Oncology/Palliative Care Flashcards
Breaking bad news
1) Quiet place where not going to be disturbed. Make sure family present if wanted
2) Find out what patient already knows
3) Ask how much pt wants to know - if anything were amiss, would you want to know all the details
4) Warning shot
5) Specific info about diagnosis and tx, specifically listing supporting people (CNS) and institutions (Hospices)
- Chunk & Check
6) ‘cancer has negative connotations for many people - 50% of cancers are cured in the developed world’
7) Summarise, make a plan and offer availability. Record details of conversation in the notes (including language uesd)
BRCA 1 mutation?
65% lifetime risk of breast cancer
40% ovarian cancer
- 40-60% risk of developing a second breast cancer
- Bilateral prophylactic mastectomy in BRCA1/2 reduces risk of breast cancer by 90%, and may be offered in conjunction with oophorectomy.
BRCA2
45% Breast cancer risk (6% in males)
11% ovarian cancer
Familial adenomatous polyposis
Dominant
Germline mutations in APC (5q)
- offspring 50% risk for being a gene carrier, with gene penetrance almost 100% for colorectal cancer by age 50
–> Total colectomy prevents inevitable development
Peutz-Jegher’s
Auto-dommutation of serine threonine kinase LKB1 or STIK11
Numerous hamaratomatous polyps in GI tract + orofacial/palm/sole pigmentation
Intestinal obstruction eg. intussusception
GI bleeding
HNPCC
Auto-Dom with incomplete penetrance
Colorectal (HNPCC1)
+ cancer of uterus, ovary, stomach, renal pelvis , small gut or pancreas (HNPCC2)
Mutations in 1 of 5 DNA mismatch repair genes
Lifetime risk of CRC: 60%
Women with mutation = 40% endometrial cancer
MEN I
3 P’s
Parathyroid hyperplasia/adenoma (95%, most present with increased Ca2+)
Pancreas endocrine tumours eg. gastrinoma/insulinoma,somatostatinoma, VIPoma, glucangonomas
Pituitary prolactinoma
Men2a?
Ret-proto-oncogene
2Ps + T
Phaeochromocytoma (50%, usually benign and bilateral)
Parathyroid hyperplasia (80%, but less than 20% have increased Ca2+)
T: Medullary thyroid carcinoma (seen in 100%)
Men 2b
Ret proto-oncogene
Similar features to men2a (phaeo, parathyroid hyperplasia + medullary thyroid carcinoma) + mucosal neuromas & Marfanoid appearance
NO hyperparathyroidism
Neutropenic sepsis?
Neutrophil 38 or 37.5 on 2 occasions, > 1 hr apart, or pt toxic, assume sepsis and start
blind combination therapy: Piperacillin-tazobactam (+ vancomycin if gram +ve suspected or isolated eg. Hickman line sepsis)
- Continue until afebrile for 72, or 5d course and until neutrophils > 0.5x10^9
If fever persists despite abx, think CMV, fungi (Candida, aspergillus) & Central line infection
- Consider Tx for pneumocystis eg. co-trimoxazole
Tumour lysis syndrome?
Particularly in haematological malignancies/ Burkitt’s
- Massive destruction of cells leading to increased K+, Urate and renal injury
Prevention: High fluid intake + allopurinol (300mg/12h PO started 24 hrs before chemo) pre-cytotoxics
- If high risk of cell lysis, rasburicase may be given
Complications:
- Hyperviscosity (if WCC >100, wbc thrombi may form in brain, lung and heart (Leukostasis)
- DIC - widespread activation of coagulation from release of procoagulants into the circulation, with consumption of clotting factors and platelets, with increased risk of bleeding
Spinal cord compression
Causes
Signs and symptoms
Investigations
Mx
Causes:
- Extradural mets normally
- extension of tumour from a vertebral body
- Direct extension of tumour
- Crush fracture
Sx:
Back pain, weakness or sensory loss with a root distribution (or sensory level), bowel and bladder dysfunction
Ix: Whole spine MRI
Mx: Dexamethasone 16mg/24 PO (8mg BD)
Discuss with neurosurgeon/clinical oncologist immediately for palliative chemo or decompressive surgery
- IF vertebral involvement from myeloma/breast cancer - start Bisphosphonates - helps pain and stability
SVC obstruction
Causes?
Sx?
Ix?
Mx?
Not emergency unless tracheal compression with airway compromise
Causes:
- Malignancy (>90%), 75% are lung cancer
Rare:
- Mediastinal enlargement (germ cell tumour), thymus malignancy, mediastinal lymphadenopathy (lymphoma)
- Thrombotic disorders (eg. Behcets or nephrotic syndromes)
Sx:
Dyspnoea, orthopnoea, plethora/cyanosis, swllen face & arms, cough, headache, engorged veins, Pemberton’s sign
Ix:
- Urgent contrast enhanced CT
Mx:
- Tissue biopsy if cause unknown
- Oral dex 8-16mg
- Consider balloon venoplasty + SVC stenting (provides most rapid relief) prior to radical or palliative chemo/radio
Malignancy associated Hypercalcaemia
10-20% of cancer pts, 40% of myeloma
Poor prognostic sign - 75% dead within 2mo
Causes:
- Lytic bone mets
- Myeloma
- Production of osteoclast activating factor or PTH like hormones by the tumour
Sx:
Lethargy, anorexia, nausea, polydipsia, polyuria, constipation, dehydration, confusion, weakness
Stones (renal/biliary), bones (bone pain), groans (Abdo pain, N+V), thrones (Polyuria & Polydipsia) & Psychic moans (Depression, confusion , anxiety)
Mx:
Acutely: Rehydration + IV bisphosphonate (or calcitonin if resistant)
Best tx = control of underlying malignancy
Oncology: raised ICP
CNS tumour or metastatic disease
Sx: Headache - worse in morning, when coughing or bending over N+V Papilloedema Fits, focal neuro
Ix: Urgent CT/MRI to diagnose expanding mass, cystic degeneration, haemorrhage within a tumour, cerebral oedema or hydrocephalus due to tumour or blocked shunt, since Mx of each scnario very different
Mx:
- Dexamethasone 8-16mg, radiotherapy & surgery as appropriate depending on cause.
- Mannitol may be tried for sx relief for cerebral oedema (Not evidence based)
Extravasation of chemotherapeutic agents?
- Can cause severe tissue necrosis, suspet if there is pain, burning or swelling at the infusion site
Mx:
- Stop infusion & disconnect drip
- Attempt to aspirate any residual drug from cannula before removing
- Take advice & follow local policies if available (many cancer wards have extravasation kits)
- Apply a cold pack (if extravasation of DNA binding drug) to vasoconstrict & mimise drug spread, or heat pack (if non-dna binding) to vasodilate and increase drug distribution.
- Liase with plastics early to discuss flush out
Radiotherapy basics?
Types:
uses ionising radiation to produce free radicals which dmg DNA
- Normal cells better at repair this than cancer cells,s o able to recover before next dose
Radical - curative intent
- 40-70 Gy in 15-35 daily fractions
Palliation:
- 80-30Gy, given in 1,2,5,10 fractions
- Bone pain, haemoptysis, cough, dyspnoea and bleeding helped in >50% of pts
Radiotherapy sideeffects?
Early:
- Tiredness (can last wks-mths)
- Skin reaction (from erythema to dry/moist desquamation + ulceration
- Mucositis (treat oral thrush eg. with Nystatin oral solution (1ml Swill + swallow every 6h) +- fluconazaole)
- N+V
- Diarrhoea
- Dysphagia
- Cystitis
- Bone marrow suppression
Late reactions:
- CNS: Somnolence, myelopathy, brachial plexopathy, reduced IQ in kids
- Lung: pneumonitis
- GI: Xerostomia , benign strictures, fistulae, radiation proctitis
- GU: urinary frequency, fertility, vaginal stenosis, dyspareunia, ED
- Other; Pit fossa –> panhypopituatitarism
Methods of delivering radiotherapy?
Conventional external beam radiotherapy
Stereotactic radiotherapy - Highly accurate from of EBRT used to target small lesions with great precision: Gamma knife
Brachytherapy
Radioisotope therapy: uses tumour seeking radionuclides to target specific tissues eg. Radioiodine 131 to ablate remaining thyroid tissue after thyroidectomy for thyroid cancer
Fertility issues in cancer pts
Semen cryopreservation from men and older boys with cancer must be offered before therapy
- If pt is infertile male post Tx, refer to specialist - Testicular sperm extraction with intracytoplasmic sperm injection could still yield normal pregnncies
Cryopreservation of embryos and ovarian tissue banking are harder options in women.
- Ovarian stimulation + oocyte collection which may result in unacceptable delays to Tx
Breast cancer 2 week referral?
• Discrete, hard lump with fixation; • Over 30 with a discrete lump persisting after a period or presenting post-menopause; • Under 30 with an enlarging lump, fixed and hard lump, or family history; • Previous breast cancer with a new lump or suspicious symptoms; • Unilateral eczematous skin or nipple change unresponsive to topical treatment; • Recent nipple distortion; • Spontaneous bloody unilateral nipple discharge; • Men over 50 with a unilateral firm subareolar mass; • Consider referral if under 30 with a lump or persistent breast pain.
Tumour markers: Germ cell/testicular HCC Ovarian Pancreatic Breast Colorectal B cell proliferative disorders (eg. myeloma) Thyroid cancers
GCC/ Testicular: AFP/ HCG
HCC: AFP
Medullary thyroid: Calcitonin
Ovarian: Ca125
Pancreatic: Ca19-9
Breast: Ca15-3
Colorectal: CEA
Gestational trophoblastic: B-HCG
B cell - Paraproteins
Thyroid; Thyroglobulins
Palliative care: N+V mx
- Treat reversible causes eg. with laxatives, fluconazole (thrust), analgeis or antibiotics. Change/reduce drugs/routse
- Pt starting strong optiiods should be prescribed regular antiemetic for first week, then PRN
Oral:
- Cyclizine 50mg/8H (antihistamine/anticholinergic with central action)
- Domperidone 10-20mg/8h(peripheral antidopaminergic, no acute dystonic SEs
- Metoclopramide 10mg/8h - blocks central chemoreceptor trigger zon + peripheral PROKINETIC EFFECTS - good in gastric stasis
Anti-emetic for drug/metabolic induced nausea?
Haloperidol (0.5-1.5mg/12)
Dopamine antagonist
Useful if chemical causes eg. drugs, renal failure, hypercalcaemia.
Avoid if risk of fitting, as it can decrease seizure threshold
Anti-emetic for chemo/radiotherapy related nausea?
Ondansetron 4-8mg/8h
Serotonin antagonist
Good for chemo/radiotherapy related nausea
Causes constipation
Anti-emetic for gastric stasis?
Metroclopramide 10mg/8h
Blocks central chemoreceptor trigger zone + Peripheral prokinetic effects
Palliative care: Constipation Mx?
Common with opiates, Ca2+ and dehydration : better to prevent than treat
All pts on opiods should be prescribed regular oral laxative (faecal softener + stimulant) unless CI
Softener:
Sodium Docusate 100-200mg BD/TDS
Osmotic laxative:
- Lactulose 10-20ml OD/PO
Movicol: Start 1-2 sachets OD PO, up to 2 BD
- 1 sachet in 125ml water
Stimulant: Senna - 1-4 tablets OD/BD 5-20ml syrup BD - Glycerine suppositories - Phosphate enema
Combination: Softener + stimulant
Co-danthramer 1-4 capsules OD/BD PO
WHO analgesic ladder?
1) Paracetamol
2) Paracetamol + codeine
+- ibuprofen
3) Paracetamol + Opiod +- Ibuprofen
Palliative care: minimising SE general advice?
o Opioids→ Give antiemetics prn and laxatives regularly
o NSAIDs/Steroids→ Consider gastric protection, e.g. lansoprazole 30mg od
o Steroids→ Prescribe early in the day (before 2pm) to avoid insomnia
Breakthrough pain dose if on 30mg MST continus BD?
= 60mg MST Daily
1/6 of 60mg = 10mg Oramorph PRN
(4hrly)
Visceral pain mx?
- Usually opioid responsive
- Consider cause + treat where possible:
- Constipation - laxatives/suppositories
- Abdo colic: Anticholinergeic - Hyoscine butylbromide (Buscopan) 20mg QDS PO or SC
- Gastric irritation: PPI/antacid
- Liver capsular pain: NSAID/ Dexamethasone 4-6mg with PPI
- Ascites : Consider drainage, diuretics, chemo if malignant
- Bladder spasm: Oxybutynin 2.5-5mg BD-QDS PO
- Rectal pain/tenesmus: GTN ointment, nifedipine
Palliative Care; Bone pain
- Partially opioid responsive
- NSAID (ibuprofen 400mg TDS with PPI)
- Consider radiotherapy, corticosteroids and IV pamidronate for metastatic pain
Consider orthopaedic referral for prophylactic fixation if risk of fracture
Palliative care; Neuropathic pain
Partially opiod responsive
Other drugs:
- TCA eg. amitrptilline
- Anticonvulsants eg. Gabapentin
Consider also nerve block/radio as adjuvant treatments if appropriate
Palliative care; Muscular pain
NSAID: Ibuprofen 400mg TDS + PPI
Muscle relaxanteg. diazepam 2-5mb BD/TDS
Consider physiotherapy, massage, heat pad
Palliative care; non medical approaches to pain relief?
For pressure areas: appropriate mattress,barrier cream/spray, regular repositioning
Relaxation exercises
TENs machine
Acupuncture
Psychological support + counselling
Complementary tx: massage, reflexology
Palliative care: Dose conversion to oramorph
1) Codeine Phosphate (60mg)
2) Tramadol 100mg
3) Oral Oxycodone 5mg
1) Codeine = 10:1 therefore 6mg
2) Tramadol = 5:1 therefore 20mg
3) Oral oxycodone 1:2 therefore 10mg
Palliative dose conversion:
1) Morphine sulphate 5mg IV/SC
2) Diamorphine 5mg IV/SC
3) Oxycodone 5mg IV/SC
4) Alfentanil 1mg IV/SC
5) Pethidine 100mg SC/IV/IM
1) Morphine sulphate IV = 1:2 therefore 10mg
2) Diamorphine IV = 1:3 therefore 15mg
3) Oxycodone 5mg IV = 1:4 therefore 20mg
4) Alfentanil 1mg IV/SC = 1:30 therefore 40mg
5) Pethidine 100mg IV = 4:1 therefore 25mg
Opioid brand names actual names?
Oramorph
Sevredol
Oxycontin
Oxynorm
Durogesic Dtrans
Abstral
BuTrans
Transtec
Oramorph® =morphine sulphate immediate release solution
Sevredol® = morphine sulphate immediate release tablets
Oxycontin® = oxycodone slow release (12-hrly) tablets or
Oxynorm® = oxycodone immediate release capsules or liquid
Durogesic DTrans® fentanyl transdermal patch (every 72 hours)
Abstral® = sublingual fentanyl (short-acting)
BuTrans® = buprenorphine 7-day patch
Transtec® = buprenorphine 3-day patch
Tramadol + SSRI risk?
Can potentially lower seizure threshold and also carry a risk of serotonin syndrome, especially when used together
Opioid toxicity: Signs?
Common:
- Mild:
V, increased drowsiness, pinpoint pupils
Moderate: Confusion Muscle twitching/myoclonus Vivid dreams/hallucinations Agitation
Severe:
- Resp depression ( RR
Potential causes of opioid toxicity?
Pt received unintentionally high dose
- Pt develops hepatic/renal impairment
- Pain responded to adjuvant therapies, leading to loewr opiod requirement
- Paid not opiod responsive
- Concomitant drugs that may dress CNS eg. Benzo/ TCAs
- Change in opioid/route administered
Opioid Toxicity Mx?
Look up local trust guidelines + seek specialist advice from palliative care team
Mild: Reduce dose by 1/3
Moderate:
Omit next dose + restart lower dose eg. decrease 1/3
Severe: If RR
Resp secretions Mx?
1) Reposition pt
2) If on IV fluid, r/v to see if this is exacerbating
3) Anticholinergic will help reduce production of secretions, but not increase absorption, so use early
- -> Hyoscine hydrobromide 400ug PRN SC
- Hyoscine butlbromide (Buscopan; use in conscious pts as does not cross BBB so less sedating) 20mg PRN SC (MAx 100mg/24hr)
Dyspnoea Mx?
1) Consider reversible causes eg. Pleural effusion, PE, airway obstruction, infection
2) Fan, position upright, breathing/relaxation exercises/ reassurance
3) Nebulisers, chest physsio and O2 as appropriate
4) Meds:
- To alleviate sensation: Oramorph 2.5-5mg PO PRN
To alleviate anxiety: Midazolam 2.5-5mg SC PRN
Terminal agitation/restlessness Mx?
1) Consider reversible causes eg. Pain, retention, constipation, drugs , deranged U+Es
2) Quiet safe environment, consider pillows, cot sides and 1:! nursing as appropriate
Midazolam 2.5-5mg SC PR
- Can also use levomepromazine
Consider use of CSCI for more continuous symptom control
Palliative care:
Troublesome cough?
Hiccups
Anorexia
Dry mouth
Pruritis
Cough - Codeine linctus 5-10ml QDS PRN
Hiccups: Metoclopramide 10mg TDS PO for gastric distention
Anorexia - consider dex 2-4mg if needed for short bursts
Dry mouth: Treat candida, regular sips of water, ice chips , pineapple chunks, chewing gum
Pruritis: emollients, antihistamines, chlorphenamine
When is a CSCI useful?
when a pt:
- Has difficulty swallowing/ taking oral meds safely
- Is N/V
- in bowel obstruction
- Too drowsy to swallow tablets or is unconscious
- Requires multiple SC injections
Nb. If skin intact/healthy, needle can be left in situ for 3-4 days before changing
- Up to 4 drugs can be combined in a CSCI over 24 hrs, depending on compatibility
CSCI morphine dose if on 80mg MST continus BD PO?
Breakthrough dose?
80 x 2 = 160mg oramorph
IV:PO = 1:2 therefore 80mg Morphine sulphate over 24 hrs via CSCI
Breakthrough dose = 24hr oral dose SC Morphine sulphate/6
(hourly max)
Advanced care planning?
ACP is a process of discussions between a patient and professionals regarding their future care. There are different ways of documenting and formalising the outcome of these discussions, which should then be circulated to other clinicians involved in their care:
• An advance statement is documentation of a patient’s preferences and wishes, e.g. that they would only wish to receive antibiotics for a future chest infection, or that they would like to be cared for at home and not return to hospital even if less well, or that they would like certain people to be involved in discussions about their care.
• An Advance Decision to Refuse Treatment (ADRT) – previously known as a living will or advance directive – is legally binding,drawn up when the patient has capacity, then to be used if they are no longer competent to make decisions, and documents refusal of specific treatments in a given situation.
• Lasting Power of Attorney (LPA) may be given by the patient to a nominated person (the attorney) so that they are legally responsible for making decisions on their behalf regarding their health or welfare
Personalised End of Life care plans?
These have replace the Liverpool care pathway and should be developed when:
• Patient is bedbound/semi-comatose/can only take sips/unable to take tablets and
• multidisciplinary team members agree that the patient is dying (last days of life), including consultant/registrar.
•
Guidelines on how to develop these will be found on local hospital/ hospice intranet.
