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Medicine > Oncology and Palliative Care > Flashcards

Oncology and Palliative Care Flashcards

1
Q

Requirements for urgent referral for lung cancer

A

> 40 with unexplained haemoptysis, CXR suggestive of cancer.

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2
Q

Requirements for urgent CXR for lung cancer

A 
>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
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3
Q

Requirements for urgent endoscopy

A

Dysphagia OR

>55 with weight loss and either upper abdominal pain, reflux or dyspepsia.

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4
Q

Requirements for urgent referral for upper GI cancer

A

> 40 and jaundice (?pancreas), or people with signs of an upper abdominal mass (?gall bladder, ?liver)

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5
Q

Requirements for urgent CT of pancreas for pancreatic cancer

A 
>60 plus weight loss plus any of:
Diarrhoea
Back pain
Abdo pain
Nausea
Constipation
New-onset DM
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6
Q

Requirements for Non-urgent endoscopy for Upper GI cancer

A 
>55 and one of:
Treatment-resistant dyspepsia
Upper abdo pain with low Hb
Raised platelet count
Nausea or vomiting
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7
Q

Requirements for urgent referral for lower GI cancer

A

> 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

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8
Q

Requirements to consider urgent referral for lower GI cancer

A

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
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9
Q

Faecal occult blood test should be offered to:

A

> 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.

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10
Q

What is the screening programme for colorectal cancer

A

Men and women aged 60-74 every 2 years.

Patients aged >74 may request screening.

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11
Q

What are the requirements for urgent referral for gynaecological cancer

A

Ascites, pelvic mass (fibroid excluded), >55 with post-menopausal bleeding

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12
Q

Requirements for urgent referral for breast cancer

A

> 30 with unexplained breast lump with or without pain

>50 with unilateral nipple discharge, retraction or other changes of concern.

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13
Q

Requirements for consideration of breast cancer urgent referral

A

Skin changes that suggest breast cancer

Aged 30 and over with unexplained lump in axilla

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14
Q

Requirements for urgent urological cancer referral

A

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.

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15
Q

Give an example of an alkylating agent, mechanism of action and adverse effects

A

Cyclophosphamide

Causes cross-linking in DNA

Haemorrhagic cystitis, myelosuppresion, transitional cell carcinoma

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16
Q

Give 2 examples of cytotoxic antibiotics, mechanism of action and adverse effects

A

Bleomycin - degrades preformed DNA - lung fibrosis

Doxorubicin - stabilises DNA-topoisomerase II complex inhibits DNA and RNA synthesis - cardiomyopathy

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17
Q

Give 3 examples of antimetabolites, mechanism of action and adverse effects

A

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

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18
Q

Give 2 examples of spindle poisons, mechanism of action and adverse effects

A

Vincristine/Vinblastine - inhibits formation of microtubules
Vincristine - peripheral neuropathy (reversible), paralytic ileus
Vinblastine - myelosuppresion

Docetaxel - prevents microtubule depolymerisation and disassembly, decreasing free tubular - neutropenia.

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19
Q

Give an example of a topoisomerase inhibitor, mechanism of action and adverse effects

A

Irinotecan - inhibits topoisomerase I which prevents relaxation of supercoiled DNA - myelosuppresion

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20
Q

Cisplatin mechanism of action and adverse effects

A

Causes cross-linking in DNA

Ototoxicity, peripheral neuropathy, hypomagnesaemia

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21
Q

Hydroxyurea mechanism of action and adverse effects

A

Inhibits ribonucleotide reductase, decreasing DNA synthesis

Myelosuppresion

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22
Q

Early reactions of radiotherapy (2-4 weeks into treatment)

A

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

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23
Q

Late reactions of radiotherapy (months-years)

A

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

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24
Q

What are the different methods of radiotherapy

A

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.

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25
Q

What is neutropenic sepsis

A

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

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26
Q

Management of neutropenic sepsis

A

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.

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27
Q

Which cancers are most likely to have spinal cord compression

A

Lung, prostate, breast, myeloma, melanoma

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28
Q

Signs and symptoms of spinal cord compression

A

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.

29
Q

Management of spinal cord compression

A

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.

30
Q

Most common cancers causing brain mets

A

Lung, breast, colorectal, melanoma

31
Q

Signs and symptoms of brain mets

A

Headache, focal neurological signs, ataxia, fits, nausea, vomiting, papilloedema

32
Q

Management of brain mets

Prognosis of brain mets

A

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.

33
Q

Features of superior vena cava obstruction

A 
Most common with lung cancer
Dyspnoea
Swelling of face, neck and arms
Headache - often worse in mornings
Visual disturbance
Pulseless jugular venous distension
34
Q

Causes of superior vena cava obstruction

A

NSCLC, lymphoma, Kaposi’s sarcoma, breast cancer, aortic aneurysm, mediastinal fibrosis, goitre, SVC thrombosis

35
Q

Management of superior vena cava obstruction

A

Dexamethasone, balloon venoplasty, stenting

Chemo or radiotherapy depending on sensitivity of underlying cancer.

36
Q

Causes of malignancy associated hypercalcaemia

A

PTH-related protein produced by tumour (eg squamous cell carcinoma of lung)

37
Q

Signs and symptoms of malignancy associated hypercalcaemia

A

Weight loss, anorexia, nausea, polydipsia, polyuria, constipation, abdominal pain, dehydration, weakness, confusion, seizure, coma

38
Q

Treatment of malignancy associated hypercalcaemia

A

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.

39
Q

What is tumour lysis syndrome

A

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.

40
Q

Features of tumour lysis syndrome

A 
High potassium
High phosphate
High uric acid
Low calcium
AKI (increased serum creatinine)
Cardiac arrhythmia or sudden death
Seizure
41
Q

Prophylaxis of tumour lysis syndrome

A

Prophylaxis
IV allopurinol or IV rasburicase

Lower risk groups - oral allopurinol

42
Q

What tumour marker is raised in testicular and hebatocellular cancer

A

Alpha-fetoprotein

43
Q

What tumour marker is raised in medullary thyroid

A

Calcitonin

44
Q

What tumour marker is raised in ovarian cancer

A

CA 125

45
Q

What tumour marker is raised in pancreatic cancer

A

CA 19-9

46
Q

What tumour marker is raised in Breast cancer

A

CA 15-3

47
Q

What tumour marker is raised in colorectal cancer

A

Carcinoembryonic antigen (CEA)

48
Q

What tumour marker is raised in testicular cancer/germ cell cancer

A

hCG

49
Q

What is the screening programme for breast cancer

A

47-73 years of age

Mammogram every 3 years.

50
Q

What dose of morphine do you start with patients for palliative care

A

20-30mg of MR morphine with 5mg morphine for breakthrough pain

51
Q

What medication should prescribed alongside strong opioids

A

Laxatives and anti-emetics

52
Q

How do you calculate daily breakthrough dose of morphine

A

1/6th of TDD

53
Q

How do you calculate modified release morphine dose

A

1/2 of TDD

54
Q

What opioids are preferred in renal failure

A

alfentanil, buprenorphine, fentanyl

55
Q

Side effects of opioids

A

Nausea, drowsiness, constipation, dry mouth

56
Q

How do you treat opioid toxicity

A

Naloxone indicated for life-threatening respiratory depression

57
Q

How do you convert oral morphine dose to transdermal fentanyl patch

A

12 microgram patch equates to 30mg oral morphine daily.

58
Q

What anti-emetic is good for intracranial disorders?

A

Cyclizine

59
Q

Where does metoclopramide act on and what is it good for?

A

Central chemoreceptor trigger zone, peripheral pro kinetic effects
Good for gastroparesis

Monitor for extra-pyramidal side-effects

60
Q

Which anti-emetic is a D2 antagonist and does not have extra-pyramidal side-effects

A

Domperidone

61
Q

Which anti-emetic is good for drug induced nausea?

A

Haloperidol

62
Q

Which anti-emetic is used first line for chemotherapy induced nausea and vomiting?

A

Ondansetron

Aprepitant second line

63
Q

Treatment of constipation in palliative care

A

Good fluid intake, treat reversible causes.

Stimulant (senna) at night +/- stool softener (docusate)

Osmotic laxative (lactulose, movicol)

Rectal treatments (bisacodyl suppositories, phosphate enema)

64
Q

What treatment types are used for N+V in Bowel Obstruction

A 
Endoscopic stenting
Venting gastrostomy to decompress
Centrally acting anti-emetic
Antispasmodic and anti-secretory agents (hyoscine butylbromide or octreotide)
Somatostatin analogue
65
Q

How to treat intractable breathlessness in palliative care

A

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.

66
Q

What are the anticipatory end of life medication and what are they used for?

A 
Pain - morphine
Agitation + N&amp;V - Haloperidol
Agitation + anxiety - Midazolam
N&amp;V - levomepromazine
Respiratory secretions - glycopyrronium
67
Q

What are the conservative and medical management options for excessive secretions in palliative care?

A

Conservative - avoid fluid overload. Educate family that patient is likely not troubled by secretions

Medical - first line: hyoscine butyl bromide. Second line: glycopyrronium bromide

68
Q

What are the management options for agitation and confusion in palliative care?

A

1st line - haloperidol
Other options - chlorpromazine, levomepromazine

Terminal phase of illness - midazolam

69
Q

What is the management of hiccups?

A

Chlorpromazine for intractable hiccups
Haloperidol and gabapentin also used
Dexamethasone used if hepatic lesions.

Medicine (15 decks)

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