Oncology - Treatments

Question 1

List the oncologic emergencies

Answer 1

• Hypercalcemia
• Superior vena cava syndrome
• Cerebral metastasis
• Spinal Cord compression

Question 2

Discuss the presentation, investigation and treatment for superior vena cava syndrome

Answer 2

• occur with lung cancer and lymphoma
• have obstruction of blood flow through SVC caused by tumour invasion or external compression
  Presentations
• facial swelling
• head fullness
• dyspnea, cough
• dysphagia
• distended neck and chest wall veins
• arm edema
  Investigation
• CXR
• CT chest with contrast
  Management
• treat underlying cause
• relieve SVC obstruction: radiotherapy, urgent stent placement
• supportive therapy
  - raise head

Question 3

Discuss the grading for superior vena cava syndrome

Answer 3

Grade 0
- asymptomatic
Grade 1
- mild: edema in head and neck, cyanosis
Grade 2
- moderate: edema in head and neck with functional impairement
      - dysphagia
      - visual disturbance
Grade 3
- severe: mild/mod cerebral edema or laryngeal edema
      - decreased cardiac reserve
Grade 4
- life threatening: significant cerebral edema or laryngeal edema
      - hemodynamic compromise

Question 4

Discuss the presentation, investigation and management for cerebral metastasis

Answer 4

• lung, breast, kidney, colorectal and melanoma most common
  Presentation
• headache: early morning and worsened with valsava
• n/v
• cognitive dysfunction
• seizure, focal neurological deficit
  Investigation
• MRI head with contrast
  Management
• treat underlying malignancy
• treat brain metastasis if favourable prognosis
• symptomatic with dexamethasone 10mg to 4-8mg Q12H
• Seizure treatment and prophylaxis
  - epival 15/mg/kg for prophylaxis

Question 5

Discuss the presentation, investigation and management for spinal cord compression from metastasis

Answer 5

- invade epidural space and compromise spinal cord
Presentation
- severe and progressive back pain
- pain radiating down limb
- progressive motor weakness
- ascending numbness, paresthesia
- urinary retention, fecal incontinence
- gait ataxia
Investigation
- MRI
Management
- dexamethesone 10mg followed by 16mg OD
- urgent referral to spine surgery or radiation oncologist

Question 6

Discuss the criteria for critically significant weight loss

Answer 6

• > 5% of baseline body weight

- 10lbs (4.5kg) in <6 months

Question 7

List the 9 D’s of decreased food intake

Answer 7

• Dentition
• Dysgeusia
• Dysphagia
• Diarrhea
• Depression
• Dementia
• Disease
• Dysfunction
• Drugs

Question 8

Discuss the approach to cancer pain management

Answer 8

Mild Pain
- non-opioid
      - NSAID, acetaminophen
Moderate Pain (4-6/10)
- weak opioid analgesic
      - tramadol or low dose opioid
Severe Pain (7-10/10)
- opioid
      - morphine, hydromorphone, oxycodone

Question 9

Discuss contraindication to oral opioids

Answer 9

• Bowel obstruction
• severe pain requiring urgent intervention
• dysphagia
• intractable n/v
• diminished GI absorption
• terminal

Question 10

Discuss the conversion between opioids

Answer 10

10 Morphine: 5 Oxycodone: 2 Hydromorphone

• • peak in 1.5hrs PO, SC in 45 minutes
• IV to PO divide PO by 2
• usually start daily dose of Morphine 5mg Q4H straight
  - PRN would be 10% of total daily dose
  - PRN dose for above would be 3mg PO Q2H PRN
  - if pain not well controlled or using PRN >=3x/day then increase straight dose by 25-50%
• renal failure use smaller dose due to risk of accumulation and neurotoxicity

Question 11

List the common side effects of opioids

Answer 11

• n/v that improve over 3-7d
• constipation
• sedation/somnolence, improve after 3-7d
• opioid neurotoxicity
  - confusion
• dry mouth
  Uncommon
• pruritis
• urinary retention, improves
• myoclonus
• respiratory depression
• postural hypotension

Question 12

Discuss strategies to reduce opioid side effects

Answer 12

Constipation
- Senna 1 tab PO OD (bowel stimulant) or lactulose 10mL PO OD (osmotic)
      - RPN dulcolax suppository as well
- bowel movement every 3 days
Nausea and Vomiting
- metoclopramide 5-10mg Q4H PRN
Sedation
- not to drive
- switch opioid
Urinary Retention
- can wait until it improves
- Foley catheter
Opioid Neurotoxicity
- rule out organic cause to delirium
- hydrate
- treat symptomatically
Respiratory depression
- naloxone

Question 13

Discuss how to switch opioid

Answer 13

• start new opioid with 30-50% lower morphine equivalent dose with appropriate breakthrough

Question 14

Discuss indications for other adjuvant therapy

Answer 14

Bone Pain
- NSAID
- bisphosphonate
- radiotherapy
Spinal Cord Compression
- steroids
Increased ICP
- steroids
Neuropathic Pain
- steroids
- anticonvulsants
- TCA
- NMDA antagonist
Opioid Neuotoxcity
- NMDA antagonist

Question 15

Discuss the treatment of cancer induced nausea

Answer 15

Non-Pharmacologic
- small, frequent meals
- cold meals
- fresh air
- liquid supplement
- attractive food presentation
First Line
- metoclopramide (if no bowel obstruction) or haldol
      - as vomiting usually from chemoreceptor trigger zone
Etiology
- bowel obstruction
      - dexamethasone
      - ocreotide
- chemotherapy
      - ondansetron
- brain tumour
      - dexamethasone
- vestibular
      - dimehydrinate
- anticipatory or anxiety induced
      - benzodiazepine