Cancer care Flashcards
How is breast cancer classified?
ductal v lobular
in situ v invasive
What are the risk factors for breast cancer?
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
Define carcinoma in situ
contained within the basement membrane of the tissue
What is the most common type of breast cancer
invasive ductal carcinoma
Describe the breast cancer screening programme
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’.
What features make it more likely that a person is at high risk of a familial breast cancer?
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)
What are the common presentations of breast cancer?
lump erythema - not high temp nipple retraction change in shape dimpling axillary lymphadenopathy discharge
What is triple assesssment
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
Describe the clinical aspect of the triple assessment
history - presenting complaint, any potential risk factors, family history and current medications.
examination -
Describe the imaging aspect of the triple assessment
Mammography
or
Ultrasound scanning
What are the benefits of USS assessment of the breast
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.
How is mammography undertaken?
involves compression views of the breast across two views (oblique and craniocaudal),
How is a cancer seen on mammography?
mass lesions
microcalcifications.
Describe the pathological aspect of the triple assessment
biopsy!
core or FNA
What are the differences between core and FNA biospy
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.
How is the triple assessment graded and used?
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
What are the treatment options for breast cancer?
Surgery
- breast conserving
- mastectomy
- sentinel node biopsy
- axillary clearance
Hormonal
- tamoxifen
- aromatase inhibitors
- immunotherapy
Describe breast conserving surgery for breast cancer and who it is suitable for
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
Describe mastectomy for breast cancer and who it is suitable for
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.
Describe sentinel node biopsy for breast cancer and who it is suitable for
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.
Describe axillary clearance for breast cancer and who it is suitable for
Axillary node clearance involves removing all nodes in the axilla, being careful not to damage many important structures located in the axilla.
What are the complications of axillary clearance for breast cancer?
Common complications from this operation include paresthesia, seroma formation, and lymphedema in the upper limb.
Explain the use and mechanism of tamoxifen
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.
What are the risks of tamoxifen use?
increased risk VTE, endometrial cancer and menopausal symptoms.
Explain the use and mechanism of aromatase inhibitors in breast cancer
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
Explain the use and mechanism of immunological therapy in breast cancer
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
How many tumours are HER2 postitive?
20-25%
What factors determine the prognosis of breast cancer
extent of nodal involvement is best prognostic indicator
NPI = nottingham prognostic indicator.
takes into account size, grade and number of nodes involved.
How is breast cancer followed up?
surveillance imaging - yearly mammogram for 5 years
What are some differentials for breast cancer?
breast cysts fibroadenoma and other benign cysts firbocystic changes mastitis breast abscess gynaecomastia in males
What is Paget’s disease?
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.
What are the signs and symptoms of paget’s disease?
itching or redness in the nipple and/or areola,
flaking and thickened skin
flattened nipple,
yellowish or bloody discharge
How can Paget’s disease and Eczema be differentiated?
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.
Define febrile neutropenia
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.
When is neutropenic sepsis most common
5-10days after chemo
What is the immediate management of neutropenic sepsis
A B - 15L oxygen if sats low C - insert cannulae, bloods, fluids, ABX D - catheterise E - check for rashes
Urgent consultant/registrar review
What investigations should be done in neutropenic sepsis
urine dip,
FBC, U+E, ABG, LFT, CRP, lactate
blood cultures, urine culture, sputum culture, line and wound swab culture, stool culture
CXR, AXR
Which antibiotic is used empirically in neutropenic sepsis
Tazocin
meropenem if penicillin allergic
What can be added to management of neutropenic sepsis if the patient has not improved after 3-7days on antibiotic therapy?
start antifungal if high risk and no identified cause of organism
What are the risk factors for neutripenic sepsis
>7 days of neutropenia severity of neutropenia comorbidities aggressive cancer central lines mucositis inpatient
When is GCSF used
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
Which cancers most commonly metastasise to the spine
prostate
lung
breast
kidney,
thyroid,
What are the symptoms and signs of spinal cord compression
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
Why does spinal cord compression occur in cancer patients?
extradural spread from a vertebral body metastasis
direct metastases
vertebral crush fracture
Describe the immediate management of spinal cord compression
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
What is the definitive management of spinal cord compression and who are these treatments suitable for?
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
What are the benefits of giving radiotherapy for spinal cord compression
relieves compression!
relieves pain
stabilises (but does not improve) neurological deficit
What supportive care measures need to be given in spinal cord compression
analgesia laxatives bladder care VTE prophylaxos physio/OT monitor BMs - can rise after dexamethasone
Define hypercalcaemia
Corrected calcium >2.6
What can cause malignant hypercalcaemia
bone metastases - osteolytic
myeloma,
PTHrP from squamous cell lung cancer
What are the symptoms of hypercalcaemia
polydipsia polyuria dehydration thirst nausea and vomiting, anorexia, lethargy, bone pain, abdominal pain, constipation, confusion weakness
symptoms of renal stones!
How should hypercalcaemia be investigated?
ECG
corrected calcium, albumin, PTH, alkaline phosphatase, U+E
X-ray, bone scan
How can hypercalcaemia be seen on ECG
Cardiac arrhythmias, shortened QT interval
How is hypercalcaemia treated?
IV fluids - 0.9% sodium chloride
IV bisphosphonates after rehydration (can cause renal failure)
consider loop diuretic if fluid overload
Define tumour lysis syndrome
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.
When is tumour lysis syndrome most common?
within 1-5 days of starting chemotherapy (but can be delayed by days or weeks in patients with a solid tumour).
Which cancers are most at risk of tumour lysis syndrom
haematological - high grade lymphoma and leukaemia
What are the risk factors for tumour lysis syndrome
CKD gout treatment sensitive tumours dehydration High pre-treatment urate, lactate and lactate dehydrogenase (LDH)
What are the signs/symptoms of tumour lysis syndrome
seizures,
acute kidney injury
cardiac arrhythmias.
How can tumour lysis syndrome be prevented
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.
What is the mechanism of action of rasburicase
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
What is the managenet of tumour lysis syndrome
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.
What are the causes of SVCO
Lung cancer (~85% of cases), lymphoma metastatic tumours
What are the signs and symptoms of SVCO
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
What are the treatment options for SVCO
stenting
chemotherapy
Radiotherapy
Describe the pathophysiology of SVCO
external pressure from a tumour
involvement of the vessel by tumour tissue,
a blood clot obstructing the lumen
What investigations should be done for SVCO and what would be seen
CXR: this may reveal a widened mediastinum or a mass on the right side of the chest.
CT scan
Which cancer most commonly causes hyponatraemia?
small cell lung cancer due to SIADH
What are the signs and symptoms of SIADH
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
How is SIADH managed?
treat the lung cancer!
fluid restriction
State the TNM staging of bowel cancer
T1 = in submucosa T2 = through muscularis mucosa T3 = through subserosa T4 = into adjacent tissues
N1 = 1-3 nodes N2 = >=4
M1 = metastasis present
State Duke’s staging colorectal cancer
A no deeper than submucosa
B through muscle
C nodes
D mets
State the difference between adjuvant and neoadjuvant chemotherapy
adjuvant = after curative treatment to decrease risk recurrence
neoadjuvant = given before treatment to decrease risk recurrence and shrink tumour to make it more operable
What is hte diffference between palliative and curative treatment
palliative = no intention to cure, but intention to treat symptoms
curative = with intention of completely curing the cancer
What are the risk factors for skin cancer?
sun exposure skin type 1 age smoking multiple atypical moles organ transplant recipient
What are the worrying signs in a mole suggestiv eof malignant melanoma
Asymmetrical Borders - irregular, notched, scalloped Changes in colour Diameter >6mm Evolution - change in shape/size/colour
What is a prognostic indicatior in malignant melanoma
Breslow depth
What is the treatment for malignant melanoma
complete excision biopsy
What are the features of basal cell carcinoma
on sun-exposed sites pearly, flesh-coloured papule telangiectasia central destructive ulceration slow progression
What are the treatment options are there for basal cell carcinoma
compete excision biopsy curettage cryotherapy topical cream: imiquimod, fluorouracil radiotherapy
What are the features of squamous cell carcinoma
indurated ulcer/hard lump rapid growth large on sun exposed areas can metastasise
What are the risk factors for squamous cell carcinoma
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
What is Moh’s micrographic excision
removal of the skin layer by layer with staged mapping procedures
What are the features of actinic keratoses
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
What are the treatment options for actinic keratoses
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
What are the side effects of fluorouracil cream
The skin will become red and inflamed
Which receptors are present at the chemoreceptor trigger zone?
D2
also NK1 and 5HT3
Which receptors are present at the vomiting centre?
H1, ACh
also 5HT2 and NK1
Metaclopramide:
Which receptors does it act on
Where does it act
When is it useful
D2 (5HT2)
CTZ, gut.
Gastric stasis (prokinetic), chemical N+V
Cyclizine
Which receptors does it act on
Where does it act
When is it useful
ACh, H1
vomiting centre
functional obstruction, opioid
Levomepromazine
Which receptors does it act on
Where does it act
When is it useful
D2, 5HT2, ACh, H1
VC and CTZ
broad spectrum
Ondanstron
Which receptors does it act on
Where does it act
When is it useful
5HT3
CTZ
post operative, opioid
Haloperidol
Which receptors does it act on
Where does it act
When is it useful
D2
CTZ
chemical
Domperidone
D2
CTZ
chemical, also gastric stasis as prokinetic`
Which antiemetics are prokinetic
domperidone
metoclopramide
Which antiemetics are good for chemical N+V
haloperidol
metaclopramide
Which antiemetics are good for N+V caused by gastric stasis
domperidone
metoclopramide
Which antiemetics are good for N+V caused by functional bowel obstruction
cyclizine
dexamethasone
Which antiemetics are good for N+V caused by raised ICP
cyclizine
dexamethasone
What can cause nausea and vomitng
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
State the meaning of the PS grading
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.
Give a atrategy for breaking bad news
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
How can you try and communicate with an angry person
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
What medications can be prescribed for pain in the last few days of life?
Morphine 2.5-5mg s/c PRN or equivalent to oral PRN
What medications can be prescribed for dyspnoea in the last few days of life?
Midazolam 2.5-5mg s/c PRN
Morphine 2.5-5mg s/c PRN
What medications can be prescribed for secretions in the last few days of life?
Glycopyrronium 200mcg s/c PRN
What medications can be prescribed for agitation in the last few days of life?
Midazolam 2.5-5mg s/c PRN
Haloperidol 1.5-2.5mg s/c PRN
Levomepromazine6.25-12.5 mg s/c PRN
What medications can be prescribed for nausea in the last few days of life?
Haloperidol 0.5-1.5mg s/c PRN
Levomepromazine2.5-6.25mg s/c PRN
In summary, what should you prescribe for someone in the last few days of life
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
What can be expected in the last few hours/days of life
more drowsy reduced appetite changes in breathing - Cheyne-Stokes breathing, noisy from secretion confusion and hallucinations loss of bladder and bowel control
Do DNACPR decisions need to be discussed with patients? How?
YES!
and write it in the notes!!!
What are the key points about DNACPR decisions that a patient should understand
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
How might you explain what CPR is to a patient
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.
What are the risks of CPR
bruising, fractured ribs and punctured lungs.
that it won’t work
That you will have long term health problems if it does work
Which drugs can be useful as adjuncts in pain relief?
Antidepressants; amitriptyline, duloxetine Anti-convulsants; gabapentin, pregabalin Benzodiazepines; diazepam, clonazepam Steroids; dexamethasone Bisphosphonates for bony pain
Which drugs can be prescribed for neuropathic pain relief
Amitriptyline start 10-25mg nocte
Gabapentin 300mg TDS over 3/7
Pregabalin 75mg BD
Which drugs are in step 2 of the analgesic ladder
Dihydrocodeine
Codeine phosphate
Tramadol
Co-codamol
Which drugs are in step 3 of the analgesic ladder
Oxycodone
Morphine
Fentanyl
Diamorphine
How are a patients total daily dose of morphine and PRN requirements calculated
total using = total daily dose. divide by 2 and give SR
PRN = TDD/6 given as oramorph for breakthrough pain
What do you need on a controlled drug prescription
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
How do you convert oral morphine to SC, keeping it at the same dose
need half the amount
20mg oral morphine = 10mg SC morphine
