Key topic lectures Flashcards
1
Q
How much does 1 bag of red cells raise the Hb
A
10 g/L (in 70 kg male)
2
Q
What are some long term lines that can be inserted for cancer treatment
A
Tunnelled central lines (between chest wall and superior vena cava)
PICC line (between anterior cubital fossa and heart)
Implantable ports
3
Q
What is tumour lysis syndrome
A
Tumour lysis releases cellular components into circulation
Imbalance: high uric acid, high potassium, high phosphorus, low calcium
Can cause: arrhythmias, sudden death, seizures
Management: allopurinol (blocks uric acid production), rasburicase (urate oxidase)
4
Q
What is the guidance around pregnancy and chemotherapy
A
Avoid pregnancy whilst on chemotherapy
Can use norethisterone (stops periods)
Avoid COCP (high thrombotic risk)
Advise barrier protection (to protect partners)
5
Q
What is criteria for neutropenic sepsis
A
Fever > 38
Fever > 37.5 for > 1 hour
Neutropenia < 0.5
Neutropenia < 1 and falling
6
Q
What is the management for neutropenic sepsis
A
Follow hospital neutropenic sepsis protocol (similar to sepsis 6)
G-CSF (granulocyte colony stimulating factor): SC injection, can reduce severity and duration of neutropenia, side effects (bone pain, headaches, nausea, fever)
7
Q
Which cells come from the myeloid line
A
Megakaryocytes (thrombocytes)
Erythrocytes
Mast cells
Myeloblasts (basophils, neutrophils, eosinophils, monocytes (macrophages))
8
Q
Which cells come from the lymphoid line
A
Small cells (B cells (plasma cells), T cells)
Natural killer cells
9
Q
What are the symptoms of hypercalcaemia
A
Fatigue
Abdominal pain
Nausea and vomiting
Constipation
Confusion
Headaches
Polydipsia
Polyuria
10
Q
What are the symptoms of hyperviscosity
A
Headaches
Somnolence
Visual disturbance
Ischaemic events
11
Q
Which drugs are now potentially curable for CML
A
Tyrosine kinase inhibitors (imatinib)
12
Q
What are the properties of cancer cells that promote growth
A
Evade apoptosis
Self-sufficiency in growth signal
Insensitive to anti-growth signal
Tissue invasion and metastasis
Limitless replicative potential
Sustained angiogenesis
13
Q
What is neoadjuvant therapy
A
Given before definitive management
Shrink tumour
Optimise outcome
14
Q
What is adjuvant therapy
A
Given after treatment
Reduce risk of recurrence
15
Q
What is palliative care
A
Symptom relief
Improve quality of life
16
Q
What is 5-fluorouracil
A
Inhibits thymidylate synthesis
17
Q
How do cancer cells develop drug resistance
A
Decreased uptake of drug
Increased drug metabolism
Altered drug targets
Impaired apoptotic pathways
Altered cell cycle checkpoints
Efflux pumps
18
Q
What things are important to remember when prescribing chemotherapy drugs
A
Narrow therapeutic index
Alter doses based on: BMI, renal/hepatic function, performance status
Often give drugs in combination (synergistic effecr)
19
Q
What are the side effects of chemotherapy
A
Brain (chemo-brain, peripheral neuropathy, fatigue)
Hair (alopecia)
Circulation (neutropenic sepsis, cardiomyopathy, myelosuppression)
GI tract (vomiting, mucositis)
Bladder (haemorrhagic cystitis)
Large intestine (diarrhoea, constipation)
Skin (rash, nail ridging/loss)
Reproductive organs (impaired fertility, decreased libido, premature menopause)
Kidneys (AKI, electrolyte disturbance)
Liver (deranged LFTs)
Lungs (pneumonitis, PE)
20
Q
What are some examples of antiemetics used in cancer treatment
A
5HT3 antagonists (ondansetron)
Dopamine receptor antagonists (metoclopramide)
Steroids (dexamethasone)
Antihistamines (cyclizine)
NK1 receptor antagonists (aprepitant)
21
Q
How do monoclonal antibodies work
A
Bind to cancer cell antigen
Block downstream signalling pathways
Arrest cell cycle proliferation
22
Q
What are the side effects of immunotherapy
A
Skin toxicity
Hair growth disorders
Pruritus
Nail changes
Fatigue
Myelosuppression
Diarrhoea
Nausea and vomiting
Hypertension
Proteinuria
GI perforation
Delayed wound healing
Arterial thromboembolic events
Cardiac ischaemia
Abnormal LFTs
Allergic reaction
23
Q
What are immunotherapy checkpoint inhibitors
A
Aid binding of PD-1 (on T cell) and PD-L1 (on tumour cell)
Block proteins that stop immune system from killing cancer cells
24
Q
What are the aims of radiotherapy
A
Deliver maximum dose to tumour
Minimise dose to surrounding normal tissue
25
What is radical radiotherapy
Aim to cure
4 - 7 weeks
20 - 37 individual sessions
Small fields of irradiation
26
What is palliative radiotherapy
Alleviates symptoms
1 - 10 individual sessions
Large field of irradiation
27
What are the short-term side effects of radiotherapy
Fatigue
Hair loss
Dysphagia
Sore throat
Oral mucositis
Diarrhoea
Sterility
Dysuria
Radiation cystitis
Pancytopenia
Lymphoedema
Erythema
Nausea and vomiting
28
What are the late side effects of chemotherapy
Skin pigmentation/necrosis/ulceration
Bone necrosis/fracture/impaired growth
Mouth ulcers/dryness
Cataracts
Loss of sight
Lung fibrosis
Cardiomyopathy
Pericardiafibrosis
Infertility
Menopause
Bowel strictures/adhesions/fistulas
29
What is imitinib
A BCR-ABL tyrosine kinase inhibitor
'Magic bullet'
Very tumour selective
Has very few side effects
30
What is growth fraction
The proportion of cells dividing at any given time
Useful indicator of the sensitivity of cancer cells to chemo drugs (large growth fraction = more responsive)
31
Which cancers are highly sensitive to chemotherapy
Lymphomas
Germ cell tumours
Small cell lung cancers
Neuroblastomas
Wilm's tumours
32
Which cancers have a moderate sensitivity to chemotherapy
Breast
Colorectal
Bladder
Ovary
Cervix
33
Which cancers have a low sensitivity to chemotherapy
Prostate
Renal
Brain
Endometrial
34
What is the main side effect of cisplatin and carboplatin
Ototoxicity
Nephrotoxicity
35
What is the main side effect of vincristine
Peripheral neuropathy
36
What is the main side effect of bleomycin and busulfan
Pulmonary fibrosis
37
What is the main side effect of transtuzuman and doxorubicin
Cardiotoxicity
38
What is the main side effect of cyclophosphamide
Haemorrhagic cystitis
39
What is the main side effect of methotrexate, 5-FU and 6-MP
Myelosuppression
40
What are the risk factors for prostate cancer
Increasing age
Family history
Genetic conditions (BRCA2...)
Ethnicity (black > white > asian)
41
How might a patient with prostate cancer present
Often asymptomatic
Raised PSA
LUTS
Bone pain
Ejaculatory symptoms (rare)
42
What investigations are needed for suspected prostate cancer
DRE
PSA
MRI prostate/pelvis (usually pre-biopsy)
Biopsy (TRUS (transrectal ultrasound), transperineal)
43
What are the common causes of raised PSA
Prostate cancer
Urinary infection
Prostatitis
BPH
Acute urinary retention
Intense exercise
Sexual activity
44
What is the management for metastasis of prostate cancer
Hormones (surgical/medical castration)
Palliation (single-dose radiotherapy, bisphosphonates)
45
What is the management for locally advanced prostate cancer
Radical radiotherapy
Adjuvant hormones
46
What is the management for localised prostate cancer
Criteria: T1/2, N0, M0, PSA < 20
Curative intent (active surveillance, radical prostatectomy, radiotherapy)
Palliative care
47
What are the cancer-related differentials of haematuria
Renal cell carcinoma
Transitional cell carcinoma
Bladder carcinoma
Advanced prostate carcinoma
48
What are the non-cancer differentials of haematuria
Stones
Infection
Inflammation
Large BPH
49
What investigations are needed for haematuria
Ultrasound
Flexible cystoscopy
Urine cytology
50
What are the tumour markers for testicular cancer
aFP
hCG
LDH
51
When should cancer be suspected in a penile lump/ulcer
STI ruled out
Persistent despite treatment
52
What are the risk factors for bladder transitional cell carcinoma
Male
White
Smoking
Occupational exposure (rubber/plastic manufacturing, painting, hairdressing...)
53
What is the management for bladder transitional cell carcinoma
Low risk, non-muscle invasive (monitoring cystoscopies)
Intermediate/high risk, non-muscle invasive (monitoring cystoscopies, intravesical chemotherapy/immunotherapy)
Muscle invasion (neoadjuvant chemotherapy, radical cystectomy/radiotherapy, palliative care)
Metastasis (systemic chemotherapy, immunotherapy, palliation)
54
Give an overview of renal cell carcinoma
95% of upper urinary tract tumours
Presentation: haematuria, incidental, palpable mass
M>F
White > non-white
Risk factors: smoking, obesity, dialysis
Management: surveillance, excision, biological therapies, palliation
55
Give an overview of testicular cancer
Germ cell tumour
Usually <45
Risk factor: undescended testis
Treatment: inguinal orchidectomy
56
What are the risk factors for penile cancer
Phimosis (hygiene, smegma)
HPV (16 and 18)
57
How quickly does cancer treatment need to start
62 days from GP referral to treatment
31 days from diagnosis to treatment
58
What are the risk factors for lung cancer
High smoking pack years
Airway obstruction
Increasing age
Family history
Exposure to carcinogens (asbestos...)
59
How might a patient with lung cancer present
Often asymptomatic
Unexplained cough
Weight loss
Shortness of breath
Lethargy
Weakness
Hoarse voice
Dysphagia
Chest pain
Wheeze
Fever
Clinical signs of: SVCO, hypercalcaemia, anaemia, SIADH, Cushing's, VTE
60
How is the T staging for lung cancer calculated
T1 - < 3 cm
T2 - 3 - 7 cm, invades visceral pleura/main bronchus
T3 - > 7 cm, invades phrenic nerve/diaphragm/chest wall/mediastinal pleura
T4 - invades mediastinal organs/vertebral bodies/carina/different lobes
61
How is the N staging for lung cancer calculated
N0 - no nodal involvement
N1 - ipsilateral bronchopulmonary/hilar nodes
N2 - ipsilateral mediastinal/subcarinal nodes
N3 - contralateral/supraclavicular nodes
62
What are the common sites of metastases in lung cancer
Liver
Adrenals
Lung
Lymph nodes
Pleura
Brain
Bone
63
What diagnostic tests are needed for lung cancer
Bloods (routine, calcium, INR)
CXR
Staging CT
Histology (ultrasound guided FNA, bronchoscopy, CT biopsy, thoracoscopy)
64
What is a malignant pleural effusion
Diagnosed by ultrasound-guided aspirate
Exudate
Indicates advanced disease (M1)
65
What are the differentials for incidental pulmonary nodes on CT
Primary bronchial carcinoma
Infection (TB, fungal)
Non-infectious granuloma (granulomatosis with polyangiitis)
Rheumatoid nodules
Bronchial carcinoid
Hamartoma
Metastasis
Management: CT surveillance for 24 months, consider removal
66
How is SIADH related to lung cancer
Due to paraneoplastic syndrome
Get hyponatraemia
Presentation: headache, lethargy, confusion, seizures
Management: fluid restriction, hypertonic saline, diuretics
67
What is the management for brain metastasis
Dexamethasone
Urgent radiotherapy
68
What is mesothelioma
Cancer of pleura
Due to asbestos exposure
69
What is Horner syndrome
Due to compression of sympathetic ganglion by Pancoast's tumour
Ptosis, miosis, anhidrosis, exophthalmos
70
How might non-small cell lung cancer present
Horner syndrome
Hypercalcaemia
71
How might small cell lung cancer present
Rapidly progressing symptoms
SVCO
SIADH
Paraneoplastic syndrome
Bulky mediastinal disease
Bone metastasis
Brain metastasis
72
What are the tumour markers for lung cancer
(All non-specific)
CEA
Ca 19-9
Ca 125
PSA
aFP
b-HCG
73
What are the types of non-small cell lung cancer
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Large cell with neuroendocrine features
Adenosquamous
74
What are the genetic conditions that can increase the risk of colorectal cancer
Familial adenomatous polyposis (autosomal dominant, develop cancer by 40 if untreated)
Hereditary non-polyposis colorectal cancer (aka Lynch syndrome, autosomal dominant, 85% cancer by age 70)
Familial colorectal cancer
Inflammatory bowel disease
75
What lifestyle factors increase the risk of colorectal cancer
Western diet (low fibre, high fat, red meat)
Obesity
Smoking
Alcohol
Lack of exercise
76
How might a patient with right colon cancer present
Weight loss
Fatigue
Obstruction rare
Iron deficiency anaemia
77
How might a patient with left colon cancer present
Constipation
Abdominal pain
Alternating bowel habits
Bright red rectal bleeding
Large bowel obstruction
78
How might a patient with rectal cancer present
Obstruction
Tenesmus
Bright red rectal bleeding
Palpable mass
79
What investigations are needed for colorectal cancer
Baseline bloods
Tumour markers (CEA)
Colonoscopy
Flexible sigmoidoscopy
Barium enema
CT colonography
Biopsy
CT CAP
80
What is the management of liver metastasis in colorectal cancer
Surgical resection
Microwave ablation
Radiofrequency ablation
Selective internal radiotherapy
81
What are the common sites of metastasis from prostate cancer
Liver
Bone
Bladder
Lymph nodes
82
How is the Gleason's pattern calculated in prostate cancer
1 - small, uniform glands
2 - more stroma between glands
3 - distinctly infiltrative margins
4 - irregular masses of neoplastic glands
5 - only occasional gland formation
83
What is the relationship between grade and Gleason's score for prostate cancer
Grade 1 - 3+3
Grade 2 - 3+4
Grade 3 - 4+3
Grade 4 - 4+4
Grade 5 - Gleason 9-10 (lack of gland formation)
84
What is the difference between active surveillance and watchful waiting for PSA testing
Active surveillance - closely monitor, regular examinations and tests, give potentially curative treatment if have progression
Watchful waiting - less intense follow-up, few tests, aim to control symptoms
85
What is the management for prostate cancer
Brachytherapy (for small, solid tumours that have not spread)
Radical prostatectomy
External beam radiation therapy
Androgen deprivation therapy (GnRH analogues - suppress FSH)
86
Head and neck cancers are mainly what type of cancer
Squamous cell carcinoma
87
What are the risk factors for developing head and neck cancers
Smoking
Alcohol
Betel nuts
HPV
EBV
Asbestos exposure
Formaldehyde exposure
88
What do head and neck cancers often present with
Lymphadenopathy
Difficulty breathing
Dysphagia
Difficulty speaking
89
What are the NICE guidelines for likely presentations of head and neck cancers
Lip/oral cavity lump - oral cancer
Persistent/unexplained neck lump - oral cancer
Unexplained neck lump in > 45 - laryngeal cancer
Persistent and unexplained hoarse voice in > 45 - laryngeal cancer
Read and white patches in oral cavity - oral cancer
Unexplained ulceration in oral cavity for > 3 weeks - oral cancer
90
Where do head and neck cancers commonly metastasise to
Lymph nodes
Lung
Bone
Liver
Brain
91
What is the management for head and neck cancers
Surgery (resection, laser, excision)
Radiotherapy
Chemotherapy
Biological therapies
Immunotherapy
92
What is the criteria for neutropenic sepsis
Undergoing systemic anticancer treatment
Temperature > 38
Neutrophil count > 0.5
93
When should neutropenic sepsis be suspected
In all chemotherapy patients who become unwell
Some may not have a fever due to corticosteroid use
94
When are patients usually most susceptible to neutropenic sepsis
Around day 10
| Bigger range for haematological malignancy
95
What are the signs and symptoms of neutropenic sepsis
Fever
Tachycardia > 90
Hypotension < 90
Respiratory rate > 20
Symptoms related to specific systems (cough, shortness of breath, mucositis)
Drowsiness
Confusion
96
What factors increase the risk of infection in cancer patients
Prolonged neutropenia (> 7 days)
Severe neutropenia
Significant co-morbidities
Aggressive cancer
Central lines
Mucosal disruption
Hospital admission
97
What investigations are needed in neutropenic sepsis
Bloods
Blood cultures (often negative)
Swabs
CXR
98
What are the common causative organisms of neutropenic sepsis
Staph aureus
Staph epidermidis
Enterococcus
Streptococcus
80% due to endogenous flora
99
What is the management for neutropenic sepsis
Don't wait for FBC to confirm neutropenia
Empirical IV broad spectrum antibiotics within 1 hour
Sepsis 6
Involve seniors early
100
What is the further management for neutropenic sepsis
Granulocyte colony stimulating factor
Patient education
Antibiotic prophylaxis
Dose reduction for further chemotherapy
Stop treatment
101
Why does metastatic spinal cord compression need to be urgently treated
To preserve function
102
How does metastatic spinal cord compression occur
Dural sac and its contents compressed at level of spinal cord/corda equina
80-85% due to collapse/compression of vertebral bodies that have metastatic spread
10% due to direct spread of tumour into epidural space (especially lymphomas)
103
What are the signs of the reversible stage of metastatic spinal cord compression
Oedema
Venous congestion
Demyelination
104
What are the signs of the irreversible stage of metastatic spinal cord compression
Prolonged compression
Vascular injury
Cord necrosis
105
Which cancers commonly cause metastatic spinal cord compression
Breast
Prostate
Lung
Lymphoma
Myeloma
Renal
Thyroid
106
How might a patient with metastatic spinal cord compression present
Motor symptoms (reduced power, difficulty standing/walking/climbing stairs, often symmetrical)
Sensory loss
Sphincter dysfunction (hesitancy, frequency, retention, overflow, incontinence)
Reduced performance status
Back pain
Poor response to normal analgesia
Exacerbated by: neck flexion, coughing, sneezing, straining, lying down
107
What are the investigations for metastatic spinal cord compression
Pain suggestive of spinal metastasis - MRI spine within 1 week
Signs of metastatic spinal cord compression - MRI within 24 hours
108
What is the management for metastatic spinal cord compression
Within 24 hours of diagnosis
Dexamethasone
Analgesia
Surgery
Radiotherapy
109
What is the prognosis for metastatic spinal cord compression
Depends on mobility at presentation
Loss of sphincter control - poor sign
Good in radiosensitive tumours - lymphoma, myeloma, breast, prostate, NSCLC
110
Which cancer types does hypercalcaemia commonly occur in
Breast
SCLC
Renal
Myeloma
Lymphoma
111
What are the causes of hypercalcaemia in cancer patients
Humeral (80%, chemicals released by tumour affect calcium levels (PTH-related protein, vitamin D))
Bone invasion (20%, osteolytic metastasis with local release of cytokines)
20% do not have bone metastasis
112
How might a patient with hypercalcaemia present
Nausea
Anorexia
Thirst
Polydipsia
Polyuria
Fatigue
Constipation
Confusion
Poor concentration
Drowsiness
Bone pain
Severe: nausea, vomiting, ileus, delirium, coma, death
113
What is the treatment for hypercalcaemia
Rehydration
Bisphosphonates (inhibit osteoclastic bone resorption)
Denosumab (SC)
Systemic treatment of malignancy
Consider: regular blood tests, bisphosphonate infusions
114
What is the prognosis for cancer patients with hypercalcaemia
Many die within 3 months
115
How might a patient with superior vena cava obstruction present
Swelling in face/neck/arms
Distended neck and chest veins
Shortness of breath
Cyanosis
Stridor
Hoarse voice
Lethargy
Headaches
Confusion
Conjunctival swelling
Blurred vision
Pemberton's sign
116
How can superior vena cava obstruction lead to death
Laryngeal oedema
Airway obstruction
117
What investigation is needed for superior vena cava obstruction
CT with contrast
118
What is the management for superior vena cava obstruction
Sit upright, elevate head
Oxygen
Dexamethasone
Opioids
Benzodiazepines
Stent insertion
Anticoagulation (if due to thrombosis)
119
What are the features of tumour lysis syndrome
Hyperuricemia
Hyperkalaemia
Hyperphosphatemia
AKI (uric acid or calcium phosphate in renal tubules)
Hypocalcaemia
120
Which cancers are most susceptible to tumour lysis syndrome
Haematological malignancy
Bulky chemo-responsive tumours
121
What are the risk factors for developing tumour lysis syndrome
High volume/bulky disease
Pre-treatment LDH high
High circulating WCC
Pre-existing renal dysfunction/nephropathy
Pre-treatment hyperuricaemia
Hypovolemia
Diuretic use
Urinary tract obstruction from tumour
122
How might a patient with tumour lysis syndrome present
3-7 days after chemotherapy
Nausea and vomiting
Diarrhoea
Anorexia
Lethargy
Haematuria
Anuria
Fluid overload
Cardiac arrhythmias (tented T waves, QTc derangement)
Muscle cramps
Tetany
Seizures
123
What is the treatment for tumour lysis syndrome
Good hydration and fluid balance
Monitor electrolytes
Allopurinol (xanthine oxidase inhibitor, get less hyperuricemia)
Rasburicase (degrades uric acid)
Dialysis
124
What is palliative care
Active, total care of patients whose disease is not responsive to curative treatment
Aim to control pain and other symptoms
Deal with social, psychological, and spiritual issues
125
When is a patient said to be end of life
Likely to die within the next 12 months
126
What are the general indicators of decline
Unplanned hospital admissions
Poor/deteriorating performance status
Dependence on carers
Carers need more help and support
Significant weight loss
Persistent symptoms despite optimal treatment
Decision to reduce/stop treatment
127
What are the stages of the clinical frailty score
1 - very fit
2 - well
3 - managing well
4 - vulnerable
5 - mildly frail
6 - moderately frail
7 - severely frail
8 - very severely frail
9 - terminally ill
128
What are the factors that indicate that death is approaching
Bedbound
Drowsiness
Impaired cognition
Difficulty taking oral medications
Reduced food and fluid intake
Increased symptom burden
129
What are the signs that a patient is entering the dying phase
Shallow breathing
Use of accessory muscles
Respiratory secretions
Skin colour changes
Temperature at extremes
Decreased consciousness
Agitation
Restlessness
Decreased urine output
Incontinence
Decreased/absent oral intake
Difficulty swallowing
130
What are some commonly used medications in the last few days of life
Morphine (pain and breathlessness)
Midazolam (anxiety, agitation, seizures)
Levomepromazine (nausea, vomiting, hallucinations)
Glycopyrronium (respiratory secretions)
131
What are the features of pain in advanced disease
Usually persistent
Can have multiple aetiologies
Impairs function
Threatens independence
Invokes fear of further suffering
Aim to optimise quality of life right up until death
132
What are the types of pain
Nociceptive
Neuropathic
Mixed
133
What is nociceptive pain
Normal nervous system, pain due to tissue damage
Somatic - from skin/muscle/bone, sharp/throbbing/well-localised
Visceral - from hollow viscus/solid organ, diffuse ache, difficult to localise
134
What is neuropathic pain
Malfunctioning nervous system
Nerve structure damaged
Stabbing, shooting, burning, stinging, numbness, hypersensitivity
135
Which NSAIDs/COX-2 inhibitors should be prescribed when there is no cardiovascular/GI risk
Ibuprofen
Diclofenac
Naproxen
136
Which NSAIDs/COX-2 inhibitors should be prescribed when there is GI risk
Celecoxib
137
Which NSAIDs/COX-2 inhibitors should be prescribed when there is cardiovascular risk
Naproxen
Ibuprofen
138
What should be prescribed alongside all NSAIDS/COX-2 inhibitors
PPI
139
What are some adjuvant (co-analgesic) medications
Antidepressants (amitriptyline, duloxetine)
Anticonvulsants (gabapentin, pregabalin)
Benzodiazepines (diazepam, clonazepam)
Steroids (dexamethasone)
Bisphosphonates
140
Which medications are on step 1 of the WHO pain ladder
Paracetamol
NSAIDs
141
Which medications are on step 2 of the WHO pain ladder
Dihydrocodeine
Codeine phosphate
Tramadol
Co-codamol
142
Which medications are on step 3 of the WHO pain ladder
Oxycodone
Morphine
Fentanyl
Diamorphine
143
How does pain respond to opioids in different parts of the body
Soft tissue - good response
Viscera - good/partial response
Bone - partial response
Neuropathic - poor response
144
What is the codeine to morphine conversion ratio
10 : 1
145
How is the morphine dose calculated
TDD / 2 = slow release dose
TDD / 6 = PRN dose
146
Which is the name of the slow release morphine
Zomorph
147
What is the name of the immediate release morphine
Oramorph
148
What are the common side effects of opioids
Constipation (give laxatives)
Dry mouth
Nausea (give antiemetics)
Vomiting
Drowsiness
Sedation
149
What are fentanyl patches
Transdermal opioid
Non-renal excretion
12-24 hours to reach steady state
Use oramorph PRN for breakthrough pain
150
What are the signs of opioid toxicity
Pinpoint pupils
Hallucinations
Drowsiness
Vomiting
Confusion
Myoclonic jerks
Respiratory depression
151
Why does opioid toxicity occur
Fast dose escalation
Renal impairment
Poor response to pain
Given with a nerve block
152
How is breathlessness as a palliative symptom managed
Stay calm
Sit upright
Air flow across face
Oxygen
Consider medications: morphine, lorazepam, midazolam
153
Which receptors are found in the chemoreceptor trigger zone of the brain
NK1
D2
5HT3
154
Which receptors are found in the vomiting centre of the brain
NK1
ACh
H1
5HT2
155
What factors increase the risk of chemo-induced nausea and vomiting
Specific chemo drugs
Female
< 50
Past history of nausea and vomiting
156
What are the causes of constipation in cancer patients
Disease-related
Fluid depletion
Weakness
Intestinal obstruction
Medications
Biochemical (hypercalcaemia, hypokalaemia)
Pain
157
How is malignant bowel obstruction managed
Non-surgical: rest bowel, limit oral fluids, NG tube for vomiting, correct electrolyte imbalance, analgesia, trial dexamethasone
Surgical: endoscopic stenting, venting gastrostomy (to decompress)
158
What are the principles of the double effect
Action must be morally good
Only good effect must be intended
Good effect must not be achieved by way of bad effect
Good result must outweigh the bad effect
159
How does alkylating agent chemotherapy work
Makes cross-links between DNA stands
Prevents DNA replication
160
How does platinum agent chemotherapy work
Makes cross-links between DNA stands
Prevents DNA replication
161
How does antimetabolite chemotherapy work
Acts as substitute for metabolites needed for DNA synthesis
162
How does topoisomerase inhibitor chemotherapy work
Prevents unwinding of DNA strands for replication
163
How does tubulin-active agent chemotherapy work
Stops spindle formation
164
What are the immediate side effects of chemotherapy
(Within minutes)
Extravasation (leaking of chemo drug into adjacent tissue)
Facial/body flushing
Cardiac arrhythmias
Hypotension
Hypersensitivity
Anaphylaxis
Haemorrhagic cystitis
165
What are the short-medium term side effects of chemotherapy
(Hours - 7 days)
Discolouration of urine
Tumour lysis syndrome
Nausea and vomiting
Mucositis
Constipation
Diarrhoea
Fatigue
166
What are the medium-long term side effects of chemotherapy
(> 7 days)
Bone marrow suppression
Alopecia
Liver dysfunction
Renal toxicity
Cardiac toxicity
Peripheral neuropathy
Pulmonary fibrosis
Changes in fertility
167
What are the modes of chemotherapy resistance
Modified cell membrane composition
Reduced drug transporters
Increased efflux pumps
Drug inactivation mechanisms develop
Drug target modification/loss
Up-regulation of pro-survival genes
168
How does checkpoint inhibitor immunotherapy work
Decrease suppression of T cell immune response (encourage immune cells to kill cancer cells)
169
How does adoptive cell therapy immunotherapy work
T cells isolated from patient, modified, multiplied, re-injected
170
How does cancer vaccine immunotherapy work
Use patient's own dendritic cells
Used in metastatic prostate cancer
171
How does cytokine immunotherapy work
Increase signalling between immune cells and other body cells
172
How does oncolytic virus immunotherapy work
Viruses target particular cancer cells
173
What is the main side effect of immunotherapy
Organitis
174
What is the NICE urgent CXR criteria for lung cancer
> 40 and 2 of (or smoker and 1 of): cough, fatigue, shortness of breath, chest pain, anorexia, weight loss
> 40 and: persistent/recurrent chest infections, finger clubbing, persistent lymphadenopathy, chest signs consistent with lung cancer, thrombocytosis
175
Give an overview of small cell lung cancer
Rare in non-smokers
60% metastatic at presentation
Aggressive
Poor prognosis
Very sensitive to chemotherapy
High relapse rate
Often use radiotherapy
Give prophylactic cranial irradiation
176
What are radiosensitizers
Drugs that make cancer cells more susceptible to radiotherapy
177
Which cancers are commonly treated with chemoradiotherapy
Head and neck cancers
Cervical cancer
Bladder cancer
Anal cancer
178
What are the side effects of radiotherapy
Hair loss
Dysphagia
Sore throat
Oral mucositis
Diarrhoea
Sterility
Dysuria
Radiation cystitis
Low blood counts
Lymphoedema
Erythema
Nausea and vomiting
Fatigue
