Master Oncology & Palliative Care
for MRCP Part 1

What the MRCP Part 1 Tests in Oncology & Palliative Care

Candidates must recognise common cancer presentations (e.g., haemoptysis in lung cancer, painless jaundice in pancreatic cancer) and interpret staging investigations (CT, PET-CT, tumour markers). They need to know first-line chemotherapy regimens (e.g., FOLFOX for colorectal cancer, ABVD for Hodgkin lymphoma), targeted therapies (e.g., trastuzumab for HER2+ breast cancer, imatinib for CML), and endocrine therapies (tamoxifen, aromatase inhibitors). Palliative care knowledge includes opioid conversion (oral morphine 30 mg ≈ parenteral morphine 10 mg), management of hypercalcaemia (zoledronic acid, IV fluids), malignant spinal cord compression (high-dose dexamethasone, urgent MRI), and the Liverpool Care Pathway principles. Genetic syndromes (BRCA1/2, Lynch syndrome, Li-Fraumeni) and paraneoplastic syndromes (SIADH in SCLC, Lambert-Eaton in SCLC) are frequently tested. Candidates must apply WHO analgesic ladder and NICE guidelines for nausea, dyspnoea, and terminal agitation.

High-Yield Concepts

• Malignant Spinal Cord Compression (MSCC): Suspect in any cancer patient with new back pain, limb weakness, or sphincter disturbance. Immediate management: high-dose dexamethasone 16 mg IV/PO stat, then 8 mg BD; urgent MRI whole spine within 24 hours. Definitive treatment: radiotherapy or surgical decompression depending on histology and stability.
• Opioid Conversion & Equianalgesic Doses: Oral morphine 30 mg/24h ≈ transdermal fentanyl 12 mcg/h (25 mcg/h patch approximates 60 mg oral morphine). For breakthrough pain: immediate-release morphine dose = 1/6 of total daily oral morphine. Rotate to oxycodone if toxicity (e.g., hallucinations, myoclonus) using 1.5–2:1 ratio (morphine:oxycodone).
• Hypercalcaemia of Malignancy: Corrected calcium >2.6 mmol/L requires treatment. First-line: IV normal saline 3–4 L/24h, then IV bisphosphonate (zoledronic acid 4 mg over 15 min or pamidronate 60–90 mg). Avoid loop diuretics unless fluid overloaded. Denosumab is alternative if bisphosphonate contraindicated.
• Tumour Lysis Syndrome (TLS): Common in high-grade lymphomas, ALL, and Burkitt lymphoma. Laboratory TLS: uric acid >476 µmol/L, K+ >6.0, phosphate >1.45, Ca2+ <1.75. Prevention: aggressive IV fluids, allopurinol 300 mg PO (or rasburicase 0.2 mg/kg IV if high risk). Monitor ECG for hyperkalaemia (peaked T waves).
• Chemotherapy-Induced Nausea & Vomiting (CINV): High emetic risk (cisplatin, doxorubicin): prophylaxis with NK1 antagonist (aprepitant), 5-HT3 antagonist (ondansetron 8 mg IV/PO), and dexamethasone 8–12 mg. Moderate risk: 5-HT3 antagonist + dexamethasone. Breakthrough: add metoclopramide 10 mg or haloperidol 1.5 mg.
• BRCA1/2 & Lynch Syndrome Screening: BRCA1/2 carriers: annual breast MRI from age 30, risk-reducing salpingo-oophorectomy by age 40. Lynch syndrome (MLH1, MSH2, MSH6, PMS2): colonoscopy every 1–2 years from age 25, annual endometrial biopsy. Tumour testing: microsatellite instability (MSI) or immunohistochemistry for mismatch repair proteins.
• Paraneoplastic Syndromes – Key Associations: SCLC: SIADH (hyponatraemia, urine osmolality >100), Lambert-Eaton myasthenic syndrome (proximal weakness, autonomic dysfunction). Thymoma: myasthenia gravis (anti-AChR antibodies). Renal cell carcinoma: polycythaemia (erythropoietin). Ovarian teratoma: anti-NMDA receptor encephalitis.
• Palliative Sedation & Terminal Agitation: Terminal agitation: first-line midazolam 2.5–5 mg SC/IV, repeat every 30 min until settled. Second-line: levomepromazine 12.5–25 mg SC/IV. For refractory dyspnoea: morphine 2.5 mg SC PRN + midazolam 2.5 mg SC. Always document goals of care and consider reversible causes (urinary retention, pain).

Common Traps in Oncology & Palliative Care Questions

• Confusing corrected calcium with ionised calcium: use formula: corrected Ca = measured Ca + 0.02 × (40 – albumin) in g/L.
• Assuming all hypercalcaemia in malignancy is due to bone metastases: remember humoral hypercalcaemia (PTHrP) in squamous cell lung cancer.
• Giving allopurinol after tumour lysis has started: allopurinol prevents uric acid formation but does not degrade existing urate – rasburicase is needed for established TLS.
• Using oral morphine for breakthrough pain without calculating the correct dose (should be 1/6 of total daily dose, not a fixed 5 mg).
• Forgetting to check for opioid-induced neurotoxicity (OIN) when rotating: symptoms include myoclonus, hyperalgesia, and sedation – reduce dose by 25–50% when switching.
• Misinterpreting a normal PSA in a patient with suspected prostate cancer: remember that 15% of prostate cancers are PSA-negative (e.g., small-cell or neuroendocrine variants).

How to Revise Oncology & Palliative Care for the MRCP Part 1

Prioritise memorising first-line regimens for common solid tumours (breast, lung, colorectal, prostate) and haematological malignancies (DLBCL, Hodgkin, CLL). Practise interpreting tumour marker trends (CEA, CA19-9, AFP, hCG) in clinical vignettes. Focus on NICE guidelines for cancer referral (e.g., 2-week wait for haematuria >45 years, breast lump). For palliative care, master opioid conversions, antiemetic algorithms, and management of malignant effusions. Questions often present a clinical scenario with lab values or imaging findings requiring a specific next step (e.g., start bisphosphonate, request MRI spine). Review the WHO analgesic ladder and the principles of the Liverpool Care Pathway (now replaced by individualised care plans). Spend time on paraneoplastic syndromes and genetic syndromes – these are high-yield because they link multiple specialties.

Practise it: MedLumen has 50 Oncology & Palliative Care questions for the MRCP Part 1, each with a full explanation and references.