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Yr 5 - cancer care > palliative and Tx > Flashcards

palliative and Tx Flashcards

1
Q

what are the ways in which a cancer can metastasise

A

1) local invasion/ direct extension –> this normally happens in locally invasive tumours like those of the head and neck
2) haeamtogenous spread (common in lung, prostate, melanoma - the secondary sites look like the primary cancer)
3) lymphatic
4) transcoelomic
5) seeding - where cancer c ells spread by direct implantation into body cavities such as the pleural or pericardial cavity

-NOTE cancers can metastasise in more than one way

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2
Q

what antiemetic is used firstline in cancer is cause of the sickness is unknown

A

metoclopramide - D2 antagonist (this is pro kinetic and does cross the BBB)

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3
Q

what SE can you get from metoclopramide

A

extrapyramidal - oculogyric crisis, hyperprolactinaemia, tar dive dyskinesia, Parkinsonism

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4
Q

what is haloperidol used for

A

D2 antagonist (cross BBB) which can be used to treat sickness caused by metabolic disturbance or agitation

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5
Q

MOA of ondansetron

A

5HT3 antagonist

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6
Q

MAO of cyclizine

A

H1 antagonist

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7
Q

what antiemetic is used as an anticipatory drug

A

levomepromazine

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8
Q

what drug can be used for large volume vomitign cause by BO

A

hyoscine butyl bromide (ACH antagonist) / ocreotide (somatostatin analogue)

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9
Q

what are some causes for N+V in cancer

A

1) reduced gastric motility –> this may be due to compression or can be due to the use of opioids
2) chemically mediated –> from chemo or from electrolyte imbalances like hypercalcaemia
3) visceral - if constipated
4) raised ICP
5) vestibular - may be due to cerebral mets or opioids
6) cortical - anxiety (in this case would treat with benzos)

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10
Q

causes of constipation in palliative care

A

1) opioids
2) bowel obstruction
3) hypercalcaemia, inadequate intake, dehydration

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11
Q

if laxatives are not sufficient to treat constipation, what an be used next?

A

Rectal treatments:
1) soft loading - bisacodyl suppository
2) hard loading - glycerol suppository
3) arachis oil enema

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12
Q

what are the 5 principles of pain management for cancer

A

1) oral administration where possible
2) prescribe based on the pain the patient says they are in, not what you think
3) start low
4) administer consistently

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13
Q

3 examples of weak opioids

A

codeine, dihydrocodeine and tramadol

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14
Q

what other considerations can be given to pain Tx, if the pain ladder does not work

A

nerve blocks, epidurals, PCA pumps

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15
Q

what is the opioid dose recommended for opioid naive patients

A

20-30mg a day

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16
Q

what would you prescribe alongside opioids

A

always a stimulant laxative, sometimes an antiemetic like metocloprmaide

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17
Q

what opioid can be used in mild renal impairment

A

oxycodone

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18
Q

what opioid can be used in severe renal impairment

A

buprenorphine patch or fentanyl

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19
Q

what can be said to the patient about how long their side effects will last with opioids

A

drowsiness and nausea are transient but constiaption will last

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20
Q

for metastatic bone pain, what should be considered

A

opioids, bisphosphonates and radiotherapy

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21
Q

what adjuvant can you not use in a Hx of heart problems

A

amitriptyline

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22
Q

what can be used for a painful mouth at the end of life

A

benzydamine hydrochloride

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23
Q

what is the difference between nociceptive and neuropathic pain

A

nociceptive pain is when there is a stimulus and the nerves are in tact where as neuropathic pain is when the stimulus has gone. Causes allodynia, hyperkalaemia and parasthesia.

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24
Q

what’s a key difference between incident pain and neuropathic pain

A

incident pain is predictable

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25
Q

conservation management of secretions

A

avoid fluid overload, advise family that the patient is not troubled by it, reposition the patient and leave their upper body elevated to allow for postural drainage

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26
Q

which secretion med is sedating

A

hyoscine hydrobromide

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27
Q

simple measures for a cough

A

humidify room air if cough is dry, sit person up

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28
Q

what are the causes of dyspnoea in cancer patient

A

1) direct causes of the cancer - lung cancer/mets
2) indirect effects of the cancer like pleural effusion of SVCO
3) non malignant - COPD, heart failure, anxiety

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29
Q

what is used for agitation in terminal phase

A

midazolam

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30
Q

as part of the gold standards framework, what are three trigger questions

A

1) surprise Q
2) general indicators of decline (weight loss, increased admission, low albumin, reduced activity)
3) specific indicators of decline

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31
Q

what are some specific indicators that someone is at the end of their life with COPD

A

MRC grade 4/5, FEV1<30% predictive, cor pulmonale

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32
Q

what is good about the gold standard framework

A

promotes better coordination and collaboration between HCP, hospital and community services and prevent hospital admissions and give people choices over their death

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33
Q

which med is used for ANTICIPATORY secretions

A

glycopyrronium (this doesn’t cross BBB so is not sedating)

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34
Q

when is someone considered for a syringe driver in their terminal phase

A

when they need 2+ anticipatory meds in 24 hours

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35
Q

for end of life, what is it important to make

A

LPoA

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36
Q

signs someone is dying

A

agitation, mottled skin, noisy secretion, weight loss, someone might express that they are dying, cheyne stokes breathing, sleeping more, no oral intake

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37
Q

what must be on a controlled drug prescription

A

address of patient

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38
Q

definition of hospice based care

A

specialist palliative care for people with terminal illnesses and their families

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39
Q

what is adjuvant treatment

A

treatment after surgery to prevent cancer reoccurrence

40
Q

what is maintenance treatment

A

treatment which is given o helps he primary treatment succeed

41
Q

what determines the cancer treatment given

A

type of cancer, stage of cancer, performance status of patient, patient wishes, comordbities, genetics

42
Q

what are the challenges of survivorship (which means anyone who has received a cancer diagnosis at some point)

A

long term toxicities from treatment, survivor guilty, uncertainty about future, effects on family / friends, trouble getting health and life insurance

43
Q

benefits of MDT

A

reduces variation in access to treatments and improves continuity to cancer

44
Q

problems with MDT (members - oncologist, CNS, histopathologist, pharmacy, PT/OT, surgeons)

A

-resource intensive
-logistics
-lose patient centeredness as focus too much on clinical considerations rather than on holistic care

45
Q

what is CAR-T therapy

A

remove T cell from patients blood by aphaeresis, genetically programme them to fight the cancer by making them produce the chimeric antigen receptor which then binds to cancer cells and labels them for destruction, multiple the cells and infuse back to patient, CAR-T cells can then destroy the patients cancer cells

46
Q

cytokine release syndrome is one problem of CAR-T therapy, what is this?

A

huge T cell response which causes an overwhelming cytokine release –> can cause symptoms ranging from flu to sepsis

47
Q

how do you treat cytokine release syndrome

A

antihistamines, some people will need an ITU admission

48
Q

what are some complications of CAR-T therapy?

A

1) cytokine release syndrome
2) neurological complications
3) infections - CAR-T cells kill normal B cells as well as cancer cells

49
Q

how do immune checkpoint inhibitors work

A

some cancers produce proteins which turn T cells off. Checkpoint inhibitors stop this happening. Eg Nivolumab.

50
Q

what are side effects of immune checkpoint inhibitors

A

all immune cells are activated by the drugs so get rashes, dry and itchy skin.
-can also get N+V
-endocrine disturbance
-pneumonitis if activated T cells attack healthy cells

51
Q

Mx of side effects from immunotherapy

A

steroids

52
Q

what are the four types of immunotherapy

A

1) immune checkpoint inhibitors
2) monoclonal antibodies
3) CAR-T
4) cancer vaccines

53
Q

what is the big SE with rituximab

A

allergic reaction

54
Q

what is radiotherapy

A

high energy ionising radiation used to treat malignant disease (the ionising radiation can kill cells directly by damaging the cells and triggering apoptosis or indirectly by making free radicals)

55
Q

what are the aims of radiotherapy treatment

A

deliver calculated doses of radiotherapy to cancer cells whilst minimising exposure to surrounding tissues to achieve a high grade of tumour control and low risk of complications

56
Q

the energy absorbed in radiotherapy is measured in what

A

grays

57
Q

why is the energy in radiotherapy delivered in fractions

A

limit damage to normal cells

58
Q

what happens in simulation before radiotherapy

A

patient is placed in a reproducible position, may make tattoos on patient so they know where to put the beams

59
Q

what are the different types of radiotherapy

A

1) external beam radiation
2) brachytherapy - internal radiation where a radioactive source in a catheter or seed is used to deliver radiation from the body directly to the tumour site
3) systemic - where the radioactive source is injected or swallowed

60
Q

early side effects of radio, which normally resolve in a few weeks

A

skin reactions, fatigue, mucositis

61
Q

when do late side effects of radiotherapy occur and why

A

months to years after a course of radiation due tot he excessive extracellular matrix and deposition of collagen and fibrogenesis (these are irreversible and progressive)

62
Q

what is a site specific side effect of radiotherapy to the chest

A

radiation pneumonitis (which if untreated becomes radiation fibrosis)
-this presents a few weeks after radiotherapy with a cough, dyspnoea, low grade fever, pleuritic chest pain
-do IX to rule out infective course
-CXR - see changes around radiation port
-Tx with steroids!

63
Q

SE of tamoxifen

A

hot flush, vaginal irritation, loss of libido, VTE, endometrial cancer

64
Q

what hormonal Tx is given to post menopausal women who are ER+

A

anastrozole (cause - hot flushes, joint pain and osteoporosis)

65
Q

SE of GnRH agonists

A

hot flushes, erection problems and low libido

66
Q

MOA of GnRH agonists

A

overstimulate –> downregulation of receptors (takes 2/3 weeks and have to use antiandrogens in the interim to stop tumour flare(

67
Q

what do phase 1 clinical trials assess

A

safety

68
Q

what do phase 2 clinical trials affect

A

efficacy - does it work?

69
Q

what do phase 3 clinical trials assess

A

effectiveness - how do they work compared to other preexisting treatments. CONTROLLED TRIALS

70
Q

what do phase 4 clinical trials do

A

post market surveillance - look at effectiveness and side effects

71
Q

what’s an umbrella trial

A

look at one treatment for one type of cancer with different mutations

72
Q

what’s a bucket trials

A

look at one treatment on lots of different cancers with the same mutation

73
Q

what is immune related colitis

A

new onset diarrhoea after starting immunotherapy, get abdominal pain, nausea, vomit, bleeding

74
Q

Ix for immune related colitis

A

rule out infective cause and IBD

75
Q

what is grade 1 immune related colitis, and how do we treat it

A

asymptomatic and treat with loperamide

76
Q

what is grade 2 IRC and how do we treat

A

abdo pain, mucous, blood in stool. Tx with oral steroids

77
Q

what is grade 3 IRC

A

severe abdo pain and peritoneal signs, this needs a scope or Ct if signs of peritonitis. Need IV steroids / infliximab

78
Q

what is grade 4 IRC

A

life threatening complications and need IV steroids and infliximab

79
Q

RF of getting radiation mucositis

A

smoking, poor oral hygiene having chemo and radio together

80
Q

complications of radiation mucositis

A

reduced oral intake, dehydration, pain, susceptibility to infection

81
Q

what is the WHO grading of radiation mucositis

A

0
1 - soreness and erythema
2- erythema, ulcers, can eat solids
3 - ulcers, can only eat liquid
4 alimentation not possible

82
Q

MX of radiation mucositis

A

good oral hygiene, soft bland diet, no smoking or alcohol, benzydamine mouthwash, may need antibiotics

83
Q

if someone is on cancer tx and they present with nose bleeds, what should you consider

A

thrombocytopenia

84
Q

what class of chemo is cisplatin

A

platinum agent which cross links DNA

85
Q

SE of cisplatin

A

ototoxic, peripheral neuropathy, hypomagnesium, seizures, highly emetic

86
Q

class of chemo is 5-FU

A

antimetabolite (can cause myelosuppression and mucositis)

87
Q

what class of chemo is cyclophosphamide

A

alkylating agent

88
Q

why is chemo often giving as a combination

A

stops resistance, maximise therapeutic effect without toxicity,

89
Q

chemo drug resistance mechanisms

A

increased drug efflux, increased DNA damage repair, drug compartmentalisation

90
Q

performance statuses

A

0 - no limitation
1 - able to do light work
2 - able to do all self care but no light work, up and about 50% of time
3 - capable of limited self care, sat for >50% waking hours
4 - completely disabled
5 - dead

91
Q

what are some acute toxicities of chemo

A

mucositis, rash, alopecia, myelosuppression, TLS

92
Q

example of a protooncogene

A

RAS (gain of function)

93
Q

example of TSG

A

BRCA

94
Q

what is it important to check in extravasation

A

vesicant? - blistering
non vesicant - no inflammation but pain
-irritant - pain and inflammation

95
Q

Mx of extravasation

A

stop infusion, leave cannula in, classify agent, extravasation kit, cold pack, aspirate out, mark with pen, can use hydrocortisone cream

96
Q
A

Yr 5 - cancer care (6 decks)

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