ONCOLOGY Flashcards
What are the big and serious side effects of chemotherapy
Neutropenic sepsis
What is radical treatment
Curative treatment (usually)
What is neo adjuvant treatment
Things you do before giving curative treatment to optimise this working (eg to reduce burden of metastatic disease)
Aim is to improve longer term survival before having curative treatment (eg surgery, radiotherapy etc)
What is adjuvant treatment
Treatment you give after your curative intent treatment
Intent is to reduce the risk of cancer coming back in the future - eg to kill little cancer cells floating around that you dont see on scans etc - would give chemo for this
What are palliative treatments
Shrink and control (not get rid of it)
Improve QOL
Improve symptom control
What is radiotherapy
Use of high energy x rays to destroy cancer cells
What is brachytherapy
internal radiation therapy - directed at a specific place
Difference between chemo and radiotherapy
Radiotherapy - local therapy
Chemo - systemic therapy
Difference between chemo and radiotherapy
Radiotherapy - local therapy
Chemo - systemic therapy (deals with micro-metastatic disease)
Time frame for neutropenic sepsis in chemo
In a 3 weeks cycle of chemo
7-10 days lowest for neutrophils
Risk factors for breast cancer
Atypical ductal hyperplasia Lobular carcinoma in situ Age Alcohol - even moderate intake Obesity (post menopaural) HRT (5 years plus) COCP Late first child (>35 years), no breastfeeding Early menarche
Red flags for breast cancer
Hard painless lump Irregular Tethered Skin tethering - pathognomic Lump and enlarged node - pathognomic Positive family hx, breast, prostate, pancreas (ductal)
Breast lump differentials
Fibroadenoma - younger pts (puberty - 30), breast tissue proliferation - benign and leave unless very large. Breast mouse - feels smooth and moveable.
Cyst - most similar to cancer as can feel hard if dense and irregular - 35-55
Papilloma
Benign breast changes - cyclical, tender, rubbery, nodules
Mastitis
Sarcoma
Nipple discharge differentials
Physiological - colour - yellow/ creamy
Hormonal - pregnancy/ hormone profile - milky large volume
Duct ectasia (dilation) - green/ brown, multi duct (can get blood sometimes)
Papilloma - blood, uniduct
DCIS - clear or bloody, uniduct
Red flags for nipple discharge
Red - blood
Uniduct
If these, probably papiloma or DCIS
Breast pain differentials
Hormonal (pre meno and post on HRT)
MSK (non cyclical)
Outline the management of breast lumps
> 40 - mammography then US and biopsy
25-40 - US and biopsy
<25 - free hand biopsy
Positive result - sentinal node biopsy
what is the inheritance pattern of lynch syndrome
autosomal dominant
what is the criteria for 2 week wait referral for ?breast cancer
age (>30), unexplained lump in breast
age (>50),
no lump but nipple discharge or retraction
consider urgent referral for unexplained lump in axilla
<30 unexplained lump - non urgent referral
what 2 clinical features in over 50s require 2 week wait referral for suspected breast cancer
(regardless of breast lump or pain)
nipple discharge
nipple retraction
what are the common gene syndromes associated with breast cancer
brca 1 and 2 (2 associated with other ductal cancers - prostate and pancreatic)
tp53 - li-fraumeni (brain, gastric)
cowdens - thyroid, endocrine
what should you ask about in a ?cancer hx to identify any possible gene penetrance/ syndromes
family hx of ANY cancers
any fhx of cancers <50 years
what age of women are screened for breast cancer, how, what are pros and cons
47-73, every 3 years, mammogram
pros picks up dcis, lcis
cons - lead time bias about whether improvement in survival is real or artifact
how are pts with cancer penetrance genes monitored for breast cancer
mri from >30 years - more sensitive than mammogram
what investigations are done for suspected breast cancer
> 40 years - mammogram then uss and biopsy
25 - 40 - uss and biospy
<25 - free hand biopsy
What are the main imaging tools for breast cancer
mammography (xr)
ultrasound
mri (if young and dense breasts, or discrepancy between clinical findings and other imaging)
what are the indications for mri in breast cancer
dense breasts <30 years and cancer genes in family
discrepancy in other imaging used and clinical findings
if needed to quantify tumour size in breast conserving surgery (i.e. need to know more precise detail of tumour size)
which breast cancer has the worst prognosis
her 2 positive
50% will get brain mets vs 20% in her 2 negative
what are patients with lynch syndrome recommended to take for prevention of colorectal cancer
aspirin
what is difference between men and women re follow up anaemia
men should not be anaemic - always needs investigating
women can be anaemia due to menstruation - once post menopausal would investigate as a man
indications for transfusion
depends on symptoms - not based on hb
how do you give iron for iron deficiency anaemia
oral
if cant tolerate this iv
give for 3 months to replace iron stores
how often would you prescribe iron for iron deficiency anaemia
od - 200mg od
tds - get less iron absorption because of symptoms
causes of thrombocytosis
inflammation, bleeding, cancer
what exam do you for constipation
rectal and abdo
to see where constipated
what exam do you need to do for confusion
neurological, gcs
what is a blood disorder than increases dvt risk
factor v leiden
what is factor v leiden
mutation of one of the clotting factors in the blood. This mutation can increase your chance of developing abnormal blood clots, most commonly in your legs or lungs.
first line for pe in cancer patients
dalteparin
what should you co prescribe with dexamethasone
ppi, antiemetic
what is first line treatment for neutropaenic sepsis
piperacillin/ tazobactam
what days are greatest risk for neutropenic sepsis
7-14
dexamethasone dose in spinal cord compression
8mg dex bd
outline current bowel cancer screening in uk
> 55 - one off scope (flexisig) in some areas
60-74 - fit test every 2 years - faecal immunochemical test
looks for small amounts of blood with antibodies for human blood (eg dont get false positive by detection of ingested blood from meat)
what is curative treatment
definitive treatment
usually surgery or radiotherapy
what is palliative treatment
treatment aimed at reducing symptom burden
what is concurrent treatment
treatment given at same time as definitive treatment
how does chemotherapy work
mechanisms that damage rapidly dividing cells and cause them to die.
Works mainly on cancer cells rather than healthy tissue as cancer cells are less developed cells and so have less defences. Health tissue has better mechanisms/ defences to deal with damage from chemo, although damage still happens.
How is toxicity graded with chemotherapy, and what levels of serious/ life-threatening
1-5 (5 is death) 1 = mild 2 = moderate 3,4 = serious, hospital admission, life threatening, need change in chemo regime 5 = death Graded based on speed of toxicity
Management of anaphylaxis
Stop drug infusion High flow oxygen (12-15L, bag valve mask) IV adrenalin (0.5 ml of 1:1000 IM) IV fluids IV antihistamine (eg chlorphenamine) IV steroid (eg hydrocortisone) Continuous monitoring
What dose and route of adrenalin should you give in anaphylaxis
0.5 mls of 1:1000 adrenaline IM
What blood test do you need to do before starting gentamicin
UandE - can cause renal failure
List some of the common side effects of chemotherapy
Anaphylaxis Neutropenic sepsis / neutropenia Extravasation Coronary spasm Nausea/ vomiting Constipation/ diarrhoea Bone marrow suppression Fatigue Alopecia Stomatitis Skin toxicity (rash, itching etc) Cognitive impairment Lung toxicity Peripheral neuropathy Late effects
Difference between chemotherapy and immunotherapy
Chemo - drugs that kill cancer cells by toxic mechanisms
Immunotherapy - antibodies that help to activate (upregulate) immune system to respond to cancer
Commonest side effects of immunotherapy
Autoimmune damage to liver (derranged LFTs), lungs (SOB, cough, chest pain), colon (diarrhoea, constipation), thyroid
Currently, what are immunotherapies used for
Palliative treatment only
When should you suspect neutropenic sepsis and how would you proceed with assessment / management
Neutrophils <1.0 and any symptoms of infection (does not have to be fever)
Consider it in ANY patient on chemo with temp of >37.5
CLINICAL DIAGNOSIS AND MANAGEMENT
Do not wait to for blood results to confirm
Any infection symptom - treat as per sepsis protocol, stat IV broadspectrum antibiotics
Check hx for blood cultures and any known resistant organisms - may mean you need to speak to microbiology about this
Contact oncall oncologist
How is anaphylaxis prevented when starting a new chemotherapy
High dose steroids day before
IV/ PO antihistamines day before
Slow infusion
What is extravasation, what are the complications and how is it prevented
When cannula tissues - cytotoxic drug accumulates into tissue and can cause necrosis
Prevent by small cannula and insert away from joints to reduce serious damage if tissues
Management - stop infusion and seek help
Of bad, ?plastics
What chemotherapy can cause coronary artery spasm and what is the management
Flurouracil
Capecitabine
Management is nitrates
What antiemetics are prescribed for nausea and vomitting
Metoclopramide - D2 antagonist
Ondansetron - 5HT
Aprepitant - only licenced for chemo
Cyclizine - antihistamine
What is the management of diarrhoea and constipation in patients on chemotherapy
Loperamide (diarrhoea)
Laxatives (constipation)
What should you always consider when a patient on chemotherapy presents with constipation
Bowel obstruction
What are the features of bone marrow suppression in a patient on chemotherapy
Anaemia
Thrombocytopenia
Neutropenia
What is dose limiting toxicity determined by with chemotherapy
Bone marrow suppression
So basically - toxicity level acceptable is when marrow is still functioning
What is pancytopenia, what does it represent
Low red cells
Low white cells
Low platelets
Represents aplastic anaemia, which is the term used for bone marrow failure
What is the management of aplastic anaemia in chemotherapy patients
Lower threshold for transfusion, want a Hb target of 100-120 - discuss with oncologist
Platelet transfusion when <10
What would make you suspicious of bone marrow suppression in a patient undergoing chemotherapy
Signs of anaemia
Pallor
Fatigue
When should you suspect neutropenic sepsis and how should it be managed
Suspect and treat based on clinic symptoms and very low threshold
Fever (>37.5) OR any infection symptom - cough, feeling unwell, dysuria, abdo pain, diarrhoea - ANYTHING
CHECK ALLERGIES then:
IV broadspectrum antibiotics - tazobactam / pipercillin
Speak to on call oncologist
Bloods and monitor
Neutrophils <1
Do not treat based on neutrophils
TREAT BASED ON SYMPTOMS
Presentation and management of stomatitis
Sore, dry, red, inflamed oral mucosa Ask about oral intake (if preventing this need to consider dehydration) Supportive: Oral anti-inflammatory gels/ mouthwash/ toothpaste Difflam mouthwash (numbs mouth) Antacid ozetocaine Aspirin gargle/ mouthwash Last resort: systemic analgesia ALCOHOL free oramorph
What can you give for the management of fatigue in cancer patients
steroids - although only if end of life/ poor prognosis as not good long term
What can you give for management of dry skin/ itch in cancer patients
emollients
antihistamines
What should you include in differential of SOB in patients on chemotherapy
Lung toxicity - rare but potentially life threatening remember in differential
Bleomycin
What neurological symptoms are common with chemotherapy
Peripheral neuropathy
Platinum in chemo is cause
What are the late effects associated with chemotherapy
Infertility Early menopause Atherosclerosis Heart failure / lung damage Chemo brain secondary cancers
What should you always check on examination when suspecting cancer
lymph nodes
what is the 2 ww referral guidelines for breast cancer
> 30 unexplained breast lump
>50 nipple retraction, discharge or lump in axilla
what is the 2 ww referral guidelines for bowel cancer
> 40 unexplained weight loss + abdo pain
50 unexplained rectal bleeding
60 iron deficiency anaemia or change in bowel habit
what is the 2 ww referral guidelines for lung cancer
> 40 unexplained haemoptysis
CXR changes suggestive of cancer
what is the 2 ww referral guidelines for prostate cancer
> 50 and PSA >3
Hard craggy mass on DRE
List some red flags for bowel cancer
Change in bowel habit Anaemia Abdominal mass Abdominal pain Blood in stool Weight loss Change in appetite Anal mass/ ulceration DVT
What should you include in differential for an unprovoked DVT
Cancer
How long should a patient who has had a PE and who has cancer be anticoagulated for (as a minimum)
3-6 months
usually 6 months
List red flags for lung cancer
Haemoptysis Cough, chest pain + smoker Dysphagia Hoarse voice SOB Head, neck, arm swelling (SVCO obstruction)
Most common symptoms of lung cancer
Cough
Chest pain
Haemoptysis
Site of lung cancer mets
lymph glands bone brain liver adrenal glands
Symptoms of lung cancer metastatic disease
bone pain headache seizures neurological deficit hepatic pain abdominal pain
What are paraneoplastic syndromes
Which cancers most commonly have paraneoplastic syndromes
Symptoms caused by the effects of a tumour rather than tumour itself (eg secreting high ACTH - Pituitary tumour/ lung tumour, or tumour acts as antigen that causes immune system to produce antibody that cross reacts eg Eaton Lambert syndrome, or tumour secretes protein that interacts with normal physiology eg parathyroid hormone related protein and hypercalcaemia)
Lung, breast, ovarian, pancreas, stomach, kidney, lymphoma, leukaemia
Investigations for lung cancer
CXR CT thorax Bronchoscopy +/- US guided biopsy Percutaneous (CT guided) needle biopsy US guided aspirate or biopsy Surgical biopsy
List the common paraneoplastic syndromes and their symptoms/ presentations
Eaton Lambert - weakness, fatigue, similar to MG
SIADH - hyponatraemia - headache, lethargy, weakness, confusion
Hypercalcaemia - parathyroid related protein (check PTH (high in primary HPT), phosphate (low in primary HPT), protein (normal to low in cancer), ALP (bone turnover)
Hypertropic osteoarthropathy - joint pain, bone pain
Clubbing
Weight los
What questions should you ask about in cancer hx to probe for paraneoplastic syndromes
Weakness Balance/ stumbling Bone/ joint pain Thirst / polyuria Nausea/ sickness / vomitting
presentation of paraneoplastic ACTH producing lung tumour
Cushing’s symptoms
what are carcinoid tumours
Tumours of neuroendocrine cells (enterochromaffin in gut that releases serotonin and histamine; and PNEC - pulmonary neuroendocrine cells that release serotonin)
how do carcinoid tumours present
Features of high plasma serotonin and bradykinin
Flushing
Low BP
Palpitation
Diarrhoea
Bronchospasm
Can get symptoms of R sided heart disease bc of metastatic spread from gut to liver to heart. Get tricuspid valve regurge, endocardial fibrosis
Can get retroperitoneal fibrosis from retroperitoneal spread - eg hydro nephrosis
Peyronies
how would you investigate carcinoid tumours
Plasma chromaffin A - screening test
24 hour urinary excretion of 5HIAA
Bloods for tumour marks including FBC, LFTs, TFTs, parathyroid hormone, calcium, calcitonin, prolactin. alpha-fetoprotein, carcinoembryonic antigen (CEA) and beta-hCG.
What radiation is used in radiotherapy and why
Gamma waves
Higher energy, more ionising, affect nucleus of cell
What is the difference between a bone scan and a DEXA scan
DEXA is X rays - looks at density
Bone scan is nuclear medicine - uses a radioisotope to look as bone activity
How does a bone scan work
Uses a radioactive tracer - usually technetium 99 - attaches it to a compound that is metabolically active with bone (medronic acid - is taken up by blasts). The tracer is then taken up more in areas of bone clast activity and turn over, eg mets or fractures and generates ‘hot spots’
What is the difference between X-rays/CT and nuclear medicine scans
XRays/ CT - anatomical scans
Nuclear medicine - functional - have a tracer that gives some index of physiology
What is the difference between PET and SPECT vs Bone scan (gamma camera)
Bone scan - 2D image
PET and SPECT - 3D image (combined with CT for anatomy)
