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Year 5 > Oncology and Palliative Care > Flashcards

Oncology and Palliative Care Flashcards

1
Q

Define palliative care

A

Care which improves the quality of life for patients AND their families rather than finding a cure.
Psychosocial, physical, spiritual.

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2
Q

When does palliative care usually begin?

A

Palliative care begins when curative care is no longer effective.

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3
Q

Which cancer is most associated with raised levels of CA 19-9?

A

Pancreatic cancer

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4
Q

Which cancer drug class can cause cardiomyopathy?

A

Anthracyclines

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5
Q

Raised alpha-feto protein (aFP) level in a 54-year-old woman. Which cancer?

A

Liver cancer

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6
Q

Raised beta-human chorionic gonadotropin (b-HCG) with a raised alpha-feto protein level. Which cancer?

A

Non-seminomatous testicular cancer

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7
Q

Which of the following cytotoxic agents is most associated with lung fibrosis?

A

Bleomycin

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8
Q

Which is the tumour marker for breast cancer?

A

CA 15-3

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9
Q

HNPCC and FAP can cause which type of cancer?

A

Colorectal cancer

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10
Q

If SVCO is suspected, which initial investigation must be undertaken?

A

CT

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11
Q

How do we manage SVCO?

A

SVC stenting, Radiotherapy and chemotherapy

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12
Q

Sclerotic lesions are associated with which cancer compared with osteolytic lesions?

A

Sclerotic lesions = Metastatic prostate cancer

Osteolytic = Paget’s, multiple myeloma

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13
Q

Do multiple polyps increase or decrease the risk of cancer and what is an appropriate treatment?

A

Multiple polyps increase the risk of malignancy.

Treatment: Colectomy.

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14
Q

Mutations in the BRCA1 and 2 genes increase the risk of one developing which cancers?

A

Breast and ovarian cancer. (More BRCA1).

BRCA2 mutation is also linked with increase risk of prostate cancer in men.

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15
Q

What is Gardners syndrome?

A

Autosomal dominant Familial adenomatous polyposis

Multiple polyps.

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16
Q

Which cancer has the strongest association with smoking?

A

Squamous cell lung cancer

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17
Q

Name four cytotoxic cancer agents used in therapy.

A

Vincristine
Bleomycin
Cisplatin
Azathioprine

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18
Q

Which cytotoxic agent is most likely to be associated with lung fibrosis?

A

Bleomycin

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19
Q

Which drug is used to manage lymphoma?

A

Vincristine

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20
Q

What is an orchiectomy?

A

Removal of the testicle. Same as orchidectomy.

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21
Q

In patients with suspected spinal cord compression i.e. back pain and leg weakness, which is the investigation of choice

A

MRI (not ct)

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22
Q

Which cancer is most associated with raised levels of carcinoembryonic antigen (CEA)?

A

Colorectal cancer

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23
Q

Which cancer is most associated with raised levels of AFP?

A

Hepatocellular carcinoma.

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24
Q

What is a common cause of SVCO?

A

Small cell lung cancer

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25
Q

Give 3 ways a patient with SVCO may present.

A

Periorbital oedema, dyspnoea, visual disturbances, flushing of face, neck, arms.

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26
Q

How does ovarian cancer usually present?

A

With very non specific abdominal symptoms

e.g. nausea, vomiting, discomfort, anorexia.

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27
Q

Which medication do we use to treat shortness of breath with anxiety in palliative state?

A

Lorazepam 0.5mg sublingual QDS.

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28
Q

Which opioid do we use to treat severe shortness of breath?

A

Oral morphine - Oromorph 10mg/5ml.

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29
Q

Which route of administering drugs is preferred at end of life?

A

Subcutaneous > NG.

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30
Q

What is Zoledronic acid?

A

A bisphosphanate

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31
Q

What are Chvostek’s and Trousseau’s sign indicative of?

A

Hypocalcaemia

NOT HYPER

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32
Q

Which are the two most common cancers to cause renal cell carcinoma and prostate cancer?

A

Renal cell carcinoma

Prostate cancer

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33
Q

What is the difference between somatic and visceral pain?

A

Somatic pain affects the joints and bones characterised by stabbing and aching.
Visceral pain affects structures such as the liver and gut.

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34
Q

What is Tramadol?

A

Weak opioid.

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35
Q

Which drug is for patients who require analgesia but have renal failure?

A

Alfentanil

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36
Q

Which drugs would we use as pain relief on the WHO step 2 vs. step 3 scale?

A

Step 2 = Codeine

Step 3 = Oxycodone

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37
Q

Which are the three opioid receptors?

A

Mu, kappa and delta.

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38
Q

Define sarcoma

A

A cancer arising from connective tissue

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39
Q

Define seminoma

A

A cancer arising from germ cells

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40
Q

Define carcinoma

A

A cancer arising from epithelial cells

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41
Q

Define adenocarcinoma

A

A cancer arising from secretory epithelium

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42
Q

Define gastrinoma

A

A cancer producing gastrin hormone

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43
Q

Give 3 ways in which liver can present

A

Painless Jaundice
Unexplained weight loss
Abdominal mass

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44
Q

Give 3 ways in which brain cancer can present

A

Seizure
Pressure headache
Visual disturbances
Focal weakness

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45
Q

Name the 5 oncological emergencies

A 
Neutropenic sepsis
Metastatic spinal cord compression
SVCO - superior vena cava obstruction
Hypercalcaemia
Tumour Lysis syndrome
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46
Q

How do we define neutropenic sepsis?

A

Neutropaenia (<1x10^9) and fever (>38 degrees).

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47
Q

Which blood cell is very likely to reduce following chemotherapy?

A

Neutrophils

= Neutropaenia

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48
Q

How do we manage febrile neutropenia?

A

Resuscitation, fluids
Blood cultures
Septic screen
Antibiotics

1st line = Tazobactam 4.5g IV QDS.
plus
Amikacin.

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49
Q

Which antibiotic do we use for neutropenic sepsis if patient is allergic to penicillin?

A

Meropenem 1g TV TDS.

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50
Q

When may teicoplanin be used as an antibiotic?

A

If there is a suspected central line or MRSA infection.

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51
Q

How could we prevent febrile neutropenia?

A

Lower doses of chemotherapy.

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52
Q

How do we examine for a metastatic spinal cord?

A

Full neurological examination
Perineal sensation
Anal tone
MRI

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53
Q

Which medication do we use to treat metastatic spinal cord?

A 
Dexamethasone 
\+ pain control. 
Bed rest
Prophylactic anticoagulation
Surgical decompression 
Radiotherapy
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54
Q

Small lung cancer is associated with which oncological emergency?

A

Superior vena cava obstruction.

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55
Q

What is the normal haemoglobin level?

A

130-180g/L.

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56
Q

Which is the key arterial blood gas change in SVCO?

A

Low haemoglobin (i.e. <130g/L)

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57
Q

Physically what is a key sign of SVCO in the patient?

A

Distended superficial veins in the neck (they will be bulging out).

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58
Q

Which is the most common cause of SVCO?

A

Non small cell lung cancer (50%)

Small cell lung cancer (20%)

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59
Q

How do we manage SVCO?

A 
Dexamethasone
Biopsy
Stenting (if haemodynamically unstable or chemo/radiotherapy not possible).
Chemotherapy
Radiotherapy
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60
Q

What is the normal calcium level?

A

2.2-2.6mmol/L.

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61
Q

What are the symptoms of hypercalcaemia?

A

Bones, stones, groans and psychic moans

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62
Q

How do we treat hypercalcaemia?

A

Bisphosphanates

Rehydration with saline.

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63
Q

How do we stage lymphoma?

A

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.

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64
Q

Name the three B symptoms

A

Fever
unintentional weight loss
Night sweats

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65
Q

What is Tumour Lysis syndrome?

A

A group of METABOLIC abnormalities which can occur AFTER CANCER TREATMENT.

e.g. seizures, arrhythmias, kidney injury.

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66
Q

Which levels characteristically change in tumour lysis syndrome?

A

High PO4
High urate
High K+
Hypocalcaemia

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67
Q

What is allopurinol used to treat?

A

To lower urate levels.

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68
Q

Name two action steps we can take to prevent tumour lysis syndrome.

A

Hydration

Allopurinol (to keep urate levels level).

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69
Q

What is the first line emergency treatment for SVCO?

A

High dose steroids (dexamethasone for e.g.).

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70
Q

What is the commonest cause of SVCO?

A

Lung cancer

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71
Q

Which is the diagnostic test for SVCO?

A

CT Chest/Abdomen/pelvis.

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72
Q

Which is the most common mutation found in adenocarcinomas?

A

EGFR mutation

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73
Q

What is Erlotinib?

A

EGFR inhibitor

74
Q

VHL mutations are seen in which cancer?

A

Renal cell carcinoma

75
Q

What is the function of the VHL gene (von hippel-lindau)?

A

VHL is a tumour suppressor gene

76
Q

Which are the signals we target in lung cancer compared to melanomas?

A

Lung cancer = EGFR inhibition

Melanoma = BRAF inhibition

77
Q

Which is the order of preference in drug route for palliative patients?

A

oral > subcutaneous > im > iv

not oral in vomiting.

78
Q

What does 30/500 co-codamol mean?

A

30 codeine, 500 paracetamol.

79
Q

When will we want to use a syringe driver?

A

If patient is unconscious or cannot take oral.

80
Q

How do we calculate any PRN dose?

A

Divide the daily dose by 6

e.g. 15mg BD = 30mg/6 = 5mg PRN

81
Q

How do we manage respiratory secretions?

A
  1. Reposition patient

2. Give a drying agent e.g. antimuscarinic e.g. glycopyrronium

82
Q

What are the 3 analgesia steps on WHO?

A
  1. Non opioid and analgesia
  2. Weak opioid e.g. tramadol and analgesia
  3. Strong opioid and analgesia
83
Q

What is glycopyronium?

A

An anti-muscarinic bronchodilator.

84
Q

How do we treat agitation?

A

Best treatment is Midazolam 2.5mg sc.

85
Q

What is Midazolam?

A

A short acting benzodiazepine

86
Q

What must we always investigate as a cause of agitation in end of life patients?

A

Urinary retention.

87
Q

What is the first line treatment for spinal cord metastases?

A

Dexamethasone.

88
Q

What is the starting dose for morphine (MST)?

A

2.5mg x6 times a day i.e. 4 hourly

NOT x4 times a day.

89
Q

How many times a day is the starting dose for morphine sulphate?

A

2.5mg x6 times a day.

90
Q

Name two weak opioids

A

Tramadol, codeine

91
Q

Which analgesia do we use instead of morphine in a patient with impaired renal function?

A

Oxycodone.

92
Q

There is a maximum dose for patients to take to stay safe with opioids. True or false?

A

False.

No maximum dose.

93
Q

How many times stronger is subcutaneous than oral?

A

x2.

94
Q

Write a starting prescription for a patient going on morphine.

A

Oral morphine immediate release

2.5mg four hourly (x6 times a day)

95
Q

How would we manage breathlessness in the palliative patient?

A

Fan
Morphine low dose
If anxiety component - benzodiazepine e.g. lorazepam/ midazolam.

96
Q

Name an anti-emetic we use to treat vomiting of a gastric cause.

A

Metoclopramide.

97
Q

Name an anti-emetic we in patients with vomiting/ nausea due to raised Intracranial pressure.

A

Cyclizine.

+would also prescribe dexamethasone as a steroid to reduce raised ICP.

98
Q

Which antiemetic would we use in patients who are undergoing chemotherapy?

A

Ondesantron.

99
Q

Name a broad spectrum anti-emetic we further down in management.

A

Levomepromazine

100
Q

How do we manage vomiting in bowel obstruction with a colic?

A

Haloperidol syringe pump NOT metoclopramide as it is a prokinetic.
Avoid prokinetics in colic.

101
Q

Which anti-emetic would we use for treatment in bowel obstruction with no colic?

A

Metoclopramide.

102
Q

What do we use to manage pain bowel obstruction?

A

Hyoscine butylbromide (Hyoscine patches)

103
Q

Name three things you would consider for a patient being treated at home

A 
A bed with socket
Medicines
DNAR? in care package
Referral to community palliative care
In need of carers?
104
Q

Which cancer drug is associated with hypomagnesaemia?

A

Cisplatin

105
Q

Which cancer drug is associated with hyponatraemia?

A

Vincristine

106
Q

Cyclophosphamide and vincristine are examples of what?

A

Chemotherapy.

107
Q

Which thyroid cancer causes a rise in calcitonin?

A

Medullary thyroid cancer; originates from the parafollicular cells.

108
Q

Which receptors does Ondansetron act on?

A

5HT3 - serotonin.

109
Q

BRCA2 mutation is associated with which cancer?

A

Prostate cancer (in men)

110
Q

Which cancer is calcitonin a tumour marker for?

A

Medullary thyroid cancer

111
Q

In spinal cord compression, which medication should be prescribed immediately?

A

Dexamethasone

112
Q

Suspicion of spinal metastasis should be investigated with which test?

A

MRI spine.

113
Q

Which cancer has the strongest association with smoking?

A

Squamous cell carcinoma

114
Q

Which thyroid cancer causes a rise in calcitonin?

A

Medullary thyroid cancer

115
Q

Which antiemetic do we use for patients on chemotherapy?

A

Ondansetron - 5-HT3 antagonist.

116
Q

Which chemotherapeutic agent can cause cardiomyopathy?

A

Doxorubicin

117
Q

Which are the markers raised in a testicular teratoma?

A

Alpha-fetoprotein and beta-hCG.

118
Q

Upper motor neuron signs can point toward which cancer diagnosis?

A

Metastasis of spinal cord

119
Q

What is adjuvant therapy?

A

Treatment given to reduce the risk of recurrence.

120
Q

What is radical treatment?

A

Given with curative intent.

121
Q

What is neoadjuvant therapy?

A

Given to improve the chances of therapy.

122
Q

What are the three things in Duke’s criteria?

A

TMN

Tumour, metastases and node.

123
Q

What is Palliative treatment?

A

Given with non-curative intent.

124
Q

Name 3 cancers that can be cured by chemotherapy alone.

A

Leukaemia
Lymphoma
Germ cell tumours

125
Q

Name 3 cancers that can be cured by radiotherapy alone.

A

Cervical ca
Bladder ca
Non melanoma
Oesophageal ca

126
Q

Why do we offer adjuvant therapy?

A

Reduce the risk of recurrence = reduces the chance of relapse.

127
Q

What is neo-adjuvant therapy?

A

A treatment given to improve chances of main therapy, so it is the primary therapy before the actual definitive therapy.

128
Q

Why do we offer palliative therapy?

A

To improve survival and quality of life.

To treat symptoms.

129
Q

What is an important aspect to consider when explaining chemotherapy/ radiotherapy to women?

A

Effects on pregnancy/ fertility.

130
Q

What is the difference between adjuvant and radical treatment?

A 
Adjuvant = given to reduce the risk of recurrence
Radical = to cure.
131
Q

What is SACT?

A

Systemic anti-cancer treatment.

132
Q

You are reviewing him in clinic prior to cycle 5. How would you assess his fitness
for further chemotherapy?

A
  1. Assess performance status.
  2. Assess drug toxicities.
  3. Assess response to chemotherapy.
133
Q

How do we assess performance status in a cancer patient?

A 
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
134
Q

How do we assess whether a patient is appropriate for chemotherapy?

A
  1. Assess performance status.
  2. Assess drug toxicities.
  3. Assess response to chemotherapy.
135
Q

What is a FOLOX regime?

A

5FU and Oxaliplatin.

Make sure to check for diarrhoea, N+V, neuropathy caused from these drugs.

136
Q

What is the main side effect of 5FU?

A

Diarrhoea.

137
Q

Name a medication we can use for diarrhoea.

A

Loperamide.

138
Q

Name two bedside tests we would want to do in someone with diarrhoea.

A

Stool MCS

C. Difficile testing.

139
Q

Name the three platinum chemotherapy drugs.

A

Cisplatin, Carboplatin, Oxaliplatin

(platins).

140
Q

Which receptors do metoclopramide work on?

A

Dopamine (D2 receptors).

141
Q

Name the broad spectrum antibiotic which works on dopamine, h1, and serotonin receptors.

A

Levomepromazine.

142
Q

Name four anti-emetics we may consider using in chemotherapy patients.

A 
Metoclopramide
Cyclizine
Haloperidol
Levomepromazine
Ondansetron
143
Q

Which anti-emetic works on serotonin receptors (5HT3)?

A

Ondansetron

144
Q

Which medication regime do we use to treat Hodgkin’s lymphoma?

A 
ABVD
Doxorubicin (an anthracycline)
Bleomycin
Vinblastine
Dacarbazine
145
Q

ABVD is used to treat which cancer? How long does the ABVD cycle take?

A 
Hodgkin's lymphoma. 
4 weeks (28 days)
146
Q

Which chemo drug class can cause cardiomyopathy?

A

Anthracyclines e.g. Doxorubicin.

147
Q

Raised AFP and hCG are indicative of which tumour?

A

Non seminomatous testicular (germ cell) cancers.

148
Q

What is a common side effect of bleomycin?

A

Pulmonary fibrosis.

149
Q

CEA is a marker for which cancer?

A

Colorectal cancer.

150
Q

Imatinib, erlotinib and crizotinib are examples of what kind of drug class?

A

Tyrosine kinase inhibitors.

151
Q

What is the most common side effect of Tyrosine kinase inhibitors?
Do you remember examples of TK inhibitors?

A

Rash.

e.g. Imatinib.

152
Q

Rituximab and Herceptin are examples of what type of anti-cancer treatment?

A

Monoclonal antibodies.

153
Q

What is another name for HNPCC?

A

Lynch syndrome

154
Q

Where is the most likely site for metastasis from colorectal cancer?

A

Liver NOT bone.

155
Q

Which of the following would suggest a left rather than right-sided colonic tumour?

A

PR bleeding.

156
Q

What type of tumours are most colorectal tumours?

A

Adenocarcinomas.

157
Q

What does T3 N1 M0 mean?

A

Tumour has grown into the serosa.
Disease within 3 lymph nodes
No distant metastases.

158
Q

What does N1 mean in the TMN staging?

A

There are tumour cells in up to 3 regional lymph nodes.

159
Q

Describe what the difference between T1, T2, T3 and T4 mean in cancer grading.

A 
T1 =  submucosa
T2 = into muscularis propria 
T3 = into serosa
T4 = penetrates the serosa and peritoneum.
160
Q

How do pleural plaques appear on chest x-rays?

A

Holly life appearance.

161
Q

Von Hippel lindau disease is a risk factor for developing which cancer?

A

Renal cell carcinoma

162
Q

What is the treatment of choice for mild dysphagia?

A

Oesophageal stent.

163
Q

What is the conversion between oral codeine to oral morphine?

A

Divide by 10. Morphine is stronger x10.

164
Q

Which medication can we use to manage respiratory secretions?

A

Hyoscine Hydrobromide.

165
Q

What mechanism does Hyoscine hydrobromide work through?

A

Muscarinic receptor antagonist.

166
Q

Which is the first line treatment for agitation?

A

Haloperidol NOT midazolam.

167
Q

What is the first step of resuscitation after seeing a patient is hypovolaemic? and the following steps?

A

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.

168
Q

Give the exact calculations for maintenance fluids.

A

25-30ml/kg/day of water
1mmol/kg/day of potassium, sodium and chloride.
50-100g/day glucose

169
Q

Name the four types of shock.

A

Hypovolaemic
Cardiogenic
Obstructive e.g. Tamponade, tension pneumothorax
Distributive e.g. capillary leaks, vasodilatation - seen in sepsis, burns

170
Q

Where may we see VQ mismatch where there is normal perfusion but insufficient ventilation?

A

Shunting - venous blood passes the lungs without participating in gas exchange.

171
Q

How may post-operative patients become susceptible to hypoxaemia?

A

Hypoventilation or

Shunting e.g. chest infection

172
Q

How may mechanical ventilation be offered?

A

Invasively: Tracheal or tracheostomy tube.

Non-invasively: tight fitting face mask

173
Q

What is the first sign of renal dysfunction?

A

Oliguria

174
Q

Give 3 indications for haemodialysis

A

Hyperkalaemia
Fluid overload
Acidosis

175
Q

How do we define oliguria?

A

<0.5ml/kg/hr

176
Q

What GCS score patient needs to be intubated?

A

GCS <8

177
Q

In which condition do we see Heinz bodies?

A

Glucose-6-phosphate dehydrogenase deficiency

178
Q

In which conditions do we see Howell-Jolly bodies? What do they look like?

A

Sickle cell disease
Hyposplenism
Megaloblastic anaemia

Basophilic (purple spot) nuclear remnants in RBCs.

179
Q

What is the difference between type 1 and type 2 respiratory failure?

A

Type 1 = low po2, low CO2

Type 2 = low po2, high CO2

180
Q

Give x3 examples of Type 1 respiratory failure

A

Pneumothorax, pulmonary oedema, pneumonia, COPD.

181
Q

Give an example of a condition which can cause type 2 respiratory failure

A

Failure of ventilation e.g. Neuromuscular e.g. GB, CNS trauma. But often Type 1 respiratory failure developing into type 2.

182
Q

Which is the characteristic cell of CML? - chronic myeloid leukaemia?

A

Increase in granulocytes (eosinophils, basophils, neutrophils).

Year 5 (8 decks)

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