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Adam's Weak Spots > Oncology > Flashcards

Oncology Flashcards

1
Q

What proportion of oncology patients say they never want to hear about palliative?

A

10%

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2
Q

What are 3 temporal models of
oncology/palliative integration?

A
  • Sequential (“hand over”)
  • Oncology-provided
  • Concurrent
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3
Q

List 4 barriers to onco/pal cooperation

A
  1. Conflicting cultures of care
    a. biomedical vs. patient-centred
  2. Delays in referral
    a. overoptimistic prognosis
    b. fear of losing hope
  3. Patient fear of abandonment
  4. Territoriality
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4
Q

Per ESMO, are oncologists taught
adequate palliative care?

A

42% say no

42% also disagree that their colleagues are skilled at it

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5
Q

Per ESMO, do oncologists routinely stay involved in patients’ EOL courses?

A

No–88% say they should
42% actually do

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6
Q

Per ESMO, what % of oncologists
believe they have no role in PC?

A

10-20%

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7
Q

What % of oncologists discussed no-treatment in one study?

A

50%
only 25% explained >1 sentence

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8
Q

What % of phase 1 trials
lead to tumour response?

A

<5%

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9
Q

What % of participants
understand the role of phase I trials?

A

<50%

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10
Q

What simple options can improve patient
understanding/satisfaction with MD visits?

A

audio recordings
lists of suggested questions

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11
Q

What are 7 features of cancer cells?

A
  • Avoid apoptosis
  • Resist aging process
  • Replicate despite control mechanisms
  • Dissolve connective tissue (MMPs)
  • Angiogenesis
  • Metastasis
  • Avoid immune system
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12
Q

What are the 2 primary cell phases at which chemotherapy drugs can act?

A

S phase (DNA synthesis)
M phase (mitosis)

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13
Q

What are the two types of actions of
cytotoxic chemotherapy?

A

Phase specific (usu. S phase)
“Cycle”-specific (i.e. any dividing cell)

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14
Q

How can you improve efficacy of
phase-specific chemo?

A

Longer exposure (e.g. continuous infusions)

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15
Q

What is the role of breaks between
cycles of chemotherapy?

A

Normal cells have better DNA repair

  • this allows rest of body time to heal
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16
Q

What are the 4 classes of chemotherapy mechanisms?

A

Alkylating agents
* platinums
* cyclophosphamide

Antibiotics
* bleomycin
* doxirubicin

Antimetabolic agents
* 5-FU

Plant alkaloids

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17
Q

List 4 cancers that can be cured
with chemotherapy alone

A
  • Germ cell tumours
  • Chorioncarcinoma
  • Non/Hodkgin Lymphoma
  • ALL
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18
Q

List 2 cancers resistant to chemotherapy

A

RCC
Endometrial ca

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19
Q

Describe the 3 phases of clinical trials

A

Phase I: dosing/toxicity
Phase II: finding where drug works
Phase III: assessing clinical benefits

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20
Q

What are the 4 outcomes assessed
when studying chemotherapy?

A
  1. Absolute survival time
  2. Time to disease recurrence
  3. Cancer response (total, >50%, <50%, none)
    a. or at worst, growth
  4. QOL
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21
Q

What is an alternative to transfusions
for chronic chemotherapy anemia?

A

EPO/darbopoetin
Target Hb >90

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22
Q

What is the usual neutrophil cutoff
for cytotoxic chemotherapy?

A

> 1.5

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23
Q

Which chemo agents are esp.
associated with alopecia?

A

Cyclophosphamide
-rubicins
-taxels

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24
Q

What agents are NOT associated
strongly w. marrow toxicity?

A

Gemcitabine
Vincristine

  • all others have moderate to severe toxicity
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25
Q

Which chemo agents are associated
with renal failure?

A

Platinums, esp. cisplatin

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26
Q

What chemotherapy agents can cause cognitive impairment?

A

Methotrexate
Ifosfamide

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27
Q

Which agent can cause cerebellar problems?

A

5-FU

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28
Q

Which agents are associated
with peripheral neuropathy?

A

Methotrexate
Platinums
Taxols
Vin- (vinca alkaloids)

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29
Q

Which 2 drugs may cause
pulmonary toxicity?

A

Bleomycin
Methotrexate
Cyclophosphamide

  • esp. w. XRT
  • bleomycin dangerous with high-flow/hyperbaric O2
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30
Q

Which class of agents is most
associated with cardiotoxicity?

A

-rubicins, esp. doxirubicin

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31
Q

List some blood markers and their cancers

A
  • CEA: colon ca
  • CA 19-9: pancreatic ca
  • CA 125: ovarian ca
  • CA 15-3: breast ca
  • PSA: prostate ca
  • LDH: lymphoma
  • AFP/HCG: Germ cell ca
  • IGs: myeloma
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32
Q

What is aromatase?

A

Adrenal androgens → estrogen

  • exists in fat, sexual organs
  • exists in 70% of breast cas
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33
Q

List 3 aromatase inhibitors

A

Letrozole (protein, reversible)
Anastrozole (protein, reversible)
Exemestane (steroid, irreversible)

  • some evidence that exemestane can help when patients progress on others
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34
Q

Which 2 hormones regulate testosterone?

A

LHRH → LH → testosterone

peripherally, testosterone → DHT

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35
Q

What is the primary site of action
for prostate ca hormone therapy?

A

Inhibiting GNRH

either drugs (e.g. goserelin) or castration

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36
Q

What are 2 peripheral testosterone-conversion inhibitors?

A

Bicalutamide
Enzalutamide
Cyproterone acetate

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37
Q

What is the role of tyrosine kinase?

A

Transmits signals from surface receptors into cell

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38
Q

What are the 2 most common sites of action of biological cancer treatment?

A

EGFR (epidermal growth factor receptor)
TK (tyrosine kinase)

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39
Q

What setting is hormone therapy for
breast cancer used first-line?

A

In non-life-threatening disease
i.e. no liver/lung mets

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40
Q

What is the role of hormone therapy
in life-threatening breast ca?

A

Adjuvant therapy following chemo

e.g. tamoxifen x 5 years

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41
Q

What is the typical response rate for first-line hormone monotherapy in breast ca?

A

30%
60% in well-selected patients

much lower as second-line treatment

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42
Q

What is the role of hormone therapy for breast ca in relapsed disease?

A

If < 1 year since tx, likely hormone resistant
If >1 year + on tamoxifen, aromatase inhibitor
If >1 year + done tamoxifen, restart tamoxifen

43
Q

What 3 paraneoplastic syndromes
are associated with SCLC?

A

SIADH
ACTH secretion
myasthenia syndrome

44
Q

What is the only curative tx
in non-small-cell lung ca?

A

Surgery (60% 5-year)
only true in early-stage disease, obvs

45
Q

What % of NSCLC are metastatic at dx?

A

50%

46
Q

What is the median survival of
un-tx stage IV NSCLC?

A

6 months

47
Q

What % of cancers cannot have
a primary tumour identified?

A

3%

48
Q

What % of cancers of unknown primary have a primary identified at autopsy?

A

66%

49
Q

What are common primaries discovered
at autopsy for adenocarcinoma?

A

lung
pancreas
stomach
prostate

50
Q

What are common primaries discovered
at autopsy for squamous carcinoma?

A

skin
ENT
esophagus
lung

51
Q

What are common primaries discovered at autopsy for undifferentiated tumours?

A

germ cell
lymphoma
melanoma
neuroendocrine

52
Q

What 3 ways does radiation directly
damage DNA?

A

single-strand breaks
double-strand breaks
base deletions

53
Q

What is the mechanism of indirect DNA damage by radiation?

A

Splitting H2O → free radicals

(majority of XRT-induced DNA damage)

54
Q

What 3 factors determine tumour radiosensitivity?

A
  1. Intact repair mechanisms (less in cancer)
  2. Perfusion (hypoxia → radioresistance)
  3. Rate/number of dividing cells (dividing tissues more sensitive)
55
Q

After how many XRT fractions is the majority of tumour killed?

Why does this matter?

A

1-2

:. in palliative settings can get excellent effect from short XRT courses

More doses matter when aiming for cure

56
Q

What 3 ways can radiation be given?

A

External beam
Brachytherapy
Systemic radioisotopes

57
Q

List examples of radioisotope therapy

A
  1. Radium-223 for prostate metastases
  2. Strontium for bone mets
  3. Radioiodine for thyroid ca
  4. Iridium in hollow viscuses
    a. uterus/vagina
    b. esophagus/intestines
    c. bronchi
58
Q

At what rate to typical linear
accelerators generate radiation?

A

1 Gy/min

59
Q

What is the mechanism of early RT toxicity?

A

Death of rapidly-dividing epithelium

→ mucositis
→ cystitis
→ gastritis/colitis

60
Q

What is the mechanism of late RT toxicity?

A

Endothelial damage → radionecrosis

→ skin atrophy
→ bowel fibrosis or perforation
→ fistula formation

61
Q

How do we define the maximum dose of XRT for a given tissue?

A

Dose at which late radiation damage is NOT expected to occur in a typical patient

62
Q

What topical treatments need to be avoided for radiation-induced skin damage?

A
  1. Talc
  2. Gentian violet
  3. Creams with metallic salts
  • can worsen reaction
63
Q

Which 3 antinauseants are preferred
for radiation-induced nausea?

A
  1. Metoclopramide
  2. -setrons
  3. Steroids
64
Q

What are tips for managing acute
radiation-induced diarrhea?

A

Avoid fruit sugars
Avoid fibre
Antidiarrheals

65
Q

What are some tips for managing
radiation-induced cystitis?

A

Potassium citrate
Cranberry juice
a-blockers
Rule out infection
Systemic analgesia

66
Q

How to prevent/manage radiation-induced
oropharyngeal mucositis?

A
  1. Chlorhexidine rinses regularly
  2. Preventative nystatin
  3. Dental hygiene with fluoride
  4. Reduce smoking (anything) + EtOH

Treatment:
- NSAID or ASA rinses
- Saliva replacement

67
Q

What is the likelihood that 8Gy x 1 will improve a patient’s bone pain?

A

80% response rate

  • most within 4 weeks
  • small few more within 8 weeks
68
Q

What is the likelihood that re-treatment with 8Gy x 1 will improve a patient’s bone pain?

A

80%

not predicted by initial response

69
Q

What is the primary concern with radiation to the spine?

A

Late radiation myelitis, c. 6-9mo

70
Q

Do large radiation fields offer more pain relief?

A

Mixed

  • earlier onset (c. 7 vs. 21 days)
  • at 4 weeks response equalises
  • more toxicity with larger fields
71
Q

What are 3 relative contraindications
for systemic radioisotope therapy?

A
  1. Incontinent of urine (req. catheter)
  2. Renal failure
  3. Pre-existing marrow failure

all radioisotopes are renally cleared

72
Q

What is the role of XRT in preventing bone mets?

A

Limited–it works but risk:benefit poor

73
Q

Where do SCCs happen in the spine?

A
  • C-spine: 20%
  • T-spine: 70%
  • L/S-spine: 30%
74
Q

If clinical picture consistent with SCC but MRI remains negative, what is the next test?

A

Lumbar puncture to r/o leptomeningeal dz

75
Q

What 3 cancers make up ⅔ of spinal cord compressions?

A

Breast
Prostate
Lung

76
Q

What % of patients who present ambulatory
remain ambulatory after SCC treatment?

A

80%

77
Q

What % of patients who present paraparetic
regain walking after SCC treatment?

A

20-40%

78
Q

Which SCC-causing cancers respond best
to radiation?

A

myeloma + lymphoma
>
breast
>
lung

79
Q

What % of cancers will met. to brain?

A

10%
Most will be multifocal

80
Q

What proportion of patients with multifocal brain mets respond to whole-brain RT?

A

80% see some neurological improvement
20% will not finish tx 2* decline

81
Q

What are positive prognostic features in patients treated with RT for brain mets?

A
  1. Brain as first or only site of relapse
  2. Brain primary
  3. Long disease-free interval
  4. ECOG 0-1
  5. <60yo
82
Q

What are negative prognostic factors in patients treated with RT for brain mets?

A
  1. 2+ lobes involved
  2. meningeal mets
  3. extracranial mets
  4. poor performance status
  5. advanced age
83
Q

Which 1* brain tumours are potentially curable?

A
  1. Meningioma
  2. oligodendroglioma
  3. Astrocytoma, grade I-II
  4. Ependymoma
84
Q

What are typical presenting sx
of meningeal carcinomatosis?

A
  • Multilevel spinal symptoms
  • Multiple facial nerve palsies
  • Sx of increased ICP
85
Q

Which cancers like the meninges?

A
  • Breast
  • Lung
  • CNS lymphoma
86
Q

What is the prognostic sig. of
meningeal metastases in solid tumours?

A

Grim–short weeks median survival

with intensive tx, short months

87
Q

What are expected response rates
to XRT for malignant neuropathic pain?

A

55% any response
25% total response

88
Q

What part of the eye do cancers met to?

A

Choroid plexus

(bresst/lung are 80%)

89
Q

Which 2 eye structures are vulnerable
to radiation damage?

A

Cornea (keratitis)
Lens (delayed cataract)

90
Q

Which two cancers cause SVCO?

A

Primary lung (75%)
Mediastinal lymphoma (15%)

91
Q

Which vein marks the line where SVCO tends to be more severe?

A

Above/below azygous v

92
Q

Is SVCO an emergency?

A

Not usually–take the time to identify the causative tumour to allow targeted treatment

93
Q

Which SVCO-causing tumours respond
best to chemotherapy?

A
  1. Lymphomas (NHL/Hodkgin)
  2. Germ-cell tumours
  3. Small-cell lung ca
94
Q

Which SCVO-causing tumour
responds best to RT?

A

Non-small-cell lung
accounts for basically all other SVCOs

95
Q

Describe approach to brachytherapy
in a hollow organ

A
  1. Endoscopic localisation of lesion
  2. Insertion of hollow plastic tube at desired site of treatment
  3. Insertion of radioactive source into tube to be held near lesion for a short period

Can be done as an outpatient procedure

96
Q

What is the most common malignant cause of dysphagia?

A

Tumour in the esophagus (⅘)

97
Q

What proportion of malignant cases of
dysphagia respond to XRT?

A

80%, persistent at 6mo

98
Q

What is the response rate to RT
for malignant hemoptysis in 1* lung ca?

A

80%

99
Q

What is the response rate to RT
for malignant hemoptysis in lung mets?

A

Minimal unless you can identify a specific site of bleeding on bronchoscopy to target

100
Q

What are non-tumour causes of hematuria in cancer patieints?

A
  1. Cyclophosphamide s/e
  2. Delayed radiation response
  3. Thromboytopenia
101
Q

Which two organs are particularly
radiosensitive, even at low doses?

A

Kidney
Liver

102
Q

Which GI organs are harder to radiate?

A

Stomach
small intestine

  • more mobile
  • stomach near liver, kidneys
  • small intestine ++ symptomatic to tx
103
Q

Why may it be OK to oversaturate the chest wall with RT in breast cancer recurrence?

A

Fungating tumours are worse than late radiation damage

104
Q

Which organ is exquisitely sensitive to RT
when infiltrated by cancer?

A

Splenic lymphoma/leukemia

  • high risk of TLS
  • treated with 1Gy weekly or less

Adam's Weak Spots (8 decks)

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