Key Topic Lectures Flashcards
What do you need to assess in a cancer pain hx?
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
How does cancer pain present?
Usually persistent
Impairs function and threatens independence
Often multiple aetiologies
Give some causes of chest pain in a patient with lung cancer
Cancer itself: chest wall invasion, bone mets, MSCC
Tx: oesophagitis, local reaction to RT
Unrelated to cancer: CAP, PE, Pneumothorax, MI, MSK, Anxiety
What different types of pain may patients present with?
Nociceptive pain = normal nervous system with identifiable lesion causing tissue damage
- Can be somatic (well localised) or visceral (diffuse)
Neuropathic pain = due to malfunctioning nervous system, nerve structure itself is damaged
- Stabbing, shooting, burning, stinging, allodynia, electric shocks, numbness
40% of pain is mixed – prolonged poorly controlled nociceptive pain may damage nervous system
What is breakthrough pain?
transient exacerbation of pain, spontaneous or secondary to trigger
Outline the cancer pain tx stepladder
Non opioid (+/- adjuvant) – often start with paracetamol (be careful giving full dose in cachexic patients) and ibuprofen!
Weak opioid (+/- adjuvant, +/- non-opioid)
Strong opioid (+/- adjuvant, +/- non-opioid)
Give some examples of non-opioids that may be used for cancer pain. What do you need to remember about these drugs?
NSAIDs
COX2 (lower risk of GI problems, doesn’t affect bleeding time)
Always prescribe a PPI alongside
These drugs may exacerbate heart failure
What are adjuvants? What may they be used for?
Primary indication is not analgesia – patients may not be compliant for this reason (e.g. if box says it is an epilepsy medication)
Can be considered for pain that is only partially responsive to opioids
Can be used synergistically – opioid sparing effect
Can help with CNS sxs
Give some examples of adjuvants
Antidepressants, Anticonvulsants, Benzodiazepines, Steroids, Bisphosphonates
Key doses to remember:
Amitriptyline start 10-25mg (S/E confusion, hypotension)
Gabapentin 300mg TD
Give some examples of weak opioids. Key facts to remember?
Codeine, dihydrocodeine, tramadol
Not recommended in kids
Tramadol is less constipating than codeine but causes more N&V and anorexia
Give some examples of strong opioids
Morphine, diamorphine, oxycodone, fentanyl
Give some key opioid side effects
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
Drowsiness / cognitive impairment / light-headedness
Respiratory depression – suddenly giving a very high dose increases risk, AKI may precipitate
- No increased risk at end of life, relatively rare
How would you address patient concerns about opioid use including addiction, tolerance and hastening of death?
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
What tx does bone pain often respond well to?
NSAIDs, radiotherapy and bisphosphonates
What pain relief is best suited to liver capsule pain?
steroids / NSAIDs
What is the common dose for codeine?
Codeine phosphate 30mg is commonly used, ceiling dose is 240mg/24hours
What types of morphine are available?
Oramorph – immediate release, lasts 3-4 hours
Zomorph – slow release, lasts 12 hours
Parenteral (morphine sulphate for injection)
Give some general rules to remember when starting a patient on opioids
When starting opioids add laxative and anti-emetics
- Metoclopramide is a good anti-emetic because is a prokinetic and acts at CNS
- Movicol is a good laxative
Don’t start too high, titrate too quickly, or make them wait 4 hours for PRN dose
No strict ceiling for PRN dose – just ensure its an opiate responsive pain
Give some signs of opioid toxicity. What may precipitate this?
Pinpoint pupils, hallucinations, drowsiness, vomiting, confusion, myoclonic jerks, respiratory depression
Causes: prescribing errors, quick dose escalation, AKI – always check renal function!
What is required for controlled drug prescriptions?
Requires name and ID of patient, exact instructions for pharmacist, drug, form, strength, total number of tablets/patches in words and figures
Give some causes of N+V in cancer patients
Gastric stasis- feel full after a couple of mouthfuls, belching, reflux symptoms, vomiting after eating, after vomiting feel better
Bowel obstruction- abdominal distension and colicky pain, absolute constipation, potentially faecal vomit
Cerebral mets / raised ICP– worse on movement, worse in the mornings, vomiting often projectile, may also complain of headaches and visual disturbance
Chemotherapy – comes alongside doses of chemotherapy, first 24 hours usually the worst
Medication side effects – digoxin, citalopram
Infection – gastroenteritis, pneumonia (severe coughing), thrush
Anxiety- nausea without vomiting, sweating, tremor, palpitations
Biochemical causes – alcohol, low sodium, high calcium, significant renal impairment, tumour toxins
What receptors are found in the CTZ?
dopamine, serotonin (5HT3)
Give some causes of constipation in cancer patients
- Disease related: immobility, reduced intake, abdominal disease, obstruction
- Fluid depletion
- Weakness
- Medication side effect
How can you manage malignant bowel obstruction?
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 cyclizine, opiates and buscopan (to reduce colic and secretions)
May use octreotide – somatostatin analogue used to reduce secretions
When should you be concerned about hypercalcaemia?
How should you treat?
anything over 2.5!
tx with aggressive fluid resus and bisphosphonates e.g. Pamidronate
What clinical scoring systems can be used in palliative care?
SPICT: used to identify patients at risk of deteriorating or dying
Clinical frailty scale – 9 phenotypes
What 5 common symptoms should you prescribe for in anticipation in an end of life patient?
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)
What types of radiotherapy are available?
External Beam: most common
Brachytherapy: internal localised radiation (e.g. through seed or capsule implanted in body cavity)
Systemic Treatment
Chemotherapy describes the use of cytotoxic drugs to destroy cancer cells.
What routes of administration are available?
- PO
- IV
- IM
- Intralesional - directly into a cancerous area
- Intrathecal - into the CSF – by lumbar puncture
- Topical - medication will be applied onto the skin
Define neoadjuvant, adjuvant and palliative treatment
Neoadjuvant: administration of a therapeutic agent before definitive treatment (surgery or radiotherapy) to shrink tumour and optimize outcomes
Adjuvant: treatment given after treatment to reduce the risk of disease recurrence (chemotherapy or radiotherapy)
Palliative: treatment designed to relieve symptoms and improve quality of life (chemotherapy, radiotherapy, sometimes surgery)
Give some examples of acute toxicity of radiotherapy
- Hair loss
- Fatigue
- Dysphagia
- Nausea and vomiting
- Diarrhoea
- Erythema
- Lymphoedema
- Dysuria / radiation cystitis
- Sterility
Give some examples of long term toxicity of radiotherapy
Skin: Pigmentation, necrosis, telangiectasia, ulceration
Bone: Necrosis, fracture, impaired growth (children)
Mouth: Ulceration, xerostomia (dry mouth)
Eyes: Cataracts, loss of sight
Lymphoedema
Lung Fibrosis
Heart: Cardiomyopathy, pericardial fibrosis
Gonads: Infertility, menopause
Bowel: strictures, adhesions, fistulas
Secondary malignancy
What is extravasation? How should you approach this?
the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue
Check whether agent is:
*vesicant: DNA-binding/non-DNA-binding
*irritant
*non-vesicant
Arrange plastics review if concerned
What supportive mx is available for acute toxicity of chemotherapy and radiotherapy?
Cold cap for alopecia– cooling reduces blood flow (and therefore chemo flow) to hair follicles
Prophylactic anti-emetics for N+V
Flamigel cream to protect skin
What are the risks to haematology patients undergoing tx?
- Infection
- Difficulties with IV access
- Renal failure and bulky disease (high WCC)
- Tumour lysis syndrome
- Impact on fertility
How should you manage neutropenic sepsis?
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
What can you give patients with haem malignancies to reduce risk of infection?
- Aciclovir – prevent varicella and herpes reactivation
- Posaconazole – antifungal
- Co-trimoxazole – prevent PCP
- G-CSF (granulocyte colony stimulating factor)
What is GCSF? Who should never receive it? Side effects?
sub cut injection, stimulates bone marrow, used for patients with healthy bone marrow that has been wiped out by chemo
DON’T give to leukaemia patients as will just stimulate their bone marrow to make more blast cells
Side effects include bone pain, fatigue, and nausea
What are the options for obtaining IV access?
Cannula
Tunnelled central line – into jugular vein
PICC Line – into subclavian vein
Portacath – nothing externally, reduced infection risk, harder to access
Complications of IV lines?
Infection
Thrombosis
Bleeding
Failure
What are the fertility considerations when treating patients with haem malignancies?
Consider fertility preservation e.g. egg preservation (only an option for slow growing cancers that don’t require urgent tx) and sperm banking
Patients need to avoid pregnancy whilst on chemo (men and women)
Avoid COCP
Give norethisterone to stop periods
How can you manage mucositis in patients undergoing anti cancer treatments?
Can impair ability to eat
Can give mouthwashes e.g chlorhexidine (antiseptic) and difflam (anaesthetic)
Can use mucane lozenges and a syringe driver for analgesic if severe
If significant diarrhoea – measure fluid losses, consider loperamide
how may haematological cancers present?
Sxs of bone marrow failure – anaemia, thrombocytopenia, neutropenia
Sxs of disease involvement – lumps, organomegaly (due to extramedullary haemopoiesis, invasion by cancer)
B sxs – weight loss, fever, night sweats
Sxs of hypercalcaemia - mostly in myeloma and lymphoma
Sxs of hyperviscosity – headache, somnolence, visual disturbance
How should suspected haematological cancer be investigated?
- FBC, U&Es, LFTs, CRP, Ca
- Blood film, reticulocytes
- LDH, urate (TLS- need urate baseline, start allopurinol early)
- Immunophenotyping (certain proteins are fluorescent, flow cytometry = immunophenotyping in peripheral blood FLOW)
- BM aspirate
- CT scan
- PET scan (lymphoma/myeloma)
- MRI spine/pelvis (myeloma)
Younger child with high WCC and blasts =
almost always ALL
Older adult with high WCC and blasts =
more likely to be AML
Dry tap (no liquid aspirated on BMB) may =
myelofibrosis
Unexplained cough for longer than 3 weeks =
urgent CXR
Erythema nodosum + unexplained cough =
think sarcoidosis (not lung cancer)
What are the 4 commonest presenting sxs of lung cancer?
- Unexplained cough
- Haemoptysis
- Weight loss
- SOB
Lung cancer rarely causes mets where?
the kidneys
Nobody leaves lung cancer clinic without having what measured?
calcium levels - risk of hypercalcemia
What are the next steps after lung cancer is detected on CXR?
Next perform a Staging CT (CT CAP)
After staging CT, explain to patient the dx and need to biopsy (can do a CT guided lung biopsy) to plan specific tx
Can use SPIKES mnemonic to help with breaking bad news
How should you investigate and manage malignant pleural effusion?
Bloods- FBC, U&Es, LFTs, CRP, INR
US guided aspirate – protein, LDH, cytology, microbiology
o If cytology +ve = cancer
o If -ve = medical thoracoscopy
Pleural effusion = usually non curative tx for cancer
Nodules (mass in the lung 5mm – 3cm) may progress to lung cancer.
How high is the risk?
Nodules > 2cm have a 50% chance of becoming lung cancer
BROCK score and HERDER score to calculate risk
How should you approach a patient with MSCC?
Ix: MRI Spine
Mx: High dose steroids IV or PO dexamethasone (don’t give at night as will keep awake) +PPI
Radiotherapy +/- surgical decompression
Urinary catheterisation
Lung Cancer + confusion, nausea and weakness =
likely hypercalcaemia
Ix: measure serum calcium!!!
Mx: IV fluids + Pamidronate (bisphosphonate) infusion over 30-60 mins
How should you approach a patient with SVCO?
Ix: Urgent CT
Mx: Admit, give oxygen and analgesia, sit upright to reduce venous pressure
Urgent steroids
Radiotherapy, intraluminal stenting or chemotherapy
Give some of the key paraneoplastic syndromes associated with lung cancer
Cushing’s syndrome – most common with SCLC, manage with metyrapone
Lambert-Eaton Syndrome
SIADH – common, presents with hypernatremia, measure serum and urine osmolality to dx, has a very poor prognosis, manage with fluid restriction and tolvaptan
How should you manage a patient with headache due to brain mets?
- CT and MRI brain
- Start Dexamethasone 4mg BD with weaning plan
- Give Keppra for seizures
- Patients cannot drive
What surgery is available for lung cancer?
- Wedge resection
- Lobectomy
- Pneumonectomy
What are the options for palliative lung cancer intervention?
- YAG Laser
- Cryotherapy
- Diathermy
- Intraluminal brachytherapy
- Bronchial stents
Biggest occupational exposure to asbestos =
plumbing!
> 1/2 of new cases of cancer in men are what?
prostate, lung or bowel
What diagnoses should you consider if you see lytic bone lesions?
think myeloma first, but consider other causes e.g. prostate and breast
What would be the issues with PSA screening for prostate cancer?
PSA can be raised for multiple reasons –poor specificity, low positive predicted value
Lead time bias – appears patients are surviving longer but there is actually just a longer time between diagnosis and death because diagnosis is earlier
Length time bias – screening picks up slow growing indolent cancer
Over diagnosis
Over-treatment
Poor cost-effectiveness
Give some urological DDx for haematuria (could also be glomerular):
Cancer
* Renal cell carcinoma (RCC)
* Upper tract TCC
* Bladder carcinoma
* Advanced prostate carcinoma
Other
* Stones
* Infection, Inflammation
* Benign prostatic hyperplasia (large)
How should you investigate a painless testicular lump?
Refer via cancer pathway to Urology!
Urgent ultrasound of scrotum to confirm diagnosis
Check testis tumour markers if testicular mass on ultrasound (aFP, hCG, LDH)
How should you approach a patient with a penile lump?
Suspect penile cancer if a sexually transmitted infection has been excluded or lump/ulcer/lesion is persistent despite treatment
Beware the male with recurrent balanitis and phimosis
