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B33CAN - Professionalism & Leadership; Clinical & Pharmacy Practice > Treatment Purposes & Modalities > Flashcards

Treatment Purposes & Modalities Flashcards

1
Q

What is the epidemiology of cancer like?

A
  • 352, 197 people diagnosed w/cancer in the UK in 2013
  • 4 in 10 deaths; but 50% survive greater or equal to 10 years
  • 42% cases are preventable; public health issue

Largely a disease of older age, but:

  • Average of 800 children diagnosed (0-14) annually in the UK
  • Average of 1100 teenagers and young adults (15-24 years)
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2
Q

What is the lifetime risk of cancer compared with previously, and projected?
Why is this?

A
  • 2010; 4 in 10 people
  • 1975; 1 in 4
  • 2030; 44% projected for women (inc. ovarian), 50% for men (inc. prostate/bladder)

> Population is living longer and better survival for chronic diseases, MI, HF.
Cancer risk increases w/age

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3
Q

Can the risks of cancer be reduced?

A

Yes:

  • CRUK estimates 4 in 10 cancers are preventable; don’t smoke, don’t drink to excess, avoid excess UV/sunbeds, avoid red meat, obesity
  • Public health campaigns for earlier and better detection (e.g. breast, prostate, lung)
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4
Q

What are the most common cancers in males and females respectively?

A

M: Prostate (25%)
F: Breast (30%; but appears in men too, which presents aggressively)

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5
Q

What do the NHS Cancer Guideline stipulate for detection, referral and treatment?

A
  • All patients referred by GP w/suspected cancer should be seen within 2 weeks by a specialist
  • Cancer patients should wait no more than 31 days from the decision to treat ot start of first treatment
  • All patients should wait no more than 62 days from their urgent GP referral to the start of treatment (includes patients referred from NHS screening programs)
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6
Q

How did the NHS perform re.. the NHS Cancer Guidelines in 2014-15 compared to 2015-16?

A

2014-15: 94.7% seen by specialist from GP referral in 2 weeks

2015-16: 93.2% seen within 2 weeks (NHS pressures?)

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7
Q

What is the process for cancer Diagnosis?

A

Biopsy required of tumour; non-invasive or invasive (minor/major), e.g. simple needle aspiration or an open procedure e.g. craniotomy.

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8
Q

How may a biopsy be obtained of a tumour (for diagnosis)?

A
  • Cytology; specimen of fluid (e.g. sputum, ascitic fluid, pleural fluid) centrifuged, cells then collected for microscopical examination.
    > Cytologist can give immediate and accurate diagnosis; low false +ve rate.
  • Cell scrapings; superficial cells removed from body surface (e.g. cervix, bronchial mucosa) by scraping/brushing. Then stained and microscopical examination.
  • FNA; fine needle aspiration, fine gauge needle (22-27 gauge) passed into tumour, sometimes with ultrasound/CT guidance.
  • Incision biopsy; small piece of tissue taken from edge of tumour
  • Excision biopsy; tumour is excised in total, w/narrow margin (1-2 cm) of normal tissue.
  • Liquid biopsies; diagnosis from blood sample, assessing DNA mutations and other material shed by tumour into the blood.
    »> Potentially even more effective, finding mutations linked to resistance not seen in tumour.
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9
Q

Why is tumour Staging established?

A
  • Define the local and distant extent of disease
  • Help determine optimal treatment
  • Provides a baseline to which response to treatment can be assessed
  • Provides prognostic information
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10
Q

What do the letters TNM of the TNM staging system represent?

A

T; primary tumour
N; regional lymph nodes
(cellular drainage system)
M; distant metastases

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11
Q

What do the numbers associated with the letters TNM of the TNM staging system represent?

A

Each category assigned a number according to extent of disease:

  • 0; carcinoma in situ (abnormal cells present but have not spread to neighbouring tissue, not a cancer; pre-invasive tissue)
  • I-III; higher number indicate more extensive disease, with larger tumour size and/or spread of the cancer beyond primary organ to nearby lymph nodes and/or tissues/organs adjacent to primary tumour.
  • IV; cancer has spread to distant tissues or organs.
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12
Q

Why is metastases measured in the TNM staging system as just M0 or M1?

A
  • Cannot measure metastases

- So M0 or M1 (present or not present)

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13
Q

Would T3N0M0 reflect the same stage for bladder vs. colon cancer?

A
  • No

- Classification of staging varies between cancers; this is stage 3 bladder, stage 2 colon.

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14
Q

Why is the TNM staging system advantageous?

A
  • Recognised by the WHO, first dropped in the 1940s
  • Gives clinician insight into extent of cancer, guide to prognosis
    »> Gives consistency in reporting of clinical trials
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15
Q

What does tumour grading entail?

A
  • Macroscopic assessment of degree of differentiation of tumour cells
  • ‘Well differentiated Grade 1’
  • ‘Poorly differentiated Grade 3’
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16
Q

What is the difference between poorly differentiated and well differentiated cancers?

A
  • Well differentiated are lower grade, less aggressive (‘proper cell’ formation)
    »> More responsive to treatment
  • Poorly differentiated are harder to treat
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17
Q

What is meant by an anaplastic tumour?

A

Tumour showing no differentiation; most aggressive, higher grade, harder to treat.

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18
Q

What factors influence cancer treatment decisions?

A
  • Performance status
  • TNM stage and Grade
  • Prognosis
  • Tumour genetics
  • Co-morbidities
  • NICE guidelines
  • Patient choice
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19
Q

What is the WHO performance scale, and how does it influence treatment?

A

0; All normal activity w/o restriction
1; Mobile and able to do light work
2; Mobile, self caring, unable to carry out work. Up and about > 50% waking hours.
3; Only limited self care, confined to chair/bed > 50% waking hours.
4; Completely disabled, totally confined to bed/chair.

> > > Some protocols only used for patients w/good performance status (0 or 1); if they will tolerate the treatment well.

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20
Q

How does TNM Stage and Grade, and Prognosis, affect treatment decisions?

A
  • TNM; determine what type of treatment (if any) is appropriate)
  • Prognosis; don’t usually treat if prognosis is < 3 months (focus on quality of remaining life)
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21
Q

How does tumour genetics affect treatment decision?

A
  • Hormone sensitive receptors e.g. HER2 status in some breast cancers.
  • EGFR mutation in e.g. NSCLC must be present for gefitinib to be effective
22
Q

How do co-morbidities influence treatment decision?

A

Patients w/significant hepatic or renal impairment, or cardiac disease, will not be appropriate for treatment w/anthracycline antibiotics (e.g. Doxorubicin).

23
Q

How do NICE guidelines influence treatment decision?

A
  • New cancer drugs require NICE approval before routinely availible on NHS.
  • Caveats; e.g. gefitinib can only be used if first line treatment in lung cancer.
  • Cancer Drug Fund; drugs rejected by NICE, based on clinical rather than social circumstances.
24
Q

How does patient choice influence treatment decision?

A
  • Patient has to consent and agree to treatment plan
  • If patient has had several courses of chemotherapy/surgery, they may decline further treatment.
    »> In which case they will receive best supportive care; symptom management.
25
Q

What does Watch and Wait surgery for treatment entail?

A
  • Patient only treated when cancer progresses
  • Trial for rectal cancer was called Watch and Wait
  • Offered to patients w/indolent lymphoma, prostate cancer, ductal breast cancer (in situ)
    »> For asymptomatic slow growing tumours
26
Q

What does Surgery entail to treat tumours WRT tumours treated, and how else may the patient be treated in conjunction?

A
  • Can be just the sole intervention in some early cancers (e.g. breast, melanoma)
  • Can be very complex w/major reconstruction of bone and soft tissue
  • Surgeon removes wide margin of tissue surrounding tumour too
  • Place in palliative care for obstructive symptoms, control of haemorrhage etc.
  • Sometimes combined w/radiotherapy either pre or -post-operative
27
Q

How is radiotherapy combined w/surgery?

A
  • Pre-op: reduce tumour size so surgery is easier, tumour “detaches” from surrounding tissue, especially if tumour close to major arteries e.g. Head & Neck cancer
  • Post-op: lower dose needed as ‘mopping up’ microscopic disease
28
Q

What tumours are not suitable for radiotherapy?

A

Melanoma is not sensitive to radiotherapy.

29
Q

What determines the dose and course of radiotherapy?

A

Tumour type and treatment intent

30
Q

What types of radiotherapy are there?

A
  • External beam RT
  • Brachytherapy
  • Radioisotope therapy
31
Q

What is the process of conducting an External beam RT?

A
  • MRI to determine target
  • Planning CT scan uses lasers to determine precise position of tumour WRT to body; may mark skin w/small tattoos
  • Software to calculate dose and where to position positron beams; delivery to tumour and minimise exposure to vital organs
  • Patient to lie very still; may use cast to ensure no movement e.g. head and neck
32
Q

What does brachytherapy entail, and what types are there?

A

Radioactive sources placed either in or close to the tumour:

  • Mould treatment; radioactive source fixed in plastic mounting and placed directly over superficial skin tumour
  • Intracavitary treatment; radioactive sources are placed within a body cavity; used for cancer of the cervix/uterus.
  • Interstitial treatment; radioactive source is in the form of needles, wires or pellets, inserted directly into tongue, floor of mouth, prostate etc.
33
Q

What does Radioisotope therapy entail?

A
  • Systemic administration of a radioactive isotope (IV)
  • Isotope concentrated in certain sites in the body:
    > 131 I for thyroid cancer
    > 89 Sr for bone metastases
  • Inpatient treatment until radioactivity fallen to safe levels (dependent on half life)
  • Select patients carefully (have to be strong enough)
  • Areas of increased radioisotope uptake include the bladder, where it is stored to be excreted.
34
Q

Where is chemotherapy’s place in treatment, and which cancers are most sensitive?

A

Not all tumours sensitive to chemotherapy:

  • Highly sensitive tumours; treatment of choice (blood-borne stuff e.g. acute leukaemias, some lymphomas, neuroblastoma)
  • Modest sensitivity; play a part, often combined w/other modalities (breast, colorectal, ovarian)
  • Low sensitivity; limited value (prostate, primary brain tumours, palliation of advanced disease)
35
Q

What are the different treatment intents of (standard) chemotherapy?

A
  • Radical (curative); cure for the patient e.g. Burkitts lymphoma, testicular cancer. (v. intensive, high S/Es)
  • Neoadjuvant; used prior, e.g. surgery etc. (shrink tumour)
  • Adjuvant; used after, e.g. surgery
  • Palliative; used for symptom relief
  • Clinical trials
36
Q

Why is chemotherapy in clinical trials not usually blinded?

A
  • Most trials compare an established regimen with tweaks or addition of a new agent against current best care
  • No placebo trials; not ethical.
37
Q

What are the terms used when describing treatment intents for haematological cancers?

A

Treatment phases:

  • Induction; high dose combination chemotherapy, given the intent of inducing a complete remission
  • Consolidation; complete remission
  • Intensification; extend remission/cure duration, chemotherapy after complete remission often w/higher doses and/or alternate combinations.
  • Salvage; regain remission, potentially curative chemotherapy given to patients who have failed or recurred after curative chemotherapy.
  • Maintenance; retain remission, long term low dose (or biological therapy) in patients who have achieved full remission, delaying regrowth of micro-residual disease.
38
Q

What are the pros and cons of oral administration?

A

+ Convenient, patient can take home
+ Thus patient can be managed via telephone clinic, requiring fewer hospital visits
+ Bloods can be taken at GP practice
- BUT some regimens can be very complicated
- Easy to accidentally overdose

39
Q

What are the counselling points for oral administration?

A
  • Only patient should handle tablets; variable absorption

- Easy to accidentally overdose.

40
Q

What types of IV administration are there? When are they used?

A

Given as a bolus or infusion, initiated in hospital:

Peripheral cannula:

  • Patient cannulated at each visit
  • Can be difficult if patient has fragile veins or several courses of IV chemotherapy

Central venous access device: (e.g. hanging out internal jugular vein)

  • Good for veins that are difficult to access, have prolonged treatment or if needle-phobic.
  • BUT, CVADs need regular flushing, liable to become blocked or infected.

PICC line (type of VAD):

  • Into antecubital fossa
  • Catheter at vein, line terminates in superior vena cava

Elastomeric device:

  • “Balloon in a bottle”
  • Mechanical devices to deliver chemotherapy over 1-7 days
  • Patient can be connected up in hospital, disconnected after course by district nurse.
  • Cheap, affordable
  • Good for palliative care as doesn’t require admission
  • 5-FL in colorectal
41
Q

What ‘other’ routes of administration are availible? What do they share in common

A

Can be managed at home:

  • Intra-arterial
  • Intramuscular
  • Subcutaneous
  • Intracavity
  • Topical
  • Intrathecal
  • Wafer
42
Q

What does intra-arterial administration entail and when is it used?

A
  • Artery feeding the organ is catheterised
  • Only in hepatic tumours
  • NOT availible at hospitals in the UK
  • Allows a much higher concentration of chemotherapy to be delivered to the tumour
43
Q

What does IM administration entail, and why is it used?

A
  • Intramuscular
  • Absorbed slowly so longer duration of action (reservoir?)
  • Make sure platelets are adequate level prior
44
Q

What does SC administration entail?

A
  • Subcutaneous

- Can be administered at home by district nurse or by self

45
Q

What are some examples of intracavity administration?

A
  • Intraperitoneal; ovarian
  • Intrapleural; mesothelioma (pleural space around lungs)
  • Intravesical; bladder (roll every 15 mins to cover bladder)
46
Q

When is topical administration used?

A

Some skin cancers.

E.g. melanoma = 5-FL

47
Q

When is intrathecal administration used? What precautions are there?

A
  • Patients at risk of CNS relapse
  • V. strict guidelines re. prescribing, screening, manufacture, checking delivery and administration of intrathecal cytotoxic chemo
48
Q

When is the Wafer administration method used?

A
  • Carmustine wafers licensed for high grade glioma and recurrent glioma multiformae
  • Cochrane review; prolonged life without increase in S/Es
  • Excise tumour in surgery then up to 8 wafers placed in cavity (look like effervescent tablets)
  • Wafer dissolves
49
Q

How frequently are cycles of chemo given? What are the conditions to be met before administering the next course?

A
  • Every 21 days
  • Need WCC and ANC to recover before next cycle; successive cycle only given when prior damage from previous sample is repaired (around 21 days = normal cells recover)
50
Q

What is the WCC nadir, and why does it happen?

A
  • The lowest point of White Cell Count
  • Nadir occurs 10 days post chemo
  • As WCCs are rapidly replicating cells too; prone to damage
  • ANC = most important factor for fighting infection
    »> Signs of bruising/sore throat = signs of infection = red flag

B33CAN - Professionalism & Leadership; Clinical & Pharmacy Practice (8 decks)

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