Cancer management Flashcards
Aim of the MDT
To coordinate high-quality diagnosis, treatment and care. The MDT should make a recommendation on the best initial treatment for cancer.
N.B. An MDT can only ‘recommend’; the decision must be made in consultation with the patient.
Members of the MDT
- Lead clinician
- Lead nurse specialist
- Radiologist
- Histopathologist
- Expert surgeons
- Oncologists (medical and surgical)
- Palliative care physicians
- Patient representative
- Admin support
Chemotherapy: Overview
- The use of any chemical substance to treat disease.
- Primarily refers to the use of cytotoxic drugs in the treatment of cancer.
- Given in intervals (cycles) to allow recovery of normal tissue.
- Chemotherapy is the only systemic treatment for cancer.
- (surgery and radiotherapy = local treatments)
Different types of chemotherapy
- Single agent
- Combination
- Adjuvant
- Neoadjuvant
- Palliative
Classes of cytotoxic drugs
- Alkylating drugs
- Angiogenesis inhibitors
- Anti-metabolites
- Anti-oestrogens
- Anti-tumour antibiotics
- Monoclonal antibodies
- Topoisomerase inhibitors
- Vinca alkaloids and taxanes
Chemotherapy: SIDE effects
Due to cytotoxic effects on non-cancerous cells. Greatest effect seen on dividing cells i.e. gut, hair, bone marrow, gametes
- Vomiting
- Alopecia
- Neutropenia*
*(Neutropenic sepsis = oncological emergency)
Extravastation of chemotherapy: Definition
Leakage of IV infused + potentially damaging medications into the extravascular tissue around the site of infusion.
Presentation: tingling, burning, pain, redness, swelling
Management: stop and disconnect infusion.
SURGICAL treatment of cancer (6)
- Prevention
- Screening
- Diagnosis and Staging
- Treatment
- Reconstruction
- Palliation
Fertility and cancer: Overview
Chemotherapy and radiotherapy may:
- Damage spermatogonia causing impaired spermatogenesis or male sterility
- Hasten oocyte depletion leading to premature ovarian failure
Fertility and cancer: Fertility preservation techniques
- Men: semen cyropreservation should be offered before treatment due to risk of genetic damage to sperm following chemotherapy.
- Women: cyropreservation:
- Embryos
- Oocytes
- Ovarian tissue
Beau’s lines: Definition
Beau’s lines are horizontal depressions in the nail plate that run parrellel to the moon-shaped portion of the nail bed.
They result from a sudden interruption of the nail keratin synthesis and may be due to local infection/trauma, systemic illness, or from medication.
Radiotherapy: Overview
It uses ionizing radiation to cause damage to the DNA.
This prevents cell division and leads to cell death.
The aim of radiotherapy treatment is to inactivate cancer cells without causing a severe reaction in normal tissue.
Radiotherapy: Types
- RADICAL treatment: given with curative intent.
- PALLIATIVE treatment: aims to relieve symptoms, may not impact on survival.
Radiotherapy: Early reactions
- Tiredness
- Skin reactions
- Mucositis
- Nausea and vomiting
- Diarrhoea
- Dysphagia
- Cystitis
Radiotherapy: Late reactions
- CNS/PNS: somnolence, spinal cord myelopathy, brachial plexopathy
- LUNG: pneumonitis
- GI: xerostomia, benign strictures, radiation proctitis
- GU: urinary frequency, vaginal stenosis, dyspareunia, erectile dysfunction, decreased fertility
- Endocrine: panhypopituitarism
- Secondary cancers
Radiotherapy: Methods of delivering radiotherapy
- Conventional external beam
- Stereotactic
- Brachytherapy
- Radioisotope
Interventional Oncology (IO): Definition
A subspecialty field of interventional radiology that deals with the diagnosis and treatment of cancer and cancer related problems using targeted minimally invasive procedures performed under image guidance.
Interventional Oncology: Disease modifying IO
Intended to modify cancer progression and/or improve prognosis. It includes:
- Image guided ablation
- Embolization
- Imaged guided brachytherapy
- Isolated perfusion chemotherapy
Interventional Oncology: Symptomatic IO
Provides relief from cancer symptoms, but does not modify underlying disease process.
Symptom control includes:
- Ascites
- Pleural effusion
- SVC obstruction
- Oesophageal obstruction
- Large bowel obstruction
- Tumour related haemorrhage
- Jaundice
- Renal tract obstruction
- Bone metastases
Factors when considering FITNESS for TREATMENT
- Surgery: cardiac and lung function
- Chemotherapy: renal and liver function
- Radiotherapy: ability to lie flat (MSK problems)
Brachytherapy: Definition
Brachytherapy uses a radioactive source inserted via an applicator into the vagina/cervix. Because the radiation has a short range, a higher dose can be delivered to the tumour with less toxicity to surrounding organs.
Cisplatin: Definition
Chemotherapy medication used to treat a number of cancers.
Cisplatin is a platinum agent which acts by causing crosslinks of DNA thereby preventing DNA repair/synthesis.
Side effects include bone marrow suppression, nephrotoxicity, ototoxcity, neurotoxicity, nausea + vomiting. It does not typically result in hair loss.
Radiotherapy: How might radiation to the pelvis impact on sexual function and fertility?
- Pelvic irradiation is likely to result in infertility due to loss of ovarian function.
- It can also cause stenosis and dryness of the vagina.
- Resulting in problems with sexual function.
- Treatments:
- Dilators: prevent stenosis
- Lubricants: deal with dryness
HPV vaccine: What does the HPV vaccination cover?
- HPV 16 and 18: which are responsible for approximately 70% of cases of cervical cancer.
- HPV 6 and 11: which are associated with genital warts.
WHO/ECOG performance: Functional status
- Grade 0: Fully active, able to carry on all pre-disease performance without restriction
- Grade 1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature
- Grade 2: Ambulatory and capable of all self care but unable to carry out any work activities, up and about more than 50% of waking hours
- Grade 3: Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
- Grade 4: Completely disabled, cannot carry on any self care, totally confined to bed or chair
- Grade 5: Deceased
Information you need to know before performing CONTRAST CT
- Previous contract reaction ?
- Renal function (if GFR <40ml/min then increased risk of contrast induced AKI)
- Diabetes mellitus - metformin therapy
Factors in deciding treatment
- Stage of disease
- Fitness or performance status
- Co-morbidities
- Histology
- Other characteristics of tumour
- Preferences for treatment
- Social support network
Immune checkpoint inhibitors: Definition
Immune checkpoint inhibitors are a type of immunotherapy that are increasingly being used to treat certain types of cancer, as an alternative to cytotoxic chemotherapy. In contrast to therapies such as chemotherapy and tumour-targeted drugs that directly affect the growth and proliferation of tumour cells, these targeted treatments harness the body’s natural anti-cancer immune response. They boost its ability to attack and destroy the cancer cells.
Immune checkpoint inhibitors: Mechanism of action
T-cells are an important part of our immune system which help destroy cancer cells. Some cancer cells make high levels of proteins that turn T-cells off. Checkpoint inhibitors block this process and reactivate and increase the body’s own T-cell population, enhancing the immune systems own ability to recognise and fight cancer cells.
Immune checkpoint inhibitors: Types (3)
- Ipilimumab (Yervoy)
- Nivolumab (Opdivo) and pembrolizumab (Keytruda)
- Atezolizumab, Avelumab and Durvalumab
Immune checkpoint inhibitors: Ipilimumab (Yervoy)
Ipilimumab (Yervoy) is a checkpoint inhibitor that blocks CTLA-4 (cytotoxic T lymphocyte-associated protein 4). It is a treatment for advanced melanoma.
CTLA-4 is found on T-cells.
Immune checkpoint inhibitors: Nivolumab (Opdivo) and pembrolizumab (Keytruda)
Nivolumab (Opdivo) and pembrolizumab (Keytruda) blocks PD-1 (programmed cell death protein 1). These are treatments for melanoma, Hodgkin’s lymphoma, non-small cell lung cancer and urological cancers.
PD-1 are found on T-cells and cancer cells.
Immune checkpoint inhibitors: Atezolizumab, Avelumab and Durvalumab
Atezolizumab, Avelumab and Durvalumab block PD-L1 and is used to treat lung cancer and urothelial cancer. It is also undergoing trials as a treatment for breast cancer.
Immune checkpoint inhibitors: Administration
All CTLA-4 inhibitors and PD-1/PD-L1 inhibitors currently available are monoclonal antibodies (laboratory-produced molecules engineered to serve as substitute antibodies that each bind to a specific protein).
They are all administered by injection/intravenous infusion.
Mostly, they are given as a single-agent treatment but sometimes, they can be combined with chemotherapy or each other. For example, ipilimumab and nivolumab can be used in combination.
Immune checkpoint inhibitors: Side effects
This mechanism of action of these drugs can result in side effects termed ‘Immune-related adverse events’ that are inflammatory and autoimmune in nature. This is because all immune cells are boosted by these drugs, not just the ones that target cancer.
The over-active T-cells can produce side effects such as:
- Dry, itchy skin and rashes (most commonly)
- Nausea and vomiting
- Decreased appetite
- Diarrhoea
- Tiredness and fatigue
- Shortness of breath and a dry cough.
Management of such side effects reflects the inflammatory nature, often involving corticosteroids.
It is important to monitor liver, kidney and thyroid function as these drugs can affect these organs.
