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Y4 Cancer Care > Key Topic Lectures > Flashcards

Key Topic Lectures Flashcards

1
Q

What do you need to assess in a cancer pain hx?

A

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

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2
Q

How does cancer pain present?

A

Usually persistent
Impairs function and threatens independence
Often multiple aetiologies

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3
Q

Give some causes of chest pain in a patient with lung cancer

A

Cancer itself: chest wall invasion, bone mets, MSCC
Tx: oesophagitis, local reaction to RT
Unrelated to cancer: CAP, PE, Pneumothorax, MI, MSK, Anxiety

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4
Q

What different types of pain may patients present with?

A

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

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5
Q

What is breakthrough pain?

A

transient exacerbation of pain, spontaneous or secondary to trigger

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6
Q

Outline the cancer pain tx stepladder

A

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)

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7
Q

Give some examples of non-opioids that may be used for cancer pain. What do you need to remember about these drugs?

A

NSAIDs
COX2 (lower risk of GI problems, doesn’t affect bleeding time)

Always prescribe a PPI alongside
These drugs may exacerbate heart failure

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8
Q

What are adjuvants? What may they be used for?

A

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

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9
Q

Give some examples of adjuvants

A

Antidepressants, Anticonvulsants, Benzodiazepines, Steroids, Bisphosphonates

Key doses to remember:
Amitriptyline start 10-25mg (S/E confusion, hypotension)
Gabapentin 300mg TD

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10
Q

Give some examples of weak opioids. Key facts to remember?

A

Codeine, dihydrocodeine, tramadol

Not recommended in kids
Tramadol is less constipating than codeine but causes more N&V and anorexia

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11
Q

Give some examples of strong opioids

A

Morphine, diamorphine, oxycodone, fentanyl

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12
Q

Give some key opioid side effects

A

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

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13
Q

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

A

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

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14
Q

What tx does bone pain often respond well to?

A

NSAIDs, radiotherapy and bisphosphonates

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15
Q

What pain relief is best suited to liver capsule pain?

A

steroids / NSAIDs

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16
Q

What is the common dose for codeine?

A

Codeine phosphate 30mg is commonly used, ceiling dose is 240mg/24hours

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17
Q

What types of morphine are available?

A

Oramorph – immediate release, lasts 3-4 hours
Zomorph – slow release, lasts 12 hours
Parenteral (morphine sulphate for injection)

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18
Q

Give some general rules to remember when starting a patient on opioids

A

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

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19
Q

Give some signs of opioid toxicity. What may precipitate this?

A

Pinpoint pupils, hallucinations, drowsiness, vomiting, confusion, myoclonic jerks, respiratory depression

Causes: prescribing errors, quick dose escalation, AKI – always check renal function!

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20
Q

What is required for controlled drug prescriptions?

A

Requires name and ID of patient, exact instructions for pharmacist, drug, form, strength, total number of tablets/patches in words and figures

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21
Q

Give some causes of N+V in cancer patients

A

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

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22
Q

What receptors are found in the CTZ?

A

dopamine, serotonin (5HT3)

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23
Q

Give some causes of constipation in cancer patients

A
  • Disease related: immobility, reduced intake, abdominal disease, obstruction
  • Fluid depletion
  • Weakness
  • Medication side effect
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24
Q

How can you manage malignant bowel obstruction?

A

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

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25
Q

When should you be concerned about hypercalcaemia?

How should you treat?

A

anything over 2.5!

tx with aggressive fluid resus and bisphosphonates e.g. Pamidronate

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26
Q

What clinical scoring systems can be used in palliative care?

A

SPICT: used to identify patients at risk of deteriorating or dying
Clinical frailty scale – 9 phenotypes

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27
Q

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

A

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)

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28
Q

What types of radiotherapy are available?

A

External Beam: most common

Brachytherapy: internal localised radiation (e.g. through seed or capsule implanted in body cavity)

Systemic Treatment

29
Q

Chemotherapy describes the use of cytotoxic drugs to destroy cancer cells.
What routes of administration are available?

A
  • PO
  • IV
  • IM
  • Intralesional - directly into a cancerous area
  • Intrathecal - into the CSF – by lumbar puncture
  • Topical - medication will be applied onto the skin
30
Q

Define neoadjuvant, adjuvant and palliative treatment

A

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)

31
Q

Give some examples of acute toxicity of radiotherapy

A
  • Hair loss
  • Fatigue
  • Dysphagia
  • Nausea and vomiting
  • Diarrhoea
  • Erythema
  • Lymphoedema
  • Dysuria / radiation cystitis
  • Sterility
32
Q

Give some examples of long term toxicity of radiotherapy

A

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

33
Q

What is extravasation? How should you approach this?

A

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

34
Q

What supportive mx is available for acute toxicity of chemotherapy and radiotherapy?

A

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

35
Q

What are the risks to haematology patients undergoing tx?

A
  • Infection
  • Difficulties with IV access
  • Renal failure and bulky disease (high WCC)
  • Tumour lysis syndrome
  • Impact on fertility
36
Q

How should you manage neutropenic sepsis?

A

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

37
Q

What can you give patients with haem malignancies to reduce risk of infection?

A
  • Aciclovir – prevent varicella and herpes reactivation
  • Posaconazole – antifungal
  • Co-trimoxazole – prevent PCP
  • G-CSF (granulocyte colony stimulating factor)
38
Q

What is GCSF? Who should never receive it? Side effects?

A

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

39
Q

What are the options for obtaining IV access?

A

Cannula
Tunnelled central line – into jugular vein
PICC Line – into subclavian vein
Portacath – nothing externally, reduced infection risk, harder to access

40
Q

Complications of IV lines?

A

Infection
Thrombosis
Bleeding
Failure

41
Q

What are the fertility considerations when treating patients with haem malignancies?

A

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

42
Q

How can you manage mucositis in patients undergoing anti cancer treatments?

A

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

43
Q

how may haematological cancers present?

A

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

44
Q

How should suspected haematological cancer be investigated?

A
  • 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)
45
Q

Younger child with high WCC and blasts =

A

almost always ALL

46
Q

Older adult with high WCC and blasts =

A

more likely to be AML

47
Q

Dry tap (no liquid aspirated on BMB) may =

A

myelofibrosis

48
Q

Unexplained cough for longer than 3 weeks =

A

urgent CXR

49
Q

Erythema nodosum + unexplained cough =

A

think sarcoidosis (not lung cancer)

50
Q

What are the 4 commonest presenting sxs of lung cancer?

A
  • Unexplained cough
  • Haemoptysis
  • Weight loss
  • SOB
51
Q

Lung cancer rarely causes mets where?

A

the kidneys

52
Q

Nobody leaves lung cancer clinic without having what measured?

A

calcium levels - risk of hypercalcemia

53
Q

What are the next steps after lung cancer is detected on CXR?

A

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

54
Q

How should you investigate and manage malignant pleural effusion?

A

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

55
Q

Nodules (mass in the lung 5mm – 3cm) may progress to lung cancer.

How high is the risk?

A

Nodules > 2cm have a 50% chance of becoming lung cancer
BROCK score and HERDER score to calculate risk

56
Q

How should you approach a patient with MSCC?

A

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

57
Q

Lung Cancer + confusion, nausea and weakness =

A

likely hypercalcaemia

Ix: measure serum calcium!!!
Mx: IV fluids + Pamidronate (bisphosphonate) infusion over 30-60 mins

58
Q

How should you approach a patient with SVCO?

A

Ix: Urgent CT
Mx: Admit, give oxygen and analgesia, sit upright to reduce venous pressure
Urgent steroids
Radiotherapy, intraluminal stenting or chemotherapy

59
Q

Give some of the key paraneoplastic syndromes associated with lung cancer

A

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

60
Q

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

A
  • CT and MRI brain
  • Start Dexamethasone 4mg BD with weaning plan
  • Give Keppra for seizures
  • Patients cannot drive
61
Q

What surgery is available for lung cancer?

A
  • Wedge resection
  • Lobectomy
  • Pneumonectomy
62
Q

What are the options for palliative lung cancer intervention?

A
  • YAG Laser
  • Cryotherapy
  • Diathermy
  • Intraluminal brachytherapy
  • Bronchial stents
63
Q

Biggest occupational exposure to asbestos =

A

plumbing!

64
Q

> 1/2 of new cases of cancer in men are what?

A

prostate, lung or bowel

65
Q

What diagnoses should you consider if you see lytic bone lesions?

A

think myeloma first, but consider other causes e.g. prostate and breast

66
Q

What would be the issues with PSA screening for prostate cancer?

A

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

67
Q

Give some urological DDx for haematuria (could also be glomerular):

A

Cancer
* Renal cell carcinoma (RCC)
* Upper tract TCC
* Bladder carcinoma
* Advanced prostate carcinoma

Other
* Stones
* Infection, Inflammation
* Benign prostatic hyperplasia (large)

68
Q

How should you investigate a painless testicular lump?

A

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)

69
Q

How should you approach a patient with a penile lump?

A

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

Y4 Cancer Care (13 decks)

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