Week 8 Oncology in Primary Care Flashcards
What does it mean to be cured of cancer?
In remission?
Means when the patient hasn’t had cancer in 5 year time span
Top 6 cancer deaths in 2023 (combined M+W)
- Lung and bronchus (top for M+W)
- Colorectum
- Pancreas
- Breast
- Prostate
- Liver and intrahepatic bile duct
Lung and bronchus d/t smoking boom in 1960s-1980s
Top 3 Estimated new cancer cases (women)
- Breast
- Lung
- Colon and rectum
Top 3 estimated cancer cases (Male)
- Prostate
- Lung and bronchus
- Colon and rectum
Most people diagnosed with cancer are above how old?
55
SDOH in context of cancer care
Factors
7 L’s
- Low income
- Low health literacy
- Long travel distance to screening sites
- Lack health insurance
- Lack of good transportation to facility
- Leave (no medical leave)
- Lack of access to clean water/air
7 L’s
Optimal Cancer Care across continuum
Steps of Cancer care (6 steps)
- Prevention and risk reduction
- Screening
- Diagnosis
- Treatment
- Survivorship
- EoL care
Which level of prevention is most optimal for cancer?
Primary prevention
- aka prevent the problem from happening in the 1st place
- Reduce modifiable risk factors
Which level of prevention is cancer screening?
Secondary
- You are detecting disease in early, asymptomatic, or preclinical state to eliminate potential impact
Risks of screening
- Bleeding from invasive tests (colonoscopy)
- False (+)
- False (-)
- DX cancer not treatable or treatment not improve QoL
- SDOH in screening
Other components in screening appointment
what else do you gather from pt/give to pt
- Complete health history (FMHx + PMHx)
- Genetic testing
- Provide evidence-based + age-appropriate screening
- PE - look for s/s
Signs/symptoms of cancer presence
TEST QUESTION
- May be asymptomatic
- Mass or lesion, skin changes
- Lymphadenopathy
- Bone pain
- Bowel/Bladder changes
- Unintentional weight loss
- Fever
- Cough, SOB
- Fatigue
- Abnormal bleeding
Special considerations of screening in older adults
- Clinical trails usually don’t include older adults
- Use individualized approach when using recommendations/guidelines
- Consider life expectancy, comorbidities, functional status, + pt’s goals/values
- Underscreening vs overscreening (don’t do mammograms on dementia pts)
- Consider lag time between cancer screening and its benefits; harms of screening are more immediate
- Life expectancy of at least 10 yrs is necesary to derive a survival benefit for breast or colorectal cancers
Choosing wisely recommendation in cancer screening
Cancer pathology descriptors
- Histological info
- to tailor txs; need to know cancer type
- Biomarker testing/genomic profiling
- Unique pattern of biomarkers/tumor markers - also to tailor prognostic info + tx
- Biopsy to assess malignant cells: Needle, endoscopic, surgical
- Tissue exam vs. Cytologic exam
- Timing: frozen section (udring surgery) vs pathology (more accurate - takes longer)
Purpose of biomarker testing
Looks for genes, proteins to help ID cancer type + tx options
surveillance cancer with these too
Types of Cancer biomarkers
- Circulating tumor markers (not diagnostic)
- Tumor tissue markers (usually from tumor tissue itself)
Purposes of circulating tumor markers
Frequency of measurement?
- Estimate prognosis
- Determine stage of cancer
- Detect cancer that remains after tx or that has returned
- Assess how well tx is working
- Monitor whether treatment has stopped working
- Measured serially during cancer tx
- Checked to retect possible recurrence
Cancer Grading system
Description of a tumor based on how abnormal the tumor cells and tumor tissues appear microscopically
GX: Grade cannot be assessed
G1: Well differentiated (low grade)
G2: Moderately differentiated (intermediate)
G3: Poorly differentiated (high)
G4: Undifferentiated (high)
Cancel cell
Differentiated vs undifferentiated
Well-differentiated: close to normal cells
Undifferentiated: abnormal looking cells
Cancer staging system
Helps to describe the extent of the cancer
TNM staging
T = size and extent of primary tumor
N = number of regional lymph nodes w/cancer
M = metastasis
Curative treatment for which cancer stage(s)?
Stage 3 or below
Standard tissue biopsies (GOLD STANDARD) involving…
Generally involve invasive procedures to detect a tumor
Local cancer treatment modalities
Surgery
Radiation therapy
Interventional procedures
Systemic cancer treatment modalities
Chemotherapy: attacks different phases of cell cycle
- Neoadjuvant - given before surgery
- Adjuvant - given after surgery
Hormonal therapy
Targeted therapy
Immunotherapy/biotherapy
- Cytokines
Vaccines
Why offer complementary/alternative medicine in oncology
Helps pt cope w/stress of cancer
Roles of PC NP during oncology treatment
there are many
- Be a case manager
- Maintain regular contact
- Be available - for any other issues
- Have knowledge of community resources + covered services
- Address ongoing health maintenance needs
- Provide appropriate pain management
- Assess for pathologic depression and other psychiatric pathology
- Be aware of therapeutic options
- Communicate w/ and support patient
What labs should the PC NP monitor?
Lab surveillance - mostly determined by cancer team
- CBC w/diff- anemia, neutropenia, thrombocytopenia
- CMP - renal + liver function
- Circulating tumor markers - serially
How often and When should the NP perform cardiac monitoring
0, 3, 6, 9, and 18 mos (more frequent if (+)Cardiac Hx)
Frequent monitoring for deteriorating LVEF
Radiation to the chest
Bone marrow/stem cell transplant or certain types of chemo
Which cardiac condition would an NP permanently discontinue cancer treatment?
S/S of CHF
Chemo tx AEs
- Hair loss (Rx for wig)
- Diarrhea
- Anemia
- Skin changes
- N/V
Radiation therapy AEs
Often dependent on site of radiation
* Mucositis
* Thrush
* Fibrosis
* Diarrhea, proctitis
Dangers of Chemo-related Diarrhea (CRD)
What to R/O 1st?
- Serious and potentially life-threatening complication of wide variety of chemo drugs, hospital admission frequently needed for adequate care
- Can result in treatment delays and diminished compliance → compromise long-term outcomes
- R/o infectious cause before tx w/anti-diarrheals
- Refractory CRD → supportive care/discontinuation of tx
General principles of N/V s/s
- Consider emetogenicity of the chemotherapy regimen
- Consider timing: acute, delayed, anticipatory, breakthrough
- Consider severity: mild, mod, severe, refractory
- Consider options of route administration
- Cost and insurance coverage
Timing:
Acute
Delayed
Anticipatory
Breakthrough
Acute: < 24hrs
Delayed: > 24hrs
Anticipatory: take meds on the way to treatment center
Breakthrough: s/s occuring despite meds
Diarrhea non-pharm measures
Avoid triggering foods that might aggravate diarrhea and aggressive oral rehydration w/fluids containing salt, water, and sugar
Foods to avoid:
* Milk + dairy products
* Spicy foods
* High fiber and high fat foods
* Some fruit juices: prune, orange
Neutropenic fever
Definition
A single oral temp of ≥ 101F (38.3C) OR
temp of ≥ 100.4F (38C) sustained over a 1hr period
Neutropenia
Definition
ANC < 1500 or 1000
Severe neutropenia: ANC < 500
Neutropenia fever treatment
Med used
- Empiric abx therapy initiated immediately → infectious workup
- Admission as needed then diagnostic reassessment
- MED used: LEVAQUIN
Hisk risk pts of Neutropenic fever
Inpatient management
* Cr > 2; LFTs > 3x normal limit
* Uncontrolled/progressive disease
* PNA risk
* Comorbidities: age, social/home status
* ANC < 1000
* Fever 101F
Low risk pts of Neutropenic fever
Outpatient management
* Tx w/Levaquin
* Cr < 2; LFTs < 3x normal limit
* No co-morbid conditions
* Limited duration of neutropenia
* Active and independent
Mucositis
Definition
Acute/short term oral toxicity realted to chemotherapy self-limited AE of either radiation or chemotherapy
- Can affect entire GI tract
When does mucositits usually occur in cancer treatment
After chemo
~7 days peak, usually healed w/in 10-14d
From radiation, more delayed and cumulative
Mucositis staging
G0: None
G1: Erythema and soreness
G2: Ulcers; able to eat solid food
G3: Ulcers; but requires liquid diet d/t mucositis
G4: Ulcers; alimentation not possible d/t mucositis
Mucositis complications
Oral candidiasis
HSV infection
Superimposed bacterial infection
Mucositis management
Magic mouthwash! (Benadryl + Maalox + Viscous lidocaine)
Mylanta (simethicone)
Many others
Fatigue causative factors and treatment in setting of cancer care
Causative factors
* Emotional distress
* Anemia
* Sleep disturbance
* Nutrition imbalance
* Activity level
* Metabolic derangements
Treatment
* Increase exercise as tolerated
* Address anxiety, depression - to help w/sleep
* Stress management
* Support groups
* Steroids, stimulants
What not to give if pts on immunotherapy?
STEROIDS
Immunotherapy common SEs
Skin: Dermatitis, pruritis
Constitutional: Fevers, chills, fatigue
GI: Diarrhea/colitis
Resp: Pneumonitis
Immunotherapy Infrequent SEs
- Hepatitis/liver enzyme abnormalities
- Endocrinopathies: hypophysitis, thyroiditis, adrenal insufficiency
- Vitiligo
Treatments for Immunotherapy SEs based on grade
Grade 1-2
- Supportive care
GRade 3-4
- Steroids (except w/endocrinopathies, which are treated w/HRT and not steroids)
Refractory to steroids
- Infliximab (hepatotoxic, not for pts w/liver disease) or mycophenolate mofetil
- Rechallenging with immunotherapy after discontinuataion if possible
When do immunotherapy SEs usually show?
10-20wks
Spinal cord compression
What is it, what does it signify, and symptoms
- Spinal column metastasis, local spread intramedullary metastasis
Symptoms
* Back pain (EARLY)
* Neurologic defecits in legs
Superior Vena Cava Syndrome
What is it, what does it signify, and symptoms
Mediastinal tumors
Venous catheters
Symptoms: Think everything head stuffiness
* Neck
* Facial, periocular swelling
* Dyspnea
* Cough
* Head pressure
* Hoarseness
* Nasal congestion
* Syncope
Pericardial tamponade
What is it, what does it signify, and symptoms
Lymphatic obstruction
Pericardial metastasis
Symptoms:
* Dyspnea
* Orthopnea
* Chest pain
* Weakness
Hypercalcemia (in cancer SEs)
What is it, what does it signify, symptoms
Bone metastasis
PTH - related protein production
Calcitriol excretion
Symptoms:
* Confusion
* Lethargy
* Sleepiness
Bisphosphonates as prophylactic treatment
Tumor Lysis Syndrome (TLS)
What is it, what does it signify, and symptoms
Rapid tumor cell destruction from chemo - chemo working too well
Multiple electrolyte abnormalities - acute renal failure
Hyperuricemia
Symptoms:
* Nausea
* Weakness
* Myalgia
* Dark urine
* Arrythmias
When to contact oncology team?
AKA REFER
- Difficult symptom management
- Critical lab values
- New suspicious findings
- Oncologic emergencies
Cancer survivorship
Definition
Any individual who has had cancer from time of DX through reminder of their life
Risk factors of cancer survivorship
Physical and Psychological effects
* Recurrence of primary cancer or through risks for a second primary cancer - chemotherapy related cancers
* Late effects of treatment
* Chronic complications
* Radiation post-effects
* Premature menopause
* Preipheral neuropathy
* Cognitive slowing
* Lymphedema
* Urinary or bowel problems
Late or long term effects of chemotherapy
- Cardiac dysfunction
- Pulmonary fibrosis
- Neuropathy
- Hearing loss
- Premature menopause, infertility
Late or long term effects of Hormonal Therapy
- Tamoxifen - clotting, uterine cancer, hot flashes, vaginal dryness
- Aromatase inhibitors - Osteoporosis, MSK pain
- Androgen deprivation (LHRH agonists, anti-androgens GnRH agonists) - hot flashes, osteoporosis, metabolic syndrome breast tenderness, reduced libido/ED, fatigue
