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RCE > Oncology and Palliative Care > Flashcards

Oncology and Palliative Care Flashcards

1
Q

Breast Cancer Screening - General Population

A

Mammogram q2-3 years from age 50-74

  • No self/clinical exam
  • No US/CT/MRI
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2
Q

Indications for high risk breast cancer screening

A
  • Hereditary mutation (BRCA 1/2, P53, PTEN, CDH1, PALB1/2) in self or 1st degree relative
  • Chest wall radiation within 8 years and before age 30

Personal or FHx of:

  • 2+ cases breast/ovarian CA in close relatives
  • Bilateral, Male, Young (<35yo), in Ashkenazi Jew
  • Invasive serous ovarian CA
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3
Q

Breast Cancer Screening- High risk

A

MRI + Mammogram q1 yr from age 30-69

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4
Q

Lung Cancer Screening Indications

A

Need all 3:

1) Current smoker or quit within 15 yrs +
2) >=30 pack year history +
3) Age 55-74

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5
Q

Lung Cancer Screening high risk

  • Method
  • Frequency
  • Age group
A

Low dose CT chest q1 yr x3 between 55-74

NO CXR or sputum cytology

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6
Q

Colorectal CA Screening - General Population (no personal/family hx CRC, polyps, IBD)

A

FIT/qFOBT q2 years OR Flexible sigmoidoscopy Q10 years (NOT c-scope)
From Age 50-74 (same age range for BCa)

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7
Q

Colorectal CA Screening in person with 1st degree relative with CRC or Advanced Adenoma

A

Colonoscopy q5-10 years starting at age 40-50 or 10 years prior to diagnosis of relative (whichever earlier)
FIT q1-2y as second line

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8
Q

Colorectal CA Screening in FAP vs Lynch (HNPCC)

A

FAP: Flex sig q1 year from age 10

HNPCC: C-scope q1-2 years from age 20 (or 10y prior to CRC dx in 1st degree relative)

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9
Q

Colorectal CA Screening in IBD

A

Colonoscopy q1-3 years starting

a) 8 years after diagnosis if hx pancolitis
b) 12-15 years after diagnosis if hx left sided colitis only

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10
Q

HCC Screening indications

A

Cirrhosis of any etiology (NOT CP-C unless pending liver transplant)
Hepatitis B carrier (SAg +) if:
- Black >20
- Asian >40M/>50F
- HIV or HDV co-infected (start at 40)
- FHX HCC in 1st degree relative (start at 40)

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11
Q

HCC Screening in high risk

A

US Q6months from onset of diagnosis of cirrhosis / chronic hep B until CP-C cirrhosis

*NO AFP if US available

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12
Q

Cervical Cancer Screening - General Population

A
  • Pap-smear (cervical cytology) Q3Y age 25-69
  • Stop once age >=70 AND >= 3 consecutive negative tests in last 10 years
  • exceptions:
  • Never sexually active,
  • Previous abnormal pap,
  • Immunocompromised,
  • Cervical Ca sx (eg abnormal bleeding),
  • Limited life expectancy
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13
Q

Esophageal CA screening

A

Do NOT screen adults w/ chronic GERD w/o alarm sx for esophageal carcinoma, Barrett, or dysplasia

*does not apply to alarm sx or those w/ barrett esophagus (w/ or without dysplasia)

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14
Q

ECOG Scale

A

1 - no limitations
2- some limitations in day to day activities, but <50% of day spent in bed
3- >=50% of day spent in bed, limited self-care
4- bedbound
5- dead

*no chemo if ECOG 3-4

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15
Q

Right Supraclavicular node

A

Intrathoracic (lung, esophageal) CA

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16
Q

Left Supraclavicular (Virchow’s) Node

A

Intra-abdominal malignancy (GI/GU - Pancreas, gastric, cholangio, RCC, testic, prostate, ovarian)
Ipsilateral lung, breast

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17
Q

Umbillical (Sister Mary Joseph) Node

A

GI or GU Malignancy (gastric, pancreas, ovarian, endometrial, CRC)

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18
Q

Breast Cancer Stages

A

1- tumor <=2cm, no lymph nodes
2- tumor 2-5 cm with <= 3 LNs OR =5cm with no LNs
3- Skin involved OR >=4 LN OR Tumor >5 cm + >=1 LN
4- Distant mets (usual lung, liver, bone, brain)

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19
Q

Work-up for breast CA

A

For all:
Bilateral Mammogram and breast US +/- MRI (before or 4-6wks s/p COVID vaccine)
Ipsilateral axillary US

If >=4 Positive LNs or stg 3 or localizing Sx:
Bone scan + CT CAP

If neuro Sx:
MRI or CT head

Core biopsy + receptor status testing: ER, PR, HER-2

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20
Q

Treatment stage 1 breast CA

A

Surgery: lumpectomy + SLN bx + rads
OR mastectomy + SLN bx
*ALN dissection if SLN+

Chemo only if triple negative

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21
Q

Treatment stage 2/3 breast CA

A

Surgery: lumpectomy + SLN bx + rads
OR mastectomy + SLN bx
*ALN dissection if SLN+

Chemo (Anthracycline eg doxo/epirubicin + Taxane eg doce/paclitaxel) *upfront if visceral crisis (organ compromise or symptoms)
Tamoxifen/AI for ER/PR +
Trastuzumab (Herceptin) for HER-2 +
Bisphosphonates

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22
Q

Treatment stage 4 breast CA

A

ER/PR +: Endocrine Tx + CDK4/6 inhib (letrozole, palbo) +/-Chemo
HER-2+: Dual HER-2 blockade (Trastu/Pertuzumab) + chemo (Taxane)
Triple +: Combine above
Triple -: Chemo +/- PDL-1 inhibitor

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23
Q

Choice of endocrine therapy in ER/PR + Breast CA

A

If pre-menopausal: Tamoxifen x5-10 years
If post-menopausal: Tamoxifen or Aromatase inhibitor x5-10 years (both inc vasomotor sx, arthralgias)
- Tamoxifen: Inc risk endometrial CA, VTE, dec risk OP in post-menopausal
- AI: No inc risk endom CA, inc risk OP and CVD

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24
Q

Benefits of bisphosphonates in breast CA (eg ZA, clodronate, Prolia)

A

In non-metastatic:

  • decreases spread to bone and skeletal related events (eg #, need for radiation, cord compression)
  • protects against AI related OP
  • decreases recurrence risk
  • improves survival

In metastatic:

  • Increases time to 1st metastatic relapse
  • Improves QoL
  • Decreases bony pain
  • No survival benefit
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25
Q

Lung CA subtypes

A

NSCLC:

  • Adeno (peripheral, non-smokers, often EGFR/ALK mutated)
  • SCC (central, smokers, unlikely mutated)
  • Rare: NET, sarcomatoid, large cell

SCLC: Central smoker, non-mutated

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26
Q

Paraneoplastic syndromes: Lung, RCC

A

Any NSCLC: Clubbing/hypertrophic arthropathy
Squamous: HyperCa from PTHrP )

SCLC:

  • HypoNa from SIADH
  • Lambert Eaton (areflexic bc less ACh release from anti-VGCC Ab)
  • Peripheral neuropathy,
  • Encephalitis (anti-hu),
  • Cushing’s (ectopic ACTH)

RCC: HTN, polycythemia, thrombosis, endovascular extension up to IVC

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27
Q

Work-up Lung CA

A

For all: CT C/A/P, CT/MRI Brain
If no obvious mets: PET + mediastinal staging with EBUS

-Biopsy (90% NSCLC vs SCLC 10%)
-Molecular markers for NSCLC: EGFR, ALK, PDL1
(SCC can also consider testing for PDL1)

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28
Q

Staging NSCLC

A

1- Tumor <= 4cm, no lymph nodes
2- Tumor >= 5 cm or ipsilateral parenchymal/hilar LNs
3- Mediastinal LNs or supraclavicular LNs
4- Metastatic disease, malignant effusion

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29
Q

Staging SCLC

A

Limited - enclosed in 1 hemithorax/radiation field

Extensive - >1 radiation field or malignant effusion

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30
Q

Treatment SCLC

A

Limited: Chemo + Radiation + PPX cranial rads
Extensive: Chemo only (NO RADS) - palliative intent

chemo (cisplatin + etoposide/irinotecan)

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31
Q

Treatment NSCLC - Stage 1/2

A 
Surgery (if pred post FEV1 and DLCO >60%) 
Adjuvant chemo (for stage 2) with platinum doublet

If not surgical candidate: rads (SBRT) +/- chemo (comparable survival to surgery)

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32
Q

Treatment NSCLC Stage 3

A

If resectable: Surgery + Chemo +/- Rads

If unresectable: Concurrent chemorads–> Immunotherapy (eg Durvalumab) x 1 year if no progression

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33
Q

Treatment NSCLC Stage 4

A

If EGFR+: EGFR inhibitor (osimertinib, gefitinib, erlotinib)
If ALK+: ALK inhibitor (Crizotinib, alectinib)
If EGFR and ALK-:
- If PDL1 >50%: Pembro
- If PDL1<50%: Chemo + pembro
Palliative care (mortality benefit)

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34
Q

CRC Stages

A

1- invades INTO muscle wall
2- invades THROUGH muscle wall
3- + LNs
4- mets

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35
Q

Work-up for CRC

A

For all:

  • C-scope to terminal ileum
  • CT C/A/P
  • CEA pre-op

If localizing symptoms:

  • Bone scan
  • CT/MRI brain
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36
Q

Treatment CRC Stages 1-3

A 
Surgical resection 
Adjuvant Chemo (FOLFOX) for 3 and 2 if peforated/obstructed
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37
Q

Treatment CRC Stage 4

A

Metastectomy if oligomets to liver/lung + chemo with curative intent

In non-operative: Palliative chemo (FOLFOX/FOLFIRI) +/- TKI +/- VEGF (bevacizumab)

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38
Q

Follow-up investigations post-resection: CRC stage 1

A

C-scope 1 year post-resection
If neg, repeat in 5 years.
If +, repeat to be determined by results

39
Q

Follow-up investigations: CRC stage 2-3

A

C-scope 1 year post-resection
Year 1-3: q6mo H&P, CEA, CT CAP
Year 4-5: annual H&P, CEA, CT CAP
If no recurrence after 5 years, discharge

*If CEA rising w/o CT findings –> PET

40
Q 
RF for esophageal Ca:
Squamous cell (MC upper/mid esophagus) vs adeno CA (MC distal esophagus)
A

Squamous:

  • EtOH/Caustic injury
  • Achalasia

Adenocarcinoma

  • GERD/Barrett’s
  • Obesity

*Smoking affects both

41
Q

Work-up prostate CA

A

DRE
PSA
Biopsies x2 with calculation of Gleason score

Imaging (Bone scan, CT CAP) if:

  • Symptomatic
  • High risk (PSA >20, Gleason >=8, tumor extends through capsule)
42
Q

Treatment early localized prostate CA

A

Active surveillance with PSA OR

Radical prostatectomy +/-

  • LN dissection or
  • Radiation or
  • Androgen deprivation therapy
43
Q

Treatment of metastatic prostate CA (includes + LNs)

A

ADT: GnRH Ag (lupron), ANT (Degarelix)
+
Chemo (Docetaxel) OR Nonsteroidal antiandrogen (abiraterone)

44
Q

Classification of testicular cancers

A

Germ Cell (95%)

  • Seminoma (high B-HCG, normal AFP)
  • Non-seminoma (high B-HCG, HIGH AFP) eg yolk sac, teratoma, choriocarcinoma

Other: Sertoli, Leydig , Granulosa cell

45
Q

Treatment Testicular CA

A

Localized = Orchiectomy
Metastatic = chemo +/- rads
*NO STAGE 4, all potentially curable

Chemo: BEP (bleomycin –> pulm fibrosis, Etoposide, Cisplatin

46
Q

Treatment Bladder CA

A

Localized non-muscle invasive: TURBT +/- intravesical BCG

Localized muscle invasive: Neoadj chemo + surgery (cystectomy + LN dissection)
OR Chemo + rads

Metastatic: Chemo

47
Q

Treatment RCC

A

Localized:

  • <1cm: Surveillance
  • 1-4 cm: Renal CT/MRI then partial nephrectomy or ablation (if poor surgical candidate)
  • > 4cm: Total nephrectomy

Metastatic: Oral TKI (Axitinib) + Immunotherapy (Pembro) vs/ Dual Immunotherapy (Ipilimu/Nivolumab) if intermediate/poor risk

48
Q

Ovarian CA workup and Tx

A

Ix: Abdo/transvag US, CT CAP, Ca-125 (used for monitoring response to tx)
**do not biopsy adnexal mass (seeding)

Tx:
- Localized:
TAH+ BSO + LN dissection + peritoneal washing

  • Stg III (peritoneal deposits + malignant ascites): Surgical cytoreduction debulking + chemo (CURATIVE intent)
  • Stg IV (mets beyond pelvis, malignant pleural effusion): PALLIATIVE chemo +/- debulking +/- VEG-F (bevacizumab) or PARP inhibitor (Olaparib, if BRCA+)
49
Q

Treatment melanoma

A

NO ROLE FOR CHEMO

Stage 1/2: Wide local excision +/- LN dissection
Stage 3/4: Immunotherapy
- If BRAF mutated = BRAF + MEK inhibitors,
- If BRAF wildtype= PDL1 +/- CTLA4 inhibition

*CT CAP if stage 3, CT/MRI Brain if Stage 4

50
Q

Cancers in which + LNs = stage 4

A

Prostate

Bladder/Urothelial

51
Q

Cancer in which malignant ascites = stage 3

A

Ovarian

52
Q

Differential of blastic bone mets

A

Prostate
SCLC
Carcinoid
Hodgkins

*Breast, GI, SCC (H&N/cervix/lung) - can be either

53
Q

Differential of lytic bone mets

A 
MM
NSCLC
RCC
Melanoma
Thyroid
NHL

*Breast, GI, SCC (H&N/cervix/lung) - can be either

54
Q

PD-1 inhibitor examples

A

Pembrolizumab

Nivolumab

55
Q

CTLA4 inhibitor example

A

ipilimumab

56
Q

Side effects of check-point inhibitors and Mx

A

Common: Thyroiditis (hypothyroid), Colitis, Pneumonitis, Dermatitis
Rare: Adrenal insuff, panhypopituitarism, hepatitis, nephritis, arthritis, myocarditis (lethal), encephalitis, uveitis, heme, DM

Mx:

  • If mild, continue checkpoint inhibitor (except neuro, cardiac, heme)
  • Topical/PO steroids prn
  • Replace hormones as needed
57
Q

Management of checkpoint inhibitor related hypoT4

A

Continue drug

Replace T4

58
Q

Management of immune checkpoint inhibitor related colitis

A 
GI to scope to r/o infection:
If mild (<4BMs /day): Continue tx, loperamide, monitor

If Grd 2 (4-6 BMs/day): Stop tx. Pred 0.5-1mg/day until resolution of symptom then taper. Tx as outpatient

Grade 3/4 (>=7 BMs/day/ end organ damage): Stop treatment. Admit. Solumedrol 1-2 mg/kg . Urgent GI consult. Infliximab 5mg/kg if no response in 72 hrs

59
Q

Work-up Cancer of unknown origin

A

-H&P (breast/ axilllary/ rectal/ pelvic/ pap/ skin exam)
-CT CAP, Mammogram, OGD + C-scope
+/- scrotal US for young male
-Cystoscopy and urine cytology
-Core biopsies of lesion with immunohistochemistry
+/- tumor markers (CEA, CA125, Ca19-9, PSA, ICH, AFP, thyroglobulin, CK7, CK20)

60
Q

Definition of CA unknown primary

A

Primary unknown despite detailed initial investigations (including pan-CTs, pan-scope, pap, cysto, biopsies)

61
Q

Investigations for adenoCA unknown primary

A

If female with axillary nodes: MRI breasts + mammo
If female with peritoneal carcinomatosis: TVUS + Ca-125
If male: PSA, bone scan

62
Q

Investigations for SCC of unknown primary

A

If cervical LND (H&N Ca): Pan-endoscopy + PET
If M and inguinal LND: C-scope (r/o anal SCC)
If F and inguinal: Pap, TVUS, C-scope (r/o anal SCC)

63
Q

Treatment of malignant Small bowel obstruction

A
  • Fluids
  • NG decompression
  • Lyte replacement

Pharmacologic:

  • Octreotide,
  • Steroids,
  • Metoclopramide (NOT if complete MBO)
IR: Intraluminal stent > venting G-tube
Surgical consult (even if palliative)
64
Q

Definition febrile neutropenia

A
  1. T>=38.3 or (>=38 for >1 hr) AND 2. ANC <=0.5 (or expected NADIR <=0.5)
    * neutropenia nadir usually 7-14d after chemo
65
Q

Indications for admission in febrile neutropenia

A

Hemodynamic instability or signs of sepsis
Haematologic (= high risk) malignancy or post-BMT
Anticipated duration of neutropenia >= 7 days

66
Q

Empiric outpatient treatment for feb neut

A

Cipro + Amox/Clav (or clinda if pen allergic)

67
Q

Empiric inpatient treatment for feb neut

A

Pip-tazo + Tobra/Gent +/- Vanco or
Mero + Vanco

*G-CSF for 2ndary ppx - does NOT improve outcomes

68
Q

Treatment of hypercalcemia of malignancy

A

FLUIDS
Bisphosphonate (Pamidronate 90x1, ZA 4mg x1) **monitor or hypoCa after
+/- Calcitonin

69
Q

Treatment of malignant SC compression (UMN findings) or cauda equina syndrome (LMN findings)
*MC cancers causing

A

Urgent MRI whole spine
Dex 10 mg IV x1 –> 4mg QID
Consult spine sx and Rad onc
Pain control

MC: Breast, lung, PCa, MM

70
Q

Empiric treatment of SVC syndrome

A

If life threatening (HoTN, obtunded, stridor): Venogram + thoracics for urgent stent +/- lytics if thrombus
If not, biopsy and treat underlying malig +/- rads for nonchemo sensitive tumor (NSCLC, mesothelioma)

  • Chemo for SCLC, NHL, germ cell
  • Steroids if can’t stent or steroid responsive (thymoma/lymphoma)

MC NSCLC (50%), SCLC, lymphoma, mets, thrombosis

71
Q

Utility of tumor markers

A

Assist with Diagnosis
Monitor response to treatment
Monitor for recurrence

72
Q

Anthracycline toxicities (eg doxorubicin)

A

Non-reversible cardiomyopathy (up to 20y s/p chemo)

Secondary leukemias

73
Q

5-FU Toxicity (for CRC and BCa)

A

Coronary vasospasm
Mucositis (baking soda rinse, viscous lidocaine, nystatin/steroid)
Diarrhea (loperamide–> lomotil–>codeine syrup –>octreotide)
Hand-foot syndrome

74
Q

Chemo tox:

  • Platinum (cisplatin, carboplatin, oxaloplatin)
  • Taxane (Paclitaxel, Docetaxel)
  • Vincristine
A

All cause peripheral neuropathy

Cisplatin ++ NV, AKI, ototoxic, hypoMg/Ca/K

75
Q

Cyclophosphamide toxicity

A

Secondary leukemias (MDS, AML)
Hemorrhagic cystitis, bladder CA
Infertility

76
Q

Trastuzumab (Herceptin) Toxicity

A 
REVERSIBLE cardiomyopathy (DC drug, do not rechallenge)
Infusion reaction (flu like)
77
Q

Management of chemo-induced NV

A 
Mildly emetogenic (paclitaxel, etoposide): 
-Zofran OR Dex
Moderately emetogenic (carboplatin based): 
- Zofran + Dex + Olanzapine
Highly emetogenic (cisplatin, anthracycline, cyclo): 
- Zofran + Dex + Olanzapine + Aprepitant
78
Q

Opioids safe for use in renal dysfunction

A

Hydromorphone
Fentanyl (good for opioid induced urticaria/itching)
Methadone

*NO morphine, codeine, tramadol, demerol

79
Q

Opioids safe for use in hepatic dysfunction

A

Hydromorphone
Fentanyl (good for opioid induced urticaria/itching)
Morphine

*NO codeine/methadone

80
Q

Opioid equivalence

*what to do when switching

A

1 HM = 5 morphine = 3.5 oxycodone
PO:IV/SC = 2:1

100 mg/day morphine = 25 mcg/hr fentanyl (patches come in 25 intervals, can be cut in half)

*Reduce dose by 25-30% when switching

81
Q

MAID eligibility

A
  • 18+ with healthcard, informed consent (voluntary and not under duress)
  • Competent at time of request & procedure (can waive final consent if losing capacity)
  • Grievous & irreversible condition (excludes mental illness), death does NOT need to be forseeable
82
Q

2 current tracks for MAID

A

1) Death is reasonably forseeable - no waiting period req

2) Death is not reasonably forseeable - waiting period now 90 days (can be shortened if pt about to lose capacity)

83
Q

Cancers NOT to screen for

A

PCa w/ PSA
Ovarian in avg risk women
Testicular
Melanoma

84
Q

Indication for BRCA testing & Tx

A

Similar to high-risk features for screening:
- Male, Young (<35), Ashkenazi Jewish <50yo, serous ovarian Ca, Breast+Ovarian in same pt

Others:

  • Triple neg BCa <60yo,
  • Pt with gastric/pancreatitic/PCa + FamHx of BRCA2-assoc’d Ca

Tx:

  • Prophylactic B/L mastectomy (unclear mortality benefit; 90% BCa reduction),
  • Oophorectomy (mortality benefit)
85
Q

Esophageal Ca Tx

A

Localized:
-Neoadjuvant chemo +/- rads –> surg –> +/- adjuvant chemo

Metastatic:
-Chemo +/- trastuzumab (if HER2+)

86
Q

PCa Tx S/E

A

ADT: OP, libido, gynecomastia, hot flash, fatigue
Docetaxel: periph neuropathy, N/V, hair loss
Abiraterone (+ pred): HTN, hyperglycemia, hypoK, CV disease
Enzalutamide : Sz, fatigue

87
Q

Radioresistant tumors

A

RCC, Melanoma, Osteosarcoma

88
Q

Erythropoeitin stimulating agents (ESA) in solid tumors

A

Use if:
-Palliative + Hgb <100 from chemo

DO NOT use if:

  • Hgb <100 from cancer (ie not on therapy)
  • From chemo with curative intent

Consider before starting:

  • R/O IDA, Iron can be added to increase ESA eficacy even if not deficient
  • Discuss VTE risk
  • No Hgb target, just target Hgb needed to avoid transfusions
  • DC if no effect by 6-8wks
89
Q

HyperCa of Malignancy Mech

A

PTHRP (SCC lung, H&N)
Lytic bone (breast, MM)
1,25-vitamin D/calcitriol production (lymphoma)

90
Q

TLS Dx & Tx

A

> =2 of following w/i 7d post chemo: hyperK (arrhythmia, weakness), hyperPO4 (sz,AKI) , hyperuric acid (AKI, stones), hypoCa (tetany, paresthesias)

Tx: IVF + rasburicase (allopurinol if no G6PD)
PPx: IVF and allopurinol or rasburicase

91
Q

Opioid S/E

A

GI (constipation, N/V), sedation
Rare: myoclonus, hallucination
Methadone: QT prolong, DDI

92
Q

Constipation Approach

A

R/O: disease, drugs, Ca, TSH

Tx:

  • Stimulants (senna) ppx w/ opioids,
  • Osmotic (lactulose/peg),
  • Enema,
  • Opoid ANT,
  • Cl channel Ag

*No stool softeners (colace) for opioid induced (same as placebo)

93
Q

Thymoma Sx

A

Paraneoplastic sx:

  • Myasthenia Gravis
  • Pure red cell aplasia
  • Non thymic cancer
  • Acquired hypogammaglobulinemia

RCE (18 decks)

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