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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
What are the properties of cancer
``` Self sufficiency in growth signals Insensitivity to anti-growth signals Tissue invasion --> metastases Limitless replicative potential Sustained angiogenesis Evades apoptosis ```
26
Define the term neoadjuvant
Administration of a therapeutic agent before definitive treatment to shrink tumour and optimise outcomes
27
Define the term adjuvant
Treatment given after definitive treatment to reduce risk of disease recurrence
28
Define the term palliative
Treatment designed to relieve symptoms and improve quality of life
29
Define the term radical
Intent is to cure
30
Define the term chemotherapy and list some examples
Treatment with drug therapy Chemo drugs interfere with essential growth steps --> apoptosis e.g. 5-FU, platinum analogues, alkylating agents, taxanes, vinca alkaloids
31
Describe the methods of cancer cell resistance
``` Decreased uptake of drug Increase in drug metabolism Alter drug targets Impair apoptosis pathway Alter cell cycle checkpoints Efflux pumps ```
32
List side effects of chemotherapy
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
33
List drugs prescribed to manage chemo toxicity
Anti-emetics e.g. ondansetron (5HT3 antagonist), metoclopramide (D2 antagonist), steroid (dexamethasone) cyclising (antihistamine), aprepitant (NK1 antagonist)
34
Define the term radiotherapy and list some examples
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
List side effects of radiotherapy
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
Define the term immunotherapy and list some examples
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
List side effects of immunotherapy
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
Describe the risk factors, clinical features, investigations and management of colorectal cancer
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
Describe staging in colorectal cancer
``` 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
Describe a screening programme for colorectal cancer
Age 55 - one off scope | Age 60-74 - faecal occult every 2 years
41
Describe the risk factors, clinical features, investigations and management of prostate cancer
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
List causes of a raised PSA
``` UTI Prostatitis BPH Urinary retention Recent ejaculation (48h) ```
43
What is the Gleason grade?
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
Explain the issues around screening for prostate cancer
``` Not recommended Overdiagnosis Overtreatment - leading to lowered QoL Not cost effective Lead/length time bias ```
45
Describe the risk factors, clinical features, investigations and management of bladder cancer
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
Describe the risk factors, clinical features, investigations and management of breast cancer
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
Describe a screening program for breast cancer
Women aged 47-73 - mammogram every 3 years
48
Explain the difference between tamoxifen and letrozole
``` Tamoxifen = oestrogen antagonist - offered to pre-menopausal women Letrozole = aromatase inhibitor - offered to post menopausal women ```
49
List side effects of endocrine treatment of breast cancer
Tamoxifen - increased DVT risk, endometrial cancer | Letrozole - increased osteoporosis risk
50
Name a scoring system used to determine prognosis of breast cancer
Nottingham Prognostic Index determines 5 year survival
51
Describe the risk factors and clinical features of skin cancer
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
Describe the types, investigations and management of malignant melanoma
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
State the risk factors and common metastatic sites of SCC skin cancer
After (renal) transplant | Metastasise to lymph, head/neck
54
Describe the types, clinical features and management of BCC skin cancer
Types - nodular, superficial, morphoeic, pigmented CFs - 'rodent ulcer', pearly rolled edge, central ulcer Mx - (Mohs) excision, topical chemotherapy, radiotherapy
55
Describe the risk factors, clinical features, investigations and management of lung cancer
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
List different types of lung cancer
``` Small cell (*increased paraneoplastic syndrome, metastatic potential) Non small cell - adenocarcinoma, SCC (*PTHrP), large cell carcinoma, adenosquamous ```
57
List signs that indicate a dying patient
``` Profoundly weak Gaunt Drowsy Disorientated Decreased oral intake Poor concentration Abnormal breathing patterns Skin colour changes Temperature changes at extremities ```
58
What is an AMBER care bundle?
``` To improve QoL for patients at risk of dying but still receiving active treatment Assessment Management Best practise Engagement Recovery uncertain ```
59
List the anticipatory drugs and what they are for
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
Define the term adjuvant analgesia and give examples
Primary indication is not for pain but has benefit | e.g. amitriptyline, diazepam, dexamethasone, bisphosphonates
61
What is the ratio of codeine to morphine
10:1
62
What is the ratio of morphine to fentanyl
30:12
63
Describe how to calculation an opioid titration prescription
24h worth = TDD New morphine SR dose = TDD/2 New morphine IR PRN dose = TDD/6
64
Describe how to prepare a TTO for a controlled drug prescription
Name & ID Write prescription as normal Write 'Supply' + drug name + strength + formulation Total number of tablets/amount of drugs in words and figures
65
Write a TTO for a patient taking Zomorph 60mg BD for two weeks
``` TTO - Take Zomorph 60mg BD for 14 days Supply 28 (twenty eight) Zomorph 60mg capsules ```
66
Define the term nausea
Unpleasant feeling of the need to vomit +/- autonomic symptoms
67
Define the term vomiting
Forceful expulsion of gastric contents through the mouth
68
List reasons for nausea/vomiting in oncological patients
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
Describe the treatment of nausea/vomiting in oncological patients
Gastric stasis - metoclopramide, domperidone Chemical - haloperidol Raised ICP - cyclizine, dexamethasone Bowel obstruction - cyclizine, dexamethasone Post op - ondansetron Chemo induced - ondansetron
70
What is the method of action of haloperidol and what kind of nausea is it used for?
Dopamine antagonist | Used in metabolic/chemical induced nausea
71
What is the method of action of metoclopramide and what kind of nausea is it used for?
Dopamine antagonist, weak serotonin antagonist | Used in metabolic/chemical induced nausea
72
What is the method of action of domperidone and what kind of nausea is it used for?
Dopamine antagonist | Used in gastric stasis
73
What is the method of action of cyclizine and what kind of nausea is it used for?
Anticholinergic, antihistamine | Used in raised ICP, motion sickness, bowel obstruction
74
What is the method of action of levomepromazine and what kind of nausea is it used for?
Dopamine antagonist, strong serotonin antagonist, weak anticholinergic, weak antihistamine Used in all (domestos of antiemetic)
75
What is the method of action of ondansetron and what kind of nausea is it used for?
Serotonin antagonist | Used in metabolic/chemical induced nausea, bowel obstruction, renal failure
76
What is the method of action of hyoscine hydrobromide and what kind of nausea is it used for?
Anticholinergic | Used for motion sickness, post operative
77
What is the method of action of prochlorperazine and what kind of nausea is it used for?
Dopamine antagonist, anticholinergic, antihistamine
78
What is the method of action of aprepitant and what kind of nausea is it used for?
Serotonin antagonist, NK1 antagonist | Used in metabolic/chemical induced nausea
79
List reversible causes of breathlessness in the oncological patient
``` Anaemia - transfuse PE - LMWH COPD - bronchodilator Respiratory infection - ABx Pleural effusion - drain SVCO - dexamethasone, stent Anxiety ```
80
Describe methods to relieve intractable breathlessness in the oncological patient
``` Position patient appropriately Air flow across face (fan, near window) Oxygen if hypoxic Low dose morphine (1-2mg PRN) Benzodiazepine ```
81
List causes of constipation in the oncological patient
Disease Fluid depletion Weakness - paraplegia Intestinal obstruction Medication - opioids Biochemical - hypercalcaemia, hypokalaemia Other - pain on defection, lack of privacy
82
List different types of laxatives and their method of action
Fybogel - bulking Lactulose, laxido, movicol - osmotic Senna - stimulant Docusate - softener

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