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Year 4 > Palliative and Oncology > Flashcards

Palliative and Oncology Flashcards

1
Q

what Pain medication is used in palliative care

A
  • Morphine
    • First line for pain management
    • Good for all types of pain
    • Monitor for constipation
    • Monitor for unwanted sedation
  • Diamorphine
  • Oxycodone
  • Alfentanyl
    • Useful for patients with renal failure who cannot take morphine
  • laxatives should be prescribed for all patients initiating strong opioids
  • metastatic bone pain may respond to strong opioids (immediate relief), bisphosphonates or radiotherapy.
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2
Q

when starting pain medication in palliative care, what is the dose and route of administration?

A
  • regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
  • the breakthrough dose of morphine isone-sixththe daily dose of morphine
  • if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain.
    • For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
  • oral modified-release morphine should be used in preference to transdermal patches
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3
Q

adverse effects of palliative pain med

A
  • patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
  • drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
    Opioid side effects: constipation, nausea, drowsiness
    Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.
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4
Q

how should pain be managed in a palliative pt with CKD?

A
  • opioids should be used with caution in patients with chronic kidney disease
    • oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
    • if renal impairment is more severe, alfentanil,buprenorphine and fentanylare preferred
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5
Q

How to increase dose of opiods

A

When increasing the dose of opioids the next dose should be increased by 30-50%.

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6
Q

Oral codeine/ tramadol → oral morphine

A

divide by 10

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7
Q

oral morphine → oral oxycodone

A

divide by 1.5/ 2

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8
Q

a transdermal fentanyl X microgram patch equates to approximately Y mg oral morphine daily

A

X = 12
Y = 30

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9
Q

a transdermal buprenorphine X microgram patch equates to approximately Y mg oral morphine daily.

A

X = 10
Y = 24

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10
Q

Oral morphine → subcutaneous morphine

A

divide by 2

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11
Q

Oral morphine → subcutaneous diamorphine

A

divide by 3

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12
Q

Oral oxycodone → subcutaneous diamorphine

A

divide by 1.5

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13
Q

agitation/ restlessness management in palliative care

A
  • Underlying causes of confusion need to be looked for and treated as appropriate → hypercalcaemia, infection, urinary retention and medication
  • If specific treatments fail then the following may be tried:
    • first choice: haloperidol
    • other options: chlorpromazine, levomepromazine
      (anti-psychotics)
  • In the terminal phase of the illness then agitation or restlessness is best treated with midazolam
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14
Q

hiccup management in palliative care

A
  • chlorpromazine is licensed for the treatment of intractable hiccups
  • haloperidol, gabapentin are also used
  • dexamethasone is also used, particularly if there are hepatic lesions
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15
Q

Six broad nausea and vomiting syndromes

A

Reduced gastric motility (stasis, may be opioid related,Related to serotonin (5HT4) and dopamine (D2) receptors)
Chemically mediated (Secondary to hypercalcaemia, opioids, or chemotherapy)
Visceral/serosal (- Due to constipation, Oral candidiasis)
Raised intra-cranial pressure (Usually in context of cerebral metastases)
Vestibular (Related to activation of acetylcholine and histamine (H1) receptors)
Cortical (May be due to anxiety, pain, fear and/or anticipatory nausea)

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16
Q

how to treat N&V due to Reduced gastric motility

A
  • Pro-kinetic agents are useful in these scenarios as the nausea and vomiting is usually resulting from gastric dysmotility and stasis
  • first-line medications include metoclopramide and domperidone
  • metoclopramide should not be used when pro-kinesis may negatively affect the gastrointestinal tract, particularly in complete bowel obstruction, gastrointestinal perforation, or immediately following gastric surgery!
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17
Q

how to treat N&V due to chemical disturbance

A
  • Secondary to hypercalcaemia, opioids, or chemotherapy
  • chemical disturbance should be corrected first
  • Key treatment options include ondansetron, haloperidol and levomepromazine
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18
Q

how to treat N&V due to Visceral/serosal

A
  • Cyclizine and levomepromazine are first-line
  • Anti-cholinergics such as hyoscine can be useful
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19
Q

how to treat N&V due to Raised intra-cranial pressure

A
  • cyclizine for nausea and vomiting due to intracranial disease
  • Dexamethasone can also be used
  • Radiotherapy can be considered if there is likely raised intra-cranial pressure due to cranial tumours
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20
Q

how to treat N&V due to vestibular causes

A
  • Related to activation of acetylcholine and histamine (H1) receptors
  • Most frequently in palliative care is opioid related
  • Can be motion related, or due to base of skull tumours
  • cyclizine as a first-line treatment in disorders due to the vestibular system
  • Refractory vestibular causes of nausea and vomiting can be treated alternatively with metoclopramide or prochlorperazine
  • Atypical antipsychotics such as olanzapine or risperidone can be used in refractory cases
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21
Q

how to treat N&V due to cortical causes

A
  • Related to GABA and histamine (H1) receptors in the cerebral cortex
  • If anticipatory nausea is the clear cause, a short acting benzodiazepine such as lorazepam can be useful
  • If benzodiazepines are not ideal→ cyclizine
  • Ondansetron and metoclopramide can also be trialled
22
Q

management of secretions in palliative patients

A

Conservative:

  • Avoiding fluid overload - particularly stopping IV or subcutaneous fluids
  • Educating the family that the patient is likely not troubled by secretions

Medical:

  • hyoscine hydrobromide or hyoscine butylbromideis generally used first-line (muscarinic receptor antagonist)
    • hyoscine butylbromide may be less sedative than hyoscine hydrobromide
  • glycopyrronium bromide/ Glycopyrronium may also be used
23
Q

management of breathlessness in palliative patients

A
  • May be a result of disease process (e.g. lung cancer, anaemia)
  • Therapeutic oxygen
  • Morphine
  • Midazolam
24
Q

what is a syringe driver, indication, types

A

A syringe driver should be considered in the palliative care setting when a patient is unable to take oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma. In the UK there are two main types of syringe driver:

  • Graseby MS16A (blue): the delivery rate is given in mm per hour
  • Graseby MS26 (green): the delivery rate is given in mm per 24 hours
25
Q

which drugs are incompatible for mixing w water for injection

A

The majority of drugs are compatible with water for injection although for the following drugs sodium chloride 0.9% is recommended:

  • granisetron
  • ketamine
  • ketorolac
  • octreotide
  • ondansetron
26
Q

5 most common causes of cancer in the UK

A
  • 1.Breast
    1. Lung
    1. Colorectal
    1. Prostate
    1. Bladder
27
Q

The 5 most common causes of death from cancer in the UK

A
  • Lung
    1. Colorectal
    1. Breast
    1. Prostate
    1. Pancreas
28
Q

How to investigate metastatic disease of unknown primary

A

NICE recommends the following investigations for all patients:

  • FBC, U&E, LFT, calcium, urinalysis, LDH
  • Chest X-ray
  • CT of chest, abdomen and pelvis
  • AFP and hCG

NICE recommends the following investigations for specific patients:

  • Myeloma screen (if lytic bone lesions)
  • Endoscopy (directed towards symptoms)
  • PSA (men)
  • CA 125 (women with peritoneal malignancy or ascites)
  • Testicular US (in men with germ cell tumours)
  • Mammography (in women with clinical or pathological features compatible with breast cancer)
29
Q

Tumour Lysis Syndrome

A

oncological emergency.

rapid cell death on starting chemotherapy

common in tumours which are rapidly proliferating classically haematological malignancies such as leukaemia and lymphoma.

Clinical features

increase in serum urate, potassium and phosphate, precipitating renal failure.

Common symptoms include nausea, vomiting and muscle pain.

Management

Management focuses on preventing this from occurring through giving prophylactic allopurinol and in some cases a recombinant urate oxidase, rasburicase. Good hydration should be maintained.

30
Q

Carcinogens

A

Aflatoxin (produced byAspergillus) -Liver - (hepatocellular carcinoma), Bladder (transitional cell carcinoma)
Asbestos-Mesothelioma and bronchial carcinoma
Nitrosamines -Oesophageal and gastric cancer
Vinyl chloride - Hepatic angiosarcoma

31
Q

HPV types and cancer

A

Human papilloma virus (HPV) infection is the most important risk factor for developing cervical cancer.

Subtypes 16,18 & 33 are particularly carcinogenic.

The other most commonsubtypes (6 & 11) are non-carcinogenic and associated with genital warts.

32
Q

what are koilocytes

A

HPV Infected endocervical cells may undergo changes resulting in the development of koilocytes

. These have the following characteristics:

  • enlarged nucleus
  • irregular nuclear membrane contour
  • the nucleus stains darker than normal (hyperchromasia)
  • a perinuclear halo may be seen
33
Q

Risk factors for colorectal cancer

A

Strong risk factors

Increasing age

Hereditary syndromes

  • Familial adenomatous polyposis
  • Hereditary nonpolyposis colorectal cancer (Lynch Syndrome)
  • Juvenile polyposis
  • Peutz-Jeghers syndrome

Increased alcohol intake

Smoking tobacco

Processed meat

Obesity

Previous exposure to radiation

Inflammatory bowel disease

Weak risk factors

Lack of dietary fibre

Limited physical activity

Asbestos exposure

Red meat (non-processed)

34
Q

Duke’s classification

A

Duke’s classification can be used to stage colorectal cancer:

A: limited to the bowel wall (i.e. not beyond the muscularis).

B: extending through the bowel wall (i.e. beyond the muscularis).

C: regional lymph node involvement.

D: distant metastases. It is important to learn the Duke’s staging for examinations.

35
Q

TNM staging of colorectal cancer

A

The TNM (tumour, node, metastases) is a more recent classification system, which provides a more uniform classification of colorectal cancer.

T: Tis (carcinoma in situ/intramucosal cancer), T1 (extends through the mucosa into the submucosa), T2 (extends through the submucosal into the muscularis), T3 (extends through the muscularis into the subserosa), T4 (extends into neighbouring organs or tissues).

N: N0 (no regional lymph node involvement), N1 (metastasis to 1-3 regional lymph nodes), N2 (metastasis to 4 or more regional lymph nodes).

M: M0 (no distant metastasis), M1 (distant metastasis). Staging informs both the prognosis and the treatment plan.

Patients with Duke’s stage C or stage III (T1-4, N1-2, M0) colon cancer benefit from adjuvant chemotherapy. Note that patients without lymph node involvement but with high risk features (such as vascular or perineural invasion) also show improved survival with adjuvant chemotherapy.

36
Q

Principles of screening for colorectal cancer

A

Current NHS screening programmes include:

Faecal immunochemical test (FIT) every 2 years for men and women age 60-74. If positive patients are referred for colonoscopy.

One-off flexible sigmoidoscopy has now beendiscontinued.

This screening programme reduces the risk of dying from bowel cancer by 16%.

37
Q

Urgent 2 week wait referral for possible colorectal cancer

A

This is based on the age of the patients and clinical symptoms. If general, if an unexplained rectal or abdominal mass is felt or there is any unexplained rectal bleeding, this warrants urgent referral. Guidelines are as follows:
Aged > 40 with unexplained weight loss AND abdominal pain
Aged > 50 with unexplained rectal bleeding
Aged > 60 and over with any of:
- Iron–deficiency anaemia
- Changes in their bowel habit (old guidelines say this had to last more than 6 weeks, but this no longer applies)

Aged under 50 with rectal bleeding AND any of the following unexplained symptoms:
- Abdominal pain
- Change in bowel habit
- Weight loss
- Iron-deficiency anaemia

Proven faecal occult blood on testing (appointment within 2 weeks)

Rectal or abdominal mass

38
Q

Uses of Faecal Occult Blood Tests

A

In some cases, it may be useful to request a faecal occult sample and refer if positive:

Aged > 50 with either:
- Unexplained abdominal pain
- Unexplained weight loss weight loss

Aged > 60 with any form of anaemia

Aged under 60 with:
- Changes in their bowel habit
- Iron-deficiency anaemia

Other symptoms may include tenesmus, change in stool form (thin, small stools) and abdominal distension.

Patients may also be identified by the current bowel screening programme which offers a faecal immunochemical test (FIT) every 2 years to all men and women aged 60 – 74.

More rarely, patients may present as a clinical emergency as a consequence of carcinoma, such as large bowel obstruction.

39
Q

colorectal cancer investigations

A

The first step in the diagnosis of colorectal carcinoma is acolonoscopy. It allows –

  • Direct visualization of the colon
  • Biopsies to be taken
  • Removal of any polyps seen

If colonoscopy cannot be performed, either due to technical difficulties, poor tolerance of bowel preparation or there is an increased risk of colonic perforation a CT colonoscopy is a suitable alternative but does not allow biopsy.

After a histological diagnosis is made, a CT chest, abdomen and pelvis should be performed to stage the disease, so an appropriate intervention can be planned.

In rectal disease, a pelvic MRI or endorectal ultrasound are preferred over CT scan, as are better for identifying locally invasive disease.

Carcinoembryonic antigen (CEA) is not used as a diagnostic tool but can be used to monitor therapeutic response to interventions.

40
Q

management of colon cancer

A

Management depends on factors relating to both the tumour (the stage and location) and the patient (surgical fitness).

For patients withcolon cancersuitable for surgery: Forstage I-III disease: surgical resection ± post-operative chemotherapy. The type of surgery depends on the tumour site: right hemicolectomy for tumours of the caecum and ascending colon, left hemicolectomy for tumours of the distal transverse colon and descending colon, and sigmoid colectomy for tumours of the sigmoid colon.

Patients withstage III disease(lymph node involvement) benefit from post-operative adjuvant chemotherapy.

Forstage IV disease(metastases): treatment is as above, but pre-operative chemotherapy may also be performed. The staged colectomy and resection of metastatic disease is performed after pre-operative chemotherapy.

41
Q

management of rectal cancer

A

For patients withrectal cancersuitable for surgery: Anterior resection for tumours >8 cm from the anal canal or involving the proximal 2/3 of the rectum. Abdomino-perineal (AP) resection for tumours <8 cm from the anal canal or involving the distal 1/3 of the rectum.

Patients with stage III disease benefit from post-operative chemotherapy.

Patients with stage IV disease benefit from post-operative chemoradiotherapy

42
Q

Non-surgical management of colorectal cancer

A

For patients unsuitable for surgery management is with chemotherapy (FOLFOX or FOLFIRI i.e. oxaliplatin/irinotecan plus folinic acid plus fluorouracil are the preferred regimens).

New monoclonal antibody therapies are becoming available. Note that NICE concluded that cetuximab (anti-EGFR), but not bevacizumab (anti-VEGF), is cost effective in combination with chemotherapy for metastatic colorectal cancer.

Note that stenting may be used as a palliative measure for patients with obstructing tumours of the sigmoid colon or rectum. If the patient presents with acute bowel obstruction, a Hartmann’s procedure may be required as an interim measure (resection of the rectosigmoid colon with formation of a temporary end colostomy and anorectal stump).

43
Q

Familial adenomatous polyposis (FAP) features

A

caused by a mutation in the adenomatous polyposis coli (APC) gene and has an autosomal dominant inheritance pattern.

Patients develop hundreds of adenomatous polyps in their teens and arevirtually guaranteedto develop colorectal cancer by their 20s, unless they undergo prophylactic proctocolectomy.

Note that there is a high risk of developing duodenal cancer, so patients undergo regular endoscopic surveillance.

Gardener’s syndromeis a variant of FAP in which patients may also develop epidermal cysts, supernumerary teeth, osteomas, and thyroid tumours.

44
Q

Hereditary non-polyposis colorectal cancer (HNPCC)/Lynch syndrome features

A

Is caused by a mutation in the mismatch repair genes MLH1/MSH2 and has an autosomal dominant inheritance pattern.

Patients have an 80% risk of developing colorectal cancer by their 30s.

There is increased risk of additional cancers such as gastric, endometrial, breast, and prostate cancer.

Patients are managed with regular endoscopic surveillance.

45
Q

Peutz-Jeghers syndrome features

A

Is caused by a mutation in the STK11 gene and has an autosomal dominant inheritance pattern.

Patients typically present in their teens with mucocutaneous pigmentaiton and hamartomatous polyps.

Note that the risk of neoplastic transformation of hamartomatous polyps is low, but many polyps are present so patients are at increased risk of developing colorectal cancer. They are managed with regular endoscopic surveillance.

46
Q

hepatocellular carcinoma investigations

A

diagnosis is difficult and due to the lack of characteristic symptoms it is often delayed. This may lead to advanced disease at diagnosis including metastases leading to poor outcomes.

Bloods: FBC, UE, CRP, LFT

Liver screen including Hepatitis Screen

AFP

Abdominal Ultrasound

CT Chest Abdomen Pelvis + - PET scan

47
Q

hepatocellular carcinoma RFs

A

HCC is the sixth most common cause of cancer and the second leading cause of cancer-related death. The global incidence of HCC varies according to the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection

It is important to recognize risk factors for hepatocellular carcinoma, which include:

Chronic viral hepatitis (Hepatitis B or C)
Cirrhosis
Non-alcoholic fatty liver disease
Primary biliary cirrhosis
Inherited metabolic diseases
Alcohol misuse
Obesity
Type 2 Diabetes
Rare diseases: Wilson’s disease, porphyria cutanea tarda, alpha1-antitrypsin

48
Q

hepatocellular carcinoma management

A

Hepatic resection, liver transplantation, and radiofrequency ablation (RFA) are considered curative treatment options for HCC.

49
Q

Ovarian cancer types

A

Epithelial ovarian tumours (90%)
- originates from epithelium
-Partially cystic
- metastic spread typically involves peritoneal cavity w seeding at bladder, parabolic gutters and the diaphragm

Germ cell tumours
- germ cells in embryonic gonad
- throw rapidly and spread predominantly via the lymphatic route
- young women
- AFP, BetaHCG

Sex stromal tumours
-originate from connective tissues
- Rare, less than 5% of ovarian tumours
- Malignant tumours but less aggressive than epithelial

Krukenberg tumour
- signet ring sub-tumour, typically GI in origin, which has metastasised to the ovary

50
Q

Ovarian tumours RFs and protective factors

A

Risk factors

Older age

Smoking

Greater number of ovulations (early menarche, late menopause)

Obesity

Hormone replacement therapy (HRT)

BRCA 1 and 2 genes

Protective factors

Parity

Breastfeeding

Early menopause

Combined oral contraceptive pill (COCP) use

51
Q

Clinical features of ovarian cancer

A

Often late presentation
Non specific - abdominal discomfort, bloating, early satiety, urinary frequency, change in bowl habits
May produce Vascular gf increasing permeability and causing ascities

Pelican, back and abdo pain

Palpable mass

Year 4 (3 decks)

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