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
