Oncology - Blue Book Flashcards
Which virus is linked to Burkitt’s Lymhoma (and other NHLs)?
EBV
What kind of exposure is linked to leukemia?
radiation
What type of cancer are aromatic amines linked to?
bladder
Name 2 cancers associated with HPV
cervical
anal
What variant of Hepatitis is linked to hepatocellular cancer?
a) A
b) B
c) C
B
which bacteria is associated with development of MALT tumours?
a) staph
b) strep
c) h pylori
d) campylobacter
h pylori
what is the most common staging system used in oncology?
TNM
what does an increase in tumour grade indicate?
worsening differentiation of cells
What type of disease response is this?
“all lesions have shrunk by at least 30% but disease still present”
partial response
What type of disease response is this?
“less than 20% increase in size or less than 30% decrease in size”
stable disease
What type of disease response is this?
“No disease detectable radiologically”
complete response
What type of disease response is this?
“new lesions or lesions that have increased in size by more than 20%”
progressive disease
what question should you always ask women of childbearing age before performing medical imaging?
are you preggerz?
which imaging technique is best to visualise the GI tract?
a) abdo x ray
b) CT
c) MRI
b) CT
how can vascular structures be made clearer on CT scans?
IV contrast medium
What imaging technique is gold-standard for neurospinal, rectal, prostate and MSK tumours?
MRI
why is it important to check whether patients have pacemakers/implanted defibrillators/metal foreign bodies before performing an MRI?
a) rust
b) magnetism
c) x-ray heat
d) no risk
b) magnetism
which form of imaging uses high-frequency sound waves aimed at soft tissue to generate an image?
a) ultrasound
b) MRI
c) X-ray
d) PET
a) ultrasound
what molecule is commonly tethered to radioisotopes in PET scanning?
a) oestrogen
b) water
c) haemoglobin
d) glucose
d) glucose
Carcino-embryonic antigen (CAE), CA125 and CA19.9 are examples of which class of tumour marker?
a) oncofetal proteins
b) enzymes
c) cell-surface glycoproteins
d) hormones
c) cell-surface glycoproteins
which of these is not an oncofetal protein tumour marker?
a) alpha-fetoprotein
b) human chorionic gonadotrophin (HCG)
c) bence jones protein
c) bence jones protein (it’s an immunoglobulin)
name 2 enzymes commonly used as tumour markers
lactate dehydrogenase (indicated glycolysis of tumour cells) alkaline phosphatase (high in bone or liver cancer) acid phosphatase (e.g. prostatic in prostate cancer) neurone-specific enolase
which chromosome abnormality is present on chromosome 22 of leukaemia cells (especially CML)
a) manhattan
b) Washington
c) Boston
d) Philadelphia
d) Philadelphia
why is it not appropriate to screen the population for tumour markers?
often can represent a broad spectrum of malignancies and also can be elevated in benign conditions
what is the most useful feature of tumour markers?
a) diagnosis
b) screening
c) treatment response
c) treatment response
what cancer commonly uses CEA as a tumour marker?
a) colorectal
b) small cell lung cancer
c) malignant melanoma
d) leukaemia
a) colorectal
what cancer most commonly uses CA125 as a marker?
a) breast
b) testicular
c) liver
d) ovarian
d) ovarian
one of these glycoproteins is raised in hepatocellular carninoma and yolk sac-containing cancers (e.g. teratoma); the other is raised in non-seminomatous testicular cancer and trophoblastic disease (e.g. hydatiform mole)
a) alpha fetoprotein
b) HCG
alpha fetoprotein raised in the first scenario
HCG raised in the second scenario
what tumour markers are most likely to be used to measure paraproteinaemias such as myeloma?
a) hormones
b) immunoglobulins
c) glycoproteins
d) enzymes
b) immunoglobulins
which of these is not a biopsy technique?
a) partial suction biopsy
b) fine needle aspiration
c) incisional biopsy
d) excisional biopsy
a) partial suction biopsy
what percentage of cancer patients are curable by surgical resection?
a) 2%
b) 10%
c) 30%
d) 65%
c) 30%
what methods can be used to reduce the risk of local recurrence
adjuvant chemotherapy and/or radiotherapy
why does lymph node involvement carry a worse prognosis?
indicator of distant micro-metastases
cytoreductive therapy to reduce the size of tumour can be used alongside chemotherapy to…
a) help palliate symptoms
b) improve survival
c) appease patients
b) improve survival
true or false: curative surgery for metastases is often indicated
false
give an example of palliative surgery
clearing obstruction
orthopaedics for bone fractures
what is the name for the therapy which uses cytotoxic agents to manage cancer systemically
chemotherapy
what proportion of cancer patients require chemo as part of their treatment?
a) 5-10%
b) 20-30%
c) 60-70%
d) 100%
c) 60-70%
what type of cells are chemotherapeutic agents preferentially toxic towards?
a) immature
b) actively proliferating
c) mature
d) lysed
b) actively proliferationg
why are tumour cells more likely to die when faced with cytotoxic agents as opposed to normal cells?
rapidly proliferate and not well differentiated therefore less able to repair damage
What word defines this type of chemo? “used frequently in osteosarcoma. Pre-operative treatment of an operable tumour before definitive surgical intervention. The aims of this are to make the tumour, smaller to allow less radical surgery, while at the same time treating occult micro metastases”
neo-adjuvant
what word defines this type of chemo? “Initial chemotherapy for a tumour that is inoperable or of uncertain operability, where a reduction in the tumour bulk in a pre-defined manner may make surgery with curative intent feasible”
primary
what word defines this type of chemo? “The use of chemotherapy following a complete macroscopic clearance at surgery. Chemotherapy in this setting treats the occult microscopic metastases which we know usually lead to relapse after surgery for lymph-node positive disease (e.g. breast cancer and colorectal cancer)”
adjuvant
What word describes this type of chemo? “This is treatment to alleviate symptoms and in some cases prolong life in patients who cannot be cured. must be a balanced decision so that the patient’s quality of life is not made worse by the treatment. It may be justified to give second or third line chemotherapy if the disease remains chemo-sensitive (e.g. breast cancer, ovarian cancer, colorectal cancer).
palliative
what word describes this type of chemo? “In some malignancies there is still a real chance of a cure even if there is metastatic disease at presentation (e.g. germ cell tumours, Hodgkin’s disease, Non-Hodgkin’s lymphoma and many childhood cancers). This justifies the use of more intensive treatment associated with greater toxicity”
curative
what word describe this type of chemo? “Hormonal treatments may be given before overt malignancy appears. For instance, tamoxifen may be used for in-situ breast cancer before invasive carcinoma is recognised”
prophylactic
describe why synergism of chemotherapy drugs can be more effective than monotherapy
different sub-lethal cell injuries which act on the different part of the cell
how is chemotherapy adapted to reduce the risk of drug-resistant malignancy arising?
poly-therapy as opposed to monotherapy
why is polytheraputic chemotherapy more toxic to tumours than monotherapy?
all drugs can be given at maximum dose and have different actions so act on all cells in the tumour in different ways
in what setting are single-agent chemotherapies often used?
palliative
why is chemo given cyclically (every 3-4 weeks)?
allows normal cells to recover
which 2 types of these cells are most likely to be affected by chemotherapy drugs?
a) GI tract lining
b) alveoli
c) transitional bladder cells
d) peripheral neurones
e) haematopoietic stem cells
f) basal skin cells
a) GI tract
e) stem cells
what is the effect on the patient of chemotherapy toxicity on haematopoietic stem cells?
myelosuppression
what is the effect on the patient of chemotherapy toxicity on the GI tract lining?
mucositis
after what time frame have chemotherapy treatments generally reached their maximum efficacy?
a) 3 months
b) 6 months
c) 9 months
d) 1 year
b) 6 months
what kind of chemotherapy dose does this describe? “drug dosage known to be effective against the particular malignancy which in the majority of patients causes tolerable side effects”
conventional
in what situations is high dose treatment (that requires bone marrow support, infusion or growth factors) with chemotherapy used?
long-term survival or cure is possible e.g. Hodgkin’s lymphoma, Ewing’s sarcoma, leukaemia, multiple myeloma, germ cell testis tumour
what is the only cancer where prolonged maintenance treatment for 18 months is recommended?
childhood leukaemia
cyclophosphamide, etoposide, capecitabine and tamoxifen are few of a minority of chemotherapy drugs which can be given ______
orally
how is chemotherapy most commonly administered?
systematically
intravesical administration of chemotherapy is most commonly used for which cancer?
a) bladder
b) lung
c) prostate
d) breast
a) bladder
what is the advantage of regional chemotherapy administration?
high dose at tumour site whilst minimising systemic absorption and toxicity
in what situation is chemotherapy administered intraperitoneally?
tumours that spread trans-coelomically (e.g. ovarian)
in what situation is chemotherapy administered intra-arterially?
tumour with a well defined blood supply (e.g. hepatic artery for liver mets)
how are chemotherapy doses normally calculated?
body surface area (DuBois & DuBois)
how is carboplatin’s dose calculated?
renal function
which phrase best applies to this group of cancers:
Hodgkin’s disease, testicular cancer, ALL, choriocarcinoma, paediatric cancers (leukaemia, lymphoma, sarcoma)
a) cure of advanced disease in >50% of cases
b) cure of advanced disease in <50% of cases
c) increase cure rate in high risk loco regional disease
d) remission
e) prolong survival but few cures if advanced
f) palliative
a) cure of advanced disease in >50% of cases
which phrase best applies to this group of cancers:
Non-Hodgkin’s disease, ovarian cancer, paediatric neuroblastoma, adult osteosarcoma/ewing’s sarcoma/rhabdomyosarcoma
a) cure of advanced disease in >50% of cases
b) cure of advanced disease in <50% of cases
c) increase cure rate in high risk loco regional disease
d) remission
e) prolong survival but few cures if advanced
f) palliative
b) cure of advanced disease in <50% of cases
which phrase best applies to this group of cancers:
breast, colorectal, NSCLC, oesophageal/gastric, bladder
a) cure of advanced disease in >50% of cases
b) cure of advanced disease in <50% of cases
c) increase cure rate in high risk loco regional disease
d) remission
e) prolong survival but few cures if advanced
f) palliative
c) increase cure rate in high risk loco regional disease
which phrase best applies to this group of cancers:
breast, SCLC, ovarian
a) cure of advanced disease in >50% of cases
b) cure of advanced disease in <50% of cases
c) increase cure rate in high risk loco regional disease
d) remission
e) prolong survival but few cures if advanced
f) palliative
d) remission
which phrase best applies to this group of cancers:
NSCLC, colorectal, gastric, breast, bladder, prostate
a) cure of advanced disease in >50% of cases
b) cure of advanced disease in <50% of cases
c) increase cure rate in high risk loco regional disease
d) remission
e) prolong survival but few cures if advanced
f) palliative
e) prolong survival but few cures if advanced
which phrase best applies to this group of cancers:
renal, melanoma, head and neck, pancreatic, biliary-tract
a) cure of advanced disease in >50% of cases
b) cure of advanced disease in <50% of cases
c) increase cure rate in high risk loco regional disease
d) remission
e) prolong survival but few cures if advanced
f) palliative
f) palliative
how do you minimise toxicity of poly-therapy in chemotherapy?
choose drugs with differing side effects to maintain high dose without high toxic effect
how are chemotherapy complications classified?
immediate (applicable to all patients)
late (considered when long-term survival likely)
which of these is NOT a likely reason why chemotherapy can cause nausea/vomiting?
a) permanent CNS damage
b) direct stimulation of vomiting centre
c) peripheral stimulation of vomiting centre
d) anticipation effect
a) permanent CNS damage
give an example of a 5-HT antagonist which can be used to help symptoms of nausea in chemotherapy
ondansetron
how does chemotherapy cause myelosupression?
killing haematopoietic stem cells
which of these is NOT an effect of myelosuppression?
a) leucopenia
b) thrombocytopenia
c) thrombophilia
c) thrombophilia
how long after a cycle of chemotherapy does myelosuppression normally occur?
a) 1-2 days
b) 10-14 days
c) around 30 days
d) after 2 months
b) 10-14 days
what is the lowest point in the drop of cells in myelosupression known as?
a) kadir
b) kamir
c) nadir
d) namir
c) nadir
a neutrophil count greater than ___x10^9 is rarely associated with clinical infection
a) 0.1
b) 1
c) 10
d) 100
1
risk of infection with a count less than ___x10^9 is very high
a) 0.05
b) 0.5
c) 5
d) 50
b) 0.5
how long is haematopoietic recovery following chemotherapy?
a) 3 days
b) 1 week
c) 3-4 weeks
d) 3-4 months
c) 3-4 weeks
________________ side effects are common with most cytotoxic drugs. Oral _________ may reflect damage to the whole ________________ epithelium, a cell population susceptible to cytotoxic chemotherapy. _________ occurs frequently due to colitis or small bowel mucosal ____________
gastrointestinal mucositis gastrointestinal diarrhoea inflammation
in chemotherapy, Constipation is usually due to ___________ with reduced oral intake due to _______ and adverse effects of other medications such as _____ analgesics or ___ antagonists
dehydration
nausea
opiate
5HT
what GI adverse effect is linked to autonomic neuropathy caused by platinum agents?
paralytic ileus
which chemotherapy side effect can be controlled by the use of a cold cap?
alopecia
cisplatin, taxanes and vinca alkaloids are all types of which chemotherapy drugs?
a) bronze
b) silver
c) gold
d) platinum
d) platinum
true or false?
peripheral sensory neuropathy caused by platinum chemotherapy drugs may recover over a period of months although patients usually have some deficit permanently
true
what type of chemotherapy drug can sometimes be associated with central neurological toxicity e.g. encephalopathy or cerebellar toxicity?
platinum
cisplatin is associated with which sensory toxicity and permanent loss?
ototoxicity due to cochlear damage
why does renal function have to be adequate before giving platinum chemotherapy agents to patients?
renal excretion and nephrotoxic particularly cisplatin and ifosfamide
if the dose is too high, what adverse effect can drugs like cyclophosphamide and ifosfamide cause on the bladder?
a) neoplasm
b) loss of wall tone
c) haemorrhagic cystitis
d) septic cystitis
c) haemorrhagic cystitis
Doxorubicin and paclitaxel are both associated with acute _____
a) arrhythmias
b) MI
c) ventricular fibrillation
d) stroke
a) arrhythmia
what skin/soft tissue chemotherapy toxicity does this describe?:
the effect of cytotoxic drugs which are highly vesicant and cause tissue damage - leakage of blood/lymph/other fluid into outside tissue
extravasation
what skin/soft tissue chemotherapy toxicity does this describe?:
erythema of the palms of hands/soles of feet, frequently seen in 5-FU, capecitabine and sunitinib/erlotininib.
palmar plantar erythema (hand-foot syndrome)
which of these is NOT a skin/soft tissue side effect of chemotherapy?
a) kaposi’s sarcoma
b) photosensitivity
c) pigmentation
a) kaposi’s sarcoma
some chemotherapy drugs cause sub-lethal DNA damage that may eventually induce a second __________. the most ____________ are alkylating agents and procarbazine.
malignancy
carcinogenic
fibrosis induced by drugs like bleomycin and busulphan can cause long term damage to which organ?
lung
can also cause cardiac fibrosis sometimes
Alongside chemotherapy, myelosuppression can be caused cancer itself. How?
bone marrow infiltration by the cancer (common in haematological malignancies and solid cancers that met to bone and para-neoplastic syndrome)
what does cancer bone marrow infiltration cause?
pancytopenia
how do you differentiate between myelosuppression caused by treatment or disease?
treatment-caused myelosuppression is transient, disease is prolonged and excessive
blood transfusion and use of erythropoetin to prevent systemic symptoms is the treatment for which symptom of myelosuppresion?
anaemia
petechial haemorrhage, spontaneous nosebleeds, corneal haemorrhage and haematuria are all clinical signs of what part of myelosupression?
thrombocytopenia
which platelet count is an urgent indication for platelet transfusion to prevent intra-cerebral haemorrhage?
a) 1 x 10^9
b) 10 x 10^9
c) 10-20 x 10^9
d) 30 x 10^9
b) 10 x 10^9
above what level do platelet counts not need a consideration of platelet transfusion?
a) 1 x 10^9
b) 10 x 10^9
c) 20 x 10^9
d) 30 x 10^9
c) 20 x 10^9
what is a risk associated with repeated platelet transfusion?
a) no risk
b) hypercholesterolaemia
c) fibrosis of peripheral vessels
d) anti-platelet antibodies developed by body
d) anti-platelet antibodies developed by body
what is the most frequent cause of morbidity and mortality associated with myelosuppression?
neutropenic sepsis
what immediate action should be taken in a patient who presents with pyrexia following cytotoxic chemotherapy?
broad spectrum, IV antibiotics then test for white cell count (less than 1 x 10^9)
why should rectal and vaginal examinations not be performed in suspected neutropenic sepsis?
risk of causing bacteraemia
what action would be taken if a patient with neutropenic sepsis didn’t respond to IV broad-spectrum antibiotics within 48 hours?
change to second-line abx or consider anti-fungal/anti-viral agents in addition
what is the suffix for drugs which are monoclonal antibodies?
a) -mab
b) - ib
c) -us
a) -mab
all given IV
trastuzumab (herceptin) is used in which cancer?
HER2+ breast cancer
what is the suffix for drugs which are tyrosine kinase inhibitors?
a) -mab
b) - ib
c) -us
b) -ib
all given orally
why must drug interactions be considered carefully with tyrosine kinase inhibitors
cytochrome p pathways
what is the general action of tyrosine kinase inhibitors?
a) inhibit cell growth, angiogenesis, reproduction
b) induce immune cell action against tumours
c) inhibit blood flow to tumours
a) inhibit cell growth, angiogenesis, reproduction
what is the suffix for drugs which are mTor inhibitors?
a) -mab
b) - ib
c) -us
c) -us (oral EVEROLIMUS and IV TEMSIROLIMUS)
what is the advantage of targeted drug therapy over cytotoxic chemotherapy?
targeted therapy is more toxic to cancer cells and so can be given at higher doses with lower damage to surrounding tissue
give 3 examples of tumours which are hormone sensitive
prostate breast endometrium lymphoma leukaemia myeloma
give an example of removal of the source of a growth-promoting hormone in cancer
orchidectomy in testicular cancer
oophorectomy in women
reversible ‘medical castration’ can be caused by which drugs?
a) oestrogen
b) testosterone
c) LHRH analogues
d) PSH analogues
c) LHRH analogues
what is tamoxifen an example of?
a) cell signaller
b) hormone agonist
c) hormone inhibitor
d) hormone replacement
c) hormone inhibitor
how do steroidal anti-androgens work in the tumour cells?
inhibit androgen receptor
how do steroidal anti-androgens work in the hypothalamus?
substitute for testosterone so stimulate negative feedback to reduce LHRH release
why must non-steroidal anti-androgens be paired with a LHRH analogue?
they inhibit the androgen receptor in the tumour but also in the hypothalamus so need the LHRH analogue to start the negative feedback and stop further LHRH oroduction
how can glucocorticoids be helpful in treating cancer?
a) slow cell proliferation
b) stop angiogenesis
c) release poison into tumour
d) induce apoptosis
d) induce apoptosis
treat lymphoid leukaemia, lymphoma, myeloma and Hodgkin’s disease
except for treatment in breast and endometrial cancer to shrink tumours, how are progestogens used in cancer therapy?
stimulate the appetite in palliative medicine
what type of therapy uses this action: “X-rays penetrate deep into body tissue whilst sparing the over-lying skin, where they produce secondary electrons and free radicals which cause DNA damage to both cancer cells and normal cells”
radiotherapy
why do tumour cells die but normal cells recover in radiotherapy?
tumour cells have defective DNA repair pathways
what is the unit for the dose of radiation?
a) red
b) gray
c) blue
d) yellow
b) gray
if a dose of 70Gys is being given in radiotherapy once every week day over 7 weeks, how many fractions are there?
35
how do palliative therapy doses of radiotherapy compare to radical/curative doses?
a) higher
b) same
c) lower
c) lower
why is chemotherapy often given alongside radiotherapy?
thought to increase radiosensitivity of cells
why, when planning radiotherapy, is there an additional margin planned around the actual tumour for radiotherapy delivery?
to allow for movement of the tumour and the patient
why is it useful for doctors to outline areas where doses of radiation should be kept at a minimum?
to avoid organs at risk being damaged e.g. rectum or heart
what is the name for radiotherapy side effects which develop after the first 5-10 fractions?
acute
localised skin reaction, oral mucositis and diarrhoea are examples of what type of radiotherapy side effect?
acute
what is the name for radiotherapy side effects which develop after at least 3 months following treatment
late
are late radiotherapy side effects reversible?
often not
lung fibrosis, skin atrophy and infertility are examples of what type of radiotherapy side effect?
late
why must radiotherapy by avoided in pregnant women?
teratogenic
what is the name for the form of radiation treatment where treatment is placed within or close to the tumour?
a) tachytherapy
b) hypotherapy
c) hypertherapy
d) brachytherapy
d) brachytherapy
what is the difference between intracavity and interstitial radioactive brachytherapy?
intracavity is inside body cavity e.g. uterus
interstitial is inside organ e.g. prostate
what element is commonly used in the treatment of thyroid cancer?
a) calcium
b) magnesium
c) iodine
d) barium
c) iodine - this is useful as few other tissues in the body take it up so reduces risk to other tissues. patient MUST be kept in a lead lined room until their radiation level decreases enough e.g. 4 days
what stage of a clinical trial does this describe?:
determine toxicity and establish maximum tolerated dose
a) phase 1
b) phase 2
c) phase 3
a) phase 1
what stage of a clinical trial does this describe?:
assess anti-tumour activity in a range of different cancers
a) phase 1
b) phase 2
c) phase 3
b) phase 2
what stage of a clinical trial does this describe?:
randomised trial comparing new with established treatment
a) phase 1
b) phase 2
c) phase 3
c) phase 3
what screening programme is available to women aged 25-49 every 3 years and 50-64 every 5 years?
a) cervical
b) breast
c) lung
d) colorectal
a) cervical
what screening programme is offered to women aged 30-70 every 3 years?
a) cervical
b) breast
c) lung
d) colorectal
b) breast
what screening programme is offered to men and women aged 60-69 (shortly to be 74)?
a) cervical
b) breast
c) lung
d) colorectal
d) colorectal
what is the name for a document used to allow patients to state their goals of care and make treatment decisions for future if they are unable to communicate?
advance care planning
in what percentage of cancer patients does pain occur?
a) 10%
b) 25%
c) 50%
d) 80%
d) 80%
what type of cancer pain does this describe?
dull ache over a large area or well localised tenderness over bone. Often worse on weight bearing or with movement
bony pain
which of these is not a recommended treatment for bony pain?
a) NSAIDs e.g. diclofenac
b) anti-convulsants e.g. gabapentin
c) radiotherapy
d) bisphosphonates
b) anti-convulsants
What type of cancer pain does this describe?
Dull, deep seated, poorly localised pain. There may be tenderness over a particular organ, can be spasmodic
visceral pain
which of these is not a treatment option for visceral pain
a) radiotherapy
b) follow analgesic ladder in constant pain
c) NSAIDs/corticosteroids to reduce inflammation
d) anticholinergics for colicky pain
a) radiotherapy
what type of cancer pain does this describe?
dull oppressive head pain usually worse on waking, coughing, sneezing and may be associated with nausea and vomiting
raised ICP headache
which of these is not a treatment option for headaches caused by raised ICP
a) corticosteroids
b) NSAIDs
c) fluids
d) paracetamol
c) fluids
what type of cancer pain does this describe?
Pain in an area of abnormal sensation. may be localised to dermatomes or over a wider area. may be altered sensation and autonomic changes such as pallor/sweating. The patient may describe the pain as ‘pins and needles’ or burning
neuropathic pain
which of these is not a treatment option for neuropathic pain?
a) antidepressants e.g. amitriptyline
b) anticonvulsants e.g. gabapentin
c) opiod analgesia e.g. morphine
d) corticosteroids if nerve compression
c) opiod analgesia e.g. morphine
what is the highest dose of codeine that can be given in co-codamol?
a) 10mg w 500mg paracetamol
b) 30mg w 500mg paracetamol
c) 50mg w 500mg paracetamol
d) 75mg w 500mg paracetamol
b) 30mg w 500mg paracetamol
what is the most common side effect of opiod analgesics?
constipation (so ALWAYS prescribe a laxative)
which of these is NOT a relatively common side effect in the first few days of opiod use?
a) psychological dependence
b) nausea and vomiting
c) drowsiness
a) psychological dependence
which of these signs of opioid toxicity is not useful in patients on long-term opioids?
a) persistent drowsiness
b) confusion
c) hallucinations
d) myoclonic jerks
e) respiratory depression
f) pinpoint pupils
f) pinpoint pupils
name an immediate release morphine tablet
oromorph
name a modified/slow release morphine tablet
morphine sulphate
zomorph
what type of morphine would expect to start working after 20-30 mins and last up to 4 hours?
immediate repease
what type of morphine would you expect to last up to 12 hours?
modified release
if a patient has been on maxixum dose co-codamol qds (30mg/500mg) what is the starting dose of morphine sulphate usually?
20mg bd
what fraction of the total daily dose should PRN morphine be precribed at?
1/6th
what should be prescribed instead of morphine in patients with renal impairement? Why?
a) paracetamol
b) naproxen
c) oxycodone
d) fentanyl
d) fentanyl
non-renally excreted.
prevents toxicity as morphine will accumulate in the kidneys
at what increments should doses be increased in morphine prescribing?
a) 5-10%
b) 30-50%
c) 60-75%
d) 100%
b) 30-50
which of these is NOT a reason for stopping increasing the dose of morphine?
a) the dose has increased three-fold since when it was first prescribed
b) pain is dealt with
c) unacceptable side effects
a) the dose has increased three-fold since when it was first prescribed
how long is the action of transdermal fentanyl patches?
a) 12 hours
b) 24 hours
c) 48 hours
d) 72 hours
d) 72 hours
what is the difference between oxynorm and oxycontin?
oxynorm is immediate release, oxycontin is modified/slow release
what infection is a common mouth problem experienced in palliative care?
oral thrush candidiasis (risk increased by dry mouth and lowered immune system)
what is the latin word for dry mouth?
xerostomia
what steroid is often used to increase appetite, but wears off after 2-3 weeks?
dexamethasone (4mg od)
megestrol acetate (160mg od) can also be used to increase appetite. which is its major side effect?
a) dehydration
b) constipation
c) fluid retention
d) diarrhoea
c) fluid retention
which of these is NOT a factor contributing towards constipation?
a) immobility
b) reduced food and fluid intake
c) drugs (opiods)
d) bowel pathology
e) duodenal paralysis
f) hypercalcaemia
e) duodenal paralysis
What serious GI side effect has a high incidence in patients with ovarian and bowel cancer?
a) perforation
b) obstruction
c) hernia
d) paralysis
b) obstruction
true or false? in the case of bowel obstruction, the patient should not eat
false - the patient should eat for enjoyment and decide themselves if the risk of vomiting outweighs the pleasure of eating
hyoscine butylbromide is an example of which of these three medications prescribed to help palliate symptoms of bowel obstruction?
a) antiemetic
b) opioid
c) antispasmodic
c) antispasmodic
why are opioids sometimes useful in dyspnoea?
decrease respiratory effect
why are BZDPs sometimes prescribed in breathlessness?
helps anxiety and panic attacks
for patients who cannot tolerate oral BZDPs, what would you prescribe?
buccal midazolam
what you prescribe to a patient with a cough that had trouble expectorating?
a) saline nebulisers
b) steroid
c) diuretic
d) BZDP
a) saline nebuliser
a simple linctus is prescribed for what type of cough?
a) productive
b) dry and irritating
c) hacking
d) constant and vomiting
b) dry and irritating
which oncological emergency most commonly occurs in breast, bronchus and prostate cancer?
metastatic spinal cord compression (commonly metastasise to bone)
in what part of the spine do 2/3rd of MSCCs occur?
a) cervical
b) thoracic
c) lumbar
d) sacral
b) thoracic
what symptom is present in 90% of people with MSCC?
pain
name 4 red flag signs and symptoms for MSCC
pain leg weakness sensory loss urinary retention faecal incontinance saddle anaesthesia loss of anal tone increased reflexes below level of compression
what imaging would you perform on a patient with suspected MSCC?
a) Ultrasound
b) X-ray
c) MRI
d) CT
whole spine MRI
steroid induced myopathy and paraneoplastic syndrome are a differential diagnosis for what oncological emergency?
a) neutropenic sepsis
b) hypercalcaemia
c) SVCO
d) MSCC
MSCC
what steroid is prescribed for the management of MSCC?
dexamethasone 16mg
is recovery likely if all motor function is lost for 48 hours in MSCC?
no
which of these is NOT a cause for superior vena cava obstruction (SVCO).?
a) aneurysm
b) compression
c) thrombosis
d) wall invasion
a) aneurysm
what oncological emergency is most commonly seen in patients with lung cancer and lymphoma?
SVCO
these signs and symptoms are indicative of what oncological emergency?
• Headache or a feeling of fullness in the head
• Facial swelling (oedema)
• Dyspnoea (often worse on lying flat)
• Cough
• Hoarse voice
• Weight loss
• Prominent blood vessels on the neck, trunk, arms
• Cyanosis
SVCO
what would your first line management plan be for a patient with suspected SVCO?
a) ultrasound surgical clearance
b) x-ray for masses, CT SVC
c) MRI chest
b) x-ray for masses, CT SVC
what surgical procedure is the treatment of choice in SVCO?
vascular stenting
what anti-coagulant is recommended to use for a thrombus in SVCO?
LMWH
what is the first line treatment for SVCO?
dexamethasone 16mg daily
goitre, mediastinal fibrosis, infection (TB), AA and thrombus are all benign causes of which oncological emergency?
SVCO
which oncological emergency is commonly seen in breast cancer, lung cancer, SCCs and myeloma?
hypercalcaemia
true or false:
you can develop hypercalcaemia without bone mets
true
how can squamous cell lung cancer (a type of NSCLC) cause increased calcium?
a) release of exogenous calcium
b) release of exogenous magnesium
c) release of exogenous PTH
c) release of exogenous PTH which leads to increased blood Ca
which oncological emergency is characterised by these symptoms? • lethargy • malaise • anorexia • polyuria • thirst • nausea • vomiting • constipation
hypercalcaemia
which of these is not a late stage feature of hypercalcaemia?
a) hypertonia
b) confusion
c) drowsiness
d) fits
e) coma
a) hypertonia
what is the 2-step management plan for hypercalcaemia?
saline IV
IV bisphospanate e.g. pamidronate or zolendronic acid
how does saline act on the kidneys in hypercalcaemia?
promotes calcium excretion by increasing diuresis
what mouth care is available for patients at the end of their lives?
sponge
gel
what are the 4 anticipatory end of life medications?
analgesic, antiemetic, anti-secretory and anxiolytic
why would you need to prescribe an anxiolytic at the end of life?
terminal restlessness. Often midazolam 2.5-5mg or syringe driver infusion 10mg/24hrs
why would you need to prescribe an anti-secretory medication at the end of life?
death rattle. also reposition patient. buscopan or hyoscine hydrobromide
through what route do syringe drivers deliver medication?
a) oral
b) subcutaneous
c) intramuscular
d) intravenous
b) subcutaneous
which of these is NOT an indication for syringe drivers?
a) inability to swallow due to reduced consciousness
b) nausea and vomiting
c) intestinal obstruction
d) inadequate pain control
e) malabsorption of drugs
f) dysphagia
d) inadequate pain control - unless there is reason to believe that oral analgesics are not being absorbed
which of these is NOT a common site for syringe driver butterfly needles to be inserted?
a) chest
b) abdomen
c) upper arm
d) thigh
e) wrist
e) wrist
if the drugs in the syringe driver have precipitated what could this indicate?
they are not compatible together. avoid mixtures of more than three compatible drugs if possible in one driver
Why are diazepam, chlorpromazine and prochlorperazine unsuitable for subcut administration i.e. syringe driver?
too irritant
which cancer is the 2nd most common for both genders?
lung
which type of lung cancer is most common?
NSCLC
what is the biggest risk factor for lung cancer?
smoking
what is the name for brachial plexus invasion in lung cancer?
pancoasts/horner’s
what is the best imaging technique to diagnose lung cancer?
CXR
then bronchoscopy & biopsy
how long is the referral time for suspected lung cancer?
2 weeks
which type of lung cancer is considered systemic at presentation?
SCLC
what is the main treatment for SCLC?
chemo - very sensitive to it
how successful is chemo in SCLC?
over 90% respond, 50% complete response
most patients relapse within 12 months into chemo resistant disease
what is the main treatment for NSCLC?
30% suitable for surgery
20% radiotherapy
30% chemo
chemo & radio v effective in palliative management too
what is the most common cancer in females?
breast
what is the most common type of breast cancer?
invasive ductal
name some risk factors for breast cancer
smoking prolonged oestrogen exposure age BRCA mutation FHx
how might a breast cancer present on examination?
hard non-mobile lump painful
skin changes
how often is mammography screening in the UK?
every 3 years from 50-70yo (or younger women with +ve FHx)
what constitutes an urgent 2 week referral for breast cancer?
> 30 & unexplained breast lump or axillary node
50 & discharge/retraction/other concerns
skin changes suggestive of Ca
what investigations are done at the 2 week referral for Breast Ca?
bilateral mammogram
FNAC
needle/incision/excision biopsy
who would receive a non-urgent referral for breast cancer
<30, painless lump
what constitutes an urgent 2 week referral for lung cancer?
> 40, smoker, unexplained symptom
40, 2 unexplained sx
(cough, SoB, fatigue, chest pain, weight loss/anorexia)
how is breast cancer treated?
surgery (mastectomy or WLE)
post-op radio
axillary lymph nodes
hormone therapy
which hormone therapies would you give for ER+ve and Her2+ve breast cancers respectively?
tamoxifen
trastuzamab
what is the next most common cancer for both genders after lung ca?
colorectal
what is the most common type of colorectal cancer?
adenocarcinoma (90-95%)
name some risk factors for colorectal cancer
Smoking, IBD, diet, alcohol, FHx (FAP, Gardner’s, HNPCC)
40% rectum, 20% sigmoid, 6% caecum.
what characteristic sign might you see on abdo x ray for colorectal cancer?
signet ring
what is the screening programme for colorectal cancer?
faecal occult blood (every 2 years age 60-69)
what tumour marker is associated with colorectal cancer?
CEA
what is the main diagnostic method used for colorectal cancer?
colonoscopy & biopsy
what is treatment for colorectal cancer?
radical resection
stenting
radio & chemo (oxaliplatin)
what imaging is used to diagnose gastric cancer?
direct access upper endoscopy
what is the commonest cancer in men?
prostate
what is the commonest type of prostate cancer?
95% adenocarcinoma
what scale is used for prostate cancer?
gleason
name some risk factors for prostate cancer
BPH, BRCA2, pTEN gene, ^age, radiation, diet, anabolic steroid
what is the main examination used to identify prostate cancer
digital rectal exam
what blood marker is used to diagnose prostate cancer?
PSA
how is prostate cancer definitively diagnosed?
transrectal biopsy
what criteria does the 2 week referral pathway for prostate cancer include?
PSA
DRE
sx (nocturia, freq, hesitancy, urgency, retention, erectile dysfunction, haematuria)
what is treatment for prostate cancer?
Often in elderly patients who won’t die from it
Surgery
radio – radical, adjuvant (wait 6 weeks after TUR to prevent stricture) or palliative
systemic therapy – LHRH agonists (goserelin – SE impotence, loss of libido, tumour flare), anti-androgens (bicalutamide),
orchidectomy
Chemo – docetaxel improves QoL & overall survival
Median survival – locally advanced tumour = 4.5 years
Radical surgery or chemo 10y survival = 80-90%
what is the most common type of testicular cancer?
germ cell tumour 95%
40% are seminomas, 60% non-seminomas (e.g. teratoma, yolk sac)
what are risk factors for testicular cancer?
Age 15-25yo, Caucasian, testicular atrophy, mal-descent of testis, FHx
what imaging/examinations are used to diagnose testicular cancer?
testicular examination and ultrasound
what tumour markers are used in testicular cancer?
b-HCG, LDH, AFP
what imaging is done at 2 week referral for testcular cancer?
direct access USS
what staging is used for testicular cancer?
royal marsden
how is testicular cancer managed?
frequently cured despite being highly metastatic
orchidectomy for localised disease
adjuvant chemo in higher risk - seminoma = carboplatin, NSGCT = BEP
radiotherapy = mainly palliative
