Oncology & Palliative Care

Sunday, December 11, 2022

Dr. Tian Xiao

www.internalmedicinereview.ca © Internal Medicine Review 2023

**HIGH YIELD **
Overview (RC Objectives*)
Marked with ⌘

• Screening and prevention (1.4.12.3.2.) *Based on the RC 2018 IM Competencies:

“Effective for residents who enter training
• Common solid tumour sites (1.4.12.3.4.) on or after July 1, 2019.”
o Breast
o Lung 0-5% of Written Exam.
Common Orals:
o Colorectal - Screening
o Prostate - Diagnosing cancer
- Oncologic Emergencies can be a
o Gastrointestinal (gastroesophageal, HCC, pancreatic) common oral scenario!
o Genitourinary (testes, bladder, renal cell)
o Gynecologic (endometrial, cervical, ovarian)
• Oncologic emergencies (1.4.12.3.1.)
• Systemic toxicities (1.4.12.3.3.)
• Palliative care (1.4.13.7.)
(The Royal College of Physicians and Surgeons of Canada: Internal
Medicine Competencies. 2018; Version 1.0:1-28.) 2
 MCQ1. Screening
A 72yF lawyer executive presents after her best friend was diagnosed with
metastatic cancer and wants to be sure she doesn’t have cancer herself. She
reports a family history of colon cancer in her paternal grandfather, and
cervical cancer in her sister, though she says her last pap test 4 years ago was
normal and never had an abnormal pap. She smoked ½ ppd from age 30-60.
What cancer screening do you recommend?
a) mammogram, pap smear, FIT testing
b) Mammogram, pap smear, colonoscopy
c) Mammogram, pap smear, colonoscopy, low dose CT Thorax
d) Mammogram, FIT testing, low dose CT Thorax
e) Mammogram, FIT testing

3
 Screening for Breast Cancer
“Average risk” guidelines (CTFPHC)1
• Pertains to the General population
o < 15% lifetime risk (using IBIS or BOADICEA tools – do NOT memorize)
o Applies to women ages 40 to 74 who are NOT “High risk” (see next slide)

• Age-based recommendations
o 40-49 yrs – Recommend AGAINST screening
o 50-74 yrs – Recommend FOR screening mammogram q2-3 yrs
o ≥ 75 yrs – No evidence of benefits/harms to make formal recommendation
Please see High
risk Screening in
• Screen with mammogram only Extra Material
o Recommend AGAINST self-breast exam, clinical breast exam, or US/CT/MRI

4
 **HIGH YIELD **
Screening for Lung cancer (CTFPHC)2
• Criteria (need all 3) (Apply to adults >=18 who are NOT suspected of
having lung cancer)
1. Age 55-74 years* Comments in CTFPHC Review:
2. ≥ 30 pack-year* smoking history
“Providers should also consider
3. Current smoker or quit within the past 15 years
overall health status … since
• Screen with annual low dose CT every year up to 3 consecutive years reasonable life expectancy and
o Recommend against screening CXR or sputum cytology suitability for treatment of lung
cancer (if identified) is required in
• After 3 years order to benefit from screening.”
o Canadian guideline doesn’t address
o US guideline suggests screening annually until quit smoking > 15
years, or develops other life-limiting illness

*USPFTF suggests ≥ 20 pack-years,

50-80 years old 5
 Screening for Colorectal Cancer (CRC)
“Average risk3,4 & Increased risk5”
• Average risk = General population (CTFPHC 2016)
o No previous CRC or polyps, no IBD, no FHx CRC
o Age 50-74 – Screen with FIT or gFOBT q2 yrs OR Flex sigmoidoscopy q10 yrs
o Recommend AGAINST screening adults aged 75+
o Recommend AGAINST using colonoscopy as a screening test in average risk

• Increased risk (CAG 2018) 5

o ≥ 1 First-degree relative with colon cancer OR advanced adenoma
o Age 40-50 yrs or 10 yrs before earliest age of relative’s diagnosis (whatever is youngest) –
Screen with colonoscopy q5-10 yrs
o FIT q1-2 yrs can be considered a 2nd-line, alternative screening test

6
**HIGH YIELD **

Screening for Hepatocellular Carcinoma (CASL, AASLD)7,8

• High risk populations (either of…)
o All patients with cirrhosis, regardless of age/etiology (Hep B/ C, NAFLD, EtOH, α-1
antitrypsin deficiency, NASH, AIH, HH, PBC, Wilson’s disease)
o Hep B carrier (sAg +) AND…
§ Asian males ≥40, Asian females ≥50
§ African or North American blacks ≥20 yrs
§ FHx of HCC in 1st degree relative (start at age 40)
§ CASL = All HIV co-infected patients (start at age 40)
§ AASLD= All Hep D co-infected patients

• Screening test – Ultrasound q6 months

o Serum AFP monitoring is NOT recommended for screening if ultrasound is available
o DO NOT screen Pts with Childs-Pugh C cirrhosis, unless awaiting liver transplant
7
 Screening for Cervical Cancer (CTFPHC)9
• Screening population
o Women ages 25-69 – Screen with cervical cytology q3 years
§ Includes HPV-vaccinated women & women who have sex with women
§ Cancer Care Ontario suggests start at 21 yrs

• Screen with pap test cervical cytology q3 yrs

• STOP screening at age ≥70 AND ≥ 3 negative tests in the last 10 yrs

• These guidelines DO NOT apply to: Never sexually active, Previous abnormal Pap tests,
Immunocompromised (eg. HIV, organ transplant, chemo, chronic corticosteroid use),
Symptomatic of cervical cancer (eg. abnormal vaginal bleeding), limited life expectancy

8
 DO NOT SCREEN for These Cancers
• Melanoma (CTFPHC 2008) – Recommend AGAINST population-based skin
screening
• Testicular (USPSTF 2011) – US guidelines recommend AGAINST screening
• Ovarian (CTFPHC 2013) – Do NOT screen in average risk women
• Prostate (CTFPHC 2014) – Do NOT screen with PSA
• Esophageal (CTFPHC 2020)10- Do NOT screen for cancer or dysplasia/ Barrett’s in
chronic GERD without alarm symptoms
– Does not apply to patients with alarm symptoms (dysphagia, odynophagia, weight loss, anemia,
bleed, loss of appetite)
– Does not apply to patients with previously diagnosed Barrett’s

CTFPH – Canadian Task Force Preventative Health Care

USPSTF – United States Preventative Service Task Force

9
 MCQ1. Screening
A 72yF lawyer executive presents after her best friend was diagnosed with
metastatic cancer and wants to be sure she doesn’t have cancer herself. She
reports a family history of colon cancer in her paternal grandfather, and
cervical cancer in her sister, though she says her last pap test 4 years ago was
normal and never had an abnormal pap. She smoked ½ ppd from age 30-60.
What cancer screening do you recommend?
Wrong answers:
a) mammogram, pap smear, FIT testing A – doesn’t need pap after age 69
b) Mammogram, pap smear, colonoscopy B – Colonoscopy never recommended
for low risk screening
c) Mammogram, pap smear, colonoscopy, low dose C+D CT Thorax
– see above re colonoscopy,
d) Mammogram, FIT testing, low dose CT Thoraxdoesn’t qualify for lung CA screening
(pack-yrs = 15)
e) Mammogram, FIT testing Correct answer:
Mammogram and FIT testing

10
 Management of
common solid tumour sites

11
 MCQ 2
A 75F is admitted to your service with back pain. Spine CT shows a sclerotic lesion at T12, L1 and
L4. MRI shows no cord compression. Her pain is well managed with hydromorphone. CT C/A/P
shows additional lesions in her lungs, liver, and bilateral axilla, suspicious for metastases. Blood
work is normal. What steps will you take next to confirm your diagnosis?

A. Colonoscopy, CEA
B. Breast exam, mammogram/ultrasound breasts
C. Pelvic exam, MRI pelvis, CA 125
D. PET scan, CA 19-9, CEA, CA 125

12
 MCQ 2
A 75F is admitted to your service with back pain. Spine CT shows a sclerotic lesion at T12, L1 and
L4. MRI shows no cord compression. Her pain is well managed with hydromorphone. CT C/A/P
shows additional lesions in her lungs, liver, and bilateral axilla, suspicious for metastases. Blood
work is normal. What steps will you take next to confirm your diagnosis?

A. Colonoscopy, CEA
B. Breast exam, mammogram/ultrasound breasts
C. Pelvic exam, MRI pelvis, CA 125
Wrong answers:
D. PET scan, CA 19-9, CEA, CA 125 • A – Colon cancer less likely to go to axillary LNs
• C – CT did not show ovarian abnormalities
• D – PET not indicated prior to cancer-specific tests
Correct answer:
• B – Most likely primary in this clinical setting (elderly
female) is metastatic breast cancer, esp. with axillary LNs
13
 Breast Cancer: Diagnostic Workup
Relevant Biology
• KNOW- Breast Cancer mainly grows on Estrogen, or HER2 signaling- How we choose treatments
Diagnosis
• Imaging
• Diagnostic bilateral breast mammogram & ultrasound of breast AND axilla*
• Biopsy/Markers
• Core needle biopsy (US-guided) + Receptor status testing: ER (estrogen hormone receptor), PR
(progesterone hormone receptor), HER-2 (human epidermal growth factor receptor)

RC EXAM TIP: Mastitis not responding to antibiotics à BIOPSY to rule out Paget’s/ Inflammatory Breast
CA) (In Clinical Practice: U/S + Mammogram with Biopsy)

Once Confirmed Localized Breast Cancer- Move on to Surgery! (Before completion of staging)

*If receiving COVID vaccine, attempt mammogram/ultrasound prior, or 4-6 weeks

after, to avoid reactive LNs form vaccine (Society of Breast Imaging recommendations) 14
 Breast Cancer: Initial Localized Management

Primary treatment
• Surgery
• Primary Tumor- 2 options
• Mastectomy
• Lumpectomy (Breast Conserving Surgery) + Whole Breast Radiation
• Regional lymph node Management- Beyond the scope of this exam. Just know they need nodal
staging
• SLNB biopsy à ± ALND (if SLN 3+)
• Palpable + Biopsy proven LN metastasis -> ALND
• Adjuvant Radiation depends on a lot of things

Bottom Line for early stage Breast CA: Mastectomy or Lumpectomy + Lymph Node Sampling/ Dissection.

Based on Surgical Path-> Complete Staging -> Decide on further treatment SLNB – Sentinel lymph node biopsy
ALND – Axillary lymph node
dissection
15
 Breast Cancer: Staging
Stage I Stage II Stage III Stage IV *AJCC 8th edition: True
prognostic staging
Small tumor, Large tumor/ Skin/ chest wall, Metastatic incorporates receptor
no nodes + nodes (<3) +++ nodes (≥4) status into defining
stages. Beyond RC scope
and not applicable
worldwide
** Reference staging. DO
NOT MEMORIZE.

T: ≤ 2 cm • Criteria 1: Any of below: Common sites:

N: 0 –T: 2-5cm + N ≤3 • Skin involved • Lung, Liver
• Criteria 2: • ≥ 4 LN • Bone, Brain
–T ≥ 5cm + N = 0 • > 5cm + ≥ 1 LN

Staging Post Surgery- Do they need imaging? High Yield

• Stage I (LN negative)à No further tests
• Stage II (LN+ up to 3)à No further tests unless symptoms
• Stage III (T4 or ≥ 4 LN positive)à STAGE! - Bone scan, CT C/A/P

breast360.org
16
 Breast Cancer: Adjuvant Therapy
Indications for adjuvant anti-estrogen therapy
• ALL Hormone receptor (ER/PR) positive (Stage I-III)
o Pre-menopausal – Tamoxifen x 5-10 years
o Post-menopausal – Aromatase inhibitor* OR Tamoxifen x 5-10 years

Indications for adjuvant chemotherapy**

• Stage II/III for ER/PR+ breast cancer
• Stage II/III for HER2+ tumor (chemo + Trastuzumab (Herceptin®))
• Stage I-III for “Triple negative” (ER-, PR-, HER2-) breast cancer
• ± Anti-resorptive therapy
RC Pearl: Systemic therapy for Breast Cancer- Most tested side effect: Cardiomyopathy
*Aromatase Inhibitor = Letrozole, Exemestane, Anastrozole
**Typical chemo regimen = Anthracycline (doxorubicin, epirubicin) + Cyclophosphamide+ Taxane
(docetaxel, paclitaxel) 17
**HIGH YIELD **

Breast Cancer: Metastatic Management

1. Hormone receptor (ER/PR) +
o Endocrine therapy + CDK 4/6 inhibitor (e.g. Letrozole + Palbociclib)
o Endocrine therapy alone
o Chemotherapy upfront if presents with “visceral crisis” (symptomatic/organ compromise)

2. HER-2 +
o Double HER-2 blockade (Trastuzumab + Pertuzumab) + chemotherapy (Taxane)

3. Triple Positive
o Double HER-2 blockade (Trastuzumab + Pertuzumab) + chemotherapy (Taxane) + Endocrine therapy

4. Triple Negative (ER/PER/HER-2 -)

o Immunotherapy (for PD-L1+ disease)
o Chemotherapy

± Anti-resorptive therapy for bone metastasis

New drugs entering clinical practice: Antibody-drug
conjugates– Game changers! Not on exam

18
**HIGH YIELD **

Breast Cancer Treatment Side Effects

Endocrine Therapy Chemotherapy
Side Effect Tamoxifen AI Anthracyclines (i.e. Doxorubicin, Epirubicin)
Endometrial cancer ↑ None • IRREVERSIBLE cardiomyopathy
• Secondary leukemia
Thrombosis ↑ - • Alopecia
Osteoporosis -/↓* ↑ • Extravasation reactions (tissue necrosis)
CV Risk -/↓ -/↑
Taxanes (i.e. Paclitaxel, Docetaxel)
Arthralgias ↑ ↑↑ • Peripheral neuropathy
Vasomotor (Hot Flashes) ↑ ↑ • Infusion reactions (fever, dyspnea, rash)
• Myalgias/arthralgias
Trastuzumab (Herceptin®) • Alopecia
• Febrile neutropenia
• REVERSIBLE cardiomyopathy
• Diarrhea
• Infusion reactions

19
 Breast Cancer: Antiresorptive therapy11
• Bisphosphonates (Zoledronic Acid, Clodronate, Ibandronate) or Denosumab

o Purposes
1. Decreases spread to bones (altered bone microenvironment, esp. for ER/PR +)
2. Protect against AI-induced osteoporosis
3. Decreased risk of skeletal related events (SRE - i.e. fracture, need for radiation,
cord compression)

o Uses
§ Adjuvant: Post-menopausal women “deemed candidates for adjuvant systemic
therapy.” ê Recurrence, é Survival
§ Metastatic: Pre- and post-menopausal women. Improves pain, QOL, ê SREs,
prolongs time to 1st SRE. No survival benefit
20
 Breast Cancer: Surveillance12 Marked with ⌘

• Annual mammogram, history, physical & breast exam

• Recommend AGAINST surveillance blood work, bone scan, CT scans⌘

• Lifestyle modifications after breast cancer (CMAJ 2017)

o Prevent weight gain
o Exercise (150 mins/wk = reduced breast cancer mortality)
o Quit smoking
o Minimize alcohol
o Limit saturated fats and high-fat dairy products
o No need to avoid soy (purported “phytoestrogens”)
o Vitamin C/D/E – questionable benefit
o Bottom line- Live healthy- same recommendations as cardiac guidelines

21
 Lung Cancer: Biology
SMALL CELL LUNG CANCER (SCLC)
• Tend to be central lesions
NON-SMALL CELL LUNG CANCER (NSCLC)
• Smoker’s tumor
• Non-EGFR/ALK mutated
• Rapidly growing
HIGH YIELD for exam:
Squamous Cell Rare(ish) • SMOKER- Squamous + SCLC
• Tend to be central lesions • Neuroendocrine • Adenocarcinoma- LOTS of MUTATIONS
• Strong link with smoking • Adenosquamous • SCLC- RAPIDLY GROWS
• Unlikely EGFR/ALK mutated • Sarcomatoid • Neuroendocrine tumor of lung – RARE
• Large cell but we strongly suggest you know this:
PREOP do an Echo if suspicious of
Adenocarcinoma carcinoid syndrome, send a serum
• Tend to be peripheral lesions Chromogranin A, and a Urine 24-HR
• Most common Urine 5-HIAA. The imaging of choice
• May be EGFR/ALK mutated here would also be an octreotide or
Gallium-PET scan, as a regular PET may
not work here. 22
 Lung Cancer: Workup
Diagnostic Imaging + Staging (DONE PRIOR TO SURGERY- unlike Breast)
1. ALL patients –Rule out metastatic disease: CT C/A/P + CT/MRI brain , ± Bone scan if symptomatic
2. If no obvious metastases- May be able to get cured (surgery or radiation/ chemoradiation)
o PET scan – look for occult metastases (to stage resectable disease/curative intent)
o Mediastinal staging (mediastinoscopy or endobronchial ultrasound [EBUS])

Biopsy/Markers- KNOW the underlined ones)

• Histology – NSCLC (~90% of cases) (i.e. adenocarcinoma or squamous) vs SCLC (~10%)
• Molecular (NSCLC only)
• Adeno: EGFR, ALK, ROS1, NTRK, KRAS, BRAF, HER2, and PDL-1.
• “Typical” EGFR+ profile – Elderly, Female, Asian, Non-smoker, Adenocarcinoma
• Squamous: PD-L1. Occasionally send molecular if rare smoking history

23
 NSCLC: Staging + Management
Primary Hilar lymph Mediastinal lymph
Pleural effusion Distant mets
tumor node node

Stage 1 Stage 2 Stage 3 Stage 4

Tumor size ≤ Tumor ≤ 4cm + Hilar LN Tumor > 7cm Malignant
3cm, OR OR effusion,
Tumor size > 4cm ≤ 7cm,
No lymph nodes Any LN that’s Distant
No lymph nodes
NOT Hilar metastases
• Lymph node terminology in Lung Cancer:
• Hilar -> Mediastinal -> Supraclav/ Scalene
• Ipsilateral vs Contralateral
AJCC 8th edition TNM staging
 Non-Small Cell Lung Cancer: Management
Stage I/II (early stage)
• Fit for surgery: Surgery ± adjuvant chemo (“platinum doublet”)
• Unfit: Radiation (SBRT*) ± adjuvant chemo (comparable survival to surgery)13
• General rule for who gets adjuvant Chemo: Stage 2+ (Tumor > 4cm, node positive). Stage 1- Little benefit/Harm
Stage III (locally advanced) (Discussed at multidisciplinary rounds)
• Resectable: Surgery à Adjuvant chemo ± Immunotherapy (Atezolizumab- new 2022. Not tested)
• Unresectable: Concurrent chemoradiation à Immunotherapy (Durvalumab) x1 yr14

Stage IV (metastatic)
• EGFR + à EGFR inhibitor (Osimertinib first line)
o “Typical” EGFR+ profile – Elderly, Female, Asian, Non-smoker, Adenocarcinoma
• Many other mutations are now targetable- Beyond scope of RC
• No driver mutation (ASCO 2020)15 à Chemo + Immunotherapy (PD-L1 < 50%) OR Immunotherapy alone
(PD-L1 ≥ 50%)
• Early Referral to palliative care= Mortality benefit
*SBRT = Stereotactic Body Radiation Treatment 25
**HIGH YIELD **

Small Cell Lung Cancer: Workup & Management

Staging
• Limited – Confined to 1 hemithorax or 1 radiation field
• Extensive – NOT confined to 1 radiation field (i.e. mets) or presence of malignant effusion

Treatment (surgery is generally NOT a part of SCLC treatment unless very early stage)
• Highly chemo/radio-sensitive, but frequently relapse
• Limited Stage- Curative intent
o Concurrent chemoradiation ± prophylactic cranial irradiation (Moving away from it)
• Extensive Stage- Palliative intent
o Chemotherapy + Immunotherapy (Atezolizumab now approved in Ontario)

Typical regimen = Cisplatin (or Carbo if not

Cisplatin eligible) + Etoposide/Irinotecan
26
**HIGH YIELD **

Lung Cancer: Paraneoplastic Syndromes

• SIADH
• Lambert-Eaton Myasthenic Syndrome (LEMS)
o Anti-VGCC Ab* : reduced presynaptic ACh release
o Absent/decreased reflexes
• Encephalomyelitis & sensory neuropathy SCLC
o Anti-Hu Ab* cross reacts w/ both SCLC antigens and neuron-
specific RNA-binding nuclear proteins
• Cushing’s syndrome
o Ectopic ACTH production
• Hypertrophic osteoarthropathy
o Clubbing + periosteal new bone formation of tubular bones NSCLC
o Symmetrical, painful arthropathy (ankles, knees, wrists, elbows)
• Hypercalcemia Squamous
o PTHrP production (NOT measured in modern assays for PTH) cell NSCLC
*Only order antibodies (serum + CSF) if suspecting the clinical syndrome. NOT used 27
as a screening test for paraneoplastic syndromes
 MCQ 3
A 45M presents to clinic with 3 week history of shortness of breath. Chest CT shows a 4 cm
spiculated lung nodule in the left upper lobe, with massive left sided pleural effusion. Which
subspecialty will you involve next in your management?

A. Radiation Oncology
B. Thoracic Surgery
C. Medical Oncology
D. Palliative Care

28
 MCQ 3
A 45M presents to clinic with 3 week history of shortness of breath. Chest CT shows a 4 cm
spiculated lung nodule in the left upper lobe, with a large left sided pleural effusion. Which
subspecialty will you involve next in your management?

A. Radiation Oncology Wrong answers:

B. Thoracic Surgery • A – Rad Onc provides symptom relief such as radiation to the chest to reduce hemoptysis or
to treat oligometastatic disease.
C. Medical Oncology • C- This is most likely stage 4 lung cancer. However, without formal pathology there is little
D. Palliative Care role for medical oncology (even for small cell we still prefer to get pathology first)- our
treatment differs drastically based on path.
• D- Palliative care is important. Though we need to get on top of figuring out this cancer first.
Correct answer:
• B – Thoracic Surgery needs to be involved first to make a diagnosis (via pleural fluid
sampling or nodule biopsy) and to provide symptomatic relief by placing a chest tube/
indwelling catheter

29
**HIGH YIELD **

Colorectal Cancer: Workup

Imaging/Staging
• Full colonoscopy to terminal ileum (all patients, pre-op)
• CT chest, abdomen and pelvis (all patients, pre-op)

Stages of Colonic Adenocarcinoma*

• Stage 1 – Invades into muscle wall
• Stage 2 – Invades through muscle wall
• Stage 3 – Lymph node involvement
• Stage 4 – Distant metastases

Tumour and molecular markers

• Carcinoembryonic antigen (CEA)
mycoloncancercoach.org
30
 Colorectal Cancer: Management
Stages I-III
• Stage 1 – Surgery
• Stage 2 – Surgery ± adjuvant chemo (if perforated or obstructed)
• Stage 3 – Surgery + adjuvant chemo

Stage IV (metastatic)
• Oligometastatic (isolated liver or lung lesions, undefined number of mets)
o Metastectomy + chemotherapy (curative-intent)16
• Non-operable
o Choice of palliative chemotherapy, immunotherapy, EGFR targeted antibody, etc
Typical regimens:
• Post-op: FOLFOX/CAPOX (5-FU/Capecitabine,
Leucovorin, Oxaliplatin)
• Metastatic: FOLFOX/FOLFIRI (Irinotecan instead of
Oxaliplatin) ± Bevacizumab/Panitumumab/Cetuximab 31
 Colorectal Cancer: Surveillance Marked with ⌘

• Stage 1
o Colonoscopy 1 year post resection (or within 6 months if a complete scope was not
performed pre-op)
o Subsequent colonoscopies based on findings of previous scope (not annually), if
negative, every 5 years. ⌘

• Stage 2-3
o Colonoscopy 1 year post resection
o Years 1-3: Q6 month history, physical exam, CEA, CT C/A/P
o Year 4-5: Annual history, physical exam, CEA, CT C/A/P

• PET scan – Only for rising CEA alone without evidence of disease on CTs

32
**HIGH YIELD **

Gastroesophageal Cancer
Squamous cell Adenocarcinoma
Common location: Upper-mid esophagus Distal esophagus
Risk factors: • EtOH • Barrett’s esophagus
• Caustic injury • GERD
• Smoking • Obesity
• Smoking

Treatment
• Localized – Neoadjuvant chemo ± radiation à Surgery à ± Adjuvant chemo
• Metastatic – Choice of Chemotherapy ± trastuzumab (if HER-2 +) ±
Immunotherapy

33
 Prostate Cancer: Workup
• Biology
o Like Breast Cancer feeds on Estrogen, Prostate Cancer feeds on Androgen
(Hence backbone treatment is Androgen Deprivation Therapy- ADT)

• Diagnosis
o Digital rectal examination
o Prostate biopsy with calculation of Gleason Score
• Tumour Markers
o Serum PSA

• Imaging (if symptomatic or “high-risk”)

o “High risk” = Gleason ≥ 8, PSA > 20, Tumor extent ≥ T3 (extends through
prostate capsule)
o Imaging = Bone scan, CT chest/abdomen/pelvis
34
 Prostate Cancer: Management
Marked with ⌘

Castrate Sensitive- Responds to lowering Androgen Castrate Resistant

Early/ Localized 1. Active surveillance (PSA monitoring, intervene if Not covered on

progression) RC

• Choosing Wisely: “Do NOT initiate management in

patients with low-risk prostate cancer without first
discussing active surveillance” ⌘
2. Radical prostatectomy ± lymph node dissection
3. Radiation
Metastatic 1. ADT* + Chemotherapy (Docetaxel) Not covered on
RC
2. ADT + CYP17 inhibitor (shuts down androgen production)
(Abiraterone)
3. ADT + second generation antiandrogen (Enzalutamide,
Apalutamide)
*ADT = GnRH agonist (Lupron) or antagonist (Degarelix) 35
 Prostate Cancer: Treatment side effects
Androgen Docetaxel (chemo) Non-steroidal antiandrogen
Deprivation Therapy
Osteoporosis Peripheral neuropathy Abiraterone (+ Prednisone)
Decreased libido N/V • HTN
Gynecomastia Hair loss • Hyperglycemia
Hot flashes • Hypokalemia
Fatigue • CV disease
Enzalutamide
• Seizure
• DRUG-DRUG INTERACTIONS

ALL patients on ADT should be on Calcium (if needed), Vitamin D supplementation, and a
Bisphosphonate for metastatic disease or low bone mineral density
36
 **HIGH YIELD **

Testicular Cancer
Imaging: Scrotal ultrasound, CT chest/abdomen/pelvis
Diagnosis: Made by radical orchiectomy, (NEVER biopsy testicular mass due to risk of tumor seeding)
Tumour markers: β-hCG, AFP, LDH
Typical chemo regimen: BEP
Management (Bleomycin, Etoposide, Cisplatin)
• Localized – Surgical orchiectomy
• Metastatic – Chemotherapy (highly curable, chemo-sensitive, good prognosis)

Tumour type β-hCG AFP If AFP elevated

1) Germ cell tumour (95%) non-seminoma will
• Seminoma (<20%) ↑ Never ALWAYS be present
• Non-seminoma (yolk sac, teratoma, ↑ ↑
embryonal, mixed, choriocarcinoma) Bleomycin (chemo) can
2) Others (5%) cause Pulmonary fibrosis
- -
• Sertoli, Leydig, Granulosa cell

37
Systemic Therapy and their Side Effects
• Chemotherapy
• Immunotherapy
• Targeted Therapy

38
 Chemotherapy Toxicities
Drug Toxicity Common Use

Anthracyclines Irreversible cardiomyopathy Breast CA (FEC-D, ddAC-T)

**HIGH YIELD **
Doxorubicin (Adriamycin), Epirubicin Secondary leukemias CHOP (“H”)
Antimetabolite Diarrhea, mucositis, hand-foot syndrome, coronary Colon CA (FOLFOX/FOLFIRI)
5-Fluourouracil, Capecitabine vasospasm Breast CA (FEC-D)
Topoisomerase inhibitors myelosuppression, diarrhea, nausea, vomiting, Colon CA (FOLFIRI)
• Irinotecan cholinergic reactions (Irinotecan) Testicular (BEP)
• Etoposide Etoposide: Hypersensitivity reactions Lung (small cell Cis + Etop)
Platinums **HIGH YIELD ** All – Peripheral neuropathy Cisplatin – Lung CA, H & N
• Cisplatin Cisplatin-specific – Highly emetogenic, nephrotoxic, Carboplatin – Ovarian CA
• Carboplatin ototoxic, hypoMg/Ca/K Oxaliplatin – Colon CA
• Oxaliplatin Oxaliplatin-specific – Cold-induced neuropathy
Taxanes Peripheral neuropathy, myalgias, hypersensitivity Breast CA (FEC-D, ddAC-T)
• Paclitaxel reaction (SOB, flushing, hypotension), fluid retention Ovarian CA
• Docetaxel (docetaxel) Prostate CA
Vinca alkaloids Peripheral neuropathy Lung CA, Breast CA
• Vincristine, Vinorelbine CHOP (“O”)
Cyclophosphamide Emetogenic Breast CA (FEC-D, ddAC-T)
Hemorrhagic cystitis, bladder CA CHOP (“C”)
**HIGH YIELD ** Secondary malignancies (MDS, AML, bladder Ca) Connective tissue diseases
Infertility
39
 Other Systemic Therapy Toxicities
Drug Toxicity Common Use

Immunotherapy Autoimmune phenomena Melanoma, Lung Cancer

• Pembrolizumab, Nivolumab Most common are dermatitis, hypothyroidism. Bladder Cancer, Renal
• Ipilimumab Rare: hypophysitis, pneumonitis, colitis Cell, Gastroesophageal
• Atezolizumab, Durvalumab
Anti-angiogenesis/VEGF inhibitors HTN, bleeding, bowel perforation, delayed wound healing, Metastatic colon CA
• Bevacizumab (Avastin) arterial thrombo-embolism (MI, CVA) Gynecologic CA

EGFR Tyrosine-kinase inhibitors Acneiform rash TIP: EGFR lives on mucosa (oral, Metastatic lung CA
• Gefitinib, erlotinib, osimertinib Diarrhea skin, GI)- Hence the side effects (NSCLC)
ILD
Trastuzumab (Herceptin) Cardiomyopathy (reversible) **HIGH YIELD ** HER2+ breast CA
Infusion-rxn (flu-like)
Rituximab Infusion rxn (flushing, hypotension, tachycardia, allergic) Lymphoma (R-CHOP)
Tyrosine-kinase inhibitors (TKIs) HTN, bleeding, hand-food skin reaction, diarrhea, RCC, HCC
• Sunitinib, Sorafenib mucositis, hypothyroidism (sunitinib)
PARP inhibitor Cytopenias BRCA + Ovarian cancer,
• Olaparib, Niraparib GI symptoms Pancreatic cancer

40
 Management of common chemo side effects
Chemo-induced Nausea + Vomiting Antiemetics
• Highly emetogenic (i.e. Cisplatin) 1. NK1-receptor antagonist (aprepitant)
o Combine antiemetics 1 + 2 + 3 ± 4 2. 5-HT3 antagonists (ondansetron)
• Moderately emetogenic (i.e. Carboplatin) 3. Steroid (dexamethasone)
o Combine antiemetics 2 + 3 ± 4 4. 5-HT2/D2 antagonist (olanzapine)
• Mildly emetogenic (i.e. Etoposide, Paclitaxel)
o Use antiemetics 2 OR 3

• Anticipatory nausea Alternatives below have insufficient

o Refer to Psychiatry (behavioural therapy) evidence to recommend use
o May use Benzodiazepines
Cannabinoids/marijuana, Ginger,
acupuncture, acupressure

41
**HIGH YIELD **

Management of common chemo side effects

Diarrhea
• DDx: Chemotherapy, immunotherapy, other meds, infections (C. difficile),
partial SBO, malabsorption, etc…
o If on immunotherapy, consider immune-mediated colitis
• Treatments
o Loperamide à Lomotil

Mucositis
• Oral ulcers, dysphagia, odynophagia
• Treatments – Baking soda rinses, viscous lidocaine, Magic Mouthwash (mix
nystatin + lidocaine + steroid)

42
**HIGH YIELD **

Management of (less) common chemo side effects

Cardiomyopathy
Secondary to Anthracyclines (i.e. Doxorubicin)
• IRRIVERSIBLE
• Delayed onset – Up to 20 years after chemotherapy completed
• Dx – Typical HF symptoms + TTE
• Rx – Routine management of HF (see Cardiology lecture)
Secondary to Trastuzumab (Herceptin®)
• REVERSIBLE
• Early onset – During treatment
• Dx – Typical HF symptoms + TTE
• Rx – STOP drug à Routine management of HF à Repeat TTE in ~1mo to
ensure recovering à Can likely stop medications for HF once recovered
(with Cardio guidance). Typically will NOT rechallenge Trastuzumab
43
**HIGH YIELD **

Immunotherapy Toxicity Management17

General principles Always rule out infection!
• “Mild” symptoms:
o HOLD treatment (unless asymptomatic hypothyroidism… just start L-thyroxine)
o Supportive management
o Consider re-challenge treatment

• “Moderate-severe” symptoms:
o Hold treatment
o IV Methylprednisolone 1mg/kg or Prednisone 0.5-1 mg/kg
o GI toxicity: GI referral for scope, rule out infection
• If no response to steroids after 72 hours or worsening symptoms, then Infliximab
5 mg/kg (can repeat 2 weeks later if symptoms persist)

https://www.cancercareontario.ca/sites/ccocancercare/files/guidelines/full/ImmuneCheckpointInhibitor.pdf 44
 MCQ 4
A 50M on pembrolizumab for melanoma presents to office with bloody diarrhea 7x per day. He
reports vague abdominal discomfort for 4 days. He denies any nausea and vomiting. No recent
sick contacts, recent travel, or eating uncooked food (Though he o His HR is 120, BP is 100/50,
SPO2 99%RA, Afebrile. What would be your next best step in management in addition to sending
off basic investigation, infectious workup and CT scan?

A. Continue pembrolizumab, monitor symptoms

B. Stop pembrolizumab, admit give IV fluids and steroid
C. Stop pembrolizumab, admit, give IV fluids and infliximab
D. Stop pembrolizumab, admit, give IV fluids and Imodium

45
 MCQ 4
A 50M on pembrolizumab for melanoma presents to office with bloody diarrhea 7x per day. He
reports vague abdominal discomfort for 4 days. He denies any nausea and vomiting. No recent
sick contacts, recent travel, or eating uncooked food (His HR is 120, BP is 100/50, SPO2 99%RA,
Afebrile. What would be your next best step in management in addition to sending off basic
investigation, infectious workup and CT scan?
A. Continue pembrolizumab, monitor symptoms
B. Stop pembrolizumab, admit, give IV fluids and steroid
C. Stop pembrolizumab, admit, give IV fluids and infliximab
D. Stop pembrolizumab, admit, give IV fluids and Imodium
Wrong answers:
• A – patient has significant immunotherapy-related Colitis. Needs to stop treatment
• C – First line treatment is steroid, not infliximab
• D – First line treatment is steroid, not imodium
Correct answer:
• B – First line treatment is steroid for moderate- severe IO toxicity (HR up, Bp Borderline
soft). Pembrolizumab needs to be stopped 46
**HIGH YIELD **

Malignant Bowel Obstruction (MBO)

Symptoms
• Crampy abdo pain, anorexia, N/V, inability to pass BM or flatus
Diagnosis
• History, physical, abdominal flat plate, CT abdomen
Treatment
• Consult Gen Surg (even if palliative)
• Supportive care (IV fluids, electrolyte management, NG decompression)
• Metoclopramide IV 10 mg Q8H (use if partial MBO, not for use in complete MBO)
• Octreotide SC 100 mcg TID (↓gastric secretions, ↓ motility, ↓ splanchnic blood flow)
• ± Corticosteroids (↓ peritumor edema, ↑ mobility) – Questionable benefit
Interventions
• Depending on location, consider intraluminal stent
• If not responsive to pharmacotherapy, consider venting G-tube
**HIGH YIELD **

Febrile Neutropenia
Definition
• Single temp ≥ 38.3˚C or ≥ 38.0 ˚C for >1hr AND ANC ≤0.5 or <1 (with predicted nadir of 0.5)
Etiology
• Nadir of neutropenia occurs 7-14 days after chemo
• ~25% infections bacteremia (source of ANY infection identified in only 20-30% of cases)
o ~70% Gram positives – Staph aureus, Staph epi, Strep pneumo
o ~20% Gram negatives – Pseudomonas, Klebsiella, E. coli
• Fungal infections occur in pts with prolonged neutropenia (>7 days) and/or prolonged Abx use
Diagnosis
• Investigations – Blood culture x2 PIV + CVC (if present), Urine culture, Skin exam, Sputum (if
present), Stool sample + C. diff (if diarrhea), CXR and Other imaging/tests as indicated
Treatment
• Broad spectrum antibiotics IMMEDIATELY (often institution-dependent)
o Examples: Piptazo + Gentamicin/Tobra ± Vancomycin OR Meropenem ± Vancomycin

G-CSF used as 2o prophylaxis – but does NOT improve outcomes

48
**HIGH YIELD **

Outpatient management of Febrile Neutropenia in adults19

• Based on MASCC score (DO NOT memorize MASCC)
o e.g. no hypotension, no active COPD, no volume depletion, no or mild symptoms,
solid tumor rather than heme malignancy, age <60
o Patients should reside within an hour of medical care, have a caregiver at home,
and be able to return to ED for follow-up
• Administer empiric Antibiotics within 1 hour of triage
• Inpatient management if anticipated neutropenia is ≥7 days, heme malignancy or SCT
• Out-patient Antibiotic regimen:
o Ciprofloxacin + amoxicillin/clavulanate or Clindamycin (if Pen allergic)
• Inpatient regimen:
o Broad-spectrum antibiotics (Pip-Tazo, Ancef/Gent, Carbapenem ± Vanco)
o Guided by symptoms, previous cultures, and hospital antibiogram

49
**HIGH YIELD **

Hypercalcemia of Malignancy
Etiology
• Most common malignancies – Breast, Lung, Multiple myeloma
• 3 common mechanisms
o Lytic bone destruction (breast ca, multiple myeloma)
o PTHrP production (H&N, squamous cell NSCLC - NOT small cell)
o 1,25-dihydroxyvit D/calcitriol production (lymphoma)
Management
• IV hydration (most effective short-terms)
• Bisphosphonates
o Pamidronate 90mg IV
o Zoledronic acid 4mg IV x 1 (remember to reduce dose for renal dysfunction)
o Max effect 4-7 days post-infusion (therefore NOT short-term solution)
o Monitor for hypocalcemia post-treatment
• Treat underlying malignancy

50
**HIGH YIELD **

Spinal Cord Compression

Etiology
• Compression of the thecal sac by tumor in the epidural space
• Most common malignancies – Breast, Lung, Prostate, Multiple myeloma
Symptoms/Diagnosis
• Clinical most important – early recognition is key to preserving neurological function
• Back pain (often 1st sign, occurs in 95% cases)
• If spinal cord compression = UMN findings
• If cauda equina syndrome = LMN findings, Saddle anesthesia
• Leg weakness, sensory loss
• Urinary retention, Bowel incontinence
Management
• URGENT MRI whole spine
• Steroids – Dexamethasone 10mg IV x1 à Dexamethasone 4mg PO/IV QID
• Pain control
• Consult Spine surgical service AND Rad Onc
51
**HIGH YIELD **

Tumor Lysis Syndrome

Diagnosis
• Requires ≥ 2 lab abnormalities within 7 days post-chemo
1. Hyper K+ – muscle weakness, ECG Δs, cardiac arrhythmias, sudden death
2. Hyper PO4 – AKI, secondary hypocalcemia, N/V, lethargy, seizures
3. Hyperuricemia – AKI (renal tubule deposition), flank pain (renal stones), N/V, anorexia
4. Hypo Ca2+ – Tetany, parasthesias, mental status changes
Etiology
• Most common in highly proliferative malignancies, large tumor burden, high-sensitivity to treatment
– Leukemia, Lymphoma, Testicular ca, Small cell lung ca
• Treatment response = cellular breakdown with release of K+, PO4, nucleic acids à uric acid
Treatment Prophylaxis
• IV fluids (target U/O of 2cc/kg/hr) • IV fluids AND
• Rasburicase • Allopurinol OR
o Allopurinol if G6PD deficient, though not • Rasburicase (if NOT G6PD deficient)
usually tested upfront in emergency G6PD Deficiency – X linked recessive*, more common in
• Treatment of electrolyte abnormalities Africa, Middle East, certain parts of Mediterranean and Asia.
52
*If MCQ says a woman, assume no G6PD defic!
 SVC Syndrome20
Etiology Management
• Malignancy (up to 90% of cases): • Life-threatening/Grade 4 symptoms* à
• NSCLC (~50% of cases) Venogram, urgent stent, consider
• SCLC thrombolytics if thrombus
• Lymphoma • Non-life threatening à obtain tissue
• metastatic lesions diagnosis to guide treatment
• Thrombosis • Stent for symptom palliation ± Radiation in non-
chemo sensitive tumors (e.g. NSCLC,
Symptoms/Diagnosis
mesothelioma)
• Obstruction of SVC, ↑ venous pressure
• Systemic chemotherapy for chemo-sensitive
• Symptoms: Facial and arm edema, distended tumors (SCLC, NHL, germ cell)
neck and chest veins, Dyspnea, cough, facial
• Steroids: Airway obstruction not amenable for
plethora, hoarseness, stridor, neurologic
stenting, or steroid-responsive tumor (thymoma,
(confusion/change in LOC)
lymphoma)
• Abnormal CXR, CT chest, head and neck. If
unstable à venography, which allows *Grade 4: Life-threatening: confusion/obtunded,
intervention stridor, hemodynamic comprise (syncope without
precipitant), hypotension, renal insufficiency 53
Palliative Care

54
 MCQ 5. Pain Management
A 56yF with metastatic ovarian CA presents with a malignant bowel
obstruction. She has been vomiting for 3 days and unable to keep anything
down. She has an acute kidney injury, Cr 217. She rates her pain as 10/10. She
was taking M-Eslon 60 mg po BID for pain plus 10mg morphine IR for
breakthrough, taking 4 doses per day before this bowel obstruction occurred.
In addition to IV hydration and anti-emetics, what treatment will you initiate
for her pain control?
a) Morphine IV 10mg q4h prn
b) Hydromorphone CR 6mg po BID + 2mg IR q2h prn
c) Hydromorphone 2mg sc q4h + 1mg sc q1h prn
d) Hydromorphone 2.5 mg sc q4h + 1.5 mg sc q1h PRN
e) Fentanyl patch 37.5 mcg q 72h + hydromorphone 2mg sc q1h PRN

55
**HIGH YIELD **

Involving Palliative Care Marked with ⌘

• Early referral to palliative care in metastatic non-small cell lung

cancer is associated with:
o Improved quality of life
o Improved mood
o Fewer aggressive interventions at the end of life
o Improved overall survival (11.6 vs. 8.9 months)23

56
**HIGH YIELD **

Performance Status
Marked with ⌘

ECOG score
Palliative Performance Scale
Score Description • 100% (perfectly well) – 0% (death)
0 Asymptomatic • Measure of physical status in palliative
care
1 Symptomatic
• PPS 50% (sit/lie throughout day) = only
Completely ambulatory
10% of pts expected to survive >6mo
Able to do light house work
2 <50% day spent in bed/chair
Capable of all self care
Not capable of work Avoid chemotherapy in those
3 >50% day spent in bed/chair who are unlikely to benefit
Only limited self-care (patients ECOG 3-4) ⌘
4 Bedbound

57
 Pain Control
Options
• Non-opioids – Acetaminophen, NSAIDs Nociceptive pain
• Opioids – Morphine, Hydromorphone, Fentanyl, etc.
• Adjuvants – Pregabalin, Gabapentin, TCAs
Neuropathic pain
Opioid titration
Goal to address most of the baseline pain with long-acting formulations
1. Start with immediate release (IR) formulation Q1-Q4H PRN (q4h PRN for opioid naïve)
2. Low dose à increase to effect/side effects
3. Allow for steady state (~24hrs = 5 half lives)
4. Once steady state achieved, calculate total use in past 24 h
5. Divide 24hr dose into distributed doses of long acting formula
6. Order breakthroughs (= 10% of total daily dose in IR tabs)

Cannabinoids
Nabilone > placebo, but benefits compared to other analgesics not proven (CADTH 2011)

58
**HIGH YIELD **
Pain Control
Picking an opioid
• No comorbidities – No one right answer. Usually based on physician comfort
• Renal dysfunction – Hydromorphone, Methadone, Fentanyl
o Do NOT use: Morphine, Codeine, Tramadol, Demerol
• Hepatic dysfunction – Hydromorphone, Morphine, Fentanyl
o Do NOT use: Codeine, Methadone
• Excess opioid-induced itching/urticaria – Fentanyl

Opioid side effects

• Common: Constipation, Nausea, Vomiting, Sedation
• Rare: Confusion, hallucination, Myoclonus **Important, lesser-known side effect
• Methadone specific: QT prolongation, Drug-drug interactions (CYP3A4 metabolism)
• If treatment addresses source of pain, need to decrease opioids to prevent toxicity

59
**HIGH YIELD **
Opioid Rotation
1. Calculate total daily dose (TDD) of drug
2. Convert TDD to ORAL MORPHINE EQUIVALENT using equianalgesic table24 below
3. Convert TDD to drug of choice
4. Calculate regular/interval dosing – long-acting (BID) or short-acting (q4h)
5. Calculate PRN dose (q1h) based on 10% of TDD or 50% of q4h dose
Equivalence to 30 To convert to PO PO : IV/SC Effect Duration
mg oral morphine morphine, multiply by
Morphine 30 mg 1 2:1 2-4 hrs
Oxycodone 20 mg 1.5 N/A 3-4 hrs
Hydromorphone 6 mg 5 2:1 2-4 hrs
Transdermal 60-130 mg morphine = 25 mcg/hr (~100mg = 25mcg/hr) 48-72 hrs
Fentanyl 135-179 mg morphine = 37.5 mcg/hr
180-224 mg morphine = 50 mcg/hr
225-269 = 75 mcg/hr
Clinical Pearl: If switching meds due to toxicity (i.e. myoclonus), consider 25-30% dose reduction to
allow for cross tolerance à BUT, if pain is not well-controlled, then no need to decrease dose

60
 Symptom Management Marked with ⌘
Dyspnea
• Stepwise approach: Non-pharmacologic therapies (i.e. fan, open window) à oxygen (if hypoxic) à
Opioids25
• Oxygen ineffective for non-hypoxemic dyspnea⌘
Nausea and Vomiting
• Direct treatment towards etiology
• Unknown etiology – Dopamine antagonist favored (haloperidol, olanzapine) or agents used for
chemotherapy-induced nausea and vomiting
Delirium
• Risperidone/haloperidol do not alleviate distress at end of life and tend towards harm (JAMA 2017)
o May slightly worsen delirium symptoms (low quality evidence, Cochrane Review 2020)
o May increase adverse side effects (EPS symptoms) (low-mod quality)
Cachexia:
• Refer for counseling + assessment re: high protein, nutrient dense food, advise against extreme
diets/fad diets
• Do NOT offer enteral tube feeding or parenteral nutrition to manage cancer cachexia
• Evidence insufficient to strongly endorse any pharmacologic agent
61
 Symptom Management Marked with ⌘

Constipation
• Considerations
o Disease and drug effects
o Check calcium & TSH
o Counsel on bowel regimen if starting opioids
• Medications
o Stimulant laxative (Senna) – Consider giving alongside opioids as prophylaxis
o Osmotic laxatives (Lactulose, PEG)
o Enema
o Selective opioid antagonist – Methylnaltrexone SC (Relistor©), Naldemidine PO
(Symproic ©)
o Chloride-channel agonist (Lubiprostone)
o Do NOT use stool softeners (Colace) alone for opioid induced constipation (no better
than placebo)⌘
62
 End-of-Life Discussion Marked with ⌘

• For patients with limited life-expectancy begin end-of-life discussion and advanced care
planning early ⌘
o Involve Palliative Care early, even if patient is pursuing disease-directed treatment
(i.e. chemo)
• Assess understanding of disease and treatment as well as goals
• Address emotional, social, and spiritual needs (Comfort Care for Patients Dying in the
Hospital, NEJM 2015)
• Discontinue statins (JAMA Int Med 2015: safe, improves QOL and saves money)
• Do not transfuse RBC at arbitrary cut-off w/o symptoms ⌘

63
 Medical Assistance In Dying –
**HIGH YIELD **

the law changed March, 2021 & changes again March 2023
Eligibility (must meet ALL of the following…)
1. Be eligible for health services funded by government (i.e. have a health card)
2. Be ≥ 18 years old and have decision making capability Pt must be capable: Cannot be
in delirium, advanced dementia
3. Have a grievous and irremediable* medical condition
• “Have a serious and incurable illness, disease or disability”
• Excludes Mental Illness… **until March 17, 2023** then law changes
• https://www.camh.ca/en/camh-news-and-stories/maid-and-mental-illness-faqs has a nice summary
•Mental Illness includes conditions primarily in domain of psychiatry (ie depression), but does
NOT include neurocognitive or neurodevelopmental disorders.
4. Make a voluntary request for MAID, free from outside pressure or influence
5. Provide informed consent to receive MAID

*Grievous and irremediable definition

• Does not need to be a fatal or terminal condition
• Must be a serious illness, disease, disability in an advanced, irreversible state
• As of March 2021 – Supreme Court removed requirement that death is reasonably foreseeable,
created 2 track approach! 64
 Stream 1: Death is reasonably Stream 2: Death is NOT foreseeable
Foreseeable
• Request in writing, signed by
• Request in writing, signed by independent witness
independent witness • 2 independent MD/NPs must
• 2 independent MD/NPs must confirm all eligibility criteria met
confirm all eligibility criteria met AND consult with expert in the
• Person must be given opportunity medical condition (if MD/NP is
to withdraw consent, and confirm unfamiliar with it)
consent expressly before receiving
MAID • The person must be informed of
means to alleviate suffering and be
*10 day reflection period is now offered consults with experts in
REMOVED for those whose death is this (incl. counselling, pall care…)
reasonably foreseeable* • The eligibility assessments must
take at least 90d, but this period
can be shortened if pt about to
lose capacity
• Person must be given opportunity
to withdraw consent, and confirm
consent expressly before receiving
MAID

MAID
MAID: Changes to Final Consent Requirement
• Pt does not have to provide consent immediately before provision of MAID if :
o Pt has been assessed and approved for MAID
o Pt was at risk of losing decision making capability prior to receiving MAID and
was made aware of that risk
o Person makes arrangement in writing with their practitioner to waive final
consent, and according to which their practitioner will provide MAID on on
their preferred date if they have lost capacity (“Audrey’s amendment” )

66
 MCQ 5. Pain Management
Opioid Rotation Calculation
A 56yF with metastatic ovarian CA presents1)with
TDDa =malignant
160mg morphinebowel po
obstruction. She has been vomiting for 3 days and unable to keep
2) Divide by 2 to get sc/IV equiv:anything
80mg
down. She has an acute kidney injury, Cr 217.
3) Due to renal toxicity, convert to non- She
She rates her pain as 10/10.
was taking M-Eslon 60 mg po BID for pain plusmorphine
10mg morphine IR for – divide by 5
(eg) hydromorphone
breakthrough, taking 4 doses per day before this bowel
= 16mg totalobstruction
daily iv/sc doseoccurred.
In addition to IV hydration and anti-emetics,
4) what
Whentreatment
converting dosewillreduce
you initiate
to avoid
for her pain control? toxicity w AKI = 2mg q4 (12mg per day)
5) Calculate PRN = 10% TDD
a) Morphine IV 10mg q4h prn Answer C
b) Hydromorphone CR 6mg po BID + 2mgNBIRFentanylq2h prn patch – takes 12h to ‘kick in’ so not
c) Hydromorphone 2mg sc q4h + 1mg scideal q1hinprn
this setting of severe acute pain
d) Hydromorphone 2.5 mg sc q4h + 1.5 mg sc q1h PRN
e) Fentanyl patch 25 mcg q 72h + hydromorphone 2mg sc q1h PRN

67
 Questions?
Many practice MCQs available in your BONUS
materials for self-study and on FLEXIQUIZ online

68
 REFERENCES
1. Canadian Task Force on Preventative Health Care: Breast Cancer Update (2018) – Klarenbach S, et al. Recommendations on screening for breast
cancer in women aged 40-74 years who are not at increased risk for breast cancer. CMAJ. 2018; 190(49):E1441-E1451.
2. Canadian Task Force on Preventative Health Care. Recommendations on screening for lung cancer. CMAJ. 2016; 188(6):425-432.
3. Canadian Task Force on Preventative Health Care. Recommendations on screening for colorectal cancer in primary care. CMAJ. 2016;
188(5):340-348.
4. Cancer Care Ontario. Guidelines & Advice. Colorectal Cancer Screening Recommendations Summary.
5. Canadian Association of Gastroenterology Banff Consensus. Leddin et al. Gastroenterology 2018;155:1325–1347
6. American Gastroenterological Association – Winawer S, et al. Colorectal Cancer Screening and Surveillance: Clinical Guidelines and Rational –
Update Based on New Evidence. Gastroenterology. 2003; 124:544-560.
7. CASL/AMMI – Coffin CS, et al. Management of Hepatitis B Virus Infection: 2018 Guidelines from the Canadian Association for the Study of the
Liver and Association of Medical Microbiology and Infectious Diseases Canada. Canadian Liver Journal. 1.4, 2018.
8. Terrault et al. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance. Clinical Liver Disease.
12. 33-34.
9. Canadian Task Force on Preventative Health Care. Recommendations on screening for cervical cancer. CMAJ. 2013; 185(1):35-45.
10. Canadian Task Force on Preventative Health Care. Guideline on screening for esophageal adenocarcinoma in patients with chronic
gastroesophageal reflux disease. CMAJ. 2020;192(27) E768-E777
11. Van Poznak C, Somerfield MR, Barlow WE, Biermann JS, Bosserman LD, Clemons MJ, Dhesy-Thind SK, Dillmon MS, Eisen A, Frank ES, Jagsi R,
Jimenez R, Theriault RL, Vandenberg TA, Yee GC, Moy B. Role of Bone-Modifying Agents in Metastatic Breast Cancer: An American Society of
Clinical Oncology-Cancer Care Ontario Focused Guideline Update. J Clin Oncol. 2017 Dec 10;35(35):3978-3986. doi: 10.1200/JCO.2017.75.4614.
Epub 2017 Oct 16. PMID: 29035643.
12. Cancer Care Ontario. Guidelines & Advice. Breast Screening for Survivors of Breast Cancer

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 REFERENCES
13. Baumann P, et al. Outcome in a prospective phase II trial of medically inoperable stage I non-small-cell lung cancer patients treated
with stereotactic body radiotherapy. J Clin Oncol. 2009; 27(20):3290-3296.
14. Antonia SJ, et all. Durvalumab after Chemotherapy in Stage III Non-Small-Cell Lung Cancer. N Engl J Med. 2017; 377:1919-1929.
15. Hanna et al. Therapy for Stage IV Non-Small-Cell Lung Cancer Without Driver Alterations: ASCO and OH (CCO) Joint Guideline Update
Summary. JCO Oncol Pract. 2020 16(8):e844-e848.
16. MacNeil et al. Rectal Cancer. In: Surgical Oncology Manual 2016. Ed. F.C. Wright
17. Cancer Care Ontario. Immune Checkpoint Inhibitor Toxicity Management: Clinical Practice Guideline.
https://www.cancercareontario.ca/sites/ccocancercare/files/guidelines/full/ImmuneCheckpointInhibitor.pdf
18. Bohlius J, et al. Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents: ASCO/ASH Clinical Practice
Guideline Update. J Clin Oncol. 2019; 37:1336-1351.
19. Zimmer and Freifeld. Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of Oncology Practice. 2019;15(1): 19-24
20. Yu et al. Superior Vena Cava Syndrome—A Proposed Classification System and Algorithm for Management. JTO. 2008. 8(3): P811-814
21. Ontario Health, Cancer Care Ontario. COVID-19 Supplemental Clinical Guidance for Patients with Cancer. March 2020.
22. Curigliano et al. Managing cancer patients during the COVID-19 pandemic: An ESMO Interdisciplinary Expert Consensus. Annals of Oncology 2020.
31(10)
23. Temel JS, et al. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. N Engl J Med. 2010; 363:733-742.
24. Reddy A, et al. The Conversion Ratio From Intravenous Hydromorphone to Oral OPIOIDS IN Cancer Patients. J Pain Symptom Manage.
2017; 54(3):280-288.
25. Hui D, et al. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol.2021; 39:1389-1411.
26. Compendium of Pharmaceutical & Specialties (Canadian Pharmacists Association 2008)

70
 **HIGH YIELD **
BONUS
Read on own
Self study: High Yield List
Lymph Node Metastases
• Right supraclavicular nodes
o Lung, Esophageal
• Left supraclavicular nodes (“Virchow’s node”)
o Abdominal malignancies (via the thoracic duct) – Gastric, gallbladder, pancreas,
kidneys, testicles, ovaries, prostate
o Ipsilateral breast & lung
• Umbilical nodes (“Sister Mary Joseph Node”) = Intra-abdominal/pelvic metastases
o GI – Gastric, colon, pancreas
o Gynecologic – Ovarian, endometrial
o Unknown primary

71
**HIGH YIELD **

Self study: Stage IV Peculiarities (i.e. Exam Fodder)

• Lung Cancer
o Pleural effusion in lung cancer = Stage IV (i.e. incurable)
• Colorectal Cancer
o “Few” liver or lung metastases = Stage IV, but may be curable with metastatectomy
• Bladder/Prostate Cancer
o Any positive lymph nodes in bladder or prostate cancer = Stage IV
• Testicular Cancer
o NO stage 4 in testicular cancer (i.e. all potentially curable)
• Ovarian Cancer
o Malignant fluid = Stage IV in all cancers EXCEPT ovarian
• Malignant ASCITES with peritoneal deposits = Stage III, high risk of recurrence
(attempt cytoreduction, adjuvant chemo) à curative intent
• Malignant PLEURAL EFFUSION = Stage IV, but may still undergo neoadjuvant
chemotherapy, debulking surgery ± chemotherapy à NOT curative intent 72
 **HIGH YIELD **
BONUS
Read on own
Self study: High Yield Lists
Bone metastases
• Osteoblastic
o Prostate, SCLC, Carcinoid, Hodgkin lymphoma
• Osteolytic
o Multiple myeloma, NSCLC, RCC, Melanoma, Thyroid, Non-Hodgkin lymphoma
• Mixed
o Breast, GI, Squamous cell carcinomas (NSCLC, H&N, Cervical ca)

Radio-resistant tumors
• RCC, Melanoma, Osteosarcoma
• For any of above, will still sometimes use radiation to alleviate pain or cord compression

73
 **HIGH YIELD **
BONUS
Read on own Self-Study: Cancer of Unknown Primary
Histology Clinical Features Work-Up Suggested treatment
“Adenocarcinoma” Woman, Axillary Mammo, MRI breast Treat as breast ca
adenopathy
Woman, Peritoneal CA-125, TVUS Treat as ovarian ca
carcinomatosis
Man, Elevated PSA, Bone PSA, Bone scan Treat as prostate ca
metastases
“Squamous cell Cervical adenopathy Pan-endoscopy, PET Treat as H&N ca
carcinoma”
Man, Inguinal adenopathy Lower endoscopy Treat as anal cancer
Woman, Inguinal Pap smear, TVUS, Treat as cervical cancer or
adenopathy endoscopy anal cancer
“Poorly- Young man, Midline Scrotal ultrasound Treat as testicular primary
differentiated tumour, Elevated hCG/AFP
carcinoma” 74

Adapted from UpToDate

 RCC once called “The Internist’s Tumor”
BONUS Self Study: Renal Cell Carcinoma due to Paraneoplastic effects including
Read on own Hypertension, Polycythemia,
Thrombosis, endovascular extension up
Localized renal mass IVC … also note seen w/ some genetic
conditons ex Von Hippel Lindau
• Localized renal mass <1cm
o Active surveillance (median growth rate = 2-3mm/yr)
• Localized renal mass 1 - 4cm
o Renal CT/MRI to better characterize
o Good surgical candidate à partial nephrectomy
o Poor surgical candidate à consider biopsy and ablation
• Localized renal mass >4cm
o Nephrectomy
Metastatic
• “Favorable risk”* à Oral TKI (Axitinib) + Immunotherapy (Pembrolizumab)
• “Intermediate/Poor risk”* à Dual immunotherapy (Ipilimumab/Nivolumab)
• s * IMDC score risk calculator
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 BONUS
Read on own
Self Study: Ovarian Cancer
• Imaging
o Abdominal + Transvaginal ultrasound AND CT chest, abdomen, pelvis
• Tumour marker: Serum CA-125 Typical regimen in adjuvant setting: platinum +
• Management taxane (Carboplatin + Paclitaxel)

• Localized
o Surgery (TAH + BSO + LN dissection + peritoneal washing)
o Do not biopsy adnexal mass = risk of seeding. Perform upfront surgery
• Stage III (visible peritoneal deposits ± malignant ascites)
o Cytoreduction (debulk) à Adjuvant chemo (curative intent)
• Stage IV (mets beyond pelvis, malignant pleural effusion)
o Palliative chemotherapy (± debulking surgery) ± VEG-F inhibitor
(Bevacizumab) OR PARP inhibitor (Olaparib, if BRCA +)
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 BONUS
Screening for Breast Cancer
Read on own
“High risk” guidelines (CCO) 2
• High risk (≥ 25% lifetime risk), includes 1 of:
o Known hereditary gene mutation (BRCA 1/2, TP53, PTEN, CDH1, PALB 1/2)
o 1st degree relative has a known hereditary gene mutation
o Personal or family history of at least one of:
• ≥2 cases of breast/ovarian CA in parent, sibling, grandparent, aunt/uncle, niece/nephew
• Bilateral breast CA
• Breast CA onset <35y old
• Invasive serous ovarian CA
• Breast/ovarian CA in Ashkenazi Jewish Female
• Male breast CA
o Radiation to the chest when < 30 yrs old and at least 8 yrs ago

• Screen from ages 30-69 yrs with mammogram AND MRI breasts annually

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 BONUS
Read on own Self-study: Genetics: BRCA 1 & 2 (JAMA)12
• BRCA 1 = ↑ Lifetime risk of Breast ca (70%) and Ovarian ca (45%)
• BRCA 2 = ↑ Lifetime risk of Breast CA (70%), Ovarian Ca (20%), Prostate Ca,
Pancreatic Ca, Gastric Ca
• Criteria for genetic testing (LOW YIELD- Always changing):
o Ashkenazi Jewish + breast ca at age < 50
o Breast cancer at age < 35
o Male breast cancer
o Triple negative breast cancer age < 60
o Serous ovarian ca at any age
o Breast + ovarian ca in same patient
o Gastric, prostate or pancreatic ca in patient with significant family
history of other BRCA 2-associated malignancies
• Therapeutic considerations: Prophylactic mastectomy, Oophorectomy
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 Cancer type Risk group Screening age Screening test(s) Frequency

Breast ca Average risk women 50-74 yrs Mammogram Q2-3 yrs

High risk women 30-69 yrs Mammogram + Q1 yr

BONUS • Germline mutation MRI breasts
Read on own • Personal Hx breast/ovarian ca
• Rads to chest < 30yrs

Lung ca At risk 55-74 yrs Low dose CT Q1 yr x3 yrs

• ≥ 30 py smoking chest
• Current smoker or quit ≤ 15 yrs ago

Colorectal ca Average risk 50-74 yrs FIT/gFOBT Q2 yrs

Sigmoidoscopy Q10 yrs
Increased risk 40-50 yrs OR Colonoscopy Q5-10 years
• ≥ 1o relative with colon ca 10 years earlier than age of
relative’s Dx
High risk - HNPCC 20 yrs OR Colonoscopy Q1-2 yrs
10yrs earlier than age of
relative’s Dx
• High risk – FAP 10yrs Sigmoidoscopy Q1 yr
• High risk – IBD 8 yrs after Dx (pancolitis) Colonoscopy Q1-3 yrs
10-12 yrs after Dx (lef-sided
colitis
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 BONUS
ReadCancer
on owntype Risk group Screening age Screening test(s) Frequency

HCC At risk - Cirrhosis From time of Dx U/S Q6months

• Cirrhosis
• Hep B and other
At risk – Hep B 40yrs U/S Q6months
• Asian male ≥ 40 yrs
• Asian female ≥ 50 yrs
• African/North American black >20 20yrs for Blacks per Only do AFP in
• 1o relative with HCC CASL 2018 irrespective areas U/S not
• HIV-infected patients (CASL) of gender available.
• HDV-infected patients (AASLD)
• Cirrhosis
Cervical ca Average risk 25-69yrs Cervical cytology Q3 yrs
STOP if ≥ 3 negative
tests after 70 yrs

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 BONUS Q1 2023
75 year old male with metastatic colon cancer, recently received FOLFIRI 9 days ago, presents to the
emergency department with diarrhea 6-8x/day. His HR is 120, BP 90/50, Temp 38.5, RR 20. Bloodwork: ANC
0.3, K 2.8, Mg 0.5, Cr 84, LFT normal. CT shows no evidence of colitis. He otherwise has no significant past
medical history and takes no medications. He tells you he lives with his wife and she has been taking
extremely good care of him as she was a previous RN. What would be your next step?
A. Discharge home with outpatient loperamide
B. Discharge home with outpatient loperamide and amoxicillin-clavulanic acid + ciprofloxacin
C. Admit to hospital, start loperamide and IVF
D. Admit to hospital, start piperacillin-tazobactam

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 BONUS Q2 2023
A 78F with locoregional breast cancer, recently resected and is currently on adjuvant Letrozole. She has a past
history of fibromyalgia on hydromorphone CONTIN 12mg BID and hydromorphone 1mg po Q4H prn. She
presents to the ER reporting over the last 2 days she has been having bilateral leg weakness, her urine has
changed to dark brown and now she’s barely peeing. She also reports a few days of loose BM but may be
something she ate. CBC shows a WBC 13, Hb 120, Plt 200, Na 128, K+ 6.2, Uric acid 343, Calcium 2.4 mmol/L,
PO4 1.5 mmol/L, Cr 325.CT C/A/P shows no evidence of lymphadenopathy, but shows a distended bladder with
bilateral hydronephrosis. Speaking to you she’s otherwise wide awake, Afeb 36.6, HR 102, BP 130/80, RR 24.
Her pupils are normal in size. What is your immediate next step?

A. Confirmation of G6PD status then urgent Rasburicase.

B. Foley Catheter insertion then send to floor.
C. Naloxone 0.4mg IV, repeat as necessary.
D. Order MRI spine and consider dexamethasone.

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 BONUS Q3 2023
A 56M with metastatic pancreatic adenocarcinoma to the liver has been admitted on the floor. He is
complaining of bloating associated with abdominal pain, dyspnea, and cough. He has a PMH of opioid use
disorder, currently on hydromorphone CONTIN 32mg po BID with breakthroughs. He is otherwise still having
BM once a day, liquid as he has not been eating much. He’s Afebrile at 36.8C, HR 90, BP 90/50, RR 33, spO2
98% RA. On exam his chest sounds clear bilaterally but there’s decreased air entry at the bases. He is noticeably
jaundiced and his abdomen is very distended. His family asks you if there is anything you can offer him. What is
the next best course of action?
A. Order CTPE protocol- rule out PE with right heart strain.
B. Prescribe Oxygen for comfort as it has been shown to increase comfort in end-stage dyspnea.
C. Change Hydromorphone to Morphine
D. Change Hydromorphone to Methadone

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 BONUS Q4 2023
A 56M is referred to your outpatient GIM clinic for a new liver lesion noted by his family doctor on ultrasound
for epigastric discomfort (to rule out gallstones). He has a past history of colon cancer resected 2 years ago,
treated with adjuvant FOLFOX, and it has been more than a year since he received any form of therapy. What is
the best course of action?

A. Referral to Cancer Centre for biopsy and consideration of curative intent treatment
B. Referral to Cancer Centre for biopsy and consideration of palliative intent treatment
C. Referral to Palliative care as this is no longer curative and the patient will pass away soon
D. Book a follow-up appointment to reassess by ultrasound in 6 months.

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 BONUS Q5 2023
A 55F with a history of metastatic hormone positive breast cancer, currently on Letrozole and Palbociclib in the
first line setting. She has a history of left sided locoregional breast cancer treated with surgery followed by
adjuvant Tamoxifen x 10 years which finished a year ago. She presents to the clinic with 1 week history of
progressive left lower leg swelling, pain, and redness. Ultrasound confirms DVT. On review of systems you also
note she has been having spotting for several months along with post-coital bleeding. What is the likely cause
of her DVT and why is she bleeding?

A. Letrozole associated DVT and Metastatic breast Cancer invasion to the uterus
B. Metastatic breast cancer associated DVT and Letrozole associated endometrial cancer
C. Letrozole associated DVT and Tamoxifen associated endometrial cancer
D. Tamoxifen associated DVT and Tamoxifen associated endometrial cancer
E. Metastatic breast cancer associated DVT and Tamoxifen associated endometrial cancer

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 BONUS Q6 2023
A 55 year old male with early stage lung cancer, resected, recently received adjuvant Cisplatin +
Vinorelbine 14 days ago, presents to the emergency department with nausea vomiting, and numbness of
his hands. He tells you he has difficulty doing his own buttons, using a spoon and fork and thus has resulted
in not being able to feed himself very well. His HR is 120, BP 100/50, Temp 38.5, RR 20. Bloodwork: ANC
(Absolute neutrophil count) 0.8, K 2.8, Mg 0.5, Cr 84, LFT normal. CT shows no evidence of colitis. He
otherwise has no significant past medical history and takes no medications. He tells you he has been feeling
weak at home but is certain within the next day he will recover, though he has not been drinking very well.
What do you tell him?

A. He has febrile neutropenia and he needs to be admitted for treatment

B. He has febrile neutropenia but he is young and can otherwise be treated at home.
C. He is 2 weeks out from his chemotherapy so his ANC should recover within a day or so. Treat him as a Non-
febrile neutropenia and thus can treat at home
D. He is 2 weeks out from his chemotherapy so his ANC should recover within a day or so. Treat him as a Non-
febrile neutropenia but he needs to come into hospital.

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 BONUS Q7 2023
A 64F with localized triple negative breast cancer presents to your clinic after she has completed her
lumpectomy with sentinel lymph node biopsy. She had 1 lymph node positive and she has decided to go with
radiation next week after declining chemotherapy. She tells you she has been doing amazing post-op. She is
biking, hiking, eating great food with friends. She says she couldn’t even imagine how sick she would be if she
had chemotherapy and tells you she was right to pursue natural molecularized water for adjuvant treatment.
She says she is otherwise feeling good aside from a gnawing ache over her lower back that is persistent for 2
weeks. She reportedly strained her back just 2 weeks prior when trying to mountain climb. Palpation of her
spine reveals a small area of tenderness around L5. She is now interested in discussing ongoing surveillance.
What is the next best step?

A. She is considered cured from her stage 2 breast cancer. Organize annual mammogram
B. She is considered cured from her stage 2 breast cancer. There is no additional follow-ups needed.
C. She has new back pain from her stage 2 breast cancer. Though guidelines would say no further staging so
she will just need annual mammogram. Monitor her symptomatically.
D. She has new back pain from her stage 2 breast cancer. She needs a bone scan

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 BONUS Q8 2023
A 68 year old Asian woman with stage 3 lung cancer presents to your clinic for evaluation. She is visibly
distraught as she tells you she has never smoked in her life, though she may have been exposed to second
hand smoke for 10 years when she was a child. She has lung adenocarcinoma, EGFR mutated, PDL-1 > 50%. She
was deemed unresectable by the the local thoracic surgeon and was told that her only option was to pursue
treatment in the palliative setting. She sees you in clinic. What is the next best course of action

A. Start Durvalumab in the Palliative Setting

B. Start Osimertinib in the Palliative Setting
C. Bring to Multi-disciplinary round for consideration of concurrent chemoradiation followed by Durvalumab.
D. Refer for a second surgical opinion as aggressive surgery with adjuvant chemotherapy is the only way to
cure her.

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 BONUS Q9 2023
The same 45M presents to clinic with 3
week history of shortness of breath,
constipation, and fatigue. Chest CT
shows a 4 cm spiculated lung nodule in
the right lower lung. He also has a
calcium of 3.4. What type of
malignancy is this most likely?

A. Squamous cell carcinoma of lung

B. Adenocarcinoma of lung
C. Small cell lung cancer
D. Large cell lung cancer

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 BONUS 2023 MCQ ANSWERS
1 D- He has Febrile Neutropenia by definition. Don’t worry about MASCC. He’s older, volume depleted (vitals deranged)- Safer to
bring in (On exam it is likely always safer to bring in)
2 D- She may not have back pain with the hydromorphone use. There’s no sign otherwise of opioid toxicity. Solid Tumor Oncology
doesn’t lead to TLS- really only Haem Onc does (ex. Lymphoma)- You can see all the changes with AKI. She should not be sent to the
floor with just a foley as you need to urgently rule out cord compression (hx of breast CA)
3 C- Hydromorphone seems to be not doing the trick as much anymore. He is likely dyspneic from the abdominal distention from
the cancer. Methadone is not appropriate as he likely has liver failure with the jaundice. His vitals would suggest low intake leading to
hypovolemia- for a PE to cause such a drop in BP you’d expect some hypoxia, tachycardia, and he’d look a lot sicker. Oxygen is not
indicated for non-hypoxic dyspnea.
4 A- Oligometastatic disease from colon cancer can be treated in a curative fashion. Need discussion with the cancer team
however. Biopsy is ideal to rule out other malignancies
5 E- The patient is off Tamoxifen for over a year- there should not be any residual DVT risk from that. She can however develop
grumbling endometrial cancer that is now manifesting. Letrozole is not associated with DVT. This is cancer-associated.
6 A- Not everyone is textbook! He is clearly suffering from TERRIBLE chemo side effects- perhaps we gave a little too much
chemotherapy. He is unwell, based on his decreased oral intake, the persistent chemotherapy side effect (we generally want the
chemo side effect to completely wear off before starting another cycle). He should be admitted for Feb Neut and treat like one.
7 D- We don’t stage asymptomatic stage 2, but certainly we stage SYMPTOMATIC stage 2. This is concerning for bone disease.
Maybe she ‘s going to need chemotherapy after all…
8 C- Remember in stage 3 lung cancer we can also cure by concurrent chemoradiation + durvalumab for those that are unresectable.
9 A – SCC Often central, with paraneoplastic hypercalcemia. Adeno typically peripheral. SCLC and Adeno uncommon with hyperCa

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 BONUS
Read on own Approach to studying solid tumor oncology
1. Relevant Biology Underlined = Extra Important
2. Diagnosis and Staging Method
3. Staging
4. Management- Early Stage
1. Neoadjuvant therapy
2. Definitive Treatment
3. Adjuvant therapy
5. Management- Metastatic Disease
6. Important systemic therapy side effects
7. Surveillance

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 BONUS
Read on own General TIPS to studying solid tumor oncology
1. Relevant Biology- rarely tested Underlined = Extra Important
2. Diagnosis- Can be tested
3. Staging Method- Rarely tested
4. Stages of Cancer- Rarely tested except for a few special cases (will be addressed)
– Know what stages require what treatment, rather than memorizing which TNM contributes to which prognostic stage

5. Management- Early Stage

1. Neoadjuvant therapy- Never tested- WILL NOT COVER
2. Definitive Treatment- Can be tested in broad overview
3. Adjuvant therapy- Can be tested in broad overview
6. Management- Metastatic Disease- Can be tested in broad overview
7. Important systemic therapy side effects- Expect to be tested
8. Surveillance- Can be tested in broad overview

Remember these are general overview of managements. There are caveats EVERYWHERE that we won’t be addressing.

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 BONUS
Read on own Current Screening Algorithms to know

• Breast Cancer
– Low-risk vs High risk
• Colon Cancer
– Average risk vs Increased risk
• Cervical Cancer
– One screening algorithm for the general population
• Hepatocellular Carcinoma
– One screening algorithm for selected population
• Lung Cancer
– One screening algorithm for selected population

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 BONUS
Chemotherapy Toxicities by Disease Site **HIGH YIELD **

Read on own

Oncologic Site Chemotherapy Agent High Yield Toxicities

Breast Cancer Anthracyclines (FEC-D, ddAC-T) Irreversible cardiomyopathy
Doxorubicin (Adriamycin), Epirubicin Secondary leukemias)
Cyclophosphamide (FEC-D, ddAC-T) Hemorrhagic cystitis, bladder CA
Secondary malignancies (MDS, AML, bladder Ca)
Infertility
Taxanes (FEC-D, ddAC-T) Peripheral neuropathy
• Docetaxel Fluid retention (Docetaxel)
• Paclitaxel
Colon Cancer Antimetabolite (FOLFOX/FOLFIRI) Diarrhea, mucositis, hand-foot syndrome, coronary
5-Fluourouracil, Capecitabine vasospasm
Topoisomerase inhibitors (FOLFIRI) Diarrhea, Cholinergic Reaction
Irinotecan
Platinums (FOLFOX) Peripheral Neuropathy
• Oxaliplatin Cold-induced neuropathy (Oxaliplatin-specific)
Testicular Cancer Bleomycin(BEP) Pneumonitis
Topoisomerase inhibitors (BEP) Myelosuppression, Hypersensitivity reaction, diarrhea
• Etoposide

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 BONUS
Chemotherapy Toxicities by Disease Site **HIGH YIELD **

Read on own

Oncologic Site Chemotherapy Agent High Yield Toxicities

Lung Cancer Platinums (Platinum Doublet Chemotherapy) All – Peripheral neuropathy

• Cisplatin Cisplatin-specific – Highly emetogenic, nephrotoxic,
• Carboplatin ototoxic, hypoMg/Ca/K
Carboplatin- Gentle version of Cisplatin- Less
ematogenic.
Vinca alkaloids (Cis+ Vinorelbine) Peripheral neuropathy
• Vincristine, Vinorelbine
Taxanes (Carboplatin+ Paclitaxel) Peripheral neuropathy
• Paclitaxel Fluid retention (Docetaxel)
• Docetaxel
Ovarian Cancer Platinums (Platinum Doublet Chemotherapy) Peripheral neuropathy
• Carboplatin Carboplatin- Gentle version of Cisplatin- Less
ematogenic.
Taxanes (Carboplatin+ Paclitaxel) Peripheral neuropathy
• Paclitaxel Fluid retention (Docetaxel)
• Docetaxel

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 BONUS
Read on own Screening for Esophageal Cancer (CTFPHC)11
• Do NOT screen adults (≥18) with chronic GERD without alarm symptoms for
o Esophageal adenocarcinoma or
o Precursor conditions (Barrett esophagus or dysplasia)

• These guidelines DO NOT apply to

o Patients with alarm symptoms (dysphagia, odynophagia, recurrent vomiting,
unexplained weight loss, anemia, loss of appetite, or GI bleed)
o Those with Barrett esophagus (with or without dysplasia)

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**HIGH YIELD **

BONUS
Immunotherapy: Use in Solid Tumours
Read on own

• Checkpoint inhibition allows re-activation of quiescent T-cells to attack tumour cells

o PD-1 inhibitors: Pembrolizumab, nivolumab
o CTLA-4 inhibitors: Ipilimumab

• Indications in multiple tumors: https://www.medgadget.com/

o Melanoma, Lung, bladder, renal cell, colon, Hodgkin’s lymphoma, breast, head and
neck, gastric ….

• Side effects- Any organitis!

o Rash (most common), endocrine (hypothyroid, panhypopituitarism, adrenal
insufficiency, diabetes), GI (colitis, hepatitis), pneumonitis, uveitis, myocarditis,
nephritis, MSK (synovitis, arthritis), hematologic, encephalitis
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 TAKE OUT
Erythropoietin stimulating agents in
BONUS
Read on own Solid Tumor Malignancies18
• Chemo-associated anemia (Hgb < 100)
o If treatment is CURATIVE – Do NOT use erythropoietin stimulating agents (ESAs)
o If treatment is PALLIATIVE – MAY use ESAs if Hgb persistently low

• Cancer-associated anemia (Hgb < 100), NOT on therapy

o Do NOT use ESAs if anemia is solely due to solid-tumor malignancy

• Factors to consider when starting ESAs

o Rule out non-cancer/chemo associated causes for anemia (i.e. Fe deficiency)
o Discuss risks of thromboembolism
o There is no “target” Hgb for this population. Target Hgb to avoid need for recurrent transfusions
o ESAs should be discontinued if not working after 6-8 weeks
o Iron supplementation may be ADDED to ESAs to increase efficacy, even if not iron deficient

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