STA: Cancer Flashcards

1
Q

What is the incidence of cancer?

A

1 in 2

Approx 375,000 new cases of cancer every year in the UK

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2
Q

Define cancer

A
  • Abnormal cells divide in uncontrolled way
  • Abnormal cells have potential to
    • Form tumour, Invade neighbouring tissues, Spread to distant tissues (metastasise)
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3
Q

Outline the normal cell cycle and the signals cells must receive to undergo cell division

A
  • Cells must receive positive signals to divide (e.g growth factors, Hormones)
    • There are also signals telling a cell not to divide:
      • Contact inhibition - surrounded by other cells, no need for new cells at the moment
      • DNA damage response - Something is wrong with your DNA, cells shouldn’t divide until the DNA is repaired
    • Cell division is controlled by the cell cycle - This is regulated by a range of signalling pathways, coded for by many genes, but mutations in these genes can lead to cancer
    CELL CYCLE:
    • Gap/Growth 1 (G1) - Longest phase, cell grows while organelles function as usual, terminates at G1 checkpoint
      • Cells with damaged DNA → G0 phase/apoptosis
    • Synthesis (S) - DNA replicated (identical chromatids created)
    • Gap/Growth 2 (G2) - Organelles duplicated, Terminates at G2 checkpoint
      • G1 + S + G2 = Interphase
    • Mitosis (M) phase - Cell divides into 2 daughter cells
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4
Q

What internal and external factors cause DNA to be constantly mutated?

A
  • Interally:
    • Reactive oxygen species (oxidative damage)
    • Ineffective DNA repair mechanisms
  • Externally:
    • UV light
    • Ionising radiatioon
    • Cigarette smoke
    • Chemical consumption
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5
Q

What do proto-oncogenes do?

A

Involved in positive control of cell growth and division

These have the potential to become oncogenes

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6
Q

What are oncogenes?

A

Mutated form of proto-oncogens

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7
Q

What are the main classes of proto-oncogenes?

A

Class I: Growth Factors

Class II: Receptors for Growth Factors and Hormones

Class III: Intracellular Signal Transducers

Class IV: Nuclear Transcription Factors

Class V: Cell-cycle Control Proteins

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8
Q

What is oncogenesis?

A

Unregulated proliferation of cellular growth due to mutations relaxing control of cellular growth

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9
Q

How do oncogenes cause oncogenesis?

A

They acts as dominant mutations at the cellular level, causing relaxation of cellular growth, allowing for unregulated proliferation

You would only need 1 mutation to be present on the alleles, hence it’s dominant

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10
Q

What are germline oncogenes?

A
  • These are variant in cancer predisposition genes that are present in all of an infected individuals nucleic cells, as well as the cancer genome, and therefore may be inherited
  • These account for about 5-10% of cancers, so most cancers are caused by somatic oncogenes
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11
Q

What are somatic oncogenes?

A

These are changes that have accumulated in the cancer genomes, either as drivers of oncogenesis, or as passenger mutations, but they are not present constitutionally in an individual

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12
Q

What do tumour suppressor genes do?

A
  • Protective genes, help control growth
  • Most inherited cancer syndromes are due to mutations in tumour suppressor genes
  • In these cases, on of the mutations is inherited and the second is somatic - this is why we tend to earlier onset of cancers
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13
Q

How do tumour suppressor genes become inactivated?

A
  • 2 mutations (one on each allele) cause inactivity of the tumour suppressor genes.
  • Hence, these mutations are recessive at cellular level
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14
Q

What is Knudson’s two-hit hypothesis of sporadic and hereditary cancer?

A

Sporadic (not inherited):

  • Single tumour
  • Unilateral
  • Late onset

1 - Fertilised egg inherits no mutation

2 - Mutation in one copy of gene occasionally occurs as cells divide (First hit)

3 - Mutation in second copy of gene occurs (Second hit)

Hereditary (inherited):

  • Multiple tumours
  • Bilateral
  • Early onset

1 - Fertilised egg has 50% chance of inheriting mutation

2 - Mutation in one copy of gene is inherited in all body cells

3 - Mutation in second copy of gene occurs

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15
Q

What do DNA repair genes do?

A

Repair damage sustained by DNA

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16
Q

How do mutations in DNA repair genes lead to oncogenesis?

A

Mutations in DNA repair genes = increased risk of mutations in oncogenes/tumour suppressor genes

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17
Q

What is epigenetics?

A

The study of changes in gene expression caused by mechanisms other than changes in the underlying DNA sequence

  • DNA methylation
  • Histone modification
18
Q

How do epigenetic mechanisms lead to oncogenesis?

A

Methylation at CpG islands (rich in repeat of CG bases consecutively together) means the gene is silenced as transcription factors are unable to bind

Transcription factors turn specific genes on or off, by binding to nearby DNA

19
Q

What are the 4 treatment modalities when treating cancer?

A
  • Drug therapy
    • Chemotherapy
    • Endocrine therapy
    • Immunotherapy
    • Cellular therapy
    • Targeted therapy
  • Surgery - Focuses on specific site of cancer (e.g. colorectal cancer)
  • Radiotherapy - Uses radiation to destroy cancer cells
  • Best supportive care (managing symptoms)
20
Q

How can surgery be used to treat cancer?

A
  • Management of primary tumour
    • Removal of malignant disease with a clear margin of normal tissue
    • Repair, reconstruction and restoration of normal function
    • Staging
  • Management of regional lymph nodes or metastases (secondary tumours)
    • Removal of lymph nodes around cancer and organs cancer is affecting
    • This can determine the number of affected lymph nodes, and staging of the disease, as can help determine treatment given to patient
    • Sentinel lymph node biopsy - Inject radioactive dye and use probe to detect where dye has gone and see main lymph node(s) affected by cancer, and then during surgery, the lymph nodes stained by the radioactive dye can be removed
  • Staging of disease
  • Palliative surgery
    • Tumour debulking (Prolong survival but not curative)
    • Symptom control
      • Tumour fungation (tumour breaks through skin)
      • Relief of obstruction
      • Fracture fixation
      • Control haemorrhage
21
Q

How is radiotherapy used to treat cancer?

A
  • High energy X-rays or gamma rays - cause DNA damage and cell death by inducing apoptosis. Affects healthy cells, but these cells often have functioning repair mechanisms, and so recover
  • Radical/Palliative
  • Single dose (fraction) or multiple doses
  • External beam
    • Linear accelerator
    • Moves person in 360 degree movements
    • CT plan - CT scan used to make radiotherapy treatment plan
      • Define treatment area
      • Identify organs at risk
      • Dose calculation
  • Brachytherapy - Radiotherapy waves injected into tumour, release radiowaves that kill tumour
22
Q

How is chemotherapy used to treat cancer and how does it work?

A
  • Chemotherapy - Usually given by IV drip
    • DNA damage- leads to double strand DNA breaks
    • Inhibit mitosis
    • Inhibit DNA replication
    • Most effective against fast growing cancers
      • High sensitivity - Leukaemia, lymphoma, germ cell tumours, small cell lung cancer
      • Moderate sensitivity - Breast, colorectal, bladder ovarian and cervical cancers
      • Low sensitivity - Prostate, kidney, primary brain tumours, melanoma - these respond better to targeted treatments
23
Q

How is endocrine therapy used to treat cancer and how does it work?

A
  • Used in hormone driven cancers
    • Breast - Tamoxifen, Anastrazole
    • Prostate - Zoladex, Enzalutamide
  • Long term adjuvant therapy - can be used after curative surgery to prevent cancer recurring
  • Prophylactic - Can be used to prevent cancer from occurring e.g. People with BRCA1 gene
24
Q

How is immunotherapy used to treat cancer and how does it work?

A
  • Used in hormone driven cancers
    • Breast - Tamoxifen, Anastrazole
    • Prostate - Zoladex, Enzalutamide
  • Long term adjuvant therapy - can be used after curative surgery to prevent cancer recurring
  • Prophylactic - Can be used to prevent cancer from occurring e.g. People with BRCA1 gene
25
Q

How is immunotherapy used to treat cancer and how does it work?

A
  • Encourage immune system to detect and attack cancer cells
  • IV infusions every 2-3 weeks that encourage producing monoclonal antibodies that target the immunosuppressive molecules expressed by cancer cells
  • Works better in cancers with lots of mutations and neo-antigens (provides greater repertoire for immune system to detect and attack)
26
Q

How is cellular therapy used to treat cancer and how does it work?

A
  • Stem cell transplants
  • Cancer vaccines - try to induce immune system to target specific cancer antigen
  • Modulated T cell therapies
    • Train immune system to recognise and fight cancer
    • TILs (tumour infiltrating lymphocytes)
    • CAR-T cells - T cells with chimeric antigen receptor, these are genetically engineered, and will target cancers
27
Q

How is targeted therapy used to treat cancer and how does it work?

A
  • Biopsy can reveal subtype of tumour or specific mutation in cancer
  • Small molcules/enzyme inhibitors (end in nib) - Tend to be oral tablets- can be taken at home
    • E.g. Sunitinib in clear cell renal cancer
  • Monoclonal antibodies (end in mab)
    • E.g. Bevacizumab in ovarian cancer
28
Q

Describe the different desired outcomes of treatment of cancer that healthcare professionals have when deciding most appropriate options

A
  • Radical/curative intent vs treatment in advanced setting - giving aggressive treatment to try and remove cancer (e.g. surgery). Advanced setting = metastasis, so may mean palliative care is advised, however, treatments can still be effective against metastasised cancer, and patients can live 5+ years
  • Single treatment modality vs combination therapy - Use of multiple treatment modalities to treat cancer
  • Neo-adjuvant therapy - Any therapy given before curative intent treatments, for example giving chemotherapy before surgery. Can increase chance of cure
  • Adjuvant therapy - Giving therapy after curative intent treatment, for example, surgically removing breast cancer and then giving patient chemotherapy or endocrine therapy after to reduce risk of cancer recurrence
  • Prophylactic therapy - Therapies to prevent cancers from developing, can be given to patients carrying known mutations that increase their risk of developing cancer e.g BRCA 1 mutation, therapy can mean removing breast tissue to prevent breast cancer from developing
29
Q

How do healthcare professionals decide the most appropriate treatments for cancer management of patients?

A
  • Cancer staginng
    • Description of how far cancer has spread
    • Can be determined by imaging (+/- surgery/biopsy)
      • Imaging is usually a CT scan or PET scan
      • Biopsy can determine whether masses are benign lesions or cancer. Surgical biopsies may be needed if suspected cancer in difficult to access area
    • Determines best modality of treatment and whether the treatment intent is curative/palliative
    • Most cancer have their own staging systems
30
Q

How do pathological features influence cancer treatment?

A

Cancers have different:

  • Histological subtypes
    • E.g. Squamous vs adenocarcinoma lung cancer
  • Receptor status
    • ER positive or HER2 positive breast cancer
  • Genomics - mutation status
    • E.g. EGFR/ALK/ROS1 mutation in lung cancer
31
Q

What are the side-effects of radiotherapy?

A

Side effects depend on:

  • Site of treatment
  • Dosage
  • Side effects are categorised into early and late (the short and long term consequences of radiotherapy)

Side effects are:

  • Sore skin (skin erythema, ulceration)
  • Tiredness
  • Hair loss (alopecia)
  • Nausea
  • Sore mouth
  • Loss of appetite
  • Discomfort when swallowing
32
Q

What are the generic side effects of chemotherapy?

A
  • Damage to rapidly dividing normal cells
  • Fatigue
  • Myelosuppression (bone marrow activity decreased, results in fewer RBCs and WBCs and platelets) + risk of severe infection, anaemia
  • Skin toxicity - rash, alopecia
  • GI disturbance - nausea, change in taste, vomiting, diarrhoea/constipation, mucositis
  • Venous thromboembolism - DVT/PE
33
Q

What are the drug-specific side effects of chemotherapy?

A
  • Peripheral neuropathy + tinnitus (Cisplatin, Paclitaxel)
  • Nephrotoxicity (Cisplatin)
  • Pneumonitis + pulmonary fibrosis (Bleomycin)
34
Q

What are the Late (long term) side effects of chemotherapy?

A
  • Cardiotoxicity
    • Cardiomyopathy
    • Atherosclerosis
    • IHD
  • Secondary malignancies - Leukaemia etc.
35
Q

What are the side effects of endocrine therapy?

A

Hormonal effects which can last for a long period of time

36
Q

What are the side effects of immunotherapy?

A
  • Inflammatory & autoimmune conditions
    • Rash
    • Colitis
    • Thyroid dysfunction
    • Pneumonitis
37
Q

What is palliative care?

A

WHO - Palliative care is an approach that improves the quality of life of patients and their families who are facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual

38
Q

What are 5 factors patients want to be addressed throughout their time with serious illness?

A
  • Receiving adequate pain and symptom control
  • Avoiding inappropriate prolongation of death
  • Achieving a sense of control
  • Relieving burden on family
  • Strengthening relationships with loved ones
39
Q

How has the model of cancer care changed overtime?

A
  • Cancer care was largely curative until treatment stopped working, at which point it became palliative care
  • Now we have screening and diagnosis, and curative care happens alongside palliative care, as many patients would like treatment to deal with the psychosocial impact of cancer

When the disease is no longer being treated by directed treatment, end of life care begins to be delivered, and when a patient passes away, there’s a bereavement process to support family and friends who are suffering with the loss of a loved one

40
Q

What are the phases of palliative care?

A

Palliative care (symptom management, palliative treatments), then end of life care (hospice, more symptom management) and then terminal care

41
Q

Describe palliative chemo/radiotherapy and surgery

A
  • Palliative chemotherapy or radiotherapy can be used to improve symptoms associated with cancers but does not have curative intent
  • These can prolong life, but must be balanced with likelihood of difficult side effects
  • Patients can have surgical procedures such as placing stents etc to help alleviate the symptoms of metastases
42
Q

How can palliate care be delivered in a hospital or community setting?

A

Hospices
- In-patients
- Out-patients
- Day-care

Community palliative care
- Macmillan nurses
- Marie Curie nurses

Hospital support teams