Master Oncology & Palliative Care
for MRCP Part 1

Core Concepts

Oncology is the study and treatment of cancer, characterised by uncontrolled cell growth, potential for local invasion, and metastasis. Palliative care aims to improve quality of life for patients and their families facing life-limiting illness, focusing on symptom relief, psychological, social, and spiritual support, from diagnosis through to bereavement.

• Cancer Pathogenesis: Accumulation of genetic mutations leading to proto-oncogene activation or tumour suppressor gene inactivation.
• Key Terms:
  • Neoplasm: Abnormal mass of tissue.
  • Benign: Non-cancerous, non-invasive, non-metastatic.
  • Malignant: Cancerous, capable of invasion and metastasis.
  • Metastasis: Spread of cancer cells from primary site to distant parts of the body.
• Staging (TNM System):
  • T (Tumour): Size/extent of primary tumour.
  • N (Nodes): Presence/extent of regional lymph node involvement.
  • M (Metastasis): Presence of distant metastasis.
• Cancer Treatments:
  • Local: Surgery, Radiotherapy.
  • Systemic: Chemotherapy, Targeted therapy (e.g., EGFR inhibitors, HER2 blockers), Immunotherapy (e.g., checkpoint inhibitors), Hormonal therapy (e.g., Tamoxifen, LHRH agonists).
• Palliative Care Principles: Early integration, holistic approach, affirmation of life, regards dying as a normal process, neither hastens nor postpones death, integrates psychological and spiritual aspects, offers support system for patients and families.

Clinical Presentation

• General "Red Flag" Symptoms: Unexplained weight loss, persistent fatigue, night sweats, unexplained lumps/masses, persistent pain (especially bone pain), changes in bowel/bladder habits, abnormal bleeding (haemoptysis, haematuria, PR bleeding, post-menopausal vaginal bleeding).
• Site-Specific Examples:
  • Lung: Chronic cough, dyspnoea, haemoptysis, chest pain.
  • Colorectal: Change in bowel habit, PR bleeding, abdominal pain, iron deficiency anaemia.
  • Breast: New lump, skin changes (peau d'orange), nipple discharge/inversion.
  • Prostate: Lower urinary tract symptoms (LUTS), bone pain.
  • Brain: Headaches (worse in morning), seizures, focal neurological deficits.
  • Leukaemia/Lymphoma: Fever, night sweats, weight loss, lymphadenopathy, splenomegaly, easy bruising/bleeding, recurrent infections.
• Paraneoplastic Syndromes: Symptoms produced by remote effects of a tumour, not direct invasion.
  • Endocrine: Hypercalcaemia (SCC), SIADH (SCC), Cushing's (SCC).
  • Neurological: Lambert-Eaton Myasthenic Syndrome (SCC), cerebellar degeneration.
  • Haematological: Trousseau's Syndrome (migratory thrombophlebitis, pancreatic/GI), anaemia, polycythaemia.

Diagnosis (Gold Standard)

Histological or Cytological Biopsy: Definitive diagnosis for almost all cancers. Type depends on suspected primary site (e.g., core needle biopsy for breast lump, endoscopic biopsy for GI lesion, bone marrow biopsy for haematological malignancies, excisional biopsy for skin lesion).

• Imaging: For staging and extent of disease (CT, MRI, PET-CT, Ultrasound, Endoscopy).
• Tumour Markers: Used primarily for monitoring treatment response and detecting recurrence, NOT for primary diagnosis (e.g., PSA for prostate, CEA for colorectal, CA125 for ovarian, AFP for hepatocellular/germ cell, hCG for germ cell).
• Other: Blood tests (FBC, U&Es, LFTs, LDH), bone marrow aspirate/trephine.

Management (First Line)

Management decisions are made by a Multidisciplinary Team (MDT) involving oncologists, surgeons, radiologists, pathologists, specialist nurses, and palliative care specialists. Treatment intent is either curative or palliative.

• Curative Intent:
  • Surgery: Primary treatment for many solid tumours, especially early stages.
  • Radiotherapy: Can be curative for localised tumours (e.g., early prostate, head and neck), adjuvant (post-surgery), or neoadjuvant (pre-surgery).
  • Chemotherapy: Often used systemically for metastatic disease, or adjuvantly/neoadjuvantly to improve surgical outcomes.
  • Targeted Therapies/Immunotherapy: Increasingly first-line in specific cancers with actionable mutations or high PD-L1 expression (e.g., EGFR inhibitors for lung cancer, trastuzumab for HER2+ breast cancer, pembrolizumab for melanoma).
  • Hormonal Therapy: For hormone-sensitive cancers (e.g., breast cancer, prostate cancer).
• Palliative Intent: Focused on symptom control and quality of life.
  • Pain Management: WHO Analgesic Ladder (Non-opioids → Weak opioids → Strong opioids). Adjuvants (e.g., gabapentin for neuropathic pain). Radiotherapy for painful bone metastases.
  • Nausea/Vomiting: Anti-emetics (e.g., metoclopramide, ondansetron, dexamethasone).
  • Dyspnoea: Opioids (morphine), bronchodilators, anxiolytics, oxygen (if hypoxic).
  • Fatigue: Non-pharmacological (activity planning), consider reversible causes.
  • Constipation: Laxatives (often needed with opioids).
  • Psychological/Spiritual Support: Counselling, chaplaincy.
  • Advance Care Planning: Discussion of patient preferences for future care.