Onc and Pallative Care Flashcards
Screening for Breast Cancer
“Average risk” guidelines (CTFPHC)1
Pertains to the General population
o Applies to women ages 40 to 74 who are NOT “High risk” (see next slide)
Age-based recommendations
o 40-49 yrs – Recommend AGAINST screening
o 50-74 yrs – Recommend FOR screening mammogram q2-3 yrs
o ≥ 75 yrs – No evidence of benefits/harms to make formal recommendation
Screen with mammogram only
o Recommend AGAINST self-breast exam, clinical breast exam, or US/CT/MRI
Screening for Lung cancer (CTFPHC)2
Criteria (need all 3)
1. Age 55-74 years
2. ≥ 30 pack-year* smoking history
3. Current smoker or quit within the past 15 years
Screen with annual low dose CT every year up to 3 consecutive years
o Recommend against screening CXR or sputum cytology
- After 3 years
o Canadian guideline doesn’t address
o US guideline suggests screening annually until quit smoking > 15
years, or develops other life-limiting illness
Screening for Colorectal Cancer (CRC)
“Average risk3,4 & Increased risk5”
General population.
No previous CRC or polyps, no IBD, no FHx CRC
- Age 50-74
- Not recommended over age 75
- Whichever youngest
- Age 40-50 yrs OR
- 10 yrs before earliest age of
relative’s diagnosis
Method of
Screening
- 2 Options
- FIT q2 yrs
- Flex sigmoidoscopy q10 yrs
- DO NOT USE colonoscopy
Increased Risk
≥ 1 First-degree relative with colon cancer OR advanced adenoma
- Whichever youngest
- Age 40-50 yrs OR
- 10 yrs before earliest age of
relative’s diagnosis - Colonoscopy q5-10 yrs
- FIT q1-2 yrs can be considered as
2nd-line/ alternative
Screening for Hepatocellular Carcinoma
(CASL 2018, AASLD new 2023)6,7
High risk populations (either of…)
o All patients with cirrhosis, regardless of age/etiology (Hep B/ C, NAFLD, EtOH, α-1
antitrypsin deficiency, NASH, AIH, HH, PBC, Wilson’s disease)
o AASLD 2023 recommends against screening Childs-Pugh C cirrhosis unless transplant candidate, or patients
with life limiting comorbidity as 1 year mortality from liver disease negates any benefit HCC screening
o Hep B carrier (sAg +) AND…
§ Endemic country (Hep BsAg prevalence >2%) (Asia): males ≥40, females ≥50
§ African or North American blacks ≥20 yrs
§ FHx of HCC in 1st degree relative (start at age 40)
§ CASL = All HIV co-infected patients (start at age 40)
§ AASLD= All Hep D co-infected patients
- Screening test – Ultrasound q6 months (CASL) / Ultrasound + AFP q6 months (AASLD 2023)
o Per AASLD 2023: Sensitivity of US alone 53%, but US+AFP sensitivity 63%
o CASL 2018 does not recommend AFP where US is available – at that time insufficient evidence to
recommend screening with both US and AFP
Screening for Cervical Cancer (CTFPHC 2013)8
Screening population
o Anyone with a cervix ages 25-69 – Screen with cervical cytology q3 years
§ Includes HPV-vaccinated women, transmen & women who have sex with
women
§ Cancer Care Ontario suggests start at 21 yrs
- Screen with pap test cervical cytology q3 yrs
- STOP screening at age ≥70 AND ≥ 3 negative tests in the last 10 yrs
- These guidelines DO NOT apply to: Never sexually active, Previous abnormal Pap tests,
Immunocompromised (eg. HIV, organ transplant, chemo, chronic corticosteroid use),
Symptomatic of cervical cancer (eg. abnormal vaginal bleeding), limited life expectancy
DO NOT SCREEN for These Cancers
- Melanoma (CTFPHC 2008) – Recommend AGAINST population-based skin
screening - Testicular (USPSTF 2011) – US guidelines recommend AGAINST screening
- Ovarian (CTFPHC 2013) – Do NOT screen in average risk women
- Prostate (CTFPHC 2014) – Do NOT screen with PSA
- Esophageal (CTFPHC 2020)9
- Do NOT screen for cancer or dysplasia/ Barrett’s in chronic GERD without alarm symptoms
– Does not apply to patients with alarm symptoms (dysphagia, odynophagia, weight loss, anemia, bleed, loss of appetite)
– Does not apply to patients with previously diagnosed Barrett’s
Breast Cancer: Diagnostic Workup
Relevant Biology
* ESTROGEN (Hormone-driven) vs HER2
Diagnosis
* Imaging
* Diagnostic bilateral mammogram & ultrasound of breast AND axilla*
* Biopsy/Markers
* Core needle biopsy (US-guided) + Receptor status testing: ER (estrogen hormone receptor), PR (progesterone
hormone receptor), HER-2 (human epidermal growth factor receptor)
RC EXAM TIP: Mastitis not responding to antibiotics à BIOPSY to rule out Paget’s/ Inflammatory Breast CA)
(In Clinical Practice: U/S + Mammogram with Biopsy)
Once Confirmed Localized Breast Cancer- Move on to Surgery! (Before completion of staging)
Breast Cancer: Initial Localized Management
Primary treatment
* Surgery
* Primary Tumor- 2 options
* Mastectomy
* Lumpectomy (Breast Conserving Surgery) + Whole Breast Radiation
- Regional lymph node Management
- They need it (Choosing Wisely Caveat for age 70, ER+, clinically node negative- NoE)
- Sentinel Lymph Node Biopsy or Axillary Lymph Node Dissection
Bottom Line for early stage Breast CA: Mastectomy or Lumpectomy + Lymph Node Sampling/ Dissection.
Based on Surgical Path-> Complete Staging -> Decide on further treatment
Breast Cancer: Staging
Staging Post Surgery- Do they need imaging?
* Stage I (LN negative)à No further tests
* Stage II (LN+ up to 3)à No further tests unless symptoms
* Stage III (T4 or ≥ 4 LN positive)à STAGE - Bone scan, CT C/A/P
Breast Cancer: Adjuvant Therapy
see chart
*Endocrine therapies: TAM = Tamoxifen. Aromatase Inhibitor = Letrozole, Exemestane, Anastrozole
**Chemotherapies: Anthracycline (doxorubicin, epirubicin) + Cyclophosphamide+ Taxane (docetaxel, paclitaxel)
~Anti-HER2 drug: Trastuzumab
Post-menopause: TAM or AI
Pre-menopause : TAM
± Anti-resorptive therapy
Breast Cancer: Metastatic Therapy
HR+
1. Endocrine therapy AND
2. CDK 4/6 inhibitor
HER2 +
1. Double HER-2
blockade AND
2. Chemo (Taxane)
Triple positive
- Double HER-2 blockade AND
- Chemotherapy (Taxane) AND
- Endocrine therapy
Triple negative
- Immunotherapy (for
PD-L1+ disease) - Chemotherapy
CDK 4/6 inhibitor: “ciclibs”- Palbociclib, Ribociclib
Double HER2 blockade: Trastuzumab + Pertuzumab
Chemotherapy examples: Taxanes (Docetaxel, paclitaxel) + Cyclophosphamide
Immunotherapy: Pembrolizumab
Breast Cancer Treatment Side Effects
Trastuzumab (Herceptin®)/ Pertuzumab
* REVERSIBLE cardiomyopathy
Anthracyclines (i.e. Doxorubicin, Epirubicin)
* IRREVERSIBLE cardiomyopathy
* Secondary leukemia
Taxanes (i.e. Paclitaxel, Docetaxel)
* Peripheral neuropathy
AI- increase OA
TAM - increase endometrial cancer and thrombosis
Breast Cancer: Antiresorptive therapy
Bisphosphonates (Zoledronic Acid, Clodronate, Ibandronate) or Denosumab
o Purposes
1. Decreases spread to bones (altered bone microenvironment, esp. for ER/PR +)
2. Protect against AI-induced osteoporosis
3. Decreased risk of skeletal related events (SRE - i.e. fracture, need for radiation,
cord compression)
Breast Cancer: Surveillance
Annual mammogram, history, physical & breast exam
Lifestyle modifications after breast cancer (CMAJ 2017)
o Bottom line- Live healthy- same recommendations as cardiac guidelines
o Prevent weight gain
o Exercise (150 mins/wk = reduced breast cancer mortality)
o Quit smoking
o Minimize alcohol
o Limit saturated fats and high-fat dairy products
o No need to avoid soy (purported “phytoestrogens”)
o Vitamin C/D/E – questionable benefit
Lung Cancer: Biology
Non-Small Cell
Squamous Cell
* Central lesions
* Strong link with smoking
* Unlikely EGFR/ALK mutated
Adenocarcinoma
* Peripheral lesions
* Most common
* Has driver mutations (EGFR)
Rare(ish) tumor types
* Neuroendocrine
* Adenosquamous
* Sarcomatoid
* Large cell
Small Cell
* Central lesions
* Strong link with smoking
* Non-EGFR/ALK mutated
* Rapidly growing
High Yield
* The 4 S’s of Lung Ca: Smokers get Squamous and the Speedy Small cell
* Adeno: “I Don’t Know why I got cancer…” – Lots of targetable mutation
* Neuroendocrine tumor of lung (RARE- know workup for carcinoid):
* PREOP do an Echo if suspicious
* Serum Chromogranin A
* Urine 24-HR Urine 5-HIAA.
* Gallium-PET scan (NOT Regular PET)
Lung Cancer:
Note on Radiation Pneumonitis
Typically 4-12 weeks (1-3 months post radiation)
• Corresponds to radiation field, depends on dose of radiation and presence of concurrent chemotherapy
• Mimics pneumonia in radiographic and clinical presentation
– Groundglass
– Interstitialchanges
• Typically by the time patients present, no longer immunosuppressed by chemo (beyond day 7 to 14 post-chemo)
• Treat with steroids.
Lung Cancer: Workup
Biopsy: Need both Histology + Markers
• Commonly done via CT guided or EBUS of primary.
• Molecular (NSCLC only)
• Adeno:PDL-1+MolecularTargets(EGFR,ALK,ROS1,NTRK,KRAS,BRAF,HER2)
• “Typical” EGFR+ profile – Elderly, Female, Asian, Non-smoker, Adenocarcinoma
• Squamous:PD-L1
Diagnostic Imaging + Staging (DONE PRIOR TO SURGERY- unlike Breast)
1. ALL patients –Rule out metastatic disease: CT C/A/P + MRI brain , ± Bone scan if symptomatic
2. If no obvious metastases- May be able to get cured (surgery or radiation/ chemoradiation)
o PET scan – look for occult metastases (to stage resectable disease/curative intent)
o Mediastinal staging (mediastinoscopy or endobronchial ultrasound [EBUS])
Non-Small Cell Lung Cancer: Early Stage Management
See chart in notes
Neoadjuvant Chemo+ Immuno becoming standard of care for resectable lung cancer
• For resectable stage 2 and 3 lung cancer with EGFR mutation- Adjuvant Osimertinib x 3 years
• For resectable stage 2 and 3 lung cancer withOUT EGFR mutation- Adjuvant Atezolizumab x 1 year
Non-Small Cell Lung Cancer: Metastatic Management
EGFR positive
Osimertinib first line
Other mutations
Chemotherapy +/- IO
aside from ALK which has first-line targeted therapy- NoE
Driver mutation negative
Immunotherapy +/- Chemo
Small Cell Lung Cancer: Workup & Management
Limited stage
Confined to 1 hemithorax/1 radiation field
Concurrent chemoradiation ±
prophylactic cranial irradiation (Moving away from brain rad since 2022)
Extended stage
Beyond 1 radiation field (i.e. mets) or presence of malignant effusion
Incurable/ Palliative Intent
Chemotherapy + Immunotherapy + Prophylactic Cranial Radiation
Highly chemo/radio-sensitive, but frequently relapse
• Surgery is generally NOT a part of SCLC treatment unless very early stage
NoE
• Chemo regimen: Cisplatin/ Carboplatin + Etoposide
• Immunotherapy: Atezolizumab OR Durvalum
Lung Cancer: Paraneoplastic Syndromes
SCLC
• SIADH
• Lambert-Eaton Myasthenic Syndrome (LEMS)
o Anti-VGCCAb:reducedpresynapticAChrelease
oSimilaritiestomyastheniagravis,butnotablyabsent/decreasedreflexes
• Encephalomyelitis & sensory neuropathy
o Anti-HuAbcrossreactsw/bothSCLCantigensandneuron-specificRNA-binding nuclear proteins
• Cushing’s syndrome
EctopicACTHproduction.NOTsuppressedbydexamethasonesupptest
Adeno NSCLC
• Hypertrophic osteoarthropathy
o Clubbing+periostealnewboneformationoftubularbones
oSymmetrical,painfularthropathy(ankles,knees,wrists,elbows)
Squamous NSCLC
• Hypercalcemia
PTHrPproduction(NOTmeasuredinmodernassaysforPTH)
Colorectal Cancer: Workup
Diagnosis
• Full colonoscopy to terminal ileum (all patients, pre-op) with biopsy
Staging
• CT chest, abdomen and pelvis (all patients, pre-op)
Tumour and molecular markers
• Carcinoembryonic antigen (CEA
Colorectal Cancer: Management
Stages I-III
• Surgery upfront
• Adjuvant chemotherapy for stage 3 and selected stage 2
Stage IV (metastatic)
• Oligometastatic (isolated liver or lung lesions, undefined number of mets)
o Metastectomy+chemotherapy(curative-intent)16
• Non-operable
o Chemotherapy±eitherVEGFInhibitor(Bevacizumab)orEGFRinhibitor (Panitumumab/Cetuximab)
Typical regimens: • Post-op: FOLFOX/CAPOX (5-FU/Capecitabine, Leucovorin, Oxaliplatin) • Metastatic: FOLFOX/FOLFIRI (Irinotecan instead of Oxaliplatin) ± Bevacizumab/Panitumumab/Cetuximab
Colorectal Cancer: Surveillance
Stage 1
o Colonoscopy 1 year post resection
o Subsequent colonoscopies based on findings of previous scope (not annually), if negative, every 5 years. ⌘
• Stage 2-3
o Colonoscopy 1 year post resection
o Years 1-3: Q6 month history, physical exam, CEA, CT C/A/P
o Year 4-5: Annual history, physical exam, CEA, CT C/A/P
Gastroesophageal Cancer
Squamous cell
Upper-mid esophagus
Risk factors:
* EtOH
* Caustic injury
* Smoking
Adenocarcinoma- distal
- Barrett’s esophagus
- GERD
- Obesity
- Smoking
W&W: Leser-Trelat sign- sudden eruption of seborrheic keratosis. Most commonly
implicating GI cancers- out of those gastric most common. Also seen in breast.
Treatment
* Localized – Pre-op Chemo+radiation (concurrent) -> Surgery
* Metastatic – NoE
Prostate Cancer: Workup
- Biology
o Like Breast Cancer feeds on Estrogen, Prostate Cancer feeds on Androgen
(Hence backbone treatment is Androgen Deprivation Therapy- ADT)
o Mets primarily to LN and bone
o W&W: associated with coagulopathy. DIC most common in metastatic
setting/ post-operatively
- Diagnosis
o Digital rectal examination
o Prostate biopsy with calculation of Gleason Score
- Tumour Markers
o Serum PSA - Staging Imaging (if symptomatic or “high-risk”- NoE)
o Imaging = Bone scan, CT chest/abdomen/pelvis
Prostate Cancer: Management
Castrate Sensitive- Responds to lowering Androgen
Early/
Localized
- Active surveillance (PSA monitoring, intervene if progression)
- Choosing Wisely: “Do NOT initiate management in patients with low-
risk prostate cancer without first discussing active surveillance” ⌘
- Radical prostatectomy ± lymph node dissection
- Radiation (Brachytherapy or External Beam)
Metastatic
1. ADT + CYP17 inhibitor (shuts down androgen production) (Abiraterone)
2. ADT + second-generation antiandrogen (Enzalutamide, Apalutamide)
3. ADT + Chemotherapy + second-generation antiandrogen (Darolutamide)
*ADT = GnRH agonist (Lupron) or antagonist (Degarelix)
ALL patients on ADT should be on Calcium (if needed), Vitamin D supplementation, and a
Bisphosphonate for metastatic disease or low bone mineral density
Prostate Cancer: Treatment side effects
Docetaxel (chemo)
Peripheral neuropathy
N/V
Hair loss
Non-steroidal antiandrogen
Abiraterone (+ Prednisone)
* Hyperaldosteronism
o HTN
o Hyperglycemia
o Hypokalemia
* CV disease
Enzalutamide/Apalutamide
* Seizure/ Cognitive issues/ Falls
* DRUG-DRUG INTERACTIONS
Testicular Cancer
Imaging: Scrotal ultrasound, CT chest/abdomen/pelvis
Diagnosis: Made by radical orchiectomy, (NEVER biopsy testicular mass due to risk of tumor seeding)
Tumour markers: β-hCG, AFP, LDH
Management
* Localized – Surgical orchiectomy
* Metastatic – Chemotherapy (highly curable, chemo-sensitive, good prognosis)
Typical chemo regimen: BEP
(Bleomycin, Etoposide, Cisplatin)
Febrile Neutropenia
Definition
* Single temp ≥ 38.3 ̊C or ≥ 38.0 ̊C for >1hr AND ANC ≤0.5 OR <1 (with predicted nadir of 0.5)
* Nadir of neutropenia occurs 7-14 days after chemo
Etiology
* source of ANY infection identified in only 20-30% of cases
* Fungal infections can occur in pts with prolonged neutropenia (>7 days) and/or prolonged Abx use
Diagnosis
* Investigations – Blood culture x2 PIV + CVC (if present), Urine culture, Skin exam, Sputum (if
present), Stool sample + C. diff (if diarrhea), CXR and Other imaging/tests as indicated
Treatment
* Broad spectrum antibiotics IMMEDIATELY (often institution-dependent)
o Examples: Piptazo to start, if still febrile add Vancomycin*HIGH YIELD **
G-CSF used as 2o prophylaxis – but does NOT improve outcomes
Outpatient management of Febrile Neutropenia in adults
Based on MASCC score (DO NOT memorize MASCC)
o e.g. no hypotension, no active COPD, no volume depletion, no or mild symptoms,
solid tumor rather than heme malignancy, age <60, anticipate neutropenia ≤ 7 days
o Patients should reside within an hour of medical care, have a caregiver at home,
and be able to return to ED for follow-up
* Administer empiric Antibiotics within 1 hour of triage
- Out-patient Antibiotic regimen:
o Ciprofloxacin + amoxicillin/clavulanate or Clindamycin (if Pen allergic)
Hypercalcemia of Malignancy
Etiology
* Most common malignancies – Breast, Lung, Multiple myeloma
* 3 common mechanisms
o Lytic bone destruction (breast ca, multiple myeloma)
o PTHrP production (H&N, squamous cell NSCLC - NOT small cell)
o 1,25-dihydroxyvit D/calcitriol production (lymphoma)
Management
* IV hydration (most effective short-terms) + Lasix
* Calcitonin
* Bisphosphonates
o Pamidronate 90mg IV
o Zoledronic acid 4mg IV x 1 (remember to reduce dose for renal dysfunction)
o Max effect 4-7 days post-infusion (therefore NOT short-term solution)
o Monitor for hypocalcemia post-treatment
* Treat underlying malignancy
Tumor Lysis Syndrome
Diagnosis
* Requires ≥ 2 lab abnormalities within 7 days post-chemo
1. Hyper K+ – muscle weakness, ECG Δs, cardiac arrhythmias, sudden death
2. Hyper PO4 – AKI, secondary hypocalcemia, N/V, lethargy, seizures
3. Hyperuricemia – AKI (renal tubule deposition), flank pain (renal stones), N/V, anorexia
4. Hypo Ca2+ – Tetany, parasthesias, mental status changes
Etiology
* Most common in highly proliferative malignancies, large tumor burden, high-sensitivity to treatment
– Leukemia, Lymphoma, Testicular ca, Small cell lung ca
* Treatment response = cellular breakdown with release of K+, PO4, nucleic acids à uric acid
Treatment
* IV fluids (target U/O of 2cc/kg/hr)
* Rasburicase
o Allopurinol if G6PD deficient, though not
usually tested upfront in emergency
* Treatment of electrolyte abnormalities
Prophylaxis
* IV fluids AND
* Allopurinol OR
* Rasburicase (if NOT G6PD deficient)
G6PD Deficiency – X linked recessive*, more common in
Africa, Middle East, certain parts of Mediterranean and Asia.
*If MCQ says a woman, no FamHx, assume no G6PD deficiency
Malignant Bowel Obstruction (MBO)
Etiology
* Intraluminal GI Ca or Peritoneal disease. Most commonly: Ovarian, Gastric, Breast, Lung
Symptoms/ Diagnosis
* Crampy abdo pain, anorexia, N/V, inability to pass BM or flatus
* History, physical, CT abdomen
Treatment
* Consult Gen Surg (even if palliative) - stent?, diverting ileostomy?, feeding tube?
* Supportive care (IV fluids, electrolyte management, NG decompression)
* Octreotide SC 100 mcg TID (↓gastric secretions, ↓ motility, ↓ splanchnic blood flow)
* ± Corticosteroids (↓ peritumor edema, ↑ mobility)
* Metoclopramide IV 10 mg Q8H (use if partial MBO, not for use in complete MBO)
SVC Syndrome
Etiology
* Malignancy (up to 90% of cases):
* NSCLC (~50% of cases)
* SCLC
* Lymphoma
* metastatic lesions
* Thrombosis
Symptoms/Diagnosis
* Obstruction of SVC, ↑ venous pressure
* Symptoms: Facial and arm edema, distended
neck and chest veins, Dyspnea, cough, facial
plethora, hoarseness, stridor, neurologic
(confusion/change in LOC)
- Abnormal CXR, CT chest, head and neck. If
unstable –> venography, which allows
intervention
Management
* Life-threatening/Grade 4 symptoms* à
Venogram, urgent stent, consider
thrombolytics if thrombus
- Non-life threatening à obtain tissue
diagnosis to guide treatment - Steroids: Airway obstruction not amenable for
stenting, or steroid-responsive tumor (thymoma,
lymphoma) - Stent for symptom palliation ± Radiation in non-
chemo sensitive tumors (e.g. NSCLC, mesothelioma) - Systemic chemotherapy for chemo-sensitive
tumors (SCLC, NHL, germ cell)
*Grade 4: Life-threatening: confusion/obtunded,
stridor, hemodynamic comprise (syncope without
precipitant), hypotension, renal insufficiency
Spinal Cord Compression
Etiology
* Compression of the thecal sac by tumor in the epidural space
* Most common malignancies – Breast, Lung, Prostate, Multiple myeloma
Symptoms/Diagnosis
* Clinical most important – early recognition is key to preserving neurological function
* Back pain (often 1st sign, occurs in 95% cases)
* If spinal cord compression = UMN findings
* If cauda equina syndrome = LMN findings, Saddle anesthesia
* Leg weakness, sensory loss
* Urinary retention, Bowel incontinence
Management
* URGENT MRI whole spine
* Steroids – Dexamethasone 10mg IV x1 à Dexamethasone 4mg PO/IV QID
* Pain control
* Consult Spine surgical service AND Rad Onc
Brain Mets/ Leptomeningeal Disease
Etiology
* Intra-parenchymal lesions causing vasogenic edema, or blockage of CSF flow
* Most common malignancies – Breast, Lung, Melanoma
Symptoms/Diagnosis
* Clinical most important – Vertigo, Ataxia, Headache, Vision changes, Neurologic deficits
Management
* Brain Mets: URGENT MRI Brain
* Leptomeningeal disease: Urgent MRI Brain + Full Spine
* Steroids – Dexamethasone 10mg IV x1 à Dexamethasone 4mg PO/IV QID
* Consult Neurosurgical service AND Rad Onc
* Rad Onc can offer palliative radiation/ treatment of brain mets
* Neurosurgery often can resect brain mets. However shunt is of limited benefit for
leptomeningeal disease.
Immunotherapy Toxicity Management
General principles
* “Mild” symptoms:
o HOLD treatment (unless asymptomatic hypothyroidism… just start L-thyroxine)
o Supportive management
o Consider re-challenge treatment
- “Moderate-severe” symptoms
o Hold treatment
o IV Methylprednisolone 1mg/kg or Prednisone 0.5-1 mg/kg
o GI toxicity: GI referral for scope, rule out infection - If no response to steroids after 72 hours or worsening symptoms, then Infliximab
5 mg/kg (can repeat 2 weeks later if symptoms persist)
2023 Highlight in Supportive Care in Oncology
- Geriatric assessment (GA)
o should be used to identify vulnerabilities or impairments for all patients over 65
years old with cancer. - Olanzapine low dose daily
o Recommended for advance cancer to improve weight gain and appetite. - Acupuncture
o Recommended for aromatase inhibitor (Letrozole, Anastrozole) –related joint pain
o may be recommended for general cancer pain or musculoskeletal pain. - Cannabinoids
o No formal recommendation yet re: pain, nausea, insomnia, anxiety
Pain Control
Opioid titration
Goal to address most of the baseline pain with long-acting formulations
1. Start with immediate release (IR) formulation Q1-Q4H PRN (q4h PRN for opioid naïve)
2. Low dose à increase to effect/side effects
3. Allow for steady state (~24hrs = 5 half lives)
4. Once steady state achieved, calculate total use in past 24 h
5. Divide 24hr dose into distributed doses of long acting formula
6. Order breakthroughs (= 10% of total daily dose in IR tabs)
- No comorbidities – No one right answer. Usually based on physician comfort
- Renal dysfunction – Hydromorphone, Methadone, Fentanyl
o Do NOT use: Morphine, Codeine, Tramadol, Demerol - Hepatic dysfunction – Hydromorphone, Morphine, Fentanyl
o Do NOT use: Codeine, Methadone - Excess opioid-induced itching/urticaria – Fentanyl
Opioid side effects - Common: Constipation, Nausea, Vomiting, Sedation
- Rare: Confusion, hallucination, Myoclonus
- Methadone specific: QT prolongation, Drug-drug interactions (CYP3A4 metabolism)
- If treatment addresses source of pain, need to decrease opioids to prevent toxicity
Clinical Pearl: If switching meds due to toxicity (i.e. myoclonus), consider 25-30% dose reduction to
allow for cross tolerance à BUT, if pain is not well-controlled, then no need to decrease dose
Palliative Care Symptoms Management
Dyspnea
* Stepwise approach: Non-pharmacologic therapies (i.e. fan, open window) - oxygen (if hypoxic)-
Opioids
* Oxygen ineffective for non-hypoxemic dyspnea⌘
Nausea and Vomiting
* Direct treatment towards etiology
* Unknown etiology – Dopamine antagonist favored (haloperidol, olanzapine) or agents used for
chemotherapy-induced nausea and vomiting
Delirium
* Risperidone/haloperidol do not alleviate distress at end of life and tend towards harm (JAMA 2017)
o May slightly worsen delirium symptoms (low quality evidence, Cochrane Review 2020)
o May increase adverse side effects (EPS symptoms) (low-mod quality)
Cachexia:
* Refer for counseling + assessment re: high protein, nutrient dense food, advise against extreme
diets/fad diets
* Do NOT offer enteral tube feeding or parenteral nutrition to manage cancer cachexia
* Evidence insufficient to strongly endorse any pharmacologic agent
Constipation
* Considerations
o Disease and drug effects
o Check calcium & TSH
o Counsel on bowel regimen if starting opioids
* Medications
o Stimulant laxative (Senna) – Consider giving alongside opioids as prophylaxis
o Osmotic laxatives (Lactulose, PEG)
o Enema
o Selective opioid antagonist – Methylnaltrexone SC (Relistor©), Naldemidine PO
(Symproic ©)
o Chloride-channel agonist (Lubiprostone)
o Do NOT use stool softeners (Colace) alone for opioid induced constipation (no better
than placebo)
Medical Assistance In Dying
Eligibility (must meet ALL of the following…)
1. Be eligible for health services funded by government (i.e. have a health card)
- Be ≥ 18 years old and have decision making capability
- Have a grievous and irremediable* medical condition
* “Have a serious and incurable illness, disease or disability”
* Excludes Mental Illness… until March 17, 2024 then law changes
* Mental Illness includes conditions primarily in domain of psychiatry (ie depression), but does
NOT include neurocognitive or neurodevelopmental disorders. - Make a voluntary request for MAID, free from outside pressure or influence
- Provide informed consent to receive MAID
*Grievous and irremediable definition
* Does not need to be a fatal or terminal condition
* Must be a serious illness, disease, disability in an advanced, irreversible state
* As of March 2021 – Supreme Court removed requirement that death is reasonably foreseeable,
created 2 track approach!
- Pt does not have to provide consent immediately before provision of MAID if :
o Pt has been assessed and approved for MAID
o Pt was at risk of losing decision making capability prior to receiving MAID and
was made aware of that risk
o Person makes arrangement in writing with their practitioner to waive final
consent, and according to which their practitioner will provide MAID on their
preferred date if they have lost capacity (“Audrey’s amendment”
Lymph Node Metastases
Right supraclavicular nodes
o Lung, Esophageal
- Left supraclavicular nodes (“Virchow’s node”)
o Abdominal malignancies (via the thoracic duct) – Gastric, gallbladder, pancreas,
kidneys, testicles, ovaries, prostate
o Ipsilateral breast & lung - Umbilical nodes (“Sister Mary Joseph Node”) = Intra-abdominal/pelvic metastases
o GI – Gastric, colon, pancreas
o Gynecologic – Ovarian, endometrial
o Unknown primary
Renal Cell Carcinoma
RCC once called “The Internist’s Tumor” due to variety of paraneoplastic phenomenons.
Remember to consider as a ddx if you see any or constellation of the following:
* Hypercalcemia
* Hypertension
* Polycythemia
* Cushing’s
* Galactorrhea
* Amyloidosis
* Anemia
* Coagulopathy/ Thrombosis
Classic Triad (occurs in less than 15% of patients)
* palpable mass
* Hematuria
* Flank pain
Management of Localized disease- Nephrectomy. Metastatic- NoE.
Genetics: BRCA 1 & 2
- BRCA 1 = ↑ Lifetime risk of Breast ca (70%) and Ovarian ca (45%)
- BRCA 2 = ↑ Lifetime risk of Breast CA (70%), Ovarian Ca (20%), Prostate Ca,
Pancreatic Ca, Gastric Ca - Criteria for genetic testing (LOW YIELD- Always changing):
o Ashkenazi Jewish + breast ca at age < 50
o Breast cancer at age < 35
o Male breast cancer
o Triple negative breast cancer age < 60
o Serous ovarian ca at any age
o Breast + ovarian ca in same patient
o Gastric, prostate or pancreatic ca in patient with significant family
history of other BRCA 2-associated malignancies
- Therapeutic considerations: Prophylactic mastectomy, Oophorectomy
Erythropoietin stimulating agents in
Solid Tumor Malignancies
- Chemo-associated anemia (Hgb < 100)
o If treatment is CURATIVE – Do NOT use erythropoietin stimulating agents (ESAs)
o If treatment is PALLIATIVE – MAY use ESAs if Hgb persistently low
- Cancer-associated anemia (Hgb < 100), NOT on therapy
o Do NOT use ESAs if anemia is solely due to solid-tumor malignancy
- Factors to consider when starting ESAs
o Rule out non-cancer/chemo associated causes for anemia (i.e. Fe deficiency)
o Discuss risks of thromboembolism
o There is no “target” Hgb for this population. Target Hgb to avoid need for recurrent transfusions
o ESAs should be discontinued if not working after 6-8 weeks
o Iron supplementation may be ADDED to ESAs to increase efficacy, even if not iron deficient
