MDS 4015 Oncology and Palliative Care Past Paper PDF

Neil Portelli MD4 2023/24 MDS 4015 – Oncology and Palliative Care Breaking Bad News: 1. List the sequence to be followed when breaking bad news. Environment, Patient’s...

Neil Portelli MD4 2023/24 MDS 4015 – Oncology and Palliative Care Breaking Bad News: 1. List the sequence to be followed when breaking bad news. Environment, Patient’s perception, Warning, Level of information patient wants, Diagnosis and treatments 2. In what way should information about diagnosis and treatment be shared with the patient? Broken down into manageable chunks, checking understanding at every stage 3. Explain the SPIKES model. Setting up, Patient’s perception, Invitation (ask for permission to explain), Knowledge (share information), Empathy while addressing emotional response, Strategy and summary The Genetics of Cancer: 4. Name the 2 types of mutations. Inherited, Acquired 5. Mutations can result in cancer due to gain of function of ___ or loss of function of ___. Oncogenes (e.g. ras protein), Tumour suppressor genes (e.g. p53) 6. Which features are suggestive of a hereditary cancer? Early age/unusual presentations, Multiple primary/bilateral/multifocal cancers, Clustering in relatives, Multiple generations affected, Rare tumour/histology, Ethnicity 7. How can the suspicion of an inherited cancer be confirmed? Genetic testing 8. Which gene mutations commonly predispose to breast/ovarian cancer? BRCA1, BRCA2 9. BRCA1 and BRCA2 function as ___ and they are ___. Tumour suppressor genes, Dominant (phenotype seen even if only 1 is mutated) 10. Which other cancers have been linked to BRCA 1 and BRCA 2 mutations. Prostate, Peritoneal, Pancreatic 11. Mention another gene mutation which predisposes to breast cancer. TP53 12. What is the management of patients with BRCA1/BRCA2/TP53 mutations? Genetic counselling, Testing for other gene mutations, Annual MRI (30-49y), Annual mammography (50-70y) 13. What is the prophylactic treatment of breast/ovarian cancer? Prophylactic tamoxifen/raloxifene, Surgery (mastectomy/oophorectomy) 14. What are the risks associated with tamoxifen and raloxifene? VTE, Endometrial cancer 15. Name 3 autosomal dominant colorectal cancer syndromes. Hereditary non-polyposis colorectal cancer (HNPCC)/Lynch syndrome, Familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome 16. How does HNPCC occur? Mutations in mismatch repair genes 17. Which cancers types does HNPCC predispose to? Colorectal, Endometrium, Ovary, Urinary tract, Stomach, Small bowel, Hepatobiliary tract 18. In which patients should HNPCC be suspected? At least 3 affected relatives from 2 successive generations (including one 1st degree relative and one 12y), Prophylactic surgery (>25y) 23. Which factors does prophylactic surgery depend on in FAP? Polyp number/size/dysplasia 24. How does Peutz-Jeghers syndrome occur? Germline mutations in STK11 (tumour suppressor gene) 25. What is the clinical manifestation of Peutz-Jeghers syndrome? Hamartomatous polyps + increased risk of colorectal/GI/breast cancer 26. Which gene mutations predispose to prostate cancer? BRCA1, BRCA2, Mismatch repair, HOXB13 27. Give examples of other familial cancer syndromes. Von Hippel-Lindau, Carney complex, MEN (multiple endocrine neoplasia), Neurofibromatosis Cancer Diagnosis: 28. Which clinical features of lung cancer warrant the patient to be admitted? Symptomatic SVCO, Stridor 29. Which clinical features of lung cancer warrant urgent referral? Haemoptysis (>40y), CXR suggestive of cancer 30. Which clinical features of lung cancer warrant an urgent CXR? >40y – Persistent/recurrent LRTI, Clubbing, Lymphadenopathy (supraclavicular/cervical), Thrombocytosis, Cough, Fatigue, SOB, Chest pain, Weight loss, Low appetite, Smoker/asbestos 31. Which clinical features of upper GI cancer warrant urgent endoscopy? Dysphagia, >55y – weight loss/upper abdominal pain/reflux/dyspepsia 32. Which clinical features of upper GI cancer warrant urgent referral? >40y – Jaundice, Upper abdominal mass 33. Which clinical features of pancreatic cancer warrant urgent CT of the pancreas? >60y – Weight loss + diarrhoea/abdominal pain/back pain/N&V/constipation/new-onset DM 34. Which clinical features of upper GI cancer warrant non-urgent endoscopy? Haematemesis, >55y – persistent dyspepsia/upper abdominal pain/anaemia/thrombocytosis/N&V/weight loss 35. Which clinical features of lower GI cancer warrant urgent referral? +ve faecal occult blood, >40y – Abdominal pain + weight loss, >50y – Rectal bleeding, >60y – IDA or change in bowel habit, Rectal/abdominal mass, Anal ulceration 36. Which clinical features of lower GI cancer warrant FOB testing (faecal occult blood)? >50y – Abdominal pain/weight loss, >60y – Anaemia, 30y – Breast/axillary lump, >40y – Change in 1 nipple, Skin changes 40. Which clinical features of urological malignancy warrant urgent referral? Irregular prostate on DRE, Abnormal PSA, >40y – Visible haematuria, >60y – Non-visible haematuria + dysuria/high WCC, Non-painful testicular enlargement/change 41. Which clinical features of CNS malignancy warrant an urgent MRI? Progressive subacute loss of central neurological function 42. Mention 3 non-specific signs of cancer. Weight loss, Anorexia (loss of appetite), DVT 43. List the members of the MDT that take care of cancer patients. Lead clinician, Lead nurse specialist, Radiologist, Histopathologist, Expert surgeons, Oncologists, Palliative care physicians, Patient representative 44. Why is staging of tumours important? MMSA-SCOME Notes Database Neil Portelli MD4 2023/24 Treatment, Prognosis, Identification of relevant clinical trials 45. Name and explain the most commonly used cancer staging system. TNM staging system – T (extent of primary tumour), N (LN spread), M (metastasis) 46. Explain the possible meanings of “T” in the TNM staging system? Tx – cannot be measured, T0 – cannot be found, Tis – carcinoma in situ, T1-4 – size and extent of invasion 47. Explain the possible meanings of “N” in the TNM staging system? Nx – cannot be measured, N0 – no LN involvement, N1-3 – number and location of LN metastasis 48. Explain the possible meanings of “M” in the TNM staging system? M0 – no distant metastasis, M1 – distant metastasis 49. Explain how the TNM staging system is converted to a simpler overall cancer stage. Stage 0 – carcinoma in situ, Stages I to III – describe size +/- extent of nearby spread, Stage IV – metastatic disease 50. Name a staging system used specifically for CRC. Duke’s classification 51. Name the imaging techniques used in oncology. US, CXR, CT, MRI, PET-CT, Monoclonal antibodies, Bone scintigraphy (bone scan) 52. Explain the PET component of PET-CT. Uses radioactive tracer (FDG) which highlights areas of increased metabolism/cell proliferation/hypoxia 53. Define monoclonal antibodies. Radio-labelled tumour antibodies specific to the tumour under investigation 54. Give examples of monoclonal antibodies. Prostate specific membrane antigen, Somatostatin (neuroendocrine tumours), Oestrogen receptor (breast) 55. Define bone scintigraphy. Detects abnormal metabolic activity in bones Cancer Treatment: Medicine and Surgery 56. Define chemotherapy. The use of cytotoxic drugs in cancer treatment 57. How does chemotherapy differ from surgery and radiotherapy? It is the only systemic treatment 58. Why is chemotherapy given at intervals (in cycles)? To allow recovery of normal tissue 59. Why is combination chemotherapy preferred over single-agent chemotherapy? Reduces likelihood of resistance and toxicity 60. What are the ideal properties of chemotherapeutic agents used in combination chemotherapy? Cytotoxic activity for the tumour, Different mechanisms of action (ideally additive/synergistic), Different mechanisms of toxicity, Non-overlapping toxicity 61. Name the 3 situations in which chemotherapy can be used. Adjuvant, Neoadjuvant, Palliative 62. Define adjuvant chemotherapy. Used after initial treatment (e.g. surgical resection) to reduce risk of relapse 63. Define neoadjuvant chemotherapy. Used to shrink tumours prior to surgery/radiotherapy 64. What are the aims of palliative chemotherapy? Symptomatic relief, Prolongs survival 65. List the classes of cytotoxic drugs. Alkylating agents, Angiogenesis inhibitors, Antimetabolites, Antioestrogens, Antitumor antibiotics, Monoclonal antibodies, Topoisomerase inhibitors, Vinca alkaloids and taxanes 66. What is the mechanism of action of alkylating agents? Bind to alkyl groups in DNA, leading to apoptosis 67. Give examples of alkylating agents. Cyclophosphamide, Chlorambucil, Busulfan MMSA-SCOME Notes Database Neil Portelli MD4 2023/24 68. Give examples of angiogenesis inhibitors. Bevacizumab, Aflibercept, Sunitinib 69. What is the mechanism of action of antimetabolites? Interfere with cell metabolism (DNA/protein synthesis) 70. Give examples of antimetabolites. Methotrexate, 5-fluorouracil (5-FU) 71. Give examples of antitumour antibiotics. Dactinomycin, Doxorubicin, Mitomycin, Bleomycin 72. What is the mechanism of action of monoclonal antibodies? Antibodies to a specific tumour antigen which can work in 2 ways: Slow tumour growth by enhancing host immunity Conjugated with chemotherapy/radioactive isotopes to allow targeted treatment 73. What is the mechanism of action of topoisomerase inhibitors? Interrupt DNA unwinding 74. Give an example of topoisomerase inhibitors. Etoposide 75. What is the mechanism of action of vinca alkaloids and taxanes? Target mechanisms of cell division 76. Give examples of vinca alkaloids and taxanes. Vincristine, Vinblastine, Docetaxel 77. Which cells are particularly affected by side effects of chemotherapy? Dividing cells – Gut, Hair, Bone marrow, Gametes 78. Mention 3 common side effects of chemotherapy. Vomiting, Alopecia, Neutropenia (neutropenic sepsis) 79. How can alopecia be managed in patients on chemotherapy? Cold cap, Wig 80. Define extravasation. Inadvertent infiltration of a drug into subcutaneous/subdermal tissue 81. How does extravasation of chemotherapy present? Tingling, Burning, Pain, Redness, Swelling, No flashback/resistance from cannula 82. What is the management of extravasation of chemotherapy? Stop and disconnect infusion, Aspirate any residual drug before removing cannula, Dry cold/warm compress 83. Distinguish between dry cold compress and dry warm compress. Dry cold compress – used for DNA-binding drugs (anthracyclines/alkylating agents/antitumour antibiotics) to vasoconstrict and decrease drug spread Dry warm compress – used for non-DNA-binding drugs (vinca alkaloids and taxanes) to vasodilate and increase drug distribution 84. What are the different aims of surgical procedures in oncology? Prevention, Screening, Diagnosis and staging, Treatment, Reconstruction, Palliation 85. What are the advantages of participating in clinical trials? Possibility of more effective treatment, Close monitoring, Possible reassurance from more frequent clinical encounters, Altruism 86. What are the disadvantages of participating in clinical trials? Possibility of less effective treatment, Unknown toxicity, Possible anxiety from more frequent clinical encounters, Time-consuming 87. How may chemotherapy and radiotherapy lead to sterility? Impaired spermatogenesis, Premature ovarian failure 88. Which fertility preservation techniques should be offered prior to chemotherapy? Men – Semen cryopreservation Women – Cryopreservation of embryos/oocytes/ovarian tissue, Ovarian transposition (oophoropexy) before pelvic radiotherapy MMSA-SCOME Notes Database Neil Portelli MD4 2023/24 89. Define Beau’s lines and state its causes. Horizontal depressions in the nail plate due to sudden interruption of nail keratin synthesis (local infection/ trauma/systemic illness/medication) 90. What do Beau’s lines signify in the context of cancer? Each line corresponds to a cycle of chemotherapy Cancer Treatment: Radiotherapy 91. Define radiotherapy. The use of ionising radiation to damage DNA, preventing cell division and leading to cell death 92. Name the 2 main uses of radiotherapy. Radical radiotherapy, Palliative radiotherapy 93. Define radical radiotherapy. The use of a high dose of radiotherapy with a curative intent 94. Define palliative radiotherapy. The use of smaller doses of radiotherapy (given in fewer fractions) for short-term tumour control with minimal side effects 95. What is the aim of palliative radiotherapy? Symptomatic relief (may not impact survival) 96. What are the indications of palliative radiotherapy? Brain metastasis, Spinal cord compression, Visceral compression, Bleeding (e.g. haemoptysis/haematuria), Bone metastasis 97. When do early reactions of radiotherapy occur? 2 weeks into treatment 98. List the early reactions to radiotherapy. Tiredness, Skin reactions, Mucositis, N&V, Diarrhoea, Dysphagia, Cystitis 99. What are patients advised with regards to tiredness? Stay active 100. Which skin reactions are common in radiotherapy? Erythema, Dry desquamation, Moist desquamation, Ulceration 101. What is the management of skin reactions in radiotherapy? Aqueous cream 102. What is the management of mucositis in radiotherapy? Dental check-up before therapy, Avoid smoking, Antiseptic mouthwashes, Aspirin gargle (soluble analgesic), PO fluconazole (if oral thrush) 103. What are the treatment options of N&V in radiotherapy? PO metoclopramide, PO domperidone, PO/IV ondansetron 104. What is the management of diarrhoea in radiotherapy? Hydration, Avoid high-fibre diets, PO loperamide 105. What is the management of dysphagia in radiotherapy? SLP, Nutrition 106. What is the management of cystitis in radiotherapy? Drink plenty of fluids 107. When do late reactions of radiotherapy occur? Months/years after treatment 108. List the different types of late reactions to radiotherapy. CNS/PNS, Lung, GI, GU, Endocrine, Secondary cancers 109. Name the late CNS/PNS reactions to radiotherapy. Somnolence, Spinal cord myelopathy, Brachial plexopathy 110. Name the late lung reaction to radiotherapy. Pneumonitis 111. Pneumonitis in radiotherapy presents with ___ and is managed by ___. MMSA-SCOME Notes Database Neil Portelli MD4 2023/24 Dry cough +/- dyspnoea, Bronchodilators and steroids 112. Name the late GI reactions to radiotherapy. Xerostomia, Benign strictures of oesophagus/bowel, Fistulas 113. Name the late GU reactions to radiotherapy. Urinary frequency, Vaginal stenosis, Dyspareunia, Erectile dysfunction, Infertility 114. Name the late endocrine reactions to radiotherapy. Panhypopituitarism, Hypothyroidism 115. What does the likelihood of developing the above complications depend on? The body parts exposed to radiotherapy 116. List the methods of delivering radiotherapy. Conventional external beam radiotherapy (EBRT), Stereotactic radiotherapy (Gamma Knife), Brachytherapy, Radioisotope therapy 117. Define EBRT. Delivers ionising radiation from an external linear accelerator (commonest) 118. Define stereotactic radiotherapy. Highly accurate form of EBRT used to treat smaller lesions (usually intracranial tumours) 119. Define brachytherapy. Radiation source placed within/close to a tumour to give a high local radiation dose 120. Define radioisotope therapy. Uses tumour-seeking radionuclides to target specific tissues Oncological Emergencies: 121. List the oncological emergencies. Neutropenic sepsis, Spinal cord compression, SVC syndrome, Malignancy-associated hyperCa, Brain metastases, Tumour lysis syndrome 122. Define neutropenic sepsis. Temperature >38 degrees and neutrophil count 38 degrees (or >37.5 on 2 separate occasions) + Neutrophil count