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Phase 2 > Cancer Care > Flashcards

Cancer Care Flashcards

1
Q

Describe the WHO performance status

A

0 - patient is fully active and more or less as they were before their illness
1 - the patient cannot carry out heavy physical work, but can do anything else
2 - the patient is up and about more than 50% of the day; and can look after themselves, but is not well enough to work
3 - the patient is in bed or sitting in a chair for more than half the day; and needs some help in looking after themselves
4 - the patient is in bed or a chair all the time and needs a lot of looking after
5 - the patient is dead

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2
Q

List the upper GI red flag symptoms

A 
Epigastric mass
Persistent vomiting
Dysphagia
Unintentional weight loss
Iron deficiency anaemia
Age >55 + dyspepsia/reflux/upper abdo pain
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3
Q

List the lower GI red flag symptoms

A

> 40 + unintentional weight, abdominal pain
50 + PR bleed
60 + change in bowel habit, iron deficiency anaemia, faecal occult blood
Rectal/abdo mass

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4
Q

List causes of cancer

A

Activation of oncogenes
Deletion of tumour suppressor genes (p53)
No apoptosis - radiation, chemicals, viruses, genetic factors

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5
Q

Describe the typical presentation, clinical features, investigations and management of Acute Lymphoblastic Leukaemia (ALL)

A

Presentation - children, young adults (good prognosis), proliferation of lymphoid blasts (B or T)
CFs - pancytopenia, bone pain, organomegaly
Ix - bloods + film, bone marrow flow cytometry
Mx - combination chemo (duration 9-12 months, 2 years maintenance) intrathecal chemo

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6
Q

Describe the typical presentation, clinical features, investigations and management of Acute Myeloid Leukaemia (AML)

A

Presentation - adults/elderly, increased incidence with age, proliferation of myeloid blasts
CFs - pancytopenia, gum hypertrophy, intracranial haemorrhage risk
Ix - bloods + film (auer rods), bone marrow flow cytometry (*cytogenetics determines prognosis)
Mx - chemotherapy (in trial) +/- allogenic stem cell transplant, palliative

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7
Q

Describe the typical presentation, clinical features, investigations and management of Chronic Lymphoid Leukaemia (CLL)

A

Presentation - may present like lymphoma (low grade), increased number of mature lymphocytes
CFs - often chance finding, fatigue, SOB, lymphadenopathy, organomegaly, atypical infections
Ix - FBC + film (smudge cells), flow cytometry
Mx - watch and wait, chemo/immunotherapy when clinically indicated
*may transform into high grade lymphoma = Richter’s transformation

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8
Q

Describe the typical presentation, clinical features, investigations and management of Chronic Myeloid Leukaemia (CML)

A

Presentation - increased number of mature myeloid cells e.g. very high WCC
CFs - hyperleucostasis = headache, blurred vision, ischaemia (heart/brain), abdominal pain, splenomegaly
Ix - bloods + film, bone marrow flow cytometry, cytogenetics/FISH = translocation of 9;22 (Philadelphia chromosome)
Mx - imatinib (tyrosine kinase inhibitor), monitor disease with blood PCR 3 monthly, allogenic bone marrow transplant

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9
Q

Describe the clinical features of polycythemia rubra vera

A

= uncontrolled production of RBCs in bone marrow despite EPO being switched off
CFs - thrombosis, pruritus, plethoric complexion, gout, splenomegaly (*beware if chronic hypoxia/smoker/high altitude)

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10
Q

Describe the typical presentation, clinical features, investigations and management of myelofibrosis

A

= clonal disorder of haemopoietic stem cells, abnormal cell cytokines –> bone marrow fibrosis
CFs - pancytopenia, splenomegaly
Ix - bloods + film, bone marrow trephine cytogenetics (JAK2 mutation)
Mx - supportive, chemo, JAK2 inhibitors, splenectomy, BM transplant
*can transform to leukaemia

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11
Q

What is a lymphoma?

A

Cancer of B or T cells

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12
Q

Describe different types of lymphoma

A

Non Hodgkin
Low grade - follicular, mantle, marginal
High grade - DLBCL, Burkitts, peripheral T cell
Hodgkin

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13
Q

Describe the typical presentation Non Hodgkin Lymphoma

A

Presentation - increased incidence with age, variable presentation, links with EBV, HIV, Hep.C

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14
Q

Describe the typical presentation, clinical features, investigations and management of follicular lymphoma

A

= type of low grade NHL
CFs - lymphadenopathy, organomegaly
Ix - lymph node excision biopsy immunohistochemistry, CT, bone marrow aspirate
Mx - watch and wait (annual CT scan), surgical excision, immunochemotherapy + rituximab *not curable

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15
Q

Describe the typical presentation, clinical features, investigations and management of diffuse large B cell lymphoma

A

= type of high grade NHL
CFs - widespread lymphadenopathy, pancytopenia, organ impairment, hypercalcaemia
Ix - bloods (LDH), lymph node excision biopsy, bone marrow aspirate, CT, PET scan
Mx - R-CHOP chemotherapy (*monitor tumour lysis bloods = 4-6hrly), allopurinol/rasburicase

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16
Q

Describe the typical presentation, clinical features, investigations and management of Hodgkin Lymphoma

A

Presentation - young adults or elderly (bimodal incidence), cervical lymphadenopathy
CFs - generalised lymphadenopathy, mediastinal nodal mass, chest pain, SOB, nodes wax and wane, B symptoms, organomegaly
Ix - bloods, lymph node excision biopsy (Reed-Sternberg cell), CT, PET scan
Mx - combined chemo/radiotherapy, steroids, fertility preservation

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17
Q

Describe the typical presentation, clinical features, investigations and management of myeloma

A

= bone marrow based cancer of plasma cells
Presentation - adults, elderly
CFs - hypercalcaemia, renal failure, anaemia, bony tenderness from lytic lesions (CRAB symptoms)
Ix - bloods + film, immunoglobulin blood (paraprotein kappa lambda, bence jones), calcium, skeletal survey/MRI, BM aspirate cytogenetics
Mx - IV fluids, bisphosphonates, chemotherapy, autologous stem cell transplant
*beware spinal cord compression

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18
Q

Describe the typical presentation, clinical features, investigations and management of neutropenic sepsis

A

Presentation - 10-14 days post chemotherapy + generally unwell
CFs - temp >38 or <36, HR >90, RR >20, confusion/drowsiness, blood glucose >7.7mmol/L, generally unwell, rigors after flushing line
Ix - FBC (neutrophil count <0.5 x10 9), LFTs, U&Es, lactate, CRP, cultures (urine, blood, sputum, stool), swabs (wounds, lines, catheters), CXR, ABG
Mx - empirical ABx IV (within 1hr), consider G-CSF if profoundly septic, sepsis six, PCP prophylaxis, stop chemotherapy drug

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19
Q

Describe the typical presentation, clinical features, investigations and management of malignant spinal cord compression

A

Presentation - breast/prostate/lung cancer or thyroid/renal/brain cancer, caused by collapse/compression of vertebral body with metastases
CFs - severe band like thoracic back pain, acute onset, worse with straining, lying down, spinal/radicular pain, bladder/bowel dysfunction, palpable bladder, limb weakness, sensory level dysfunction, well defined dermatomal level, flaccid paralysis, spasticity
Ix - (T2 weighted) urgent MRI spine
Mx - admit, bed rest + rolling, analgesia, dexamethasone 16mg + PPI, surgery (balloon kyphoplasty), radiotherapy, supportive nursing, PT/OT

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20
Q

Describe the typical presentation, clinical features, investigations and management of hypercalcaemia

A

Presentation - lung, breast, renal, myeloma, T cell lymphoma, poor prognostic indicator, due to tumour secretion of PTHrP or osteolytic metastases releasing cytokines
CFs - stones, moans, bones, psychiatric undertones (abdominal pain, bone pain, confusion, constipation, nausea, vomiting, polydipsia, polyuria, arrhythmia, non specific
Ix - ionised calcium or total calcium corrected, ALP, calcitonin, phosphate, X-ray, bone scan
Mx - IV fluids (3L in 24h), IV bisphosphonates (pamidronate or zolendronic acid), denosumab (for refractory hypercalcaemia), somastatin analogue (reduces PTHrP)

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21
Q

Describe the typical presentation, clinical features, investigations and management of superior vena cava obstruction

A

= obstruction of blood flow through SVC due to compression/occlusion
Presentation - lung cancer (SCLC), lymphoma, post radiotherapy fibrosis, TB, thrombus
CFs - breathlessness, swelling of face/neck/trunk/arm, choking sensation, headache, chest pain, dysphagia, hallucinations, thoracic vein distension, superficial neck vein distention, tachypnoea, cyanosis, laryngeal stridor, Pemberton’s sign
Ix - CXR (widened mediating, mass on R), CT contrast, venogram
Mx - elevate head, steroids, diuretics, stunting, chemotherapy (if SCLC, lymphoma, teratoma), radiotherapy (if malignancy not chemo sensitive), anticoagulation

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22
Q

Describe the risk factors, clinical features, investigations and management of tumour lysis syndrome

A

= abrupt release of cellular components following rapid lysis of malignant cells
Presentation - day 3-5 post chemo, raised uric acid, potassium, phosphate, low calcium
RFs - haematological malignancy (Burkitt lymphoma, ALL), large tumour burden, pre-existing renal impairment, pre-treatment hyperuricaemia, hypovolaemia/diuretic use, pre-treatment raised LDH, urinary tract obstruction from tumour
CFs - nausea, vomiting, diarrhoea, anorexia, lethargy, tetany, arrhythmia (tented T waves, QT widening), renal failure
Ix - full metabolic/biochemical profile, 4-6hrly bloods
Mx - increase hydration, allopurinol (for prevention) or rasburicase 3mg (for treatment/high risk patients), ECG, calcium, phosphate binders

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23
Q

What is the mechanism of action of allopurinol

A

Xanthine oxidase inhibitor

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24
Q

What is the mechanism of action of rasburicase

A

Synthetic uricase

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25
Q

What are the properties of cancer

A 
Self sufficiency in growth signals
Insensitivity to anti-growth signals
Tissue invasion --> metastases
Limitless replicative potential
Sustained angiogenesis
Evades apoptosis
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26
Q

Define the term neoadjuvant

A

Administration of a therapeutic agent before definitive treatment to shrink tumour and optimise outcomes

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27
Q

Define the term adjuvant

A

Treatment given after definitive treatment to reduce risk of disease recurrence

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28
Q

Define the term palliative

A

Treatment designed to relieve symptoms and improve quality of life

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29
Q

Define the term radical

A

Intent is to cure

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30
Q

Define the term chemotherapy and list some examples

A

Treatment with drug therapy
Chemo drugs interfere with essential growth steps –> apoptosis
e.g. 5-FU, platinum analogues, alkylating agents, taxanes, vinca alkaloids

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31
Q

Describe the methods of cancer cell resistance

A 
Decreased uptake of drug
Increase in drug metabolism
Alter drug targets
Impair apoptosis pathway
Alter cell cycle checkpoints
Efflux pumps
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32
Q

List side effects of chemotherapy

A

Brain - ‘chemo brain’, fatigue
Hair - alopecia
Lungs - pneumonitis, PE
Heart/blood - cardiomyopathy, neutropenic sepsis, myelosuppression
Liver - deranged LFTs
Stomach/GI tract - vomitng, mucositis, diarrhoea, constipation
Kidneys - AKI, electrolyte disturbance
Bladder - haemorrhage cystitis
Reproductive organs - impaired fertility, decreased libido, premature menopause
Skin - rash, nail ridging, peripheral neuropathy
Hands/feet - hand/foot erythema

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33
Q

List drugs prescribed to manage chemo toxicity

A

Anti-emetics e.g. ondansetron (5HT3 antagonist), metoclopramide (D2 antagonist), steroid (dexamethasone) cyclising (antihistamine), aprepitant (NK1 antagonist)

34
Q

Define the term radiotherapy and list some examples

A

The use of high energy ionising radiation to treat malignant disease
Aims to deliver the highest dose possible to tumour whilst minimising dose to surrounding ‘normal tissue’
e.g. external beam, brachytherapy, systemic (temozolamide, capecitabine, cisplatin, cetuximab, 5-FU)

35
Q

List side effects of radiotherapy

A

Depends on area treated
Brain - fatigue, nausea
Hair - alopecia
Eyes - cataracts, loss of sight
Mouth/throat - dysphagia, sore throat, oral mucositis, xerostomia
Lungs - fibrosis, pneumonitis
Heart - cardiomyopathy
Skin - erythema, lymphoedema, pigmentation, necrosis, telangiectasia, ulceration
Bones - necrosis, fractures, impaired grow
GIT - diarrhoea, vomiting, strictures, adhesions, fistulas
Kidneys - dysuria, radiation cystitis
Reproductive organs - sterility, menopause, erectile dysfunction, dyspareunia

36
Q

Define the term immunotherapy and list some examples

A

Checkpoint blockers, PD-1/PD-L1 inhibitors allow T cells to destroy cancer cells
e.g. rivolumab, pembrolizumab
Used in melanoma, lung, renal cancer

37
Q

List side effects of immunotherapy

A

Inflammatory - diarrhoea, bloody stools, deranged LFTs, rash, endocrinopathy, excessive immune activity
GIT - abdominal pain, perforation, ileus
Skin - dermatitis, pruritus, rash (Stevens Johnson/toxic epidermal necrolysis)
Hepatic - deranged LFTs and bilirubin, hepatitis
Neuro - uni/bilateral weakness, sensory changes, myasthenia gravis, Guillain Barre syndrome
Endocrine - hypophysitis, hypopituitarism, adrenal insufficiency, hypothyroidism
Other - eosinophilia, vasculitis, arthritis
*may present months after last dose, treat with corticosteroids

38
Q

Describe the risk factors, clinical features, investigations and management of colorectal cancer

A

RFs - Lynch syndrome, FAP, IBD, western diet (low fibre, processed food), obesity, smoking, alcohol
CFs - constipation, abdo pain, change in bowel habit, PR bleed, large bowel obstruction (left sided), obstruction, tenesmus, PR bleeding, palpable mass on DRE (rectal), weight loss, weakness, iron deficiency anaemia (right sided)
Ix - bloods, CEA tumour marker, colonoscopy + biopsy, CT colonography (if frail), CT CAP
Mx - surgery +/- (neo)adjuvant chemo, radiotherapy (rectal), immunotherapy

39
Q

Describe staging in colorectal cancer

A 
Duke's:
A - in bowel wall
B - through bowel wall
C - nodal involvement
D - distant metastases
TNM:
T1 - invades mucosa
T2 - invades propria
T3 - through propria --> pericolorectal tissues
T4 - invades peritoneum/adjacent organs
N1 - 1-3 nodes
N2 - >4 nodes
M - metastases >1 distant site of peritoneal metastases
40
Q

Describe a screening programme for colorectal cancer

A

Age 55 - one off scope

Age 60-74 - faecal occult every 2 years

41
Q

Describe the risk factors, clinical features, investigations and management of prostate cancer

A

RFs - older, FH (1st degree relative <60), BRCA2 gene, ethnicity (black>white>asian)
CFs - asymptomatic (due to peripheral adenocarcinoma), urinary symptoms, boney/back pain, haematuria, haematspermia
Ix - DRE, PSA, TRUS + biopsy (x8), MRI pelvis, bone scan
Mx - active surveillance, radical prostatectomy, radiotherapy, watchful wait/hormones, surgical/medical castration (LHRH agonist), palliation with radio, bisphosphonates

42
Q

List causes of a raised PSA

A 
UTI
Prostatitis
BPH
Urinary retention
Recent ejaculation (48h)
43
Q

What is the Gleason grade?

A

Determines grade of prostate cancer
Low/intermediate/high risk (8-10)
Commonest type + 2nd commonest type
e.g. 75% of 3, 25% of 5 –> 3+5=8

44
Q

Explain the issues around screening for prostate cancer

A 
Not recommended
Overdiagnosis
Overtreatment - leading to lowered QoL
Not cost effective
Lead/length time bias
45
Q

Describe the risk factors, clinical features, investigations and management of bladder cancer

A

RFs - smoking, occupational exposure (rubber, plastic, carbon, aromatic amines), schistosomiasis
CFs - visible/non visible haematuria
Ix - BP, dipstick, U&Es, eGFR, ACR, MSU, urine cytology, USS KUB, flexible cystoscopy, CT CAP, MRI pelvis
Mx - regular cystoscopies, intravesicle chemo/immunotherapy, neoadjuvant chemotherapy + radical cystectomy (–> ileal conduit/reconstruction)

46
Q

Describe the risk factors, clinical features, investigations and management of breast cancer

A

RFs - female, older, early menarche, late menopause, no children, few/late children, COCP/HRT use, obesity, hx of benign breast disease, FH (BRCA)
CFs - (painless) lump/thickening, nipple discharge/bleeding/inversion, change in size/contour/colour, peau d’orange skin
Ix - triple assessment = history and examination, radiology (mammogram/USS), pathology (FNA cytology/core biopsy)
Mx - neoadjuvant chemotherapy, surgery (WLE/mastectomy) + axilla (sentinel lymph/clearance), reconstruction, adjuvant radiotherapy to breast/chest wall, immunotherapy (tamoxifen/letrozole, herceptin)

47
Q

Describe a screening program for breast cancer

A

Women aged 47-73 - mammogram every 3 years

48
Q

Explain the difference between tamoxifen and letrozole

A 
Tamoxifen = oestrogen antagonist - offered to pre-menopausal women
Letrozole = aromatase inhibitor - offered to post menopausal women
49
Q

List side effects of endocrine treatment of breast cancer

A

Tamoxifen - increased DVT risk, endometrial cancer

Letrozole - increased osteoporosis risk

50
Q

Name a scoring system used to determine prognosis of breast cancer

A

Nottingham Prognostic Index determines 5 year survival

51
Q

Describe the risk factors and clinical features of skin cancer

A

RFs - multiple moles, increased sun exposure, sunbed use, genetic, previous cancer, immunosuppression, skin type 1
CFs - Asymettry, Border irregular, Colour changes, Diameter >6mm, Evolution, bleeding, oozing, itching, crusting

52
Q

Describe the types, investigations and management of malignant melanoma

A

Types - superficial spreading, nodular, lentigo maligna, acral lentiginous
Ix - dermatoscope, punch biopsy, excision biopsy, sentinel lymph biopsy, staging USS/CT/MRI
Mx - chemotherapy, biologics, cryotherapy

53
Q

State the risk factors and common metastatic sites of SCC skin cancer

A

After (renal) transplant

Metastasise to lymph, head/neck

54
Q

Describe the types, clinical features and management of BCC skin cancer

A

Types - nodular, superficial, morphoeic, pigmented
CFs - ‘rodent ulcer’, pearly rolled edge, central ulcer
Mx - (Mohs) excision, topical chemotherapy, radiotherapy

55
Q

Describe the risk factors, clinical features, investigations and management of lung cancer

A

RFs - high number of pack years, older, HIV, FH, radiotherapy, carcinogen exposure (asbestos, radon), lung disease (COPD, TB)
CFs - cough, haemoptysis, dyspnoea, chest pain, weight loss, anorexia, cachexia, clubbing, anaemia, lymphadenopathy, SVCO, Horner’s, pleural effusion, consolidation, SIADH, paraneoplastic syndrome, mediastinal disease, bone/brain mets (SCLC), Pancoast tumour (hoarse voice, bovine cough), hypercalcaemia (NSCLC)
Ix - bloods (FBC, U&Es, LFTs, bone profile, CRP, tumour markers, (urgent) CXR, contact CT CAP, PET scan
Mx - SCLC = surgery/chemoradio, prophylactic cranial radio, NSCLC = surgery, adjuvant chemo/radio, palliative

56
Q

List different types of lung cancer

A 
Small cell (*increased paraneoplastic syndrome, metastatic potential)
Non small cell - adenocarcinoma, SCC (*PTHrP), large cell carcinoma, adenosquamous
57
Q

List signs that indicate a dying patient

A 
Profoundly weak
Gaunt
Drowsy
Disorientated
Decreased oral intake
Poor concentration
Abnormal breathing patterns
Skin colour changes
Temperature changes at extremities
58
Q

What is an AMBER care bundle?

A 
To improve QoL for patients at risk of dying but still receiving active treatment
Assessment
Management
Best practise
Engagement
Recovery uncertain
59
Q

List the anticipatory drugs and what they are for

A

Pain - morphine 2.5-5mg
Dyspnoea - midazolam 2.5-5mg OR morphine 2.5-5mg
Secretions - glycopyronium 200mcg
Agitation - midazolam 2.5-5mg OR haloperidol 2.5-5mg OR levomepromazine 12.5mg
Nausea - haloperidol 1.5mg OR levomepromazine 6.25mg

60
Q

Define the term adjuvant analgesia and give examples

A

Primary indication is not for pain but has benefit

e.g. amitriptyline, diazepam, dexamethasone, bisphosphonates

61
Q

What is the ratio of codeine to morphine

A

10:1

62
Q

What is the ratio of morphine to fentanyl

A

30:12

63
Q

Describe how to calculation an opioid titration prescription

A

24h worth = TDD
New morphine SR dose = TDD/2
New morphine IR PRN dose = TDD/6

64
Q

Describe how to prepare a TTO for a controlled drug prescription

A

Name & ID
Write prescription as normal
Write ‘Supply’ + drug name + strength + formulation
Total number of tablets/amount of drugs in words and figures

65
Q

Write a TTO for a patient taking Zomorph 60mg BD for two weeks

A 
TTO - Take Zomorph 60mg BD for 14 days
Supply 28 (twenty eight) Zomorph 60mg capsules
66
Q

Define the term nausea

A

Unpleasant feeling of the need to vomit +/- autonomic symptoms

67
Q

Define the term vomiting

A

Forceful expulsion of gastric contents through the mouth

68
Q

List reasons for nausea/vomiting in oncological patients

A

Impaired gastric emptying - locally advanced cancer, liver mets, ascites, morphine, anticholinergics
Chemical/metabolic disturbances - opioids, ABx, SSRIs, digoxin, renal/hepatic failure, hyponatraemia, hypercalcaemia, sepsis
Raised ICP - cerebral mets/haemorrhage, meningitis
Malignant bowel obstruction - abdominal/pelvic cancer, autonomic neuropathy

69
Q

Describe the treatment of nausea/vomiting in oncological patients

A

Gastric stasis - metoclopramide, domperidone
Chemical - haloperidol
Raised ICP - cyclizine, dexamethasone
Bowel obstruction - cyclizine, dexamethasone
Post op - ondansetron
Chemo induced - ondansetron

70
Q

What is the method of action of haloperidol and what kind of nausea is it used for?

A

Dopamine antagonist

Used in metabolic/chemical induced nausea

71
Q

What is the method of action of metoclopramide and what kind of nausea is it used for?

A

Dopamine antagonist, weak serotonin antagonist

Used in metabolic/chemical induced nausea

72
Q

What is the method of action of domperidone and what kind of nausea is it used for?

A

Dopamine antagonist

Used in gastric stasis

73
Q

What is the method of action of cyclizine and what kind of nausea is it used for?

A

Anticholinergic, antihistamine

Used in raised ICP, motion sickness, bowel obstruction

74
Q

What is the method of action of levomepromazine and what kind of nausea is it used for?

A

Dopamine antagonist, strong serotonin antagonist, weak anticholinergic, weak antihistamine
Used in all (domestos of antiemetic)

75
Q

What is the method of action of ondansetron and what kind of nausea is it used for?

A

Serotonin antagonist

Used in metabolic/chemical induced nausea, bowel obstruction, renal failure

76
Q

What is the method of action of hyoscine hydrobromide and what kind of nausea is it used for?

A

Anticholinergic

Used for motion sickness, post operative

77
Q

What is the method of action of prochlorperazine and what kind of nausea is it used for?

A

Dopamine antagonist, anticholinergic, antihistamine

78
Q

What is the method of action of aprepitant and what kind of nausea is it used for?

A

Serotonin antagonist, NK1 antagonist

Used in metabolic/chemical induced nausea

79
Q

List reversible causes of breathlessness in the oncological patient

A 
Anaemia - transfuse
PE - LMWH
COPD - bronchodilator
Respiratory infection - ABx
Pleural effusion - drain
SVCO - dexamethasone, stent
Anxiety
80
Q

Describe methods to relieve intractable breathlessness in the oncological patient

A 
Position patient appropriately
Air flow across face (fan, near window)
Oxygen if hypoxic
Low dose morphine (1-2mg PRN)
Benzodiazepine
81
Q

List causes of constipation in the oncological patient

A

Disease
Fluid depletion
Weakness - paraplegia
Intestinal obstruction
Medication - opioids
Biochemical - hypercalcaemia, hypokalaemia
Other - pain on defection, lack of privacy

82
Q

List different types of laxatives and their method of action

A

Fybogel - bulking
Lactulose, laxido, movicol - osmotic
Senna - stimulant
Docusate - softener

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