Oncology approach Flashcards
Oncology PRICMCP
In P, write chronological hx of Ca. In C - complications should be focused on tx related ones, PE…etc, recurrence should be placed in P as a part of chronology.
P: initial symptoms (or screening), dx date, staging. How was it treated (if surgery, was neo-adjuvant and/or adjuvant therapy given - if not inc risk of relapse)? When did it recur? does the patient know molecular subtype** (if Breast Ca - BRCA status, receptor status) - chronological hx.
R: FH***, smoking, occupation (e.g. asbestos)…etc
I: was the cancer dx by biopsy? if recurred, what is the findings from the biopsy? current staging? (if does not know, ask size, location, LN involvement, spread) and attempt to roughly work out the staging.
C: of chemotherapy, immunotherapy, RTx. DVT/PE, infection.
M: what tx is the patient currently on, plan for further therapy? is the palliative care team involved - (earlier is better - evidence for improved survival)
C: is the treatment working or not. How is patient & family coping with the treatment/appointment/test schedule, parking, transport, carer stress? Impact on work, mood, what is current ECOG? Can patient do what she/he enjoys? - e.g. golf, looking after grandkids…etc.
P: insight into prognosis, wills, Advanced Care plan
What is your approach to making treatment decisions in oncology? (5)
- Review pathology & radiology - diagnosis & staging
- Assess comorbidities (since e.g. -rubicins [cardiotoxicity], thyroid function in Immunotherapy…etc) that may influence the treatment & functional status
- Can the patient cope with intensive tx schedule - cycles, RTx, scans, bloods…etc
- Consult guidelines - what is the EBM standard of care?
- Dedicated consultation - targetted discussion to assess patient’s values and preferences, consider family conference. Would the patient accept the degree of risk and benefit?
- Discuss in MDT: all option within the limits of patient’s function/comorbidities/preference should be discussed
You’ve mentioned that you will forge a good therapeutic relationship with this patient. How are you going to achieve that? (4)
- create a safe place (to discuss difficult issues without family…etc)
- I would listen attentively, show empathy
- Encourage him/her to talk about fear, distress and normalize and validate distress
- Educate and debunk myth - a common one is a therapy leads to hair loss
- I would continuously probe for his/her feelings and respond to that
The patient has developed a significant side effect to anti-cancer therapy. Would you consider stop or change (or even continue)? What is your approach? (5)
Key components to assess
- Severity
- Functional impairment resulting from treatment
- Aim of treatment
- Patient preference
- Alternative therapies.
E.g. diarrhoea.
The patient is currently suffering a severe side effect, impacting his/her functional status, preventing him/her from (…).
The aim of treatment is curative (likely for long case patient) so the treatment should ideally continue wherever possible, but given the severity, this should stop, at least temporarily.
I would have further discussion with the patient with respect to their preference (& values) and I will consult the guidelines and discuss in MDT meeting to work out the best treatment strategy.
How would you broadly stage cancer?
I would formally stage cancer using TNM staging (or other cancer-relevant ones) but broadly speaking,
Stage 1-2 = localised disease
Stage 3 = node involvement
Stage 4 = metastatic
or localised, locoregional, metastatic.
If the patient had adjuvant therapy, what does it tell you?
It tells you that initial cancer probably had node positivity (i.e. stage III) or high-risk features (e.g. positive margin, lymphatic or vessel invasion).
So this fact can be used to assess the future risk of relapse.
What do you think this patient’s prognosis is? (3)
Keep it vague - examiner is not after a specific time to survival.
It is more about - “what are the possible/probable outcomes for the patient” and “how does this influence treatment decision making”
Key buzz words: performance status, disease burden, critical organs at risk.
then discuss a) likelihood of relapse/recurrence and b) failure of treatment
Generally, metastatic disease, survival is <12 months.
“This patient has a poor performance status, high disease burden with some of the critical orgain including the lung/kidney are at risk of failure.
“Thus, there is a substantial risk of the patient not tolerating the therapy (or not responding to the therapy)” or “significant risk of relapse”
“Reflecting on these, I believe that the prognosis is poor. I would like to plan a dedicated session to discuss this and identify his/her long-term values, goals and preferences which would be critical for next steps of care”
For the patient wanting to know the prognosis / survival, what is the useful approach to answer this?
Describe an average, worst and best case scenarios.
Rule of 3.
If average survival is 3 years, say worst = 1 year to best 9 years for example.
General Chemotherapy side effects to Ask in Oncology long cases? (10)
Head-to-toe: the Chemo-man
Ototoxicity (platins)
Mucositis
Pulmonary fibrosis (Bleomycin)
Cardiotoxicity (Doxorubicin, 5-FU: spasm)
Diarrhoea
Renal impairment
Bone marrow disorders
Peripheral neuropathy
Haemorrhagic cystitis
Hands and foot syndrome
Secondary Leukaemia
General RTx side effects? (5)
The main issue = fibrotic changes to wherever the beam was shone.
- Cardiac: cardiomyopathy, conduction disease
- Pulmonary: fibrosis
- GI: radiation proctitis/enteritis
- Lymphoedema
- Angiosarcoma
Complications of immunotherapy in general? (9)
Hypophysitis
Anterior uveitis
Thyroiditis
pneumonitis
Hepatitis
Colitis
Adrenal insufficiency
Motor & sensory neuropathies (weakness, numbness, tingling)
Arthritis
Dermatitis
What is your approach to this patient with Cancer?
Goals: curative vs palliative, maximise QOL, advanced care planning
Confirm dx: review - histopathology, radiology, molecular profiles to work out histological type and staging.
A: screen & treat depression, any potentially reversible causes such as infection, VTE
Screen for complications:
- Clinical exam - postural BP, mucositis, signs of pulmonary fibrosis, peripheral neuropathy, urine for haematuria.
- Bloods: FBC (BM), LFTs (Hepatitis), inflammatory markers (infection), EUC, TFT, pituitary panel (if on immunotherapy)
- ECG (anthracyclin/Trastuzumab), consider TTE and Spirometry depending on clinical findings to look for restrictive pattern (fibrosis), cardiomyopathy
T: Non-pharm
- Acknowledge: difficult Mx issue that require continuous support from multidisciplinary team and family
- Educate: insight on prognosis, complications of drug toxicity, action plan - in particular when to seek medical attention
- Advanced Care planning: what arrangement (e.g. finance) does the patient need to make, ACD, who will be responsible to make medical/social decisions should the patient lose the capacity.
- To facilitate these important processes, I will organise a dedicated consultation to discuss these issues and better understand patient’s values and preferences, consider family conferences.
- Involve palliative care early (evidence for prolonging survival and improving QOL)
- Lifestyle changes: increase activity, smoking cessation, moderation of alcohol, healthy-balance diet and good sleep hygiene improves general well-being
- Infection prophylaxis: vaccination, contacts…etc.
Treatment: Pharm
- Specific to tumour type
Involve patient’s local GP, OT especially with falls prevention in mind, PT to engage patient in exercise program (benefitting both mental/physical). Dietician, palliative care team.
Ensure follow-up and regularly screen for complications
- Review patient’s symptomatology and clinical findings, coping with treatment
- Routine bloods including drug to monitor for drug toxicity such as BM
- ECG if on Rubicins or Trastuzumab + 3 monthly TTEs
- DEXA if on Aromatase inhibitor
