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.
2
Q
When does palliative care usually begin?
A
Palliative care begins when curative care is no longer effective.
3
Q
Which cancer is most associated with raised levels of CA 19-9?
A
Pancreatic cancer
4
Q
Which cancer drug class can cause cardiomyopathy?
A
Anthracyclines
5
Q
Raised alpha-feto protein (aFP) level in a 54-year-old woman. Which cancer?
A
Liver cancer
6
Q
Raised beta-human chorionic gonadotropin (b-HCG) with a raised alpha-feto protein level. Which cancer?
A
Non-seminomatous testicular cancer
7
Q
Which of the following cytotoxic agents is most associated with lung fibrosis?
A
Bleomycin
8
Q
Which is the tumour marker for breast cancer?
A
CA 15-3
9
Q
HNPCC and FAP can cause which type of cancer?
A
Colorectal cancer
10
Q
If SVCO is suspected, which initial investigation must be undertaken?
A
CT
11
Q
How do we manage SVCO?
A
SVC stenting, Radiotherapy and chemotherapy
12
Q
Sclerotic lesions are associated with which cancer compared with osteolytic lesions?
A
Sclerotic lesions = Metastatic prostate cancer
Osteolytic = Paget’s, multiple myeloma
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.
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.
15
Q
What is Gardners syndrome?
A
Autosomal dominant Familial adenomatous polyposis
Multiple polyps.
16
Q
Which cancer has the strongest association with smoking?
A
Squamous cell lung cancer
17
Q
Name four cytotoxic cancer agents used in therapy.
A
Vincristine
Bleomycin
Cisplatin
Azathioprine
18
Q
Which cytotoxic agent is most likely to be associated with lung fibrosis?
A
Bleomycin
19
Q
Which drug is used to manage lymphoma?
A
Vincristine
20
Q
What is an orchiectomy?
A
Removal of the testicle. Same as orchidectomy.
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)
22
Q
Which cancer is most associated with raised levels of carcinoembryonic antigen (CEA)?
A
Colorectal cancer
23
Q
Which cancer is most associated with raised levels of AFP?
A
Hepatocellular carcinoma.
24
Q
What is a common cause of SVCO?
A
Small cell lung cancer
25
Give 3 ways a patient with SVCO may present.
Periorbital oedema, dyspnoea, visual disturbances, flushing of face, neck, arms.
26
How does ovarian cancer usually present?
With very non specific abdominal symptoms
| e.g. nausea, vomiting, discomfort, anorexia.
27
Which medication do we use to treat shortness of breath with anxiety in palliative state?
Lorazepam 0.5mg sublingual QDS.
28
Which opioid do we use to treat severe shortness of breath?
Oral morphine - Oromorph 10mg/5ml.
29
Which route of administering drugs is preferred at end of life?
Subcutaneous > NG.
30
What is Zoledronic acid?
A bisphosphanate
31
What are Chvostek's and Trousseau's sign indicative of?
Hypocalcaemia
NOT HYPER
32
Which are the two most common cancers to cause renal cell carcinoma and prostate cancer?
Renal cell carcinoma
| Prostate cancer
33
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.
34
What is Tramadol?
Weak opioid.
35
Which drug is for patients who require analgesia but have renal failure?
Alfentanil
36
Which drugs would we use as pain relief on the WHO step 2 vs. step 3 scale?
Step 2 = Codeine
| Step 3 = Oxycodone
37
Which are the three opioid receptors?
Mu, kappa and delta.
38
Define sarcoma
A cancer arising from connective tissue
39
Define seminoma
A cancer arising from germ cells
40
Define carcinoma
A cancer arising from epithelial cells
41
Define adenocarcinoma
A cancer arising from secretory epithelium
42
Define gastrinoma
A cancer producing gastrin hormone
43
Give 3 ways in which liver can present
Painless Jaundice
Unexplained weight loss
Abdominal mass
44
Give 3 ways in which brain cancer can present
Seizure
Pressure headache
Visual disturbances
Focal weakness
45
Name the 5 oncological emergencies
```
Neutropenic sepsis
Metastatic spinal cord compression
SVCO - superior vena cava obstruction
Hypercalcaemia
Tumour Lysis syndrome
```
46
How do we define neutropenic sepsis?
Neutropaenia (<1x10^9) and fever (>38 degrees).
47
Which blood cell is very likely to reduce following chemotherapy?
Neutrophils
| = Neutropaenia
48
How do we manage febrile neutropenia?
Resuscitation, fluids
Blood cultures
Septic screen
Antibiotics
1st line = Tazobactam 4.5g IV QDS.
plus
Amikacin.
49
Which antibiotic do we use for neutropenic sepsis if patient is allergic to penicillin?
Meropenem 1g TV TDS.
50
When may teicoplanin be used as an antibiotic?
If there is a suspected central line or MRSA infection.
51
How could we prevent febrile neutropenia?
Lower doses of chemotherapy.
52
How do we examine for a metastatic spinal cord?
Full neurological examination
Perineal sensation
Anal tone
MRI
53
Which medication do we use to treat metastatic spinal cord?
```
Dexamethasone
+ pain control.
Bed rest
Prophylactic anticoagulation
Surgical decompression
Radiotherapy
```
54
Small lung cancer is associated with which oncological emergency?
Superior vena cava obstruction.
55
What is the normal haemoglobin level?
130-180g/L.
56
Which is the key arterial blood gas change in SVCO?
Low haemoglobin (i.e. <130g/L)
57
Physically what is a key sign of SVCO in the patient?
Distended superficial veins in the neck (they will be bulging out).
58
Which is the most common cause of SVCO?
Non small cell lung cancer (50%)
| Small cell lung cancer (20%)
59
How do we manage SVCO?
```
Dexamethasone
Biopsy
Stenting (if haemodynamically unstable or chemo/radiotherapy not possible).
Chemotherapy
Radiotherapy
```
60
What is the normal calcium level?
2.2-2.6mmol/L.
61
What are the symptoms of hypercalcaemia?
Bones, stones, groans and psychic moans
62
How do we treat hypercalcaemia?
Bisphosphanates
| Rehydration with saline.
63
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.
64
Name the three B symptoms
Fever
unintentional weight loss
Night sweats
65
What is Tumour Lysis syndrome?
A group of METABOLIC abnormalities which can occur AFTER CANCER TREATMENT.
e.g. seizures, arrhythmias, kidney injury.
66
Which levels characteristically change in tumour lysis syndrome?
High PO4
High urate
High K+
Hypocalcaemia
67
What is allopurinol used to treat?
To lower urate levels.
68
Name two action steps we can take to prevent tumour lysis syndrome.
Hydration
| Allopurinol (to keep urate levels level).
69
What is the first line emergency treatment for SVCO?
High dose steroids (dexamethasone for e.g.).
70
What is the commonest cause of SVCO?
Lung cancer
71
Which is the diagnostic test for SVCO?
CT Chest/Abdomen/pelvis.
72
Which is the most common mutation found in adenocarcinomas?
EGFR mutation
73
What is Erlotinib?
EGFR inhibitor
74
VHL mutations are seen in which cancer?
Renal cell carcinoma
75
What is the function of the VHL gene (von hippel-lindau)?
VHL is a tumour suppressor gene
76
Which are the signals we target in lung cancer compared to melanomas?
Lung cancer = EGFR inhibition
| Melanoma = BRAF inhibition
77
Which is the order of preference in drug route for palliative patients?
oral > subcutaneous > im > iv
| not oral in vomiting.
78
What does 30/500 co-codamol mean?
30 codeine, 500 paracetamol.
79
When will we want to use a syringe driver?
If patient is unconscious or cannot take oral.
80
How do we calculate any PRN dose?
Divide the daily dose by 6
| e.g. 15mg BD = 30mg/6 = 5mg PRN
81
How do we manage respiratory secretions?
1. Reposition patient
| 2. Give a drying agent e.g. antimuscarinic e.g. glycopyrronium
82
What are the 3 analgesia steps on WHO?
1. Non opioid and analgesia
2. Weak opioid e.g. tramadol and analgesia
3. Strong opioid and analgesia
83
What is glycopyronium?
An anti-muscarinic bronchodilator.
84
How do we treat agitation?
Best treatment is Midazolam 2.5mg sc.
85
What is Midazolam?
A short acting benzodiazepine
86
What must we always investigate as a cause of agitation in end of life patients?
Urinary retention.
87
What is the first line treatment for spinal cord metastases?
Dexamethasone.
88
What is the starting dose for morphine (MST)?
2.5mg x6 times a day i.e. 4 hourly
| NOT x4 times a day.
89
How many times a day is the starting dose for morphine sulphate?
2.5mg x6 times a day.
90
Name two weak opioids
Tramadol, codeine
91
Which analgesia do we use instead of morphine in a patient with impaired renal function?
Oxycodone.
92
There is a maximum dose for patients to take to stay safe with opioids. True or false?
False.
No maximum dose.
93
How many times stronger is subcutaneous than oral?
x2.
94
Write a starting prescription for a patient going on morphine.
Oral morphine immediate release
| 2.5mg four hourly (x6 times a day)
95
How would we manage breathlessness in the palliative patient?
Fan
Morphine low dose
If anxiety component - benzodiazepine e.g. lorazepam/ midazolam.
96
Name an anti-emetic we use to treat vomiting of a gastric cause.
Metoclopramide.
97
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.
98
Which antiemetic would we use in patients who are undergoing chemotherapy?
Ondesantron.
99
Name a broad spectrum anti-emetic we further down in management.
Levomepromazine
100
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.
101
Which anti-emetic would we use for treatment in bowel obstruction with no colic?
Metoclopramide.
102
What do we use to manage pain bowel obstruction?
Hyoscine butylbromide (Hyoscine patches)
103
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?
```
104
Which cancer drug is associated with hypomagnesaemia?
Cisplatin
105
Which cancer drug is associated with hyponatraemia?
Vincristine
106
Cyclophosphamide and vincristine are examples of what?
Chemotherapy.
107
Which thyroid cancer causes a rise in calcitonin?
Medullary thyroid cancer; originates from the parafollicular cells.
108
Which receptors does Ondansetron act on?
5HT3 - serotonin.
109
BRCA2 mutation is associated with which cancer?
Prostate cancer (in men)
110
Which cancer is calcitonin a tumour marker for?
Medullary thyroid cancer
111
In spinal cord compression, which medication should be prescribed immediately?
Dexamethasone
112
Suspicion of spinal metastasis should be investigated with which test?
MRI spine.
113
Which cancer has the strongest association with smoking?
Squamous cell carcinoma
114
Which thyroid cancer causes a rise in calcitonin?
Medullary thyroid cancer
115
Which antiemetic do we use for patients on chemotherapy?
Ondansetron - 5-HT3 antagonist.
116
Which chemotherapeutic agent can cause cardiomyopathy?
Doxorubicin
117
Which are the markers raised in a testicular teratoma?
Alpha-fetoprotein and beta-hCG.
118
Upper motor neuron signs can point toward which cancer diagnosis?
Metastasis of spinal cord
119
What is adjuvant therapy?
Treatment given to reduce the risk of recurrence.
120
What is radical treatment?
Given with curative intent.
121
What is neoadjuvant therapy?
Given to improve the chances of therapy.
122
What are the three things in Duke's criteria?
TMN
| Tumour, metastases and node.
123
What is Palliative treatment?
Given with non-curative intent.
124
Name 3 cancers that can be cured by chemotherapy alone.
Leukaemia
Lymphoma
Germ cell tumours
125
Name 3 cancers that can be cured by radiotherapy alone.
Cervical ca
Bladder ca
Non melanoma
Oesophageal ca
126
Why do we offer adjuvant therapy?
Reduce the risk of recurrence = reduces the chance of relapse.
127
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.
128
Why do we offer palliative therapy?
To improve survival and quality of life.
| To treat symptoms.
129
What is an important aspect to consider when explaining chemotherapy/ radiotherapy to women?
Effects on pregnancy/ fertility.
130
What is the difference between adjuvant and radical treatment?
```
Adjuvant = given to reduce the risk of recurrence
Radical = to cure.
```
131
What is SACT?
Systemic anti-cancer treatment.
132
You are reviewing him in clinic prior to cycle 5. How would you assess his fitness
for further chemotherapy?
1. Assess performance status.
2. Assess drug toxicities.
3. Assess response to chemotherapy.
133
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
```
134
How do we assess whether a patient is appropriate for chemotherapy?
1. Assess performance status.
2. Assess drug toxicities.
3. Assess response to chemotherapy.
135
What is a FOLOX regime?
5FU and Oxaliplatin.
| Make sure to check for diarrhoea, N+V, neuropathy caused from these drugs.
136
What is the main side effect of 5FU?
Diarrhoea.
137
Name a medication we can use for diarrhoea.
Loperamide.
138
Name two bedside tests we would want to do in someone with diarrhoea.
Stool MCS
| C. Difficile testing.
139
Name the three platinum chemotherapy drugs.
Cisplatin, Carboplatin, Oxaliplatin
(platins).
140
Which receptors do metoclopramide work on?
Dopamine (D2 receptors).
141
Name the broad spectrum antibiotic which works on dopamine, h1, and serotonin receptors.
Levomepromazine.
142
Name four anti-emetics we may consider using in chemotherapy patients.
```
Metoclopramide
Cyclizine
Haloperidol
Levomepromazine
Ondansetron
```
143
Which anti-emetic works on serotonin receptors (5HT3)?
Ondansetron
144
Which medication regime do we use to treat Hodgkin's lymphoma?
```
ABVD
Doxorubicin (an anthracycline)
Bleomycin
Vinblastine
Dacarbazine
```
145
ABVD is used to treat which cancer? How long does the ABVD cycle take?
```
Hodgkin's lymphoma.
4 weeks (28 days)
```
146
Which chemo drug class can cause cardiomyopathy?
Anthracyclines e.g. Doxorubicin.
147
Raised AFP and hCG are indicative of which tumour?
Non seminomatous testicular (germ cell) cancers.
148
What is a common side effect of bleomycin?
Pulmonary fibrosis.
149
CEA is a marker for which cancer?
Colorectal cancer.
150
Imatinib, erlotinib and crizotinib are examples of what kind of drug class?
Tyrosine kinase inhibitors.
151
What is the most common side effect of Tyrosine kinase inhibitors?
Do you remember examples of TK inhibitors?
Rash.
e.g. Imatinib.
152
Rituximab and Herceptin are examples of what type of anti-cancer treatment?
Monoclonal antibodies.
153
What is another name for HNPCC?
Lynch syndrome
154
Where is the most likely site for metastasis from colorectal cancer?
Liver NOT bone.
155
Which of the following would suggest a left rather than right-sided colonic tumour?
PR bleeding.
156
What type of tumours are most colorectal tumours?
Adenocarcinomas.
157
What does T3 N1 M0 mean?
Tumour has grown into the serosa.
Disease within 3 lymph nodes
No distant metastases.
158
What does N1 mean in the TMN staging?
There are tumour cells in up to 3 regional lymph nodes.
159
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.
```
160
How do pleural plaques appear on chest x-rays?
Holly life appearance.
161
Von Hippel lindau disease is a risk factor for developing which cancer?
Renal cell carcinoma
162
What is the treatment of choice for mild dysphagia?
Oesophageal stent.
163
What is the conversion between oral codeine to oral morphine?
Divide by 10. Morphine is stronger x10.
164
Which medication can we use to manage respiratory secretions?
Hyoscine Hydrobromide.
165
What mechanism does Hyoscine hydrobromide work through?
Muscarinic receptor antagonist.
166
Which is the first line treatment for agitation?
Haloperidol NOT midazolam.
167
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.
168
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
169
Name the four types of shock.
Hypovolaemic
Cardiogenic
Obstructive e.g. Tamponade, tension pneumothorax
Distributive e.g. capillary leaks, vasodilatation - seen in sepsis, burns
170
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.
171
How may post-operative patients become susceptible to hypoxaemia?
Hypoventilation or
| Shunting e.g. chest infection
172
How may mechanical ventilation be offered?
Invasively: Tracheal or tracheostomy tube.
| Non-invasively: tight fitting face mask
173
What is the first sign of renal dysfunction?
Oliguria
174
Give 3 indications for haemodialysis
Hyperkalaemia
Fluid overload
Acidosis
175
How do we define oliguria?
<0.5ml/kg/hr
176
What GCS score patient needs to be intubated?
GCS <8
177
In which condition do we see Heinz bodies?
Glucose-6-phosphate dehydrogenase deficiency
178
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.
179
What is the difference between type 1 and type 2 respiratory failure?
Type 1 = low po2, low CO2
| Type 2 = low po2, high CO2
180
Give x3 examples of Type 1 respiratory failure
Pneumothorax, pulmonary oedema, pneumonia, COPD.
181
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.
182
Which is the characteristic cell of CML? - chronic myeloid leukaemia?
Increase in granulocytes (eosinophils, basophils, neutrophils).
