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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
Lung CA subtypes
NSCLC: - Adeno (peripheral, non-smokers, often EGFR/ALK mutated) - SCC (central, smokers, unlikely mutated) - Rare: NET, sarcomatoid, large cell SCLC: Central smoker, non-mutated
26
Paraneoplastic syndromes: Lung, RCC
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
27
Work-up Lung CA
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)
28
Staging NSCLC
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
29
Staging SCLC
Limited - enclosed in 1 hemithorax/radiation field | Extensive - >1 radiation field or malignant effusion
30
Treatment SCLC
Limited: Chemo + Radiation + PPX cranial rads Extensive: Chemo only (NO RADS) - palliative intent chemo (cisplatin + etoposide/irinotecan)
31
Treatment NSCLC - Stage 1/2
``` 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)
32
Treatment NSCLC Stage 3
If resectable: Surgery + Chemo +/- Rads | If unresectable: Concurrent chemorads--> Immunotherapy (eg Durvalumab) x 1 year if no progression
33
Treatment NSCLC Stage 4
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)
34
CRC Stages
1- invades INTO muscle wall 2- invades THROUGH muscle wall 3- + LNs 4- mets
35
Work-up for CRC
For all: - C-scope to terminal ileum - CT C/A/P - CEA pre-op If localizing symptoms: - Bone scan - CT/MRI brain
36
Treatment CRC Stages 1-3
``` Surgical resection Adjuvant Chemo (FOLFOX) for 3 and 2 if peforated/obstructed ```
37
Treatment CRC Stage 4
Metastectomy if oligomets to liver/lung + chemo with curative intent In non-operative: Palliative chemo (FOLFOX/FOLFIRI) +/- TKI +/- VEGF (bevacizumab)
38
Follow-up investigations post-resection: CRC stage 1
C-scope 1 year post-resection If neg, repeat in 5 years. If +, repeat to be determined by results
39
Follow-up investigations: CRC stage 2-3
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
``` RF for esophageal Ca: Squamous cell (MC upper/mid esophagus) vs adeno CA (MC distal esophagus) ```
Squamous: - EtOH/Caustic injury - Achalasia Adenocarcinoma - GERD/Barrett's - Obesity *Smoking affects both
41
Work-up prostate CA
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
Treatment early localized prostate CA
Active surveillance with PSA OR Radical prostatectomy +/- - LN dissection or - Radiation or - Androgen deprivation therapy
43
Treatment of metastatic prostate CA (includes + LNs)
ADT: GnRH Ag (lupron), ANT (Degarelix) + Chemo (Docetaxel) OR Nonsteroidal antiandrogen (abiraterone)
44
Classification of testicular cancers
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
Treatment Testicular CA
Localized = Orchiectomy Metastatic = chemo +/- rads *NO STAGE 4, all potentially curable Chemo: BEP (bleomycin --> pulm fibrosis, Etoposide, Cisplatin
46
Treatment Bladder CA
Localized non-muscle invasive: TURBT +/- intravesical BCG Localized muscle invasive: Neoadj chemo + surgery (cystectomy + LN dissection) OR Chemo + rads Metastatic: Chemo
47
Treatment RCC
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
Ovarian CA workup and Tx
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
Treatment melanoma
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
Cancers in which + LNs = stage 4
Prostate | Bladder/Urothelial
51
Cancer in which malignant ascites = stage 3
Ovarian
52
Differential of blastic bone mets
Prostate SCLC Carcinoid Hodgkins *Breast, GI, SCC (H&N/cervix/lung) - can be either
53
Differential of lytic bone mets
``` MM NSCLC RCC Melanoma Thyroid NHL ``` *Breast, GI, SCC (H&N/cervix/lung) - can be either
54
PD-1 inhibitor examples
Pembrolizumab | Nivolumab
55
CTLA4 inhibitor example
ipilimumab
56
Side effects of check-point inhibitors and Mx
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
Management of checkpoint inhibitor related hypoT4
Continue drug | Replace T4
58
Management of immune checkpoint inhibitor related colitis
``` 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
Work-up Cancer of unknown origin
-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
Definition of CA unknown primary
Primary unknown despite detailed initial investigations (including pan-CTs, pan-scope, pap, cysto, biopsies)
61
Investigations for adenoCA unknown primary
If female with axillary nodes: MRI breasts + mammo If female with peritoneal carcinomatosis: TVUS + Ca-125 If male: PSA, bone scan
62
Investigations for SCC of unknown primary
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
Treatment of malignant Small bowel obstruction
- 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
Definition febrile neutropenia
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
Indications for admission in febrile neutropenia
Hemodynamic instability or signs of sepsis Haematologic (= high risk) malignancy or post-BMT Anticipated duration of neutropenia >= 7 days
66
Empiric outpatient treatment for feb neut
Cipro + Amox/Clav (or clinda if pen allergic)
67
Empiric inpatient treatment for feb neut
Pip-tazo + Tobra/Gent +/- Vanco or Mero + Vanco *G-CSF for 2ndary ppx - does NOT improve outcomes
68
Treatment of hypercalcemia of malignancy
FLUIDS Bisphosphonate (Pamidronate 90x1, ZA 4mg x1) **monitor or hypoCa after +/- Calcitonin
69
Treatment of malignant SC compression (UMN findings) or cauda equina syndrome (LMN findings) *MC cancers causing
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
Empiric treatment of SVC syndrome
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
Utility of tumor markers
Assist with Diagnosis Monitor response to treatment Monitor for recurrence
72
Anthracycline toxicities (eg doxorubicin)
Non-reversible cardiomyopathy (up to 20y s/p chemo) | Secondary leukemias
73
5-FU Toxicity (for CRC and BCa)
Coronary vasospasm Mucositis (baking soda rinse, viscous lidocaine, nystatin/steroid) Diarrhea (loperamide--> lomotil-->codeine syrup -->octreotide) Hand-foot syndrome
74
Chemo tox: - Platinum (cisplatin, carboplatin, oxaloplatin) - Taxane (Paclitaxel, Docetaxel) - Vincristine
All cause peripheral neuropathy Cisplatin ++ NV, AKI, ototoxic, hypoMg/Ca/K
75
Cyclophosphamide toxicity
Secondary leukemias (MDS, AML) Hemorrhagic cystitis, bladder CA Infertility
76
Trastuzumab (Herceptin) Toxicity
``` REVERSIBLE cardiomyopathy (DC drug, do not rechallenge) Infusion reaction (flu like) ```
77
Management of chemo-induced NV
``` Mildly emetogenic (paclitaxel, etoposide): -Zofran OR Dex ``` ``` Moderately emetogenic (carboplatin based): - Zofran + Dex + Olanzapine ``` ``` Highly emetogenic (cisplatin, anthracycline, cyclo): - Zofran + Dex + Olanzapine + Aprepitant ```
78
Opioids safe for use in renal dysfunction
Hydromorphone Fentanyl (good for opioid induced urticaria/itching) Methadone *NO morphine, codeine, tramadol, demerol
79
Opioids safe for use in hepatic dysfunction
Hydromorphone Fentanyl (good for opioid induced urticaria/itching) Morphine *NO codeine/methadone
80
Opioid equivalence | *what to do when switching
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
MAID eligibility
- 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
2 current tracks for MAID
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
Cancers NOT to screen for
PCa w/ PSA Ovarian in avg risk women Testicular Melanoma
84
Indication for BRCA testing & Tx
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
Esophageal Ca Tx
Localized: -Neoadjuvant chemo +/- rads --> surg --> +/- adjuvant chemo Metastatic: -Chemo +/- trastuzumab (if HER2+)
86
PCa Tx S/E
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
Radioresistant tumors
RCC, Melanoma, Osteosarcoma
88
Erythropoeitin stimulating agents (ESA) in solid tumors
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
HyperCa of Malignancy Mech
PTHRP (SCC lung, H&N) Lytic bone (breast, MM) 1,25-vitamin D/calcitriol production (lymphoma)
90
TLS Dx & Tx
>=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
Opioid S/E
GI (constipation, N/V), sedation Rare: myoclonus, hallucination Methadone: QT prolong, DDI
92
Constipation Approach
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
Thymoma Sx
Paraneoplastic sx: - Myasthenia Gravis - Pure red cell aplasia - Non thymic cancer - Acquired hypogammaglobulinemia

RCE (18 decks)

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