

Ulcerated lesion
Hard, raised edges
In sun-exposed sites

131
Q

How is SCC treated?

A

Excision and local radiotherapy

132
Q

How is basal cell carcinoma managed?

A

Excision and radiotherapy if >60y
Doesn’t metastasise but can cause problems due to local erosion
No 2ww, normal referral is fine as they won’t change in this time

Phase 2 (21 decks)

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