Oncology 1 Flashcards
______ is the 2nd leading cause of death in adults/kids in the US
cancer
_____ is the MC preventable cause of cancer death
tobacco
Most cancers are in people greater than _____ yrs old
50
How common is cancer in the US in men vs women?
1 in 2 men, and 1 in 3 women
Most common cancer in men?
prostate
Most common cancer in women?
breast cancer
____ cancer is the most common killer for men and women
lung
TNM staging
T = tumor
N=nodes
M=metastasis
TNM Staging: TNM staging helps determine the ___ of the cancer.
stage
TX
tumor cant be measured
T0
Tumor cant be found
Tis:
in situ
T1-T4:
Describes the tumor size and spread into adjacent structures
NX:
nodes cant be evaluated
N0
no nodal involvement
N1-N3:
Describes size, location, and/or number of lymph nodes affected
Interpret M0
No distant metastasis
Interpret M1
there are distant metastases
Bone metastases are common, especially in prostate, thyroid, breast, lung, and ______ cancers
kidney
PT Barnum Loves Kids
Prostate thyroid breast lung and kidney cancers
Bone metastases may present with:
hypercalcemia, pathologic fracture, pain, spinal cord compression
Imaging depends on the _____ tumor and location of pain
primary.
Imaging types: X-ray, CT, MRI, bone scan, PET/CT
Bone Mets therapy
Observation,
Opioids,
Osteoclast inhibitors, External beam radiation therapy, Stereotactic body radiotherapy (SBRT), and Surgery
Opioids are commonly used for ______
analgesia
Examples of osteoclast inhibitor medication and their function
bisphosphonates (ie: Boniva)
↓ Skeletal-Related Events (SREs) and help with pain
External beam radiation therapy is effective for ..
pain reduction in 50-80%
Bone mets can be ______ or painful
asymptomatic
A Pt with bone metastases would be a viable surgery candidate if they have ____
completed or impending pathological fracture
Osteoclast vs osteoblast
osteoBLAST–> forms (builds) bone
osteoCLAST–> consumes bone
What is a Skeletal-related event? (not on her slide)
SRE’s are a common complication of bone metastases, and have serious negative consequences for patients with castrate-resistant prostate cancer
Most common primary tumors that met to the brain are ________. Which are the MOST common cancers that met to the brain?
carcinomas
Examples of MC cancers that met to the brain: Lung, breast, kidney, colorectal, melanoma
Which cancers rarely metastasize to the brain?
Prostate, esophagus, oropharynx, non-melanoma skin cancers rarely met to brain. (PEON)
What is the most common mechanism for cancers to spread?
Hematogenous spread (through the blood)
Brain Met:
Patient presentation
(people may present with): Headache, focal neurologic dysfunction, cognitive dysfunction, seizure, stroke
For a Pt with suspected Brain Met, what imaging should you order?
MRI with contrast preferred to detect
Brain Mets- Therapy (tx options)
- Surgical resection if possible
- Stereotactic Radiosurgery (SRS)
- WBRT (Whole Brain Radiation Therapy)
- steroids
When would SRS be used?
-if a tumor is inaccessible, or if someone has multiple, small tumors, or the tumor is near a delicate structure
Describe SRS
Stereotactic Radiosurgery (SRS) is a non-surgical radiation therapy used to treat functional abnormalities and small tumors of the brain. It can deliver precisely-targeted radiation in fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue.
Patients can develop ____, ______, ______, & ____ following Stereotactic radiosurgery
transient swelling afterwards: nausea, dizziness/vertigo, seizure, headache
When would WBRT (Whole Brain Radiation Therapy) be a good treatment option?
Often for those with multiple, large tumors
Response rate of 40-60%
Describe the early S/E and Late S/E of WBRT
Early S/E: Alopecia, fatigue
Late S/E: Brain atrophy–> cognitive deterioration/dementia, radiation necrosis, NPH (normal pressure hydro), cerebrovascular disease, neuroendocrine dysfunction, esp. hypothyroidism
–Can use Namenda prophylactically (to try to help with their cognitive dysfunction)
How can steroids be used as a Tx option?
steroids can help reduce inflammation and swelling (following radiation therapy)
T/F: almost any primary cancer can met to the lungs
True
**Through vascular, lymphatic, or direct spread
Sx of Pulmonary Metastases
Sx include: cough, hemoptysis, dyspnea/hypoxia, malignant pleural effusion
**if someone has a new pleural effusion–> sample that fluid and check for malignant cells
Dx of Pulmonary Metastases
chest imaging or sometimes on thoracentesis fluid eval
Tx of Pulmonary Metastases
Surgical resection, stereotactic body radiotherapy, PleurX catheter, radioablation, cryotherapy
General Radiation S/E
-Skin dryness, irritation, blistering, peeling
-Fatigue
-Secondary cancer
Head & neck: Xerostomia (dry mouth), tooth decay, dysphagia, sores of mouth/gums
- Chest: radiation pneumonitis (cough, fever, chest fullness), pain, radiation fibrosis, dysphagia
- Abdomen: n/v, diarrhea
- Pelvis: diarrhea, bladder irritation, infertility, rectal bleeding, sexual dysfunction, menstrual disturbance
Advantage of a PleurX catheter
If someone gets recurrent pleural effusions (this will disrupt breathing) so they can have a catheter placed (PleurX catheter) which stays in all the time, and the Pt can keep draining their excess fluid
Chemo Side Effects
Nausea/vomiting Fatigue Neuropathy Pain Mucositis
Cytopenias–> cause Pts to be more susceptible to Infection
Cognitive dysfunction
Infertility
Hair loss
Mucositis=
painful inflammation and ulceration of the mucous membranes lining the digestive tract
Cytopenias=
a reduction in the number of mature blood cells. It is common in cancer patients being treated with radiation and/or chemotherapy.
End of Life concerns
Pain Nausea Fatigue Anorexia Constipation Xerostomia Delirium
For Pain and Dyspnea, what medications are the mainstay of treatment?
Opioids are the mainstay!
Generally short-acting PO/SL is recommended.
Ex: Roxanol (liquid morphine) 20 mg/mL is a standard
–Normal starting dose might be 5 mg (0.25 mL) PO/SL Q4H prn pain/SOB
Adjust dose and/or frequency to patient comfort
- *May need to add standing doses if a patient is consistently in pain/regularly using the med
- -Can do a therapeutic trial of oxygen if dyspneic
Meds used for Tx of Nausea
-Zofran (ondansetron)
Start with 4 mg Q6H prn
-Compazine (prochlorperazine)
Oral 5-10 mg TID-QID
Rectal 25 mg PR BID prn
**important to note that compazine can be given via rectal suppository
-Haldol (haloperidol)
1 mg PO or 0.5 mg SQ/IV Q6-8H prn
-Medical marijuana?
Meds used for Tx of Anxiety/Terminal Restlessness, Delirium
-Ativan (lorazepam)
PO: Start with 0.5 mg PO Q4H prn
SL: 2 mg/mL. 0.5 mg (0.25 mL) PO Q4H prn
-Haldol (haloperidol)
(dont memorize doses)
Xerostomia- Tx
Tx for dry mouth:
- Glycerin swabs
- Biotene
- Artificial saliva
- Pilocarpine 5 mg PO TID
Secretions- Tx
(this is referring to the death rattle)—> this is telling you their body cant handle the extra secretions. The fluid is getting stuck in their lungs.
Tx options: -D/C IVF or TF (discontinue IVs) -Atropine ophthalmic drops 1-3 gtts SL Q2-4H -Scopolamine (hyoscine) patch -Glycopyrrolate
Anorexia- Tx
-Megace (megestrol acetate)
S/E: Edema, VTE, and deaths more common in patients taking
- Glucocorticoids: Can try prednisone 20-40 mg/day or dexamethasone
- *No evidence that artificial nutrition prolongs life or improves functional status
Effectiveness of CPR
Various studies with differing outcomes, but overall, much more dismal than portrayed in movies/on TV
- -2% of out-of-hospital cardiac arrests recover fully
- -4-16% out of hospital cardiac arrests live to be discharged from hospital
- -16% of elderly who arrest in hospital live to be discharged.
Is there Neurologic/function status after resuscitation?
Probably not at the patient’s baseline
Pacemakers- what is the protocol
- -Pacemaker/ICD
- Find out what brand a patient has–> Rep can come wherever needed or deactivate remotely
Elements of quality of life (what do People care about?)
Symptoms and personal care:
- Pain & symptom management
- Being clean
- Having physical touch
Being prepared for death:
- Having affairs in order
- Believing family is prepared
- Knowing what to expect
- Communicating treatment preferences and naming a proxy decision maker
Elements of quality end of life care (what do ppl care about?)
Achieving a sense of completion:
- Saying goodbye to important people
- Recognizing one’s own accomplishments
- Resolving unfinished business
Being treated as a whole person: -Maintaining dignity -Keeping a sense of humor -Not dying alone Having someone who will listen
Elements of quality end of life care:
Relating to family, society, care providers, and transcendent
- Trust in and comfort with physician and nurses
- Being able to discuss personal fears, including death and dying
- Not being a burden to family or society
- Being able to help others
- Coming to peace with God
When is Hospice Appropriate?
Very specific criteria must be met for each disease process
- -Hospice (is a program ran through medicare, and the Pt must sign up for it) vs. palliative care
- -Insurance implications
Once a Pt signs up for Hospice this means that the Pt is no longer seeking a curative approach.
vs paliative care which is used a bridge to Hospice
Advanced Care Planning-Why we care?
- Higher rates of completion of advance directives
- Increased likelihood that clinicians & families understand a patient’s wishes & comply with them
- Reduction in hospitalization at end of life
- Receipt of less intensive treatments at end of life
- Increased utilization of hospice services
- Increased likelihood that a patient will die at his/her preferred place
- Higher satisfaction with quality of care
Advanced Directives:
When should they be completed by the Patient?
- Completed while a patient has decisional capacity
- Only to be followed when a patient loses capacity
Advanced Directives: When may they be revoked?
May be revoked verbally by a patient at any time so long as they have capacity
- Power of Attorney for Health Care (POA or Health Care Proxy)–> is the person that knows the Pt, and makes decisions in accordance that the Pt would have made for themselves
- Living Will (summarizes someone’s preferences for healthcare, addresses resuscitation and life support)
POLST/MOST Forms
Called different things in different states:
-called MOST in Colorado
= A medical order for the treatments a patient wants in case of emergency. It Provides medical orders for emergency health care professionals.
-these forms are Specifically for those with advanced illness or frailty
(first section includes whether the Pt wants CPR or no. 2nd section has whether the Pt wants hospital intervention or comfort care.)
End of Life Discussions- Some questions to get you started
Tell me what you know about your disease
How do you think you’re doing?
What are your goals?
What does a good day look like to you?
What are the most important things in your life?
Quality of life means different things to different people
Are you religious? Do you have any particular beliefs or opinions regarding death that are important?
Tell me what you know about your disease
How do you think you’re doing?
What are your goals?
What does a good day look like to you?
What are the most important things in your life?
Quality of life means different things to different people
Are you religious? Do you have any particular beliefs or opinions regarding death that are important?
More questions to ask a terminally ill Pt
-Have you had experiences with friends or family members in this situation?
What would you like to do similarly? What didn’t go as you would hope?
Where would your ideal place to die be? Are there particular people you want with you?
Would you like CPR ? Mechanical ventilation? Tube feeding? Dialysis?
Are there any circumstances in which you’d want these things?
Would you like to go to the hospital?
Give the patient honest, direct information about their health status
Some people request not to know
