CCC revision Flashcards
risk factors for breast cancer
- uninterrupted oestrogen exposure e.g. nulliparity, not breastfeeding, early menarche, late menopause, HRT, prolonged use OCP, obesity (after menopause)
- alcohol and smoking
- chest and mediastinal radiotherapy
characteristics of inherited breast cancers (BRCA 1 and 2)
- often younger presentation
- cluster in family of young members, male and ovarian cancers
- bilateral BC
between what ages are women screened for breast cancer
50-70 years - mammogram every 3 years
what are interval cancers
cancers occurring between each episode of screening
why is peau d’orange / breast inflammation an important sign to pick up on
can indicate inflammatory breast cancer - rapid onset, metastases quickly and has poorer cure rates and responses to treatment
breast cancer triple assessment
- imaging: mammogram/USS/MRI, CT or bone scan for mets
- clinical examination of breast and axilla
- biopsy - core needle or FNA
= confident diagnosis in 95% cases
questions to ask in breast cancer history
- how long
- any skin/nipple changes
- pain/discharge
- related to menstrual cycle?
- lumps under arm?
tumour markers for breast cancer
Ca15.3, CEA
what is a triple negative breast cancer
negative for oestrogen receptor (ER), progesterone receptor and HER2 receptor
difficult to treat with conventional therapy - most common subtype in BRCA1 carriers
poor prognostic factors for breast cancer
- > 5cm
- higher grade
- ER negative
- HER2 positive
- LN involvement
- triple negative
types of curative surgery for breast cancer
breast: wide local excision, mastectomy
axilla: sentinel node biopsy - axillary clearance if evidence of spread to LNs
3 main areas of metastatic spread in breast cancer
lung bones liver
which type of breast cancer responds best to chemo
ER negative/HER2 positive
50% of breast cancers are ER positive (oestrogen receptor positive)
during the menopause where is oestrogen produced
adipose tissue skin liver muscle breast tissue
3 main types of hormonal treatments for breast cancer
- oestrogen antagonists (tamoxifen)
- oophorectomy (younger women)
- aromatase inhibitors
what type of breast cancer does tamoxifen work on
ER positive - because blocks oestrogen receptors = reduced tumour growth
how do aromatase inhibitors (anastrozole, letrozole) work
aromatase = rate limiting enzyme in oestrogen synthesis = reduces oestrogen levels in body
used in post-menopausal women or in combination with something else in pre-menopausal
what are tamoxifen side effects similar to
menopause symptoms - because due to reduced oestrogen
NB: increases risk of VTE and PE
how effective is adjuvant radiotherapy for breast cancer
reduces risk of local relapse by 50-66%
how often are the chemotherapy cycles for breast cancers and how many cycles are given
cycle every 3 weeks
6-8 cycles
how does HER-2 receptor breast cancer function
- HER2 receptors send signals to the cells to grow and divide
- too many HER2 receptors can send too many growth signals = cells grow too quickly
what is used for the treatment of HER2 positive breast cancer
HERCEPTIN - trastuzumab
how does Herceptin work
monoclonal Ab - specific for HER2 - binds to HER2 = slows tumour growth
NOT chemotherapy
three weekly regimen
risk of allergic reaction
major side effect of herceptin
cardio toxicity - so must have good cardiac function and needs cardiac monitoring during treatment
most common type of lung cancer
NSCLC 85%
adenocarcinoma (35%)
SCC (30%)
large cell (10%)
types of pain common in lung cancer (especially late disease)
chest pain
bone pain (mets)
RUQ pain (liver pain)
headaches (brain mets)
when might haemoptysis be an early sign of lung cancer
very central cancer - T3/4
what syndrome might be associated with an apical tumour (Pancoast tumour)
Horner’s syndrome - ptosis, miosis, anhidrosis
main treatment of SCLC
chemotherapy - responsive but high relapse rate
why to give prophylactic brain radiotherapy in SCLC
often metastasise to brain
2 main mutations driving adenocarcinomas lung cancer
ALK
EGFR
which receptors are implicated in immunotherapy for lung cancer
PD-1
PDL
side effects of cancer immunotherapy
not as many as chemo
but can lead to autoimmune side effects e.g. lung fibrosis and destruction of thyroid gland
T1-T4 staging for colorectal cancer
- T1 = tumour invades submucosa only
- T2 = tumour also invades muscularis propria (muscle)
- T3 = tumour invades peri-colonic tissues
- T4a = tumour invades local peritoneum
- T4b = tumour invades local organs
M1a-M1c staging for colorectal cancer
M1a = 1 organ M1b = >1 organ M1c = peritoneal surface
5 year survival of stage 1-4 CRC
1 = 95% 2 = 80-90% 3 = 65% 4 = 5-10%
red flag bowel cancer symptoms
PR bleeding weight loss change in bowel habits PR mucous anorexia
2 main referral options for urgent suspected CRC
- straight to test if are fit - colonoscopy or flexible sigmoidoscopy
OR - colorectal surgeon/gastro review within 14 days if significant comorbidities or frail
another method of bowel cancer screening (apart from the FIT test age 60-74)
bowel screening scope (sigmoidoscopy) at 55 - one off test to detect left sided polyps) - if normal then go to normal bowel screening at 60 years
how is CRC treated
neoadjuvant chemo (usually)
before surgery
might have radiotherapy alone for rectal cancer
why is rectal cancer treated more aggressively (neoadjuvant therapy) than colon cancer
more local recurrence
what are patients tested for before receiving 5FU/capecitabine therapy
DPD enzyme deficiency - results in an inability to metabolise 5FU = toxicity and much more severe side effects to the chemo
follow up investigations for CRC
CEA 6-monthly
CT 18 months, 3 years and 5 yearly
colonoscopy within 12 months if not completed at diagnosis and 3 years post last colonoscopy
at what age can men request a PSA test from their GP
over 50
urinary symptoms which might merit a PSA test
reduced flow
increased frequency
nocturia
hesitancy
metastatic symptoms of prostate cancer
anaemia
bone pain
fatigue
what would be the pathway after an elevated PSA
- urology clinic on 2-week wait (urinary symptoms, sexual and bowel functions, other comorbidities, DRE)
- referral for pre-biopsy MRI scan
- TRUS biopsy
histological grading system for prostate adenocarcinoma
Gleason grading (being replaced with ISUP score)
T1-T4 staging of prostate cancer
T1. No palpable/visible cancer
T2. Cancer WITHIN the prostate
T3. Cancer breaching prostate capsule
T4. T4 is cancer growing into rectum/bladder
what would constitute a low risk prostate cancer
T1c/T2a, GS<=6, PSA<=10
what would constitute an intermediate risk prostate cancer
T2b/c or GS 7 or PSA 10-20
what would constitute a high risk prostate cancer
GS>=8 or PSA>=20
main treatment options for prostate cancer
- surgery - in men <70 with no comorbidities (long term incontinence and impotence risks)
- radiotherapy including brachytherapy
- hormonal treatment
- active surveillance
when might radiotherapy be used for prostate cancer instead of surgery
older men or with comorbidities - long term bowel problems risk
when might brachytherapy be used for prostate cancer and who should it be avoided in
fit men with no comorbidities
avoid in men with larger prostates/significant urinary symptoms
options for advanced prostate cancer
chemo, palliative radio
androgen deprivation therapy (ADT) - side effects such as hot flushes, shrinkage of penis, loss of muscle, weight gain, higher risk DM, osteoporosis, hyperlipidaemia, mood changes
major risk of ADT
increase in CV mortality in those with pre-existing CVD
2 gene mutations increasing risk of prostate cancer
BRCA II
pTEN
most common metastatic spread from prostate cancer
bones - especially lumbar spine (MSCC) and pelvis
where does BPH vs prostate cancer occur
BPH = centre of gland
adenocarcinomas = posterior/peripheral parts of gland
why is prostate cancer often asymptomatic
1st affected area is peripheral/posterior zone = far from urethra = no symptoms
investigations for prostate cancer apart from DRE
TRUS biopsy
MRI scan
isotope radio nucleotide bone scan - bone mets
TNM staging for prostate cancer
TX: Primary tumour cannot be assessed
T0: No evidence of primary tumour
T1: Clinically unapparent tumour not palpable nor visible by imaging
T2: Tumour confined within prostate
T3: Tumour extends through the prostate capsule
T3a: Extracapsular extension (unilateral or bilateral)
T3b: Tumour invades seminal vesicle(s)
T4: Tumour is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
N0 No regional lymph node involvement.
N1 Regional lymph node involvement
M0: No distant metastasis M1: Distant metastasis M1a: Non-regional lymph node(s) M1b: Bone(s) M1c: Other or multiple site(s) with or without bone disease
LFT which might suggest bone mets in prostate cancer
raised ALP
4 main types of hormonal treatment for prostate cancer (advanced disease or in conjunction with radiotherapy)
chemical castration
- LHRH agonists: leuprorelin, goserelin
- GNrH antagonist: degarelix
- oestrogen therapy
- anti-androgens: bicalutamide, enzalutamide
side effects of LHRH agonists
- loss of libido
- tumour flare on initiation of treatment
- long term = increased cardiac risk, osteoporosis
benefit of GNrH antagonists
no risk of tumour flare
given monthly via SC injection when tumour flare can lead to significant symptoms e.g. with MSCC
how might chemotherapy be used in prostate cancer
cytotoxic treatment with docetaxel and prednisolone + carbazitaxel with metastatic disease
prognosis of prostate cancer
- low risk = 99% at 10 years
- all patients = 84% at 10 years
- metastatic disease = median survival 3.5 years
what is raised in hepatocellular carcinoma
alpha fetoprotein
how is oxycodone metabolised and when should it be avoided
metabolised and excreted hepatically
so should be avoided in liver injury - use morphine instead
most common sites of metastases for lung cancer
BRAIN
liver
bones
adrenals
another name for herceptin
trastuzumab
what should be monitored during Herceptin treatment
left ventricular function due to risk of cardiomyopathy = frequent ECHOs
what can venlafaxine be used to treat in context of breast cancer
hot flushes due to medical/surgical menopause
what is the CHAD2DS2-VASc score
CHF/LVEF <40% Hypertension Age >75 years = 2 Diabetes Stroke/TIA/Thromboembolism = 2
Vascular disease
Age 64-75 years
Sex category (female)
what is the HAS BLED score
Hypertension (>160mmHg)
Abnormal liver/renal function
Stroke
Bleeding Hx/predisposition
Labile INR
Elderly >65 years
Drug/alcohol use
normal HbA1c levels
20-42
main antibiotic used for prophylaxis of neutropenic sepsis
levofloxacin
what is extrinsic vs intrinsic asthma
- extrinsic - more commonly starts in childhood, common in atopic people
- intrinsic - tends to develop in adulthood = ‘non-allergic’ asthma
what is FeNO and when is it offered to diagnose asthma
fractional exhaled nitrous oxide
measures amount of fractional exhaled NO which is increased by eosinophil activity
should be offered to adults aged 17+ AND if there is diagnostic uncertainty in under 17s, OR normal/obstructive spirometry with negative BD reversibility
asthma spirometry
FEV1/FVC <70% - obstructive
how is the bronchodilator test carried out
- Patients are asked to stop their SABA 6 hours beforehand, and LABA 12 hours beforehand
- Carry out the initial spirometry if not already done so
- Patient given 400 micrograms of Salbutamol and must wait for 15 minutes
- Carry out spirometry:
what would indicate a positive bronchodilator reversibility result
increase in FEV1 of 12% or more and 200ml or more increase in volume
negative test result = COPD??? v mild increase could be COPD on a background of asthma???
when might PEFR be used for asthma
Should be carried out over 2-4 weeks weeks in adults if there is diagnostic uncertainty after initial assessment and FeNO test with normal spirometry OR obstructive with normal FeNO
VERY COMMONLY USED IN CHILDREN
when are asthma symptoms usually worst
evenings - lowest cortisol levels
normal PEFR of adults
80-100% of their normal means asthma is well controlled
400-700ml for an adult
absolute gold standard for diagnosing asthma
direct bronchial challenge test with histamine/metacholine
what allergens to avoid in asthma
high levels pollution
smoke
NSAIDs
beta blockers
how much can CO be reduced by in AF
20% - ventricles not fully filled by atria
characteristics of:
a. initial episode
b. paroxysmal AF
a) . Initial episode:
- AF > 30 seconds diagnosed on an ECG
b). Paroxysmal AF
- > 2 Self-terminating, recurrent episodes lasting 30 seconds to 7 days
OR
- <48 hours terminated with cardioversion
characteristics of
a. persistent AF
b. long-standing AF
a) . Persistent:
- Episodes lasting more than 7 days CONTINUOSLY
- OR AF >48 hours which needs cardioversion
After 48 hours, spontaneous termination unlikely after this length of time
b). Continuous AF >12 months