Oncology and Palliative Care Flashcards
Requirements for urgent referral for lung cancer
> 40 with unexplained haemoptysis, CXR suggestive of cancer.
Requirements for urgent CXR for lung cancer
>40 and have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 of the following unexplained symptoms: Cough Fatigue Shortness of breath Chest pain Weight loss Appetite loss
Requirements for urgent endoscopy
Dysphagia OR
>55 with weight loss and either upper abdominal pain, reflux or dyspepsia.
Requirements for urgent referral for upper GI cancer
> 40 and jaundice (?pancreas), or people with signs of an upper abdominal mass (?gall bladder, ?liver)
Requirements for urgent CT of pancreas for pancreatic cancer
>60 plus weight loss plus any of: Diarrhoea Back pain Abdo pain Nausea Constipation New-onset DM
Requirements for Non-urgent endoscopy for Upper GI cancer
>55 and one of: Treatment-resistant dyspepsia Upper abdo pain with low Hb Raised platelet count Nausea or vomiting
Requirements for urgent referral for lower GI cancer
> 40 with unexplained weight loss & abdominal pain
50 with unexplained rectal bleeding
60 with iron def. anaemia OR change in bowel habit
Test positive faecal occult blood
Requirements to consider urgent referral for lower GI cancer
Rectal or abdominal mass
Unexplained anal mass or anal ulceration
<50 years with rectal bleeding AND any of: Abdo pain Change in bowel habit Weight loss Iron def. anaemia
Faecal occult blood test should be offered to:
> 50 and unexplained abdominal pain or weight loss
<60 with change in bowel habit or iron def. anaemia
60 with anaemia even in absence of iron def.
What is the screening programme for colorectal cancer
Men and women aged 60-74 every 2 years.
Patients aged >74 may request screening.
What are the requirements for urgent referral for gynaecological cancer
Ascites, pelvic mass (fibroid excluded), >55 with post-menopausal bleeding
Requirements for urgent referral for breast cancer
> 30 with unexplained breast lump with or without pain
>50 with unilateral nipple discharge, retraction or other changes of concern.
Requirements for consideration of breast cancer urgent referral
Skin changes that suggest breast cancer
Aged 30 and over with unexplained lump in axilla
Requirements for urgent urological cancer referral
Irregular prostate on PR, abnormal age-specific PSA
>40 with unexplained visible haematuria
>60 with unexplained non-visible haematuria + dysuria or increased WCC
Non-painful enlargement or change in shape/texture of testicle.
Give an example of an alkylating agent, mechanism of action and adverse effects
Cyclophosphamide
Causes cross-linking in DNA
Haemorrhagic cystitis, myelosuppresion, transitional cell carcinoma
Give 2 examples of cytotoxic antibiotics, mechanism of action and adverse effects
Bleomycin - degrades preformed DNA - lung fibrosis
Doxorubicin - stabilises DNA-topoisomerase II complex inhibits DNA and RNA synthesis - cardiomyopathy
Give 3 examples of antimetabolites, mechanism of action and adverse effects
Methotrexate - inhibits dihydrofolate reductase and thymidylate synthesis - myelosuppresion, mucositis, liver fibrosis, lung fibrosis
Fluorouracil (5-FU) - pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase - myelosuppresion, mucositis, dermatitis
6-MP - purine analogue, decreases purine synthesis - myelosuppresion
Give 2 examples of spindle poisons, mechanism of action and adverse effects
Vincristine/Vinblastine - inhibits formation of microtubules
Vincristine - peripheral neuropathy (reversible), paralytic ileus
Vinblastine - myelosuppresion
Docetaxel - prevents microtubule depolymerisation and disassembly, decreasing free tubular - neutropenia.
Give an example of a topoisomerase inhibitor, mechanism of action and adverse effects
Irinotecan - inhibits topoisomerase I which prevents relaxation of supercoiled DNA - myelosuppresion
Cisplatin mechanism of action and adverse effects
Causes cross-linking in DNA
Ototoxicity, peripheral neuropathy, hypomagnesaemia
Hydroxyurea mechanism of action and adverse effects
Inhibits ribonucleotide reductase, decreasing DNA synthesis
Myelosuppresion
Early reactions of radiotherapy (2-4 weeks into treatment)
Tiredness
Skin reactions - dry desquamation, erythema, moist desquamation, ulceration
Mucositis
Nausea and vomiting (treat with either metoclopramide, ondansetron or domperidone)
Diarrhoea (treat with loperamide)
Dysphagia
Cystitis
Late reactions of radiotherapy (months-years)
CNS/PNS - somnolence, spinal cord myelopathy, brachial plexopathy
Lung - pneumonitis
GI - xerostomia, benign strictures of oesophagus or bowel, radiation proctitis
GU - urinary frequency, vaginal stenosis, dyspareunia, erectile dysfunction
Endocrine - panhypopituitarism
What are the different methods of radiotherapy
Conventional external beam radiotherapy (EBRT)
Stereotactic radiotherapy - targets small lesions with great precision (eg gamma knife therapy)
Brachytherapy - radiation source placed within or close to tumour, allowing high local radiation dose.
Radioisotope therapy - eg radioiodine to ablate remaining thyroid tissue after thyroidectomy for thyroid cancer.
What is neutropenic sepsis
Consequence of chemotherapy 7-14 days after chemo.
Neutrophil count <0.5 and one of the following:
Temperature >38
Signs or symptoms consistent with clinically significant sepsis:
Chills and shivering, tachycardia, tachypnoea, clammy, cold, mottled skin, dizziness, confusion, disorientation, slurred speech, diarrhoea, nausea and vomiting
Management of neutropenic sepsis
Prophylaxis - fluoroquinolone
Tazocin first-line
If patients still febrile and unwell after 48 hours, switch to meropenem +/- vancomycin
If still not improving after 4-6 days - order investigations for fungal infections
Role of G-CSF for selected patients.
Which cancers are most likely to have spinal cord compression
Lung, prostate, breast, myeloma, melanoma
Signs and symptoms of spinal cord compression
Back pain (earliest and most common), worse on lying down and coughing
Lower limb weakness
Sensory changes - sensory loss and numbness
Neurological signs depend on level of lesion - lesion above L1 usually result in UMN signs in legs and a sensory level. Lesions below L1 cause LMN signs in legs and perianal numbness
Tendon reflexes tend to be increased below level of lesion and absent at level of lesion.
Management of spinal cord compression
Admit for bed rest and arrange urgent MRI whole spine within 24 hours.
Dexamethasone 16mg/24 hours PO with PPI
Radiotherapy is most common treatment and should be given within 24 hours of MRI diagnosis.
Decompressive surgery +/- radiotherapy may be appropriate depending on prognosis.
Patients with loss of motor function after 48 hours are unlikely to recover function.
Most common cancers causing brain mets
Lung, breast, colorectal, melanoma
Signs and symptoms of brain mets
Headache, focal neurological signs, ataxia, fits, nausea, vomiting, papilloedema
Management of brain mets
Prognosis of brain mets
Urgent CT/MRI depending on underlying diagnosis, disease staging, performance status.
Dexamethasone 16mg/24 hours to reduce cerebral oedema.
Stereotactic radiotherapy
Prognosis - 1-2 months survival. Better prognosis with single lesion, breast cancer.
Features of superior vena cava obstruction
Most common with lung cancer Dyspnoea Swelling of face, neck and arms Headache - often worse in mornings Visual disturbance Pulseless jugular venous distension
Causes of superior vena cava obstruction
NSCLC, lymphoma, Kaposi’s sarcoma, breast cancer, aortic aneurysm, mediastinal fibrosis, goitre, SVC thrombosis
Management of superior vena cava obstruction
Dexamethasone, balloon venoplasty, stenting
Chemo or radiotherapy depending on sensitivity of underlying cancer.
Causes of malignancy associated hypercalcaemia
PTH-related protein produced by tumour (eg squamous cell carcinoma of lung)
Signs and symptoms of malignancy associated hypercalcaemia
Weight loss, anorexia, nausea, polydipsia, polyuria, constipation, abdominal pain, dehydration, weakness, confusion, seizure, coma
Treatment of malignancy associated hypercalcaemia
Aggressive rehydration - 3-4 litres/day
Bisphosphonates eg zolendronic acid IV normalises calcium within 3 days.
Can repeat infusion.
Calcitonin has quicker effect than bisphosphonates.
What is tumour lysis syndrome
Related to treatment of high grade lymphomas and leukaemia. Can occur in absence of chemotherapy, but usually triggered by introduction of combination chemotherapy.
Occurs from breakdown of tumour cells and subsequent release of chemicals from cell.
Features of tumour lysis syndrome
High potassium High phosphate High uric acid Low calcium AKI (increased serum creatinine) Cardiac arrhythmia or sudden death Seizure
Prophylaxis of tumour lysis syndrome
Prophylaxis
IV allopurinol or IV rasburicase
Lower risk groups - oral allopurinol
What tumour marker is raised in testicular and hebatocellular cancer
Alpha-fetoprotein
What tumour marker is raised in medullary thyroid
Calcitonin
What tumour marker is raised in ovarian cancer
CA 125
What tumour marker is raised in pancreatic cancer
CA 19-9
What tumour marker is raised in Breast cancer
CA 15-3
What tumour marker is raised in colorectal cancer
Carcinoembryonic antigen (CEA)
What tumour marker is raised in testicular cancer/germ cell cancer
hCG
What is the screening programme for breast cancer
47-73 years of age
Mammogram every 3 years.
What dose of morphine do you start with patients for palliative care
20-30mg of MR morphine with 5mg morphine for breakthrough pain
What medication should prescribed alongside strong opioids
Laxatives and anti-emetics
How do you calculate daily breakthrough dose of morphine
1/6th of TDD
How do you calculate modified release morphine dose
1/2 of TDD
What opioids are preferred in renal failure
alfentanil, buprenorphine, fentanyl
Side effects of opioids
Nausea, drowsiness, constipation, dry mouth
How do you treat opioid toxicity
Naloxone indicated for life-threatening respiratory depression
How do you convert oral morphine dose to transdermal fentanyl patch
12 microgram patch equates to 30mg oral morphine daily.
What anti-emetic is good for intracranial disorders?
Cyclizine
Where does metoclopramide act on and what is it good for?
Central chemoreceptor trigger zone, peripheral pro kinetic effects
Good for gastroparesis
Monitor for extra-pyramidal side-effects
Which anti-emetic is a D2 antagonist and does not have extra-pyramidal side-effects
Domperidone
Which anti-emetic is good for drug induced nausea?
Haloperidol
Which anti-emetic is used first line for chemotherapy induced nausea and vomiting?
Ondansetron
Aprepitant second line
Treatment of constipation in palliative care
Good fluid intake, treat reversible causes.
Stimulant (senna) at night +/- stool softener (docusate)
Osmotic laxative (lactulose, movicol)
Rectal treatments (bisacodyl suppositories, phosphate enema)
What treatment types are used for N+V in Bowel Obstruction
Endoscopic stenting Venting gastrostomy to decompress Centrally acting anti-emetic Antispasmodic and anti-secretory agents (hyoscine butylbromide or octreotide) Somatostatin analogue
How to treat intractable breathlessness in palliative care
Airflow across face
Position patient so using gravity to aid diaphragm
Trial of oxygen if hypoxic
Consider trial of low dose opioids
Consider lorazepam for anxiety.
What are the anticipatory end of life medication and what are they used for?
Pain - morphine Agitation + N&V - Haloperidol Agitation + anxiety - Midazolam N&V - levomepromazine Respiratory secretions - glycopyrronium
What are the conservative and medical management options for excessive secretions in palliative care?
Conservative - avoid fluid overload. Educate family that patient is likely not troubled by secretions
Medical - first line: hyoscine butyl bromide. Second line: glycopyrronium bromide
What are the management options for agitation and confusion in palliative care?
1st line - haloperidol
Other options - chlorpromazine, levomepromazine
Terminal phase of illness - midazolam
What is the management of hiccups?
Chlorpromazine for intractable hiccups
Haloperidol and gabapentin also used
Dexamethasone used if hepatic lesions.
