Oncology Flashcards
Which external factor poses the highest risk to developing cancer?
Smoking
What % of all cancers worldwide are caused by smoking?
15%
What % of lung cancers are caused by smoking?
90%
In addition to lung cancer, what other cancers is smoking attributed to? (8)
- Mesothelioma
- Myeloid leukaemia
- GI tract including oesophageal, gastric and pancreatic
- ENT e.g. pharyngeal, laryngeal
- Bladder
- Renal
- Liver
- Cervical
Which cancers is high consumption of alcohol linked to? (4)
- Head and neck cancer
- Oesophageal cancer
- Breast cancer
- Hepatocellular carcinoma
Adult obesity is a risk factor for which solid tumours? (5)
- Endometrial cancer
- Post-menopausal breast cancer
- Kidney cancer
- Oesophageal carcinoma
- Colorectal carcinoma
In terms of dietary risk factors, which foods are associated with lowering risk of colorectal cancer, and which increase the risk?
- High levels of vegetable consumption reduces risk
2. High levels of red meat increases risk
What % of the worldwide incidence of cancer is due to infection?
16%
Which viral infection accounts for 80% of cervical cancers worldwide?
HPV
Hep B and C infections are attributable for 81% of cases of which cancer?
Hepatocellular carcinoma
Which cancer can epstein-barr virus cause?
Hodgkin’s lymphoma
Which bacteria accounts for 1/3 of cases of adenocarcinoma?
H.pylori
The parasitic infection; Schistosomiasis haematobium can cause which kind of cancer?
Invasive carcinoma of the bladder (8% of bladder cancer)
Name the 4 tumour suppressor genes?
- p53
- Rb
- MTS1
- BRCA 1 & BRCA 2
Which cancers are associated with p53? (5)
- Breast
- Lung
- Colon
- Glioma
- Sarcoma
Which cancers are associated with Rb? (3)
- Retinoblastoma
- Small-cell lung cancer
- Osteosarcoma
Which cancers are associated with MTS1? (5)
- Glioma
- Melanoma
- Lung
- Bladder
- Mesothelioma
Which cancers are associated with BRCA1 and 2? (2)
- Familial breast cancer
2. Ovarian cancer
Which syndromes are linked to bowel cancer? (3)
- Familial adenomatous polyposis (FAP)
- Peutz-Jegher
3 Lynch (HNPCC)
What four roles does surgery have in the management of cancer?
- Diagnosis and staging
- Curative
- Palliative
- Prophylactically / pre-emptively
Which routes of spread are common in breast and colorectal cancer?
Blood and lymphatic spread
Which route is most common for metastases of upper GI tract and upper airway cancers?
Lymphatics
Which surgery technique is used most commonly for cancers which spread lymphatically?
En-bloc
What can be a problem with fine needle aspiration in attempting to diagnose/stage cancer?
It could result in tumour seeding. Therefore the needle track needs to be excised in the definitive surgery
Laparoscopy is used for staging which malignancies before definitive surgery? (6)
- Oesophageal cancer
- Gastric cancer
- Pancreatic cancer
- Liver cancer
- Prostate cancer
- Ovarian cancer
When may surgery be used palliatively in cancer? (5)
- Bowel obstruction
- Fistulas
- Jaundice
- Ascites
- Pain
- GI bleeding
- Palliative resection of the primary tumour
What % of cancer patients have brain secondaries?
10%
In relation to radiotherapy, what is fractionation?
It is the division of a total dose of external beam radiotherapy (EBRT) into small, often once daily doses. It results in preferential sparing of normal tissue damage, allowing safe delivery of higher total doses of radiation with increased cancer cell kill.
What are the acute effects of radiotherapy? (occurring up to 8 weeks post-radiotherapy)
Mainly affects the skin, mucosa and haemopoietic system (AKA skin, GI tract and bone marrow).
Cell loss is predominantly due to loss of reproductive capacity as radiotherapy interferes with the replacement of lost cells.
What are the late effects of radiotherapy?
Affects: lung, kidney, CNS, heart, connective tissue
The severity of this effect depends on the total dose, and dose per fraction. Recovery may be incomplete
How does radiotherapy affect the skin?
Early effects:
1. Erythema ‘sunburn’ reaction - skin feels hot, itchy and sore
2. Desquamation - dry, peeling epidermis
Late effects can include; telangiectasia, atrophy, fibrosis
How can radiotherapy affect the oral mucosa? (2)
- Ulceration
2. Dry mouth
How does radiotherapy affect the GI tract? (4)
- Oesophagitis
- Nausea and vomiting
- Diarrhoea
- Rectal discharge/bleeding
Late effects can include: fibrosis/obstruction
How can a large single radiotherapy fraction/dose affect the lungs?
Acute deterioration airway obstruction
What is the connection between radiotherapy treatment and hypoxia?
Some tumours have areas of hypoxic cells that are less sensitive to radiotherapy than oxygenated cells.`During a fractionated course, response of the cancer to treatment may result in re-oxygenation of hypoxic areas, further enhancing tumour cell kill.
What are the oldest chemotherapy agents used and what do they do?
Alkylating agents - are an anti proliferative drug because they bind covalently via alkyl groups to DNA. Following cross-linking there is thought to be arrest in G1-S transition following either DNA repair or apoptosis.
When are alkylating chemotherapy agents used?
Extensively used to treat leukaemia and lymphoma
Name some examples of alkylating agents?
- Melphalan (nitrogen mustard and phenylalanine)
- Chlorambucil
- Cyclophosphamide - cytotoxic chemotherapy - used extensively
Busulphan is a alkylating cytotoxic drug used specifically in the treatment of which cancer?
Chronic myeloid leukaemia
How does the WHO define palliative care?
It is an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention of and relief of suffering by means of early detection and impeccable;e assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
What are the steps involved in breaking bad news? (10)
- Preparation - know the facts, arrange the meeting, arrange not to be disturbed.
- Establish what the patient already knows
- Establish whether the patient wants more information
- Allow denial, this is a defence mechanism and a way of coping.
- Give a warning shot - this gives the patient time to consider their own reactions and whether they feel able to ask more questions
- Explain if requested. Be clear and simple. Avoid harsh statements and medical jargon. Check understanding. Be as optimistic as possible.
- Listen to concerns, avoid premature reassurance
- Encourage ventilation of feelings
- Summarise and make a plan. This minimises uncertainty and confusion
- Offer availability - provide written information and provide details of who to contact.
Other than the common pain ladder used in pain management, what adjuvants may be used alongside?
- Steroids
- Tricyclic antidepressants
- Anticonvulsants
- NMDA
- Benzodiazepines
What are the most common types of lung cancers?
- Squamous cell carcinoma (30%)
- Small-cell carcinoma (15-20%)
- Adenocarcinoma (40%)
What are the common signs and symptoms associated with lung cancer? (9)
- Persistent cough/haemoptysis
- Recurrent chest infections
- Pleural effusion
- Chest pain
- Hoarse voice
- Wheeze/stridor
- Horner’s syndrome
- Fatigue
- Anorexia, weight loss
What investigations are carried out with suspected lung cancer? (5)
- Physical examination
- CXR
- Sputum cytology
- FNA
- Bronchoscopy
What are the causes of nausea and vomiting in someone with cancer? (13)
- Anxiety
- Fear
- Pain
- Psychological stimuli
- Anticipatory nausea
- Emotions
- Smell
- Biochemical abnormalities e.g. hypercalcaemia
- Uraemia
- Drug toxicity
- Opioids
- Toxins (bacterial/tumour)
- Chemotherapy
Which area of the brain lies outside the blood-brain barrier and therefore responds to drugs and toxins and can stimulate nausea and vomiting?
The area postrema (AP)
What are the common metabolic causes of vomiting and nausea in people with cancer? (6)
- Raised levels of Ca2+ (may be accompanied by dehydration, constipation, abdominal pain, confusion)
- Uraemia
- Hyponatraemia
- Secretion of inappropriate anti-diuretic hormone (SIADH) (caused by specific malignancies, drugs, chemotherapy and head injuries)
- Opioids
- Antibiotics
Which anti-emetic drugs are useful in the treatment of nausea and vomiting in people with cancer? (8)
- Metoclopramide & Domperidone
- Haloperidol - careful- watch for extrapyramidal side effects
- Cyclizine - 1st choice if N&V caused by raised ICP
- Levomepromazine
- Lorazepam (anticipatory)
- Dexamethasone - used in conjunction with other anti-emetics during chemotherapy
- Ondansetron
- Aprepitant - newly developed
What are the causes of constipation in people with malignancy? (7)
- Drugs - particularly the more water-soluble opioid analgesics, many anti-emetics, and some forms of chemotherapy
- Dehydration - due to inadequate fluid intake or secondary to vomiting
- Anorexia
- Immobility
- Hypercalcaemia
- Spinal cord compression
- Intestinal obstruction
Which drugs come first one the WHO pain ladder?
Paracetamol and Ibuprofen
What is the maximum dose per day of paracetamol?
4g
What is second on the WHO pain ladder?
Codeine
Tramadol
DF118
What are the standard doses of co-codamol?
8/500
15/500
30/500
If a patient weights less than 50kg, what is the recommended dose of paracetamol?
1/2 of the usual dose - so do not exceed 2g per day
Why does the mechanism of action of tramadol mean it is very rarely prescribed in elderly patients?
It has a dual mode of action, in addition to pain relief, also a tricyclic which can cause delirium in elderly patients
Name 6 different types of morphine?
- Diamorphine
- Oromorph
- Oxycodon
- Fentanyl
- Buprenorphine
- Methadone
Which two morphine drugs are in the form of patches and why is this beneficial?
Buprenorphine and fentanyl
Useful if the patient does not have a safe swallow or suffering from vomiting etc.
In addition to the patches being useful as a different route of administration, why else of these two morphine drugs indicated for use?
For patients with renal failure
In addition to opioids, what are the other forms of pain relief medication? (e.g. for neuropathic pain)
- Amytriptyline
- Gabapentin
- Pregabalin
- NSAIDs
- Steroids
What is the difference between side effect and toxicity?
A side effect is a symptom that occurs within the therapeutic range and can be expected
Toxicity is the result of an overdose or the drug dose not within the therapeutic range, and could be fatal
What are the side effects of opioids?
- Constipation (constant)
- Dry mouth (constant and debilitating)
- Nausea and vomiting
- Drowsiness
What are the signs/symptoms of opioid toxicity? (5)
- Delirium
- Vivid dreams
- Hallucinations (visual)
- Myoclonus
- Respiratory depression
Which symptom/sign of opioid toxicity is ‘barn door’?
Visual hallucinations - and the patient will not volunteer this normally due to embarrassment/concern.
When is opioid toxicity most likely to occur?
In a patient whose drug dose is increased or different drug started.
It could also occur even in the patient has been on the same drug for 6 months for example, but this would indicate something else is going on.
If you have used the pain ladder and are up to step 3 and prescribing morphine, should you continue with steps 1 and 2?
Only continue with step 1, but stop step 2.
What should the dose of breakthrough IR (PRN) morphine be (normally oromorph) in relation to the MST (modified slow release)?
1/6 of total MST dose
If a patient receives 15mg bd of MST morphine, what should their IR be?
15 x 2 = 30mg total dose, therefore breakthrough IR dose should be 30/6 = 5mg
Approximately how much is 240mg of codeine converted to morphine?
24mg
How do you re-calculate a new MST if someone is on MST 20mg bd and IR 5mg qds?
So current MST = 20 x 2 = 40mg
IR = 5mg x 4 = 20mg
Therefore the current total daily dose is 60mg.
So the new MST should be 30mg bd
Having re-calculated the new MST, what should the breakthrough dose now be?
60mg / 6 = 10mg.
What is the antidote to opioid toxicity?
Naloxone
What are the GI associated causes of nausea and vomiting? (4)
- Bowel obstruction
- Ascites (change in intra-abdominal pressure)
- Spleno/hepato-megaly
- Physical barrier e.g. tumour
What are the different causes of toxicity leading to nausea? (6)
- Chemotherapy
- Radiotherapy
- Drugs
- Infection
- Hypercalcaemia
- Renal failure
Which drugs treat GI-related vomiting? (2)
- Metoclopramide
- Domperidone
(10mg ads, before meals)
What is the drug used to treat toxicity induced vomiting?
Haloperidol
What type of drugs are metoclopramide/domperidone?
Prokinetic dopamine antagonists
What are the 4 key principles of palliative medicine?
- Physical
- Psychological
- Social
- Spiritual
Which neuropathic pain relief drugs should be avoided in people with Renault failure?
Pregabalin/Gabapentin
In which people should amitriptyline be avoided in?
Elderly people with cardiac histories
When should NSAIDs be prescribed with caution?
In people with:
- Renal failure
- Heart failure
- Previous GI ulcers
- Bleeding tendency
What is the standard dose of metoclopramide?
10mg TDS/QDS (max 80mg/day)
Which anti emetic should metoclopramide never be prescribed alongside due to its prokinetic action?
Cyclizine
In what way is domperidone different to metoclopramide?
It does not cross the blood brain barrier, so does not cause Parkinsonian effects/extra-pyramidal effects
Why is metoclopramide more useful than domperidone?
Because it can be administered sub-cut whereas domperidone is only by oral route
When is haloperidol indicated?
For drug-induced or biochemical induced nausea
What is the standard dose of haloperidol?
1.5-3mg PRN (max 10mg/day)
Which form of morphine is indicated for use in someone with an eGFR or less than 40?
Oxycodone
What are anticipatories?
Drugs that are supplied PRN for patients who it is suspected have hours/days to live
What are the most common anticipatory drugs?
Morphine for pain relief
Hyasine butyl bromide (buscapan) for secretions and to help with the ‘death rattle’
Haloperidol (or other anti emetic)
Medazolam or lorazepam (a sedative)
Name two stimulant laxatives?
Senna
Docusate
Name two softener laxatives?
Lactulose
Movicol
Which drugs are used to treat nausea and vomiting due to raised intra-cranial pressure?
Steroids normally dexamethasone
Cyclizine
Which drug is used to treat hypercalcaemia?
Bisphosphonates
What does of dexamethasone do you give to treat spinal cord compression?
16mg
Which drugs can you give to reduce someone’s respiratory rate in palliative care?
Opioids
Midazolam
Which cancers most commonly spread to bone?
- Breast
- Lung
- Prostate
- Thyroid
- Renal
What are the 5 commonly used anticipatory drugs?
- Diamorphine
- Buscopan
- Midazolam
- Haloperidol
- Levomepromazine
When is a syringe driver useful?
When patients are:
- Unable to swallow
- Reduce the need of injections
- Provide constant analgesia (no peaks and troughs)
- Usually reloaded once in 24 hours
- Patient comfort
- Can be managed effectively at home or in a care environment
Which two forms of morphine are most potent?
Diamorphine
Oxycodone
When is midazolam indicated for use in end of life card?
- Pain
- Anxiety
- Restlessness/agitation
- Dyspnoea
- Muscles - myoclonic jerks
- Fits
What does Buscopan Hyoscine Butylbromide treat?
- Smooth muscle spasm, bladder and bowel
- Diarrhoea, drooling and death rattle
- Inoperable bowel obstruction, paraneoplastic, pyrexia, sweating
What is levomepromazine?
It is an anti-psychotic used in palliative care to treat patients who are distressed, agitated, restless or in pain.
How is levomepromazine normally administered?
As it is used in end of life care, it is normally via a syringe driver, so subcutaneously, but it can also be IM or IV.
What are the contraindications for use of levomepromazine? (3)
- CNS depression
- Comatose state
- Phaechromocytoma
What is Bence-Jones protein, and which cancer is it associated with?
Bence-Jones protein is an immunoglobulin chain that can be measured in urine output. It is associated with myeloma.
MALT lymphomas are often caused by which infection?
H.pylori
Which type of imaging investigation is best for picking up occult malignancies?
PET scan
Which type of investigation is useful to perform in a patient with possible bone metastases from prostate cancer?
Bone scintigraphy
In someone who has vomiting associated with chemotherapy, and metoclopramide hasn’t worked, which drug would be recommended next? (and what is its method of action)?
Ondansetron - 5HT3 antagonist
