Oncology and Palliative Care Flashcards
Breast Cancer Screening - General Population
Mammogram q2-3 years from age 50-74
- No self/clinical exam
- No US/CT/MRI
Indications for high risk breast cancer screening
- 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
Breast Cancer Screening- High risk
MRI + Mammogram q1 yr from age 30-69
Lung Cancer Screening Indications
Need all 3:
1) Current smoker or quit within 15 yrs +
2) >=30 pack year history +
3) Age 55-74
Lung Cancer Screening high risk
- Method
- Frequency
- Age group
Low dose CT chest q1 yr x3 between 55-74
NO CXR or sputum cytology
Colorectal CA Screening - General Population (no personal/family hx CRC, polyps, IBD)
FIT/qFOBT q2 years OR Flexible sigmoidoscopy Q10 years (NOT c-scope)
From Age 50-74 (same age range for BCa)
Colorectal CA Screening in person with 1st degree relative with CRC or Advanced Adenoma
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
Colorectal CA Screening in FAP vs Lynch (HNPCC)
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)
Colorectal CA Screening in IBD
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
HCC Screening indications
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)
HCC Screening in high risk
US Q6months from onset of diagnosis of cirrhosis / chronic hep B until CP-C cirrhosis
*NO AFP if US available
Cervical Cancer Screening - General Population
- 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
Esophageal CA screening
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)
ECOG Scale
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
Right Supraclavicular node
Intrathoracic (lung, esophageal) CA
Left Supraclavicular (Virchow’s) Node
Intra-abdominal malignancy (GI/GU - Pancreas, gastric, cholangio, RCC, testic, prostate, ovarian)
Ipsilateral lung, breast
Umbillical (Sister Mary Joseph) Node
GI or GU Malignancy (gastric, pancreas, ovarian, endometrial, CRC)
Breast Cancer Stages
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)
Work-up for breast CA
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
Treatment stage 1 breast CA
Surgery: lumpectomy + SLN bx + rads
OR mastectomy + SLN bx
*ALN dissection if SLN+
Chemo only if triple negative
Treatment stage 2/3 breast CA
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
Treatment stage 4 breast CA
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
Choice of endocrine therapy in ER/PR + Breast CA
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
Benefits of bisphosphonates in breast CA (eg ZA, clodronate, Prolia)
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
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
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
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)
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
Staging SCLC
Limited - enclosed in 1 hemithorax/radiation field
Extensive - >1 radiation field or malignant effusion
Treatment SCLC
Limited: Chemo + Radiation + PPX cranial rads
Extensive: Chemo only (NO RADS) - palliative intent
chemo (cisplatin + etoposide/irinotecan)
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)
Treatment NSCLC Stage 3
If resectable: Surgery + Chemo +/- Rads
If unresectable: Concurrent chemorads–> Immunotherapy (eg Durvalumab) x 1 year if no progression
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)
CRC Stages
1- invades INTO muscle wall
2- invades THROUGH muscle wall
3- + LNs
4- mets
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
Treatment CRC Stages 1-3
Surgical resection Adjuvant Chemo (FOLFOX) for 3 and 2 if peforated/obstructed
Treatment CRC Stage 4
Metastectomy if oligomets to liver/lung + chemo with curative intent
In non-operative: Palliative chemo (FOLFOX/FOLFIRI) +/- TKI +/- VEGF (bevacizumab)
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
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
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
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)
Treatment early localized prostate CA
Active surveillance with PSA OR
Radical prostatectomy +/-
- LN dissection or
- Radiation or
- Androgen deprivation therapy
Treatment of metastatic prostate CA (includes + LNs)
ADT: GnRH Ag (lupron), ANT (Degarelix)
+
Chemo (Docetaxel) OR Nonsteroidal antiandrogen (abiraterone)
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
Treatment Testicular CA
Localized = Orchiectomy
Metastatic = chemo +/- rads
*NO STAGE 4, all potentially curable
Chemo: BEP (bleomycin –> pulm fibrosis, Etoposide, Cisplatin
Treatment Bladder CA
Localized non-muscle invasive: TURBT +/- intravesical BCG
Localized muscle invasive: Neoadj chemo + surgery (cystectomy + LN dissection)
OR Chemo + rads
Metastatic: Chemo
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
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+)
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
Cancers in which + LNs = stage 4
Prostate
Bladder/Urothelial
Cancer in which malignant ascites = stage 3
Ovarian
Differential of blastic bone mets
Prostate
SCLC
Carcinoid
Hodgkins
*Breast, GI, SCC (H&N/cervix/lung) - can be either
Differential of lytic bone mets
MM NSCLC RCC Melanoma Thyroid NHL
*Breast, GI, SCC (H&N/cervix/lung) - can be either
PD-1 inhibitor examples
Pembrolizumab
Nivolumab
CTLA4 inhibitor example
ipilimumab
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
Management of checkpoint inhibitor related hypoT4
Continue drug
Replace T4
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
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)
Definition of CA unknown primary
Primary unknown despite detailed initial investigations (including pan-CTs, pan-scope, pap, cysto, biopsies)
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
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)
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)
Definition febrile neutropenia
- 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
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
Empiric outpatient treatment for feb neut
Cipro + Amox/Clav (or clinda if pen allergic)
Empiric inpatient treatment for feb neut
Pip-tazo + Tobra/Gent +/- Vanco or
Mero + Vanco
*G-CSF for 2ndary ppx - does NOT improve outcomes
Treatment of hypercalcemia of malignancy
FLUIDS
Bisphosphonate (Pamidronate 90x1, ZA 4mg x1) **monitor or hypoCa after
+/- Calcitonin
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
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
Utility of tumor markers
Assist with Diagnosis
Monitor response to treatment
Monitor for recurrence
Anthracycline toxicities (eg doxorubicin)
Non-reversible cardiomyopathy (up to 20y s/p chemo)
Secondary leukemias
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
Chemo tox:
- Platinum (cisplatin, carboplatin, oxaloplatin)
- Taxane (Paclitaxel, Docetaxel)
- Vincristine
All cause peripheral neuropathy
Cisplatin ++ NV, AKI, ototoxic, hypoMg/Ca/K
Cyclophosphamide toxicity
Secondary leukemias (MDS, AML)
Hemorrhagic cystitis, bladder CA
Infertility
Trastuzumab (Herceptin) Toxicity
REVERSIBLE cardiomyopathy (DC drug, do not rechallenge) Infusion reaction (flu like)
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
Opioids safe for use in renal dysfunction
Hydromorphone
Fentanyl (good for opioid induced urticaria/itching)
Methadone
*NO morphine, codeine, tramadol, demerol
Opioids safe for use in hepatic dysfunction
Hydromorphone
Fentanyl (good for opioid induced urticaria/itching)
Morphine
*NO codeine/methadone
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
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
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)
Cancers NOT to screen for
PCa w/ PSA
Ovarian in avg risk women
Testicular
Melanoma
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)
Esophageal Ca Tx
Localized:
-Neoadjuvant chemo +/- rads –> surg –> +/- adjuvant chemo
Metastatic:
-Chemo +/- trastuzumab (if HER2+)
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
Radioresistant tumors
RCC, Melanoma, Osteosarcoma
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
HyperCa of Malignancy Mech
PTHRP (SCC lung, H&N)
Lytic bone (breast, MM)
1,25-vitamin D/calcitriol production (lymphoma)
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
Opioid S/E
GI (constipation, N/V), sedation
Rare: myoclonus, hallucination
Methadone: QT prolong, DDI
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)
Thymoma Sx
Paraneoplastic sx:
- Myasthenia Gravis
- Pure red cell aplasia
- Non thymic cancer
- Acquired hypogammaglobulinemia
