Cancer Care History and Management

Question 1

Outline the SPIKES mnemonic for breaking bad news

Answer 1

Setting
Perception
Invitation
Knowledge
Empathy
Strategy and Summary

Question 2

Outline the SETTING part of the SPIKES mnemonic

Answer 2

Ensure it is in a private place and sitting down!

‘I was hoping to have a conversation with you, are you okay to have that discussion right now? is it alright if we do it here? Would you like a family member or friend with you?’

Question 3

Outline the PERCEPTION part of the SPIKES mnemonic

Answer 3

Discuss the sequence of events up to this point

What do you know already about what’s been happening?

Give a warning shot:
“Symptoms like the ones you’ve been describing can sometimes be as a result of … , but sometimes they can be as a result of more serious underlying conditions”

Question 4

Outline the INVITATION part of the SPIKES mnemonic

Answer 4

Check if the patient wants to receive their results today – “I have the result here today, would you like me to explain it to you now?”.

Question 5

Outline the KNOWLEDGE part of the SPIKES mnemonic

Answer 5

Use a warning shot to indicate that you have bad news: “As you know we took a biopsy/did a scan, and unfortunately the results were not as we hoped”.

Pause so the patient can digest the information

Provide the diagnosis using simple language: “I’m sorry to tell you this, but the results from the investigations show you have cancer”.

Question 6

Outline the EMPATHY part of the SPIKES mnemonic

Answer 6

Give the patient time to take everything in

‘I can see that this is not the news that you expected, I’m so sorry’

‘I know this is a lot to take in, I am here to support you through this and answer any questions you might have’

Question 7

What can you say if a patient asks you a question that you can’t answer e.g. about their prognosis?

Answer 7

“I’m so sorry, but at this stage, I don’t have enough information to answer that. Hopefully in the next few weeks once we’ve completed other tests I can be clearer. Sorry, I can appreciate that it’s frustrating to be left with unanswered questions’

Question 8

Outline the STRATEGY AND SUMMARY part of the SPIKES mnemonic

Answer 8

Inform them of the follow-up arrangements:
‘I am going to refer you to…. ‘
or
‘ I will see you back in clinic so that we can have another conversation once you’ve had some time to process’

Check the patient’s understanding of the bad news you have delivered - ‘ I appreciate once you’ve heard news like this it can be hard to take in what someone is saying - is there anything you didn’t quite understand or would like me to clarify? ‘

‘If you would like me to help you to tell family or friends about this news I am happy to help’

‘If you have any more questions when you’re home you can talk to our clinical nurse specialists’

‘You can find out more information online at…’

Question 9

What questions should you ask to explore someone’s cancer history before delving into the presenting complaint?

Answer 9

When were you diagnosed?
What treatment have you been receiving and when did have it?
When did you last see someone about your cancer?
How are your symptoms and how are you managing?

Question 10

What questions should you ask a cancer patient who is presenting with shortness of breath?

Answer 10

Onset of SOB? Gradual or acute? Aggravating and relieving factors?

Systematically ask questions to rule in/ out differentials:

When was recent treatment? (pneumonitis)

Swelling of face or neck? (SVCO)

Chest pain? (PE, pneumothorax, MI)

Chest pain w radiation down arm? Palpitations? Syncope? (Cardiac cause)

New cough? Productive? Haemoptysis?
Fever? (pneumonia)

Leg swelling? (DVT)

Question 11

What may cause shortness of breath in a patient with cancer?

Answer 11

cancer itself- SVC0 (emergency!), lung mets, primary lung cancer, malignant pleural effusion

cancer tx - respiratory depression from opiate use, pneumonitis

other - pneumonia, PE, pneumothorax, cardiac, asthma / COPD

Question 12

How can you explain a malignant pleural effusion to a patient?

Answer 12

there is a collection of fluid around your lungs, which we call a pleural effusion

this is stopping your lungs from expanding fully which is why you feel so short of breath

unfortunately, when this happens it usually has quite a serious underlying cause…

this usually suggests that your cancer has spread to the lining of your lungs

Question 13

How can you explain management of a malignant pleural effusion to a patient?

Answer 13

What we can do is insert a drain to allow all of that fluid to escape and allow your lungs to expand fully, which will hopefully mean that you feel less short of breath

explain that this does not get rid of the underlying cancer and you will need to speak to the whole oncology team to decide on a plan going forwards - usually by the time people have pleural effusion we are looking at a non-curative mx of cancer

explain that any planned surgery cannot go ahead as malignant pleural effusion is a contraindication

Question 14

What do you need to ask when a cancer patient is presenting with pain? (beyond SQITARS)

Answer 14

Need to assess the impact of pain on the patient day to day, their understanding of the cause of the sxs (do they assume that escalating pain means that their cancer is spreading?), what management has been tried, do they have any concerns about proposed tx

Question 15

How would you address patient concerns about opioid use including addiction, tolerance and hastening of death?

Answer 15

Many patients are concerned about becoming addicted to opioids: if it is taken as prescribed for pain there is a low risk of becoming dependent, if they are using it for other reasons for example to sedate themselves at night then risk of addiction increases

Patients also worry about tolerance: giving opioids early to get on top of pain does not increase risk of worse pain down the line

No evidence that opioids shorten life: Good pain relief can lengthen life- allows to stay active for longer, keep eating and drinking

Question 16

What key opioid side effects should you make a patient aware of?

Answer 16

Constipation – on-going, prescribe with laxatives

Nausea and Vomiting – only in 1/3 of patients, usually transient, lasts up to a week, can prescribe an antiemetic PRN alongside

Dry mouth – on-going, can be managed with ice-lollies, sugar free sweets, chewing gum

Sedation – usually at the start of new dose, lasts 2/3 days

Respiratory depression – suddenly giving a very high dose increases risk, AKI may precipitate (No increased risk at end of life, relatively rare)

Question 17

How could you answer a patient who asks ‘ what can I expect to experience at the end of life’?

Answer 17

Everybody is different but some of the things that people commonly experience as they come towards the end of their life include:

Sleepiness and difficulty waking
Restlessness
Feeling confused
Difficulty swallowing or not wanting to eat or drink at all
Feeling sick
Loss of bladder and bowel control
Changes in breathing

But it is our job to keep you comfortable and there are medications that we can prescribe the reduce these symptoms.

Is there anything you are particularly worried about?
Is there anyone that you would like to have present at the end of your life? Family, friends, faith leaders?

Question 18

What 5 common symptoms should you prescribe for in anticipation in an end of life patient?

Answer 18

Pain – morphine 2.5-5mg

Breathlessness / changes in breathing (e.g. Cheynes-Stokes irregular breathing) – morphine 2.5-5mg

Nausea and vomiting – levomepromazine 2.5-5mg

Terminal agitation – midazolam 2.5-5mg, consider haloperidol if hallucinating

Respiratory secretions – glycoperronium 200-400mcg (less sedating and doesn’t cross BBB)

Question 19

How can you answer a patient who asks ‘ how long have I got left’?

Answer 19

Oh gosh, that’s a big question. Is it Ok if I ask what prompted you to ask that?

Unfortunately, I don’t have all the answers and I can’t give you a specific timeline, but when people start to have symptoms like ….. it is likely that time is very short.

Question 20

How should you respond to a patient with cancer who asks ‘ is this my fault’?

Answer 20

Cue to explore concerns:
Can I ask, what makes you say that?
Why are you worried that this is your fault?

Cancer is not anybody’s fault. Unfortunately, sometimes it just happens.

If they are concerned about a particular risk factor – e.g., is it my fault I have lung cancer because I have smoked?

As you probably already know, smoking is a risk factor for lung cancer. But there are people who never smoke who get lung cancer, and there are people who chain smoke who don’t, so sometimes these things are not within our control. I don’t think it is helpful for you to blame yourself for what has happened. What’s happened has happened, and I think we should focus on looking after you and keeping you as comfortable as possible.

Question 21

What questions should you ask a patient presenting with bone pain?

Answer 21

SQITARS

Impact on daily life and mobility

Screen for hypercalcaemia:
tummy pain, N+V, constipation?
change in appetite, inc thirst?
inc urination?
muscle twitches?
feeling more tired or confused?

Assess their understanding of the cause of the sxs (do they assume that escalating pain means that their cancer is spreading?)

What management has been tried?

Question 22

What managment options can you suggest for someone with bone pain due to bone mets?

Answer 22

NSAIDs

bisphosphonates - type of medication that can slow down or prevent bone damage and lower calcium levels

radiotherapy

Question 23

You should always have a high index of suspicion for any cancer patients (especially those with known bone mets) who might have hypercalcaemia.

What symptoms may it present with?

How does this present on bloods and ECG?

How should you manage this?

Answer 23

‘bones, stones, groans and psychic moans’
fractures, renal stones, GI upset, confusion / lethargy

Calcium level over 2.5
Short QT interval

rehydration with normal saline, typically 3-4 litres/day
then bisphosphonates (e.g. Pamidronate) , takes 2-3 days to work
calcitonin works faster

Question 24

Lung Cancer + confusion, nausea and weakness =

Answer 24

likely hypercalcaemia

Ix: measure serum calcium!!!
can also do an ECG

Mx: IV fluids + Pamidronate (bisphosphonate) infusion over 30-60 mins

Question 25

How should you explore a presenting complaint of N+V in a cancer patient?

Answer 25

When was their last cancer treatment? (chemotherapy induced)
When were they started on their medications? (opioid induced)

When are they vomiting? (in the morning, after eating, throughout the day)
How much are they bringing up?
What are they bringing up? (bile, blood, faecal vomitus)

Any headache / visual disturbance? (brain mets)
Any abdo pain / constipation? (malignant BO)
bone pain, inc thirst / urination, muscle twitches, confusion? (hypercalcaemia)
Anxiety, tremor, palpitations?
Oral discomfort? (thrush, mucositis)

Question 26

What can cause N+V in a cancer patient?

Answer 26

Chemotherapy
Medication side effects

Cerebral mets / raised ICP

Gastric stasis
Bowel obstruction

Infection

Anxiety

Biochemical causes

Question 27

How does N+V due to gastric stasis present?

Answer 27

feel full after a couple of mouthfuls, belching, reflux symptoms, vomiting after eating, after vomiting feel better

Question 28

How does N+V due to cerebral mets present?

Answer 28

worse on movement, worse in the mornings, vomiting often projectile, may also complain of headaches and visual disturbance

Question 29

When does N+V due to chemotherapy usually come on?

Answer 29

In the first 24 hours

Question 30

What are the infectious causes of N+V in cancer patients?

Answer 30

gastroenteritis, pneumonia (severe coughing), thrush

Question 31

What are the biochemical causes of N+V in cancer patients?

Answer 31

low sodium, high calcium, significant renal impairment, tumour toxins

Question 32

How should you explore a presenting complaint of constipation in a cancer patient?

Answer 32

When was the last time they received treatment / medication?

When was the last time they opened their bowels? Have they passed small amounts or nothing at all? Passing flatus?

Any abdo pain / distension? N+V? (bowel obstruction)

fluid and food intake? mobilising?

feeling generally weaker?

Screen for hypercalcemia

Question 33

What are the differentials for constipation in a cancer patient?

Answer 33

Immobility
Dehydration, reduced intake
Weakness
Medication side effect
Abdominal disease / obstruction
Hypercalcaemia

Question 34

How can you manage malignant bowel obstruction?

Answer 34

Can use drip and suck – may not be appropriate for all patients because only a holding measure until surgery and they may not be candidate for surgery (e.g. multi-level disease, last weeks of life) – conservative management is more appropriate

Can use a syringe driver with cyclize, opiates and buscopan (to reduce colic and secretions)

May use octreotide – somatostatin analogue used to reduce secretions

Question 35

How should you explore a patient with cancer who has had a seizure?

Answer 35

Explore what happened before during and after

Screen for:
Brain mets - headache, vision changes, behavioural changes, N+V
Meningitis / Encephalitis / Sepsis - fever, neck stiffness, rash?
Electrolyte imbalance - bone pain, abdo pain, changes in bowels or waterworks, confusion?

Question 36

How should you manage a patient with headache due to suspected brain mets?

Answer 36

CT and MRI brain to confirm diagnosis
Start Dexamethasone 4mg BD with weaning plan
Give Keppra for seizures
Patients cannot drive

Question 37

When does neutropenic sepsis commonly occur in relation to chemotherapy?

Answer 37

7-14 days after chemotherapy

Question 38

Define neutropenic sepsis

Answer 38

a neutrophil count of < 0.5 * 109 in a patient who is having anticancer treatment and has one of the following:

a temperature higher than 38ºC or
other signs or symptoms consistent with clinically significant sepsis

Question 39

What questions should you ask a patient with suspected neutropenic sepsis?

Answer 39

Recent chemotherapy?

Fever?
New rashes?
Pain in your mouth / new ulcers?
Chest pain, cough, sputum?
N+V? Changes in bowels or waterworks?
Discomfort around genitals?

Catheter / cannula in situ?
Redness around catheter site?

Question 40

How should you manage neutropenic sepsis?

Answer 40

Sepsis Six – give abx, IV fluids and oxygen, take urine output, lactate and blood culture

Tazocin first line antibiotic unless obvious contraindication (Meropenem if Penicillin allergy)
Can also give GCSF

Don’t automatically put catheter in neutropenic patient unless renal injury due to risk of UTI and ascending infections

Take cultures from peripheral vein and indwelling lines

If not responding to abx consider fungal infection