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Cancer care Flashcards

1
Q

How is breast cancer classified?

A

ductal v lobular

in situ v invasive

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2
Q

What are the risk factors for breast cancer?

A

age
BRCA genes - 40% lifetime risk of breast/ovarian cancer
1st degree relative premenopausal relative with breast cancer (e.g. mother)
nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
early menarche, late menopause
hormone replacement therapy,, combined oral contraceptive use
past breast cancer
not breast feeding
ionising radiation
p53 gene mutations
obesity

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3
Q

Define carcinoma in situ

A

contained within the basement membrane of the tissue

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4
Q

What is the most common type of breast cancer

A

invasive ductal carcinoma

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5
Q

Describe the breast cancer screening programme

A

women aged 47-73 years f
offered a mammogram every 3 years.

After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.

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6
Q

What features make it more likely that a person is at high risk of a familial breast cancer?

A

Family history of:

age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative younger than age 45 years
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal history of breast cancer (two or more relatives on the father’s side of the family)

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7
Q

What are the common presentations of breast cancer?

A 
lump
erythema - not high temp
nipple retraction
change in shape
dimpling
axillary lymphadenopathy
discharge
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8
Q

What is triple assesssment

A

hospital-based assessment clinic that allows for the early and rapid detection of breast cancer.

referred by their GP if they have signs or symptoms that meet the breast cancer “2 week wait” referral criteria, or if there has been a suspicious finding on their routine breast cancer screening mammography.

clinical
imaging
pathological

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9
Q

Describe the clinical aspect of the triple assessment

A

history - presenting complaint, any potential risk factors, family history and current medications.
examination -

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10
Q

Describe the imaging aspect of the triple assessment

A

Mammography
or
Ultrasound scanning

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11
Q

What are the benefits of USS assessment of the breast

A

more useful in women <35 years and in men, due to the density of the breast tissue in identifying anomalies.

routinely used during core biopsies.

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12
Q

How is mammography undertaken?

A

involves compression views of the breast across two views (oblique and craniocaudal),

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13
Q

How is a cancer seen on mammography?

A

mass lesions

microcalcifications.

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14
Q

Describe the pathological aspect of the triple assessment

A

biopsy!

core or FNA

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15
Q

What are the differences between core and FNA biospy

A

A core biopsy provides full histology wheras fine needle aspiration (FNA) only provides cytology - allowing differentiation between invasive and in-situ carcinoma.

A core biopsy also gives tumour grading and staging,

Core biopsy has higher sensitivity and specificity than FNA for detecting breast cancer.

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16
Q

How is the triple assessment graded and used?

A

Each part is given a score out of five.

P = examination, M = mammography, U = USS, B = biopsy

P1 – Normal	
P2 – Benign	
P3 – Uncertain/likely benign	
P4 – Suspicious of malignancy
P5 – Malignant etc

Aim is to establish whether this is likely a benign lesion or whether the patient should go onto have more definitive biopsy and further intervention.

Cases suspicious for breast cancer are discussed by the MDT to create a suitable treatment plan

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17
Q

What are the treatment options for breast cancer?

A

Surgery

  • breast conserving
  • mastectomy
  • sentinel node biopsy
  • axillary clearance

Hormonal

  • tamoxifen
  • aromatase inhibitors
  • immunotherapy
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18
Q

Describe breast conserving surgery for breast cancer and who it is suitable for

A

A Wide Local Excision (WLE) involves excision of the tumour, ensuring a 1cm margin of macroscopically normal tissue is taken along with the malignancy.

This option is only suitable for:
single cancers <4cm in diameter with no metastatic disease
peripheral tumour

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19
Q

Describe mastectomy for breast cancer and who it is suitable for

A

mastectomy removes all the tissue of the affected breast, along with a significant portion of the overlying skin, with the muscles of the chest wall left intact.

Mastectomies are indicated when:
multifocal tumour
central tumour
large lesion in small breast
>4cm
patient choice.
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20
Q

Describe sentinel node biopsy for breast cancer and who it is suitable for

A

A sentinel node biopsy involves removing the nodes responsible for draining the tumour; the nodes are identified by injecting a blue dye with associated radioisotope into the skin overlying the malignancy.

A radioactivity detection or visual assessment (for the nodes which become blue) is then carried out to establish the location of the sentinel nodes. Once identified the nodes are removed and sent for histological analysis.

Performed alongside WLE and mastectomies, in order to assess the sentinel lymph node, as this indicates prognosis of the disease.

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21
Q

Describe axillary clearance for breast cancer and who it is suitable for

A

Axillary node clearance involves removing all nodes in the axilla, being careful not to damage many important structures located in the axilla.

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22
Q

What are the complications of axillary clearance for breast cancer?

A

Common complications from this operation include paresthesia, seroma formation, and lymphedema in the upper limb.

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23
Q

Explain the use and mechanism of tamoxifen

A

used typically if an aromatase inhibitor is not appropriate. and can be used pre-menopausally or peri-menopausally

It acts through blockade of oestrogen receptors at the cell nucleus, preventing the cancer cell proliferation and growth.

However, it is known to increase the risk of thromboembolism during and after surgery or periods of immobility.

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24
Q

What are the risks of tamoxifen use?

A

increased risk VTE, endometrial cancer and menopausal symptoms.

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25
Q

Explain the use and mechanism of aromatase inhibitors in breast cancer

A

Used in post menopausal women

Prevent conversion androgens made in peripheral tissues into oestrogen. Therefore inhibits further malignant growth of the tumour.

NOT for use in pre menopausal women

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26
Q

Explain the use and mechanism of immunological therapy in breast cancer

A

block HER2 receptor - human epidermal growth factor receptor. stops them from receiving growth signals. By blocking the signals, Herceptin can slow or stop the growth of the breast cancer.

given IV or SC and forms part of adjuvant therapy, or can be administered as monotherapy in patients who have received at least two chemotherapy regimens for metastatic breast cancer

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27
Q

How many tumours are HER2 postitive?

A

20-25%

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28
Q

What factors determine the prognosis of breast cancer

A

extent of nodal involvement is best prognostic indicator

NPI = nottingham prognostic indicator.
takes into account size, grade and number of nodes involved.

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29
Q

How is breast cancer followed up?

A

surveillance imaging - yearly mammogram for 5 years

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30
Q

What are some differentials for breast cancer?

A 
breast cysts
fibroadenoma and other benign cysts
firbocystic changes
mastitis
breast abscess
gynaecomastia in males
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31
Q

What is Paget’s disease?

A

Paget’s disease of the nipple is roughening, reddening, and slight ulceration of the nipple related to ductal carcinoma of the breast.

Microscopically there is involvement of the epidermis by malignant ductal carcinoma cells.

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32
Q

What are the signs and symptoms of paget’s disease?

A

itching or redness in the nipple and/or areola,
flaking and thickened skin
flattened nipple,
yellowish or bloody discharge

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33
Q

How can Paget’s disease and Eczema be differentiated?

A

Paget’s disease always affects the nipple and only involves the areola as a secondary event,

Eczema nearly always only involves the areola and spares the nipple.

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34
Q

Define febrile neutropenia

A

oral temperature ≥38.5°C or two consecutive readings of ≥38.0°C for two hours

and an absolute neutrophil count ≤0.5 x 109/L.

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35
Q

When is neutropenic sepsis most common

A

5-10days after chemo

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36
Q

What is the immediate management of neutropenic sepsis

A 
A
B - 15L oxygen if sats low
C - insert cannulae, bloods, fluids, ABX
D - catheterise
E - check for rashes

Urgent consultant/registrar review

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37
Q

What investigations should be done in neutropenic sepsis

A

urine dip,
FBC, U+E, ABG, LFT, CRP, lactate
blood cultures, urine culture, sputum culture, line and wound swab culture, stool culture
CXR, AXR

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38
Q

Which antibiotic is used empirically in neutropenic sepsis

A

Tazocin

meropenem if penicillin allergic

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39
Q

What can be added to management of neutropenic sepsis if the patient has not improved after 3-7days on antibiotic therapy?

A

start antifungal if high risk and no identified cause of organism

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40
Q

What are the risk factors for neutripenic sepsis

A 
>7 days of neutropenia
severity of neutropenia
comorbidities
aggressive cancer
central lines
mucositis
inpatient
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41
Q

When is GCSF used

A

in the management of neutropenic sepsis

Granulocyte-colony stimulating factor (G-CSF or GCSF) stimulates the bone marrow to produce granulocytes and stem cells and release them into the bloodstream

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42
Q

Which cancers most commonly metastasise to the spine

A

prostate
lung
breast

kidney,
thyroid,

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43
Q

What are the symptoms and signs of spinal cord compression

A

back pain - worse on lying down and coughing
lower limb weakness
sensory loss and numbness

neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level.
Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness.
Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

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44
Q

Why does spinal cord compression occur in cancer patients?

A

extradural spread from a vertebral body metastasis
direct metastases
vertebral crush fracture

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45
Q

Describe the immediate management of spinal cord compression

A

Nurse flat
dexamethasone 16mg PO within 24 hours
MRI within 24 hours
Insert a catheter to manage bladder dysfunction.

If definitive treatment of the cord compression is appropriate, it should be started before patients lose the ability to walk or before other neurological deterioration occurs, and ideally within 24 hours.
Definitive treatment may be using surgery (eg, laminectomy, posterior decompression ± internal fixation) or using radiotherapy.
Discharge should be fully planned and community-based rehabilitation and support should be available when the patient returns home. This includes support and any necessary training of carers and familie

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46
Q

What is the definitive management of spinal cord compression and who are these treatments suitable for?

A

radiotherapy
- for those with extensive disease and poor physiological reserve

surgery - laminectomy, posterior decompression ± internal fixation
- for those with good prognosis, good performance status and good motor function

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47
Q

What are the benefits of giving radiotherapy for spinal cord compression

A

relieves compression!
relieves pain
stabilises (but does not improve) neurological deficit

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48
Q

What supportive care measures need to be given in spinal cord compression

A 
analgesia
laxatives
bladder care
VTE prophylaxos
physio/OT
monitor BMs - can rise after dexamethasone
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49
Q

Define hypercalcaemia

A

Corrected calcium >2.6

50
Q

What can cause malignant hypercalcaemia

A

bone metastases - osteolytic
myeloma,
PTHrP from squamous cell lung cancer

51
Q

What are the symptoms of hypercalcaemia

A 
polydipsia
polyuria
dehydration
thirst
nausea and vomiting, anorexia, 
lethargy, 
bone pain, 
abdominal pain, 
constipation, 
confusion 
weakness

symptoms of renal stones!

52
Q

How should hypercalcaemia be investigated?

A

ECG
corrected calcium, albumin, PTH, alkaline phosphatase, U+E
X-ray, bone scan

53
Q

How can hypercalcaemia be seen on ECG

A

Cardiac arrhythmias, shortened QT interval

54
Q

How is hypercalcaemia treated?

A

IV fluids - 0.9% sodium chloride
IV bisphosphonates after rehydration (can cause renal failure)

consider loop diuretic if fluid overload

55
Q

Define tumour lysis syndrome

A

hyperuricaemia, hyperkalaemia, hyperphosphataemia and hypocalcaemia

caused by the abrupt release of large quantities of cellular components into the blood following the rapid lysis of malignant cells.

56
Q

When is tumour lysis syndrome most common?

A

within 1-5 days of starting chemotherapy (but can be delayed by days or weeks in patients with a solid tumour).

57
Q

Which cancers are most at risk of tumour lysis syndrom

A

haematological - high grade lymphoma and leukaemia

58
Q

What are the risk factors for tumour lysis syndrome

A 
CKD
gout
treatment sensitive tumours
dehydration
High pre-treatment urate, lactate and lactate dehydrogenase (LDH)
59
Q

What are the signs/symptoms of tumour lysis syndrome

A

seizures,
acute kidney injury
cardiac arrhythmias.

60
Q

How can tumour lysis syndrome be prevented

A

Low-risk patients: vigilant monitoring of electrolyte levels and fluid status.

Intermediate-risk patients: seven days of oral allopurinol along with increased hydration.

High-risk patients: prophylaxis, usually with a fixed single dose of 3 mg rasburicase (recombinant urate oxidase), along with increased hydration.

61
Q

What is the mechanism of action of rasburicase

A

Rasburicase is a recombinant version of urate oxidase, an enzyme that metabolises uric acid to allantoin.

Allantoin is much more water soluble than uric acid and is therefore more easily excreted by the kidneys

62
Q

What is the managenet of tumour lysis syndrome

A 
admit to ITU/HDU
IV fluids (without potassium).
Daily rasburicase infusion.
Intravenous calcium gluconate for symptomatic hypocalcaemia .
Cardiac monitoring
Dialysis may be needed in severe cases.
63
Q

What are the causes of SVCO

A 
Lung cancer (~85% of cases), 
lymphoma 
metastatic tumours
64
Q

What are the signs and symptoms of SVCO

A 
dyspnoea
cough 
chest pain at rest 
swelling of the face, neck and arms 
conjunctival and periorbital oedema
headache: often worse in the mornings
visual disturbance
pulseless jugular venous distension
65
Q

What are the treatment options for SVCO

A

stenting
chemotherapy
Radiotherapy

66
Q

Describe the pathophysiology of SVCO

A

external pressure from a tumour
involvement of the vessel by tumour tissue,
a blood clot obstructing the lumen

67
Q

What investigations should be done for SVCO and what would be seen

A

CXR: this may reveal a widened mediastinum or a mass on the right side of the chest.

CT scan

68
Q

Which cancer most commonly causes hyponatraemia?

A

small cell lung cancer due to SIADH

69
Q

What are the signs and symptoms of SIADH

A

Depression and lethargy.
Irritability and other behavioural changes.
Muscle cramps.
Seizures.
Depressed consciousness leading to coma.
Neurological signs (such as impaired deep tendon reflexes and pseudobulbar palsy).
Hyponatraemia

70
Q

How is SIADH managed?

A

treat the lung cancer!

fluid restriction

71
Q

State the TNM staging of bowel cancer

A 
T1 = in submucosa
T2 = through muscularis mucosa
T3 = through subserosa
T4 = into adjacent tissues
N1 = 1-3 nodes
N2 = >=4

M1 = metastasis present

72
Q

State Duke’s staging colorectal cancer

A

A no deeper than submucosa
B through muscle
C nodes
D mets

73
Q

State the difference between adjuvant and neoadjuvant chemotherapy

A

adjuvant = after curative treatment to decrease risk recurrence

neoadjuvant = given before treatment to decrease risk recurrence and shrink tumour to make it more operable

74
Q

What is hte diffference between palliative and curative treatment

A

palliative = no intention to cure, but intention to treat symptoms

curative = with intention of completely curing the cancer

75
Q

What are the risk factors for skin cancer?

A 
sun exposure
skin type 1
age
smoking
multiple atypical moles
organ transplant recipient
76
Q

What are the worrying signs in a mole suggestiv eof malignant melanoma

A 
Asymmetrical
Borders - irregular, notched, scalloped
Changes in colour
Diameter >6mm
Evolution - change in shape/size/colour
77
Q

What is a prognostic indicatior in malignant melanoma

A

Breslow depth

78
Q

What is the treatment for malignant melanoma

A

complete excision biopsy

79
Q

What are the features of basal cell carcinoma

A 
on sun-exposed sites
pearly, flesh-coloured papule
telangiectasia
central destructive ulceration
slow progression
80
Q

What are the treatment options are there for basal cell carcinoma

A 
compete excision biopsy
curettage
cryotherapy
topical cream: imiquimod, fluorouracil
radiotherapy
81
Q

What are the features of squamous cell carcinoma

A 
indurated ulcer/hard lump
rapid growth
large
on sun exposed areas
can metastasise
82
Q

What are the risk factors for squamous cell carcinoma

A

excessive exposure to sunlight
actinic keratoses and Bowen’s disease
immunosuppression e.g. following renal transplant, HIV
smoking
genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

83
Q

What is Moh’s micrographic excision

A

removal of the skin layer by layer with staged mapping procedures

84
Q

What are the features of actinic keratoses

A

premalignant skin lesion that develops as a consequence of chronic sun exposure

small, crusty or scaly, lesions
may be pink, red, brown or the same colour as the skin
typically on sun-exposed areas e.g. temples of head
multiple lesions may be present

85
Q

What are the treatment options for actinic keratoses

A

prevention of further risk: e.g. sun avoidance, sun cream
fluorouracil cream: typically a 2 to 3 week course.
topical imiquimod: trials have shown good efficacy
cryotherapy
curettage and cautery

86
Q

What are the side effects of fluorouracil cream

A

The skin will become red and inflamed

87
Q

Which receptors are present at the chemoreceptor trigger zone?

A

D2

also NK1 and 5HT3

88
Q

Which receptors are present at the vomiting centre?

A

H1, ACh

also 5HT2 and NK1

89
Q

Metaclopramide:

Which receptors does it act on
Where does it act
When is it useful

A

D2 (5HT2)

CTZ, gut.

Gastric stasis (prokinetic), chemical N+V

90
Q

Cyclizine

Which receptors does it act on
Where does it act
When is it useful

A

ACh, H1

vomiting centre

functional obstruction, opioid

91
Q

Levomepromazine

Which receptors does it act on
Where does it act
When is it useful

A

D2, 5HT2, ACh, H1

VC and CTZ

broad spectrum

92
Q

Ondanstron

Which receptors does it act on
Where does it act
When is it useful

A

5HT3

CTZ

post operative, opioid

93
Q

Haloperidol

Which receptors does it act on
Where does it act
When is it useful

A

D2

CTZ

chemical

94
Q

Domperidone

A

D2

CTZ

chemical, also gastric stasis as prokinetic`

95
Q

Which antiemetics are prokinetic

A

domperidone

metoclopramide

96
Q

Which antiemetics are good for chemical N+V

A

haloperidol

metaclopramide

97
Q

Which antiemetics are good for N+V caused by gastric stasis

A

domperidone

metoclopramide

98
Q

Which antiemetics are good for N+V caused by functional bowel obstruction

A

cyclizine

dexamethasone

99
Q

Which antiemetics are good for N+V caused by raised ICP

A

cyclizine

dexamethasone

100
Q

What can cause nausea and vomitng

A

infection
metabolic - renal or hepatic impairment, low sodium, hypercalcaemia, tumour toxins
drug related - opioids, chemo, SSRI,
gastric stasis - ascites, opioids, anticholinergics,
GI disturbance - constipation, obstruction
organ damage - distension, obstruction, radiotherapy
neurological - raised ICP, motion sickness
psychological - anxiety, fear

101
Q

State the meaning of the PS grading

A

0= no symptoms from cancer.

1= minimal symptoms from cancer, patient able to complete light work without symptoms.

2= resting in bed/chair less than 50% of the day.

3= resting in bed/chair more than 50% of the day, able to mobilise to independently manage limited self care.

4= patient bed bound.

102
Q

Give a atrategy for breaking bad news

A

Rapport - how are you doing today? Check they’re okay to speak to you?

Setting - anyone they’d like with them?
Perception - what do they understand? Maybe give warning shots
Invitation - Would the patient like to know the result now?
Knowledge - explain in small chunks, checking understanding
Emotions and empathy
Strategy and Summary - next steps, reassurance of care, check understanding.

Any questions
Help with telling relatives
Clinical nurse specialist, written info, online support groups

103
Q

How can you try and communicate with an angry person

A

acknowledge anger!!! - “from my perspective, it seems that you’re feeling quite frustrated by this whole situation”
don’t be threatening

Tell me more!
thank you for explaining that to me
i can see why you’d feel that way
i’m sorry that this situation has made you feel that way

Anything I can do to help this situation?
Explain

Thank patient
Plan going forwards

104
Q

What medications can be prescribed for pain in the last few days of life?

A

Morphine 2.5-5mg s/c PRN or equivalent to oral PRN

105
Q

What medications can be prescribed for dyspnoea in the last few days of life?

A

Midazolam 2.5-5mg s/c PRN

Morphine 2.5-5mg s/c PRN

106
Q

What medications can be prescribed for secretions in the last few days of life?

A

Glycopyrronium 200mcg s/c PRN

107
Q

What medications can be prescribed for agitation in the last few days of life?

A

Midazolam 2.5-5mg s/c PRN
Haloperidol 1.5-2.5mg s/c PRN
Levomepromazine6.25-12.5 mg s/c PRN

108
Q

What medications can be prescribed for nausea in the last few days of life?

A

Haloperidol 0.5-1.5mg s/c PRN

Levomepromazine2.5-6.25mg s/c PRN

109
Q

In summary, what should you prescribe for someone in the last few days of life

A

Midazolam 2.5-5mg s/c PRN for dyspnoea and agitation

Morphine 2.5-5mg s/c PRN for pain and dyspnoea

Glycopyrronium 200mcg s/c PRN

Haloperidol 1.5-2.5mg s/c PRN for agitation

Levomepromazine6.25-12.5 mg s/c PRN for agitation and nausea

110
Q

What can be expected in the last few hours/days of life

A 
more drowsy
reduced appetite
changes in breathing - Cheyne-Stokes breathing, noisy from secretion
confusion and hallucinations
loss of bladder and bowel control
111
Q

Do DNACPR decisions need to be discussed with patients? How?

A

YES!

and write it in the notes!!!

112
Q

What are the key points about DNACPR decisions that a patient should understand

A

Only 3% of over-80s survive CPR and 1.9% of secondary cancer patients.

A decision about CPR will not affect the rest of your treatment.

it is ultimately a medical decision, but we want to know your opinion

113
Q

How might you explain what CPR is to a patient

A

Cardiopulmonary arrest means that a person’s heart and breathing has stopped.

When this happens it is sometimes possible to restart their heart and breathing with an emergency treatment called CPR.

CPR can include:
• repeatedly pushing down very firmly on the chest
• using electric shocks to try to restart the heart
• artificially inflating the lungs through a mask over the nose and mouth or a tube inserted into the windpipe.

114
Q

What are the risks of CPR

A

bruising, fractured ribs and punctured lungs.
that it won’t work
That you will have long term health problems if it does work

115
Q

Which drugs can be useful as adjuncts in pain relief?

A 
Antidepressants; amitriptyline, duloxetine
Anti-convulsants; gabapentin, pregabalin
Benzodiazepines; diazepam, clonazepam
Steroids; dexamethasone
Bisphosphonates for bony pain
116
Q

Which drugs can be prescribed for neuropathic pain relief

A

Amitriptyline start 10-25mg nocte
Gabapentin 300mg TDS over 3/7
Pregabalin 75mg BD

117
Q

Which drugs are in step 2 of the analgesic ladder

A

Dihydrocodeine
Codeine phosphate
Tramadol
Co-codamol

118
Q

Which drugs are in step 3 of the analgesic ladder

A

Oxycodone
Morphine
Fentanyl
Diamorphine

119
Q

How are a patients total daily dose of morphine and PRN requirements calculated

A

total using = total daily dose. divide by 2 and give SR

PRN = TDD/6 given as oramorph for breakthrough pain

120
Q

What do you need on a controlled drug prescription

A

Then write SUPPLY and give the
pharmacist EXACT instructions

 Drug name and formulation (be explicit
re tablets/capsules/patches) - NAME, FORM and STRENGTH

 Total number of tablets or amount of
drugs in words and figures

121
Q

How do you convert oral morphine to SC, keeping it at the same dose

A

need half the amount

20mg oral morphine = 10mg SC morphine

Finals (32 decks)

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