Oncology and Palliative Care

Question 1

Who is considered “high risk” for breast cancer and how do you screen them?

Answer 1

High risk = personal or FHx breast or ovarian cancer <60 years or gene mutation, chest radiation <30 year of age and >8 years ago. Screen women ages 30-69 years with yearly mammogram and MRI.

Question 2

How do you define and work up stage 3 breast cancer?

Answer 2

Tumour >5cm and 1+ lymph nodes or 4+ lymph nodes or skin involvement. Work up with CT CAP and bone scan.

Question 3

What would be 5 medical options for triple positive metastatic breast cancer in a 65 year old woman?

Answer 3

1. Hormone receptor therapy - tamoxifen or letrozole.
2. CD4/6 inhibitor - palbociclib.
3. HER2 dual blockage - trastuzumab and pertuzumab.
4. Chemotherapy - taxane
5. Antiresorptive agent - zoledronic acid or denosumab.

Question 4

Tamoxifen and letrozole side effects.

Answer 4

Tamoxifen: increased endometrial cancer, thrombosis, arthralgias, hot flashes, decreased CV risk.
Letrozole: not for pre-menopausal, increased severe arthralgias, hot flashes, CV risk, osteoporosis

Question 5

Three side effects of anthracyclines (doxorubicin, epirubicin).

Answer 5

Irreversible cardiomyopathy, remote secondary leukemia, alopecia.

Question 6

Four side effects of taxanes (paclitaxel, docetaxel).

Answer 6

Peripheral neuropathy (give pyridoxime), alopecia, febrile neutropenia, myalgias/arthralgias.

Question 7

What has mortality benefit in BRCA 1/2 mutation carriers?

Answer 7

Prophylactic bilateral salpingo-oophorectomy (mastectomies reduce breast cancer but have no proven mortality benefit).

Question 8

What are seven populations who should be screened for BRCA mutation?

Answer 8

1. Ashkenazi Jewish women with breast Ca < 50 years.
2. Breast cancer < 35 years.
3. Triple negative breast cancer < 60 years.
4. Any serous ovarian cancer.
5. Male with breast cancer.
6. Breast and ovarian cancer in same patient.
7. Gastric, pancreatic, or prostate cancer with family history of BRCA2-associated cancers.

Question 9

How do you screen for lung cancer?

Answer 9

Age 55-74 years with 30+ pack year smoking history and current smoker or quit <15 years ago. Screen with low dose CT chest yearly for 3 years.

Question 10

List 4 uncommon lung cancers.

Answer 10

Neuroendocrine, sarcoma, large cell, adenosquamous.

Question 11

How do you work up non-small cell lung cancer?

Answer 11

CT CAP, CT/MRI brain, bone scan. If no metastases, must do PET scan and lymph node sampling via EBUS or mediastinoscopy.

Question 12

What is stage 3 lung cancer and how do you treat?

Answer 12

Mediastinal or supraclavicular lymph nodes. Treat with resection if IIIA, chemoradiation, and one year of durvalumab.

Question 13

What are four paraneoplastic syndromes associated with NSCLC?

Answer 13

1. SIADH
2. ACTH-mediated Cushing’s syndrome.
3. Lambert-Eaton myasthenic syndrome (weak, poor reflexes).
4. Anti-Hu mediated encephalomyelitis and sensory neuropathy.

Question 14

How do you screen for colorectal cancer in IBD?

Answer 14

Colonoscopy every 1-3 years 8 years after pancolitis diagnosis or 10-12 years for left-sided colitis.

Question 15

How do you work up colorectal cancer?

Answer 15

CT CAP, full colonoscopy, and CEA.

Question 16

What is surveillance for stage II-III colorectal cancer?

Answer 16

Colonoscopy 1 year after resection, H+P/CT-CAP/CEA every 6 months for first 3 years then yearly for years 4-5, PET scan if rising CEA and CT-CAP normal.

Question 17

How do you work up prostate cancer?

Answer 17

CT CAP and bone scan for high risk = Gleason score >8, PSA >20, tumour extent >T3.

Question 18

What is standard of care of metastatic prostate cancer?

Answer 18

Androgen deprivation therapy (e.g. Lupron) with either chemo (e.g. docetaxel) or non-steroidal antiandrogen (e.g. abiraterone).

Question 19

What is the tumour marker profile for seminoma testicular cancer?

Answer 19

bHCG and LDH, AFP never elevated in seminoma.

Question 20

What are 4 risk factors for esophageal adenocarcinoma?

Answer 20

Barrett’s esophagus > GERD > smoking > obesity.

Question 21

What are 4 risk factors for esophageal squamous cell carcinoma?

Answer 21

Smoking, alcohol, caustic injury, achalasia.

Question 22

What are the treatment options for localized renal cell carcinoma?

Answer 22

<1 cm = active surveillance
1-4 cm = CT/MRI and either partial nephrectomy or biopsy for suspicious lesions.
>4cm = nephrectomy

Question 23

What are the treatment options for metastatic renal cell carcinoma?

Answer 23

Favourable risk based on IMDCC risk calculator = TKI +/- cytoreductive nephrectomy. Unfavourable risk = dual immunoptherapy with ipilimumab and nivolumab.

Question 24

Which cancers must you not biopsy?

Answer 24

Ovarian and testicular.

Question 25

What are the main side effects of immunotherapy?

Answer 25

Permanent hypothyroidism, panhypopituitarism, adrenal insufficiency, colitis, nephritis, pneumonitis, myocarditis, hepatitis.

Question 26

What work up in needed to define cancer as unknown primary?

Answer 26

1. History and physical.
2. Biopsy with immunohistochemistry for CK7/20.
3. CT CAP, mammogram, endoscopies, cystoscopy and urine cytology.
4. CEA, Ca 19-9, Ca-125, PSA, thyroglobulin, hCG, AFP

Question 27

What makes prostate or bladder cancer stage IV?

Answer 27

Presence of any lymph nodes.

Question 28

Name 3 cancers that cause osteoblastic and 3 that cause mixed bone metastases.

Answer 28

Osteoblastic - prostate, SCLC, Hodgkin’s lymphoma, carcinoid.
Mixed - Breast, GI, squamous cell carcinoma (lung, H+N, cervical).

Question 29

What is Virchow’s node?

Answer 29

Left supraclavicular node associated with abdominal malignancy.

Question 30

What are three side effects of cisplatin?

Answer 30

Nausea/vomiting, ototoxicity, nephrotoxicity.

Question 31

Name three treatment options for chemotherapy-induced diarrhea.

Answer 31

Loperamide, octreotide, steroids +/- infliximab if immunotherapy colitis.

Question 32

What is the treatment regimen for chemotherapy-induced nausea/vomiting?

Answer 32

NK1 antagonist (aprepitant), 5HT3 antagonist (ondansetron), steroid (dexamethasone) +/- olanzapine

Question 33

What is an indication for erythropoietin stimulating agents in cancer?

Answer 33

Chemotherapy-induced anemia (Hgb<100) with chemo being used for palliative intent. May cause thrombosis.

Question 34

What is the definition of febrile neutropenia?

Answer 34

Fever >38.3 or >38 for >1hr AND ANC<0.5 or <1.0 with expected nadir (7-14d after chemo) <0.5.

Question 35

Which cancers metastasize to the spine?

Answer 35

Lung, breast, prostate, multiple myeloma.

Question 36

What is the definition of tumour lysis syndrome?

Answer 36

2+ lab abnormalities (high K, PO4, uric acid, low Ca) within 7 days of chemotherapy.

Question 37

Which cancer shows improved overall survival with early palliative care referral?

Answer 37

Metastatic non-small cell lung cancer.

Question 38

Define ECOG 2.

Answer 38

Bedbound <50% of the time, fully independent for self-care, not working.

Question 39

Which opioids are acceptable in renal impairment?

Answer 39

Hydromorphone, fentanyl, methadone.

Question 40

What is the approximate conversion of oral morphine units for oxycodone, hydromorphone, and fentanyl patch?

Answer 40

1.5, 5, 100 mg = 25 mcg/hr, respectively.

Question 41

Who is eligible for medical assistance and dying?

Answer 41

Age >18, health card, no mental health issues, freely requested MAID with no coercion, informed consent obtained, grievous (unbearable suffering and reasonably foreseeable natural death) and irremediable (irreversible state).

Question 42

What is the latency period between requested and administering MAID?

Answer 42

10 days (less if medical consensus that death is fast approaching and there is likely to be loss of ability to provide informed consent).