Oncology and Palliative Care Flashcards
Define palliative care
Care which improves the quality of life for patients AND their families rather than finding a cure.
Psychosocial, physical, spiritual.
When does palliative care usually begin?
Palliative care begins when curative care is no longer effective.
Which cancer is most associated with raised levels of CA 19-9?
Pancreatic cancer
Which cancer drug class can cause cardiomyopathy?
Anthracyclines
Raised alpha-feto protein (aFP) level in a 54-year-old woman. Which cancer?
Liver cancer
Raised beta-human chorionic gonadotropin (b-HCG) with a raised alpha-feto protein level. Which cancer?
Non-seminomatous testicular cancer
Which of the following cytotoxic agents is most associated with lung fibrosis?
Bleomycin
Which is the tumour marker for breast cancer?
CA 15-3
HNPCC and FAP can cause which type of cancer?
Colorectal cancer
If SVCO is suspected, which initial investigation must be undertaken?
CT
How do we manage SVCO?
SVC stenting, Radiotherapy and chemotherapy
Sclerotic lesions are associated with which cancer compared with osteolytic lesions?
Sclerotic lesions = Metastatic prostate cancer
Osteolytic = Paget’s, multiple myeloma
Do multiple polyps increase or decrease the risk of cancer and what is an appropriate treatment?
Multiple polyps increase the risk of malignancy.
Treatment: Colectomy.
Mutations in the BRCA1 and 2 genes increase the risk of one developing which cancers?
Breast and ovarian cancer. (More BRCA1).
BRCA2 mutation is also linked with increase risk of prostate cancer in men.
What is Gardners syndrome?
Autosomal dominant Familial adenomatous polyposis
Multiple polyps.
Which cancer has the strongest association with smoking?
Squamous cell lung cancer
Name four cytotoxic cancer agents used in therapy.
Vincristine
Bleomycin
Cisplatin
Azathioprine
Which cytotoxic agent is most likely to be associated with lung fibrosis?
Bleomycin
Which drug is used to manage lymphoma?
Vincristine
What is an orchiectomy?
Removal of the testicle. Same as orchidectomy.
In patients with suspected spinal cord compression i.e. back pain and leg weakness, which is the investigation of choice
MRI (not ct)
Which cancer is most associated with raised levels of carcinoembryonic antigen (CEA)?
Colorectal cancer
Which cancer is most associated with raised levels of AFP?
Hepatocellular carcinoma.
What is a common cause of SVCO?
Small cell lung cancer
Give 3 ways a patient with SVCO may present.
Periorbital oedema, dyspnoea, visual disturbances, flushing of face, neck, arms.
How does ovarian cancer usually present?
With very non specific abdominal symptoms
e.g. nausea, vomiting, discomfort, anorexia.
Which medication do we use to treat shortness of breath with anxiety in palliative state?
Lorazepam 0.5mg sublingual QDS.
Which opioid do we use to treat severe shortness of breath?
Oral morphine - Oromorph 10mg/5ml.
Which route of administering drugs is preferred at end of life?
Subcutaneous > NG.
What is Zoledronic acid?
A bisphosphanate
What are Chvostek’s and Trousseau’s sign indicative of?
Hypocalcaemia
NOT HYPER
Which are the two most common cancers to cause renal cell carcinoma and prostate cancer?
Renal cell carcinoma
Prostate cancer
What is the difference between somatic and visceral pain?
Somatic pain affects the joints and bones characterised by stabbing and aching.
Visceral pain affects structures such as the liver and gut.
What is Tramadol?
Weak opioid.
Which drug is for patients who require analgesia but have renal failure?
Alfentanil
Which drugs would we use as pain relief on the WHO step 2 vs. step 3 scale?
Step 2 = Codeine
Step 3 = Oxycodone
Which are the three opioid receptors?
Mu, kappa and delta.
Define sarcoma
A cancer arising from connective tissue
Define seminoma
A cancer arising from germ cells
Define carcinoma
A cancer arising from epithelial cells
Define adenocarcinoma
A cancer arising from secretory epithelium
Define gastrinoma
A cancer producing gastrin hormone
Give 3 ways in which liver can present
Painless Jaundice
Unexplained weight loss
Abdominal mass
Give 3 ways in which brain cancer can present
Seizure
Pressure headache
Visual disturbances
Focal weakness
Name the 5 oncological emergencies
Neutropenic sepsis Metastatic spinal cord compression SVCO - superior vena cava obstruction Hypercalcaemia Tumour Lysis syndrome
How do we define neutropenic sepsis?
Neutropaenia (<1x10^9) and fever (>38 degrees).
Which blood cell is very likely to reduce following chemotherapy?
Neutrophils
= Neutropaenia
How do we manage febrile neutropenia?
Resuscitation, fluids
Blood cultures
Septic screen
Antibiotics
1st line = Tazobactam 4.5g IV QDS.
plus
Amikacin.
Which antibiotic do we use for neutropenic sepsis if patient is allergic to penicillin?
Meropenem 1g TV TDS.
When may teicoplanin be used as an antibiotic?
If there is a suspected central line or MRSA infection.
How could we prevent febrile neutropenia?
Lower doses of chemotherapy.
How do we examine for a metastatic spinal cord?
Full neurological examination
Perineal sensation
Anal tone
MRI
Which medication do we use to treat metastatic spinal cord?
Dexamethasone \+ pain control. Bed rest Prophylactic anticoagulation Surgical decompression Radiotherapy
Small lung cancer is associated with which oncological emergency?
Superior vena cava obstruction.
What is the normal haemoglobin level?
130-180g/L.
Which is the key arterial blood gas change in SVCO?
Low haemoglobin (i.e. <130g/L)
Physically what is a key sign of SVCO in the patient?
Distended superficial veins in the neck (they will be bulging out).
Which is the most common cause of SVCO?
Non small cell lung cancer (50%)
Small cell lung cancer (20%)
How do we manage SVCO?
Dexamethasone Biopsy Stenting (if haemodynamically unstable or chemo/radiotherapy not possible). Chemotherapy Radiotherapy
What is the normal calcium level?
2.2-2.6mmol/L.
What are the symptoms of hypercalcaemia?
Bones, stones, groans and psychic moans
How do we treat hypercalcaemia?
Bisphosphanates
Rehydration with saline.
How do we stage lymphoma?
1-4
1 = Lymphatic area
2 = Two or more lymph nodes above OR below diaphragm (same side).
3 = Two or more lymph nodes above AND below diaphragm.
4 = spread to organs.
Name the three B symptoms
Fever
unintentional weight loss
Night sweats
What is Tumour Lysis syndrome?
A group of METABOLIC abnormalities which can occur AFTER CANCER TREATMENT.
e.g. seizures, arrhythmias, kidney injury.
Which levels characteristically change in tumour lysis syndrome?
High PO4
High urate
High K+
Hypocalcaemia
What is allopurinol used to treat?
To lower urate levels.
Name two action steps we can take to prevent tumour lysis syndrome.
Hydration
Allopurinol (to keep urate levels level).
What is the first line emergency treatment for SVCO?
High dose steroids (dexamethasone for e.g.).
What is the commonest cause of SVCO?
Lung cancer
Which is the diagnostic test for SVCO?
CT Chest/Abdomen/pelvis.
Which is the most common mutation found in adenocarcinomas?
EGFR mutation
What is Erlotinib?
EGFR inhibitor
VHL mutations are seen in which cancer?
Renal cell carcinoma
What is the function of the VHL gene (von hippel-lindau)?
VHL is a tumour suppressor gene
Which are the signals we target in lung cancer compared to melanomas?
Lung cancer = EGFR inhibition
Melanoma = BRAF inhibition
Which is the order of preference in drug route for palliative patients?
oral > subcutaneous > im > iv
not oral in vomiting.
What does 30/500 co-codamol mean?
30 codeine, 500 paracetamol.
When will we want to use a syringe driver?
If patient is unconscious or cannot take oral.
How do we calculate any PRN dose?
Divide the daily dose by 6
e.g. 15mg BD = 30mg/6 = 5mg PRN
How do we manage respiratory secretions?
- Reposition patient
2. Give a drying agent e.g. antimuscarinic e.g. glycopyrronium
What are the 3 analgesia steps on WHO?
- Non opioid and analgesia
- Weak opioid e.g. tramadol and analgesia
- Strong opioid and analgesia
What is glycopyronium?
An anti-muscarinic bronchodilator.
How do we treat agitation?
Best treatment is Midazolam 2.5mg sc.
What is Midazolam?
A short acting benzodiazepine
What must we always investigate as a cause of agitation in end of life patients?
Urinary retention.
What is the first line treatment for spinal cord metastases?
Dexamethasone.
What is the starting dose for morphine (MST)?
2.5mg x6 times a day i.e. 4 hourly
NOT x4 times a day.
How many times a day is the starting dose for morphine sulphate?
2.5mg x6 times a day.
Name two weak opioids
Tramadol, codeine
Which analgesia do we use instead of morphine in a patient with impaired renal function?
Oxycodone.
There is a maximum dose for patients to take to stay safe with opioids. True or false?
False.
No maximum dose.
How many times stronger is subcutaneous than oral?
x2.
Write a starting prescription for a patient going on morphine.
Oral morphine immediate release
2.5mg four hourly (x6 times a day)
How would we manage breathlessness in the palliative patient?
Fan
Morphine low dose
If anxiety component - benzodiazepine e.g. lorazepam/ midazolam.
Name an anti-emetic we use to treat vomiting of a gastric cause.
Metoclopramide.
Name an anti-emetic we in patients with vomiting/ nausea due to raised Intracranial pressure.
Cyclizine.
+would also prescribe dexamethasone as a steroid to reduce raised ICP.
Which antiemetic would we use in patients who are undergoing chemotherapy?
Ondesantron.
Name a broad spectrum anti-emetic we further down in management.
Levomepromazine
How do we manage vomiting in bowel obstruction with a colic?
Haloperidol syringe pump NOT metoclopramide as it is a prokinetic.
Avoid prokinetics in colic.
Which anti-emetic would we use for treatment in bowel obstruction with no colic?
Metoclopramide.
What do we use to manage pain bowel obstruction?
Hyoscine butylbromide (Hyoscine patches)
Name three things you would consider for a patient being treated at home
A bed with socket Medicines DNAR? in care package Referral to community palliative care In need of carers?
Which cancer drug is associated with hypomagnesaemia?
Cisplatin
Which cancer drug is associated with hyponatraemia?
Vincristine
Cyclophosphamide and vincristine are examples of what?
Chemotherapy.
Which thyroid cancer causes a rise in calcitonin?
Medullary thyroid cancer; originates from the parafollicular cells.
Which receptors does Ondansetron act on?
5HT3 - serotonin.
BRCA2 mutation is associated with which cancer?
Prostate cancer (in men)
Which cancer is calcitonin a tumour marker for?
Medullary thyroid cancer
In spinal cord compression, which medication should be prescribed immediately?
Dexamethasone
Suspicion of spinal metastasis should be investigated with which test?
MRI spine.
Which cancer has the strongest association with smoking?
Squamous cell carcinoma
Which thyroid cancer causes a rise in calcitonin?
Medullary thyroid cancer
Which antiemetic do we use for patients on chemotherapy?
Ondansetron - 5-HT3 antagonist.
Which chemotherapeutic agent can cause cardiomyopathy?
Doxorubicin
Which are the markers raised in a testicular teratoma?
Alpha-fetoprotein and beta-hCG.
Upper motor neuron signs can point toward which cancer diagnosis?
Metastasis of spinal cord
What is adjuvant therapy?
Treatment given to reduce the risk of recurrence.
What is radical treatment?
Given with curative intent.
What is neoadjuvant therapy?
Given to improve the chances of therapy.
What are the three things in Duke’s criteria?
TMN
Tumour, metastases and node.
What is Palliative treatment?
Given with non-curative intent.
Name 3 cancers that can be cured by chemotherapy alone.
Leukaemia
Lymphoma
Germ cell tumours
Name 3 cancers that can be cured by radiotherapy alone.
Cervical ca
Bladder ca
Non melanoma
Oesophageal ca
Why do we offer adjuvant therapy?
Reduce the risk of recurrence = reduces the chance of relapse.
What is neo-adjuvant therapy?
A treatment given to improve chances of main therapy, so it is the primary therapy before the actual definitive therapy.
Why do we offer palliative therapy?
To improve survival and quality of life.
To treat symptoms.
What is an important aspect to consider when explaining chemotherapy/ radiotherapy to women?
Effects on pregnancy/ fertility.
What is the difference between adjuvant and radical treatment?
Adjuvant = given to reduce the risk of recurrence Radical = to cure.
What is SACT?
Systemic anti-cancer treatment.
You are reviewing him in clinic prior to cycle 5. How would you assess his fitness
for further chemotherapy?
- Assess performance status.
- Assess drug toxicities.
- Assess response to chemotherapy.
How do we assess performance status in a cancer patient?
WHO classification 0-5. 0 = Asymptomatic 1 = symptomatic but completely ambulatory 2 = symptomatic but <50% in bed 3 = symptomatic but >50% in bed 4 = Bedbound 5 = death
How do we assess whether a patient is appropriate for chemotherapy?
- Assess performance status.
- Assess drug toxicities.
- Assess response to chemotherapy.
What is a FOLOX regime?
5FU and Oxaliplatin.
Make sure to check for diarrhoea, N+V, neuropathy caused from these drugs.
What is the main side effect of 5FU?
Diarrhoea.
Name a medication we can use for diarrhoea.
Loperamide.
Name two bedside tests we would want to do in someone with diarrhoea.
Stool MCS
C. Difficile testing.
Name the three platinum chemotherapy drugs.
Cisplatin, Carboplatin, Oxaliplatin
(platins).
Which receptors do metoclopramide work on?
Dopamine (D2 receptors).
Name the broad spectrum antibiotic which works on dopamine, h1, and serotonin receptors.
Levomepromazine.
Name four anti-emetics we may consider using in chemotherapy patients.
Metoclopramide Cyclizine Haloperidol Levomepromazine Ondansetron
Which anti-emetic works on serotonin receptors (5HT3)?
Ondansetron
Which medication regime do we use to treat Hodgkin’s lymphoma?
ABVD Doxorubicin (an anthracycline) Bleomycin Vinblastine Dacarbazine
ABVD is used to treat which cancer? How long does the ABVD cycle take?
Hodgkin's lymphoma. 4 weeks (28 days)
Which chemo drug class can cause cardiomyopathy?
Anthracyclines e.g. Doxorubicin.
Raised AFP and hCG are indicative of which tumour?
Non seminomatous testicular (germ cell) cancers.
What is a common side effect of bleomycin?
Pulmonary fibrosis.
CEA is a marker for which cancer?
Colorectal cancer.
Imatinib, erlotinib and crizotinib are examples of what kind of drug class?
Tyrosine kinase inhibitors.
What is the most common side effect of Tyrosine kinase inhibitors?
Do you remember examples of TK inhibitors?
Rash.
e.g. Imatinib.
Rituximab and Herceptin are examples of what type of anti-cancer treatment?
Monoclonal antibodies.
What is another name for HNPCC?
Lynch syndrome
Where is the most likely site for metastasis from colorectal cancer?
Liver NOT bone.
Which of the following would suggest a left rather than right-sided colonic tumour?
PR bleeding.
What type of tumours are most colorectal tumours?
Adenocarcinomas.
What does T3 N1 M0 mean?
Tumour has grown into the serosa.
Disease within 3 lymph nodes
No distant metastases.
What does N1 mean in the TMN staging?
There are tumour cells in up to 3 regional lymph nodes.
Describe what the difference between T1, T2, T3 and T4 mean in cancer grading.
T1 = submucosa T2 = into muscularis propria T3 = into serosa T4 = penetrates the serosa and peritoneum.
How do pleural plaques appear on chest x-rays?
Holly life appearance.
Von Hippel lindau disease is a risk factor for developing which cancer?
Renal cell carcinoma
What is the treatment of choice for mild dysphagia?
Oesophageal stent.
What is the conversion between oral codeine to oral morphine?
Divide by 10. Morphine is stronger x10.
Which medication can we use to manage respiratory secretions?
Hyoscine Hydrobromide.
What mechanism does Hyoscine hydrobromide work through?
Muscarinic receptor antagonist.
Which is the first line treatment for agitation?
Haloperidol NOT midazolam.
What is the first step of resuscitation after seeing a patient is hypovolaemic? and the following steps?
Initial fluid bolus of 500ml Hartmann’s solution over <15 minutes
Then take ABCDE approach
If patient is still hypovolaemic, give 250-500ml bolus solution.
Give the exact calculations for maintenance fluids.
25-30ml/kg/day of water
1mmol/kg/day of potassium, sodium and chloride.
50-100g/day glucose
Name the four types of shock.
Hypovolaemic
Cardiogenic
Obstructive e.g. Tamponade, tension pneumothorax
Distributive e.g. capillary leaks, vasodilatation - seen in sepsis, burns
Where may we see VQ mismatch where there is normal perfusion but insufficient ventilation?
Shunting - venous blood passes the lungs without participating in gas exchange.
How may post-operative patients become susceptible to hypoxaemia?
Hypoventilation or
Shunting e.g. chest infection
How may mechanical ventilation be offered?
Invasively: Tracheal or tracheostomy tube.
Non-invasively: tight fitting face mask
What is the first sign of renal dysfunction?
Oliguria
Give 3 indications for haemodialysis
Hyperkalaemia
Fluid overload
Acidosis
How do we define oliguria?
<0.5ml/kg/hr
What GCS score patient needs to be intubated?
GCS <8
In which condition do we see Heinz bodies?
Glucose-6-phosphate dehydrogenase deficiency
In which conditions do we see Howell-Jolly bodies? What do they look like?
Sickle cell disease
Hyposplenism
Megaloblastic anaemia
Basophilic (purple spot) nuclear remnants in RBCs.
What is the difference between type 1 and type 2 respiratory failure?
Type 1 = low po2, low CO2
Type 2 = low po2, high CO2
Give x3 examples of Type 1 respiratory failure
Pneumothorax, pulmonary oedema, pneumonia, COPD.
Give an example of a condition which can cause type 2 respiratory failure
Failure of ventilation e.g. Neuromuscular e.g. GB, CNS trauma. But often Type 1 respiratory failure developing into type 2.
Which is the characteristic cell of CML? - chronic myeloid leukaemia?
Increase in granulocytes (eosinophils, basophils, neutrophils).
