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Everyone will just be giving you a couple of minutes for people to get joined and then we'll get started. Hi, everyone. Welcome to our second. We've been our in our Oncology series. Tonight will be having a talk on Symptom Control in Oncology by topic, Harden. Doctor Hardin's an S T seven in clinical oncology in Tayside and four or five junior doctors in case I degree. He is their favorite oncology. Reg Oh, do you when you're ready? Topic? Thank you, Julie. I quite like to know. Is that one out of five? I'm not happy about that anyway. Hello, everyone. And good evening, my name is at Tawfiq High Rudan. I am a clinical uncalled specialist registrar and a working night with hospital in Dundee Tayside. Um So today, first of all, we'd like to thank the organizer, the team from mind the bleed for approaching me and giving me the opportunity to do this talk to do this webinar. I hope this talk will be useful for everybody, uh, particularly junior doctors. And if there's a medical student because as mentioned on the website, whether you are interested in oncology or not looking after patients with cancer, um will be an inevitable part of your job. So regardless of whether you're going to do medicine or surgery or G P or any other medical specialties, you will encounter cancer patient's. And I hope this talk will be relevant because we estimated that half of the population will be affected by cancer, half the UK population. Um, so either they have cancer or they had cancer or they're being investigated for suspected, for suspicion of cancer. Uh So like it or not, you will encounter patient with history. Cancer. Okay. Uh Right now, I don't know if any of you have been to any oncology talk or any oncology teaching. Uh Normally in talks or lectures about oncology, there will be a lot of statistics involved, there will be charts, there will be data, there will be Kaplan meier curve flying about endless p values, has it ratio and all that. But fortunately, or unfortunately, depending on which we're looking at it, I have none of that. The only thing that will resemble any statistical data would be me saying phrases like statistically speaking or most commonly or in comparison. That's, that's all the statistics that you're going to get from me. Otherwise I'll do my best not to bore you with any statistics. Uh My talk is very simple and I hope it's very relevant and very practical to your day to day job. Okay. Uh So uh let's start then shall we uh this is an on quality talk, we're talking about cancer or cancer symptoms. Um So this is my obligatory slide of the hallmarks of cancer. I'm sure you've seen this before. If you haven't, this is it, uh the hallmarks of cancer suggest the complex mechanism and interactions of how our cancer is developed. Initially in the year 2000. It is thought that there are six features which allows cells of our own body to go rogue and become, become cancer. Uh And then more research were done and then, then we realized that there were eight and then there were 10. And so you can see on this slide here, there are actually 14 hallmarks of cancer. I'm not going to bore you with each and every one of these. Uh But the reason why this is relevant is because some of these hallmarks of cancer or features are the reason why patients develop symptoms from the cancer, especially features like evading goethe suppressors, enabling, replicated. I've immortality, activating uh invasion and metastases and resisting cell death. Okay. Um So what what this the hallmark cancer, what it tells us is that um the nature of cancer is uh they want to grow okay and they want to spread, they want to metastasize and nothing is going to stop the cancer from growing unless you do something about it. I you treat the cancer. So patient's develop symptoms because cancer grows and they grow within organs within structures. Um And they cause pain, they cause fragility, which can lead to, for example, pathological bone fractures and they can grow and cause obstruction, which lead to symptoms like pain, vomiting and so on. And when they grow, they can also cause pressure. Uh which while you get symptoms from malignant spinal cord compression, uh while you get symptoms from S V C obstruction and raise intracranial pressure, okay. Um Now, I also said that cancer will continue to grow unless you do something about it. So we treat the cancer, either surgery or radiotherapy or sacked. So you're going to hear me say sack a couple of times. S A C T which stands for systemic and the cancer treatment. In the past, we only have surgery, radiotherapy and chemotherapy. Whereas nowadays, if you look in the red box there, these are some of the systemic treatment that we use to treat cancer. It's not just chemotherapy, it's getting more exciting treating cancer nowadays. So to make things simpler, I will say sacked rather than um just chemotherapy or just immunotherapy. Um Now these systemic treatments particularly radiotherapy or sacked, they're, you know, they're technically, they're, they're poisonous, they're toxic. Uh Sometimes ironically, some of these patient's were not that symptomatic from the cancer, but they become very symptomatic to a point that would affect their quality of life because of cancer treatment, not because of their cancer. So cancer treatment itself can lead to symptoms and sometimes can be quite severe, even life threatening symptoms. I've seen a patient who had chemotherapy and then died from severe diarrhea. Um, this is on site even before we do DPD testing. So, um, it's, it's really important to consider that if they're on cancer treatment, sometimes the symptoms not due to the cancer but due to the cancer treatment. Right. Um, okay, very rarely. Uh, cancer can also be poisonous in inverted commerce. Uh This is more commonly known as paraneoplastic syndrome, which is a lot of time. It's a diagnosis of exclusion. Cancer itself is not poisonous but sometimes they release hormones and peptides or cyto kinds or they can interact with your immune system or with our immune system which can lead to symptoms. Hypocalcaemia is probably the most common one that we see having said that hypercalcemia due to extensive boarding metastases, which is not a paraneoplastic syndrome. It's more common than hypercalcemia due to paraneoplastic syndrome. So again, bear in mind hyper paraneoplastic syndrome. Yes, that can happen. But it's it's it's a rare thing and a lot of the time it's diagnosis of exclusion. Um Finally, when talking about symptoms in cancer patient, we also need to remember that they can also develop symptoms which are not related to the cancer or sometimes not even related to the cancer treatment. So, brain metastases can cause headaches. We know that but patient with brain metastases can also have migraines which causes headaches as well and it's not related to the cancer. So please remember just because they have cancer, it does mean that all of their symptoms are due to cancer occasionally. Uh It's not due to Catholic occasionally. It's something unrelated to the treatment. Okay. So uh as I said, my talk is going to be very simple. Hopefully, very straightforward. What are the principles of treating or managing symptoms in cancer? Patient? Rule number one, treat the symptoms of stabilize the patient. Now, this sounds a bit daft like why would I say rule number one of managing symptoms in cancer patient is treat the symptoms. That's the title of the talk. Not really the solution. I might as well just you know, have this slide. Here. There we go. Here are my presentation. There we go. If you can read that, then you can deal with cancer patient sometimes. Uh it's not as straightforward but that what I'm trying to say is that sometimes we're so caught up on the cancer. We say that they have cancer. So we have to treat the cancer. Yes, we do have to take the cancer and, and a lot of time their symptoms are due to their cancer. Uh but we forget to actually treat the symptoms or stabilize the patient first. Uh managing symptoms in cancer is the same as managing symptoms in patient's without cancer. You need to alleviate the symptoms first, uh investigate the cause and then you need to treat the cause. Um So even if somebody without cancer you would do the same thing. You do. That sort of, that's, that's the protest. Well, not the protocol. That's what you normally do. They come in with pain, you keep the pain and then you investigate what causes the pain and then you treat the cause of the pain. Yeah. Um, but remember, you don't have to wait until the patient's symptoms are totally gone before you investigate. But at least you need to put some effort to make the patient feel more comfortable and then you investigate. Um, I'll give an example, imagine if you have a 60 year old man with a history of heavy smoking and alcohol intake and also a history of poorly controlled diabetes. These mind presented with the central crushing chest pain associated with breakfast, nous sweats, uh, nose and palpitations. You suspect that the patient might have a myocardial infarction. So, what do you do first? Uh You wouldn't, you wouldn't just pick up the phone and say to the cardiology registrar. But I think this patient has had a heart attack and you need to take him to the Cath Lab immediately because he needs PCI. The cardiology registrar is then ask you what are you doing about his pain? Have you given him anti emetic for the nausea? If he's breathless, easy on occident. Have you done any C G, have you checked his troponin? So on and so forth? Um I'm sure if you haven't done any of those. You're more likely to get your head better know off by the cardiology registrar rather than get a helpful advice if you refer a patient without managing the symptoms person than to the investigation. If you know what I mean? If there is any cardiologist in this talk, uh, my apologies. I'm not saying that you're a horrible person. I'm just using this scenario as an example. Okay. Right. Um, In real life, my day to day job as an oncology registrar, I've lost kind of the number of times when I was referred a patient uh for consideration of radio fed before paying control. And then when I asked what analgesia had the patient been prescribed. Uh The answer is paracetamol and not even regular parson and just PRN parson animal and no wonder the patient still paying. So please remember, alleviate the symptoms as best as he can first and then you investigate the cause and then you treat the cause uh symptoms due to cancer or cancer treatment can be very severe and sometimes very complex as well. So remember palliative care team. So, referral to the party of care team often needed in cancer patient, particularly when it comes to pain, when it comes to complex museum, vomiting and also end of life care. Um The other thing about palliative care team, you have to remember that they don't just support patient who are for palliation or patient's on palliative treatment. They also support patient who are on radical or curative treatment. Okay. Right. Uh Now let me move forward, move forward to that. Okay. So I'm going to talk about specific oncological treatment. So one of the main reasons for treating cancer is to improve the patient symptoms. Okay. So it makes sense if patient, uh if cancer is the course of the symptoms, then we should use specific oncological treatment such as surgery which includes, you know, resection or stent placements, radiotherapy or sacked. Um But uh these treatments while they can be very, very effective, can take time to want to organize and it takes time for them to work. So for example, if I give palliative radiotherapy to a patient for pain control, one, I have to organize it first had to get in touch with radiotherapy team and stuff the patient we need planning ct scan first, we cannot, we can get it done or within one day, there's a 75% chance that it would work, but it can take up to 1 to 2 weeks for uh the patient to notice that their pain is better after the radiotherapy. So um these specific specific oncological treatment such as surgery, radiotherapy sack could be the ultimate solution because they treat cancer but not the immediate solutions. Your patient might still be suffering, your patient might still be in pain, your your patient might still feeling sick. Um So you have to treat the symptoms okay. Uh Right before we go war two, uh specific symptoms which is associated with cancer or cancer treatment or common in cancer patient. Uh A special shout to steroids. Um We in oncology, we love steroids. Uh The reason they're special shout about steroids is not just because we love them because steroids is very, very versatile and we prescribed buck loads of, of steroids. We use them as anti emetics. Very, very effective. They are anti inflammatory as well. So we use them to be to swelling around cancers in hematological cancers, especially lymphoma. Um uh steroids are actually part of their sack, part of their anti cancer treatment. Um and uh steroids can give patient's energy boost and they boost the appetite. It doesn't work for everyone though. Um but, but it does help to majority of our patient. When we go through some of the common symptoms in cancer patient, you will see that I will be mentioning steroids again and again and again. Uh and again, however, we do know that steroids is not the magic pill. Unfortunately, steroids can lead to horrendous side effects, which can lead to more symptoms. Uh Ironic, unfortunately. Right. Okay. So uh these are the symptoms that I'm going to go through. Okay. I'm going to start off with pain, nausea, vomiting, fatigue and anorexia. So these are sort of general symptoms and we see them quite a lot and then we go from like system to system from head down to your gut, to your lungs and then um abdomen and pelvis. Okay. Um It's not going to cover all the symptoms, obviously, but if you have encountered symptoms, which I have not mentioned, uh, feel free to ask and I will try my best to answer those questions. Okay. Um Right. I have got a few scans in my presentation because I like looking at scans. I'm not a radiologist, but it's part of my job to actually look at scans because I do radiotherapy, right? The the image on the images on these slides are from the same patient, both sides. Yeah. Um There's a patient that I saw recently, the sagittal image on the left showed a soft tissue mass vertebral body. I don't know how clear you can see that uh L1 and T 12 and you can see the mask has grown into the spinal canal and it's causing spinal cord compression and spinal cord compression can be really, really sore. Uh The images on the right, the one on the top uh it shows what a normal spinal canal should look like. You can see there's a dark gray structure in the middle of the spinal spinal canal, that's the spinal cord and the spinal cord is surrounded by uh this white area which is the CSF uh the image below. Uh It's the same patient is further down the patient spine. Uh You can see that there's mass growing into the spinal canal from the vertebral body and there's barely any CSF around the spinal cord. So this mass is actually pressing on the spinal cord. And as I, as I say before, spinal cord compression can be extremely sore. I've got more images on the left. I don't know if you can see as a patient of mine with recurrent metastatic breast cancer, you can see there's a soft tissue mass in the left axilla or near the supraclavicular fossa. You can, you can compare it with the uh with the other side. So the mass is pressing on her brachial plexus and have vasculature. So it's causing neuropathic pain to the left arm and also lymphedema. The image on the right is another patient of my metastatic breast cancer as well. Widespread born in with this is unfortunately, she had, she had a fall and she sustained a pathological fracture of her left tibia. Even just looking at that image, you'll be thinking, oh, that's, that looks really sore, right? Okay. So let's move on. So we're gonna talk frankly about pain. Uh probably the most common symptoms you had to deal with in cancer patient's remember rule number one, treat the symptoms, so treat the pain, give them analgesia okay. I'm sure everybody has seen this. It's the analgesic ladder. Uh You start off with non opiate such as paracetamol. You might want to give some nonsteroidal such as Ibuprofen and naproxen uh provided that there's no contra indication. Uh Then you go up the ladder, you add in big opiates such as codeine or traMADol. Uh Then if the pain is still not well controlled, then you go on too strong opiates such as morphine, oxyCODONE, HYDROmorphone and fentaNYL depending on what they normally use in your hospital. Uh Most of our cancer patient's are going to be on the top of the ladder. Cancer patients', cancer pain is quite of the year. So a lot of our patient's are on strong opiates. Okay. A few things I would like to mention though, when you prescribe opiates, like codeine or traMADol, please only prescribed one of them and not both of them never prescribed codeine and traMADol together. Um If they're still sore, for example, you prescribed and codeine and they're still so you increase the dose of codeine rather than adding in traMADol. If they're still sore, despite maximum dose of codeine, then you go up the ladder and introduce strong opiates. I've seen patient being prescribed coding and traMADol together. That that's, that doesn't make sense to me because they have the same mechanism of Axion. So it's the same principle as prescribing proton pump inhibitor PPI for patient with heartburn or acid reflux. If they're on omeprazole and they still have heartburn, you increase the dose you don't add in lansoprazole on top or alongside the omeprazole. That doesn't make sense. Okay. And the other thing is once you are on the top of the ladder. Do not prescribe weak and strong opiates together if they're on M S T, for example. Oh, Zoom of twice a day. And you use automa for breakthrough pain killers. Um Right. But don't, don't, don't use codeine if they're on M S D, use autumn off if they're on oxyCODONE long acting, use OxyContin short acting. Okay. Um So, um Right. So once you give them uh analgesia, once you give these patient with pain analgesia to at least take the edge of your pain, you start to investigate the cause of the pain and then you treat it. If they sustain a pathological fracture, for example, then they will need a referral to the orthopedic team. Um if they didn't have a fracture, but they have bone pain, do two boney metastases, then sometimes bisphosphonates can help either permission, eight or Zoledronic acid. If they have obstructions such as bowel obstruction or urinary retention, then you need to release the obstruction. Uh, steroids can sometimes help because steroids can reduce swelling around cancer. Um But they may need surgery or procedure to release the obstruction such as laparotomy catheterization or standing okay. Um Remember pain in cancer patient can be quite severe. So getting the palliative care team involved can be very helpful. Uh Please also remember that cancer patient can also have pain which is not related to their cancers, which is migraine, heartburn, osteoarthritis and so on. Right. That's pain. Um Here, I've got a picture of uh one of the patient I've seen recently with spina quote compression. Uh the patient who I showed you the MRI before. So that's, that's the radiotherapy plan for this patient. I'm going to talk briefly about radiotherapy and pain. Um I mentioned this before. New therapy can be very effective and I give a lot of radiotherapy for pain control and three quarters of patient who receive radiotherapy notice that their pain is much better after radiotherapy. Uh there's a 25% chance that it won't work though. Unfortunately, and radiotherapy causes inflammation. So we usually warn our patient that their pain can potentially get worse temporarily before they get better. And as I mentioned before, the effects of re you therapy can take 1 to 2 weeks to work. So it's very important that you try and manage the symptoms with medications, analgesia first before considering maybe therapy for pain control. Okay. Next, symptoms, nausea and vomiting again, very common uh either due to cancer but sometimes more commonly due to their cancer treatment. Chemotherapy particularly uh remember rule number one, treat the symptoms, give them antiemetics. Uh on the slides are the least of a list of antiemetics that we quite commonly use for our cancer patient. Uh I'm sure you would use a lot of these for uh non cancer patient's as well. Again, a couple of things I would like to mention and like to remind you never prescribed me to co promote and don't paradigm together because they're both pro kinetic. So they have the same mechanism of Axion. Never prescribed. You either prescribe one or the other and never prescribe metric. Open might end cyclizine together because they have opposing mechanism. If you tried metoclopramide, it doesn't work, stop the medical permite and then um start them on cyclizine instead or do it the other way around. Um uh There we go. Uh what's, uh, right, once you've treated their symptoms, investigate the cause, um, you will see a pattern here. So treat the symptoms, investigate the cause and then treat the cause. Um, you investigate the cause. So if it's bubble obstruction, it's very common in our guided patient, particularly ovarian and primary peritoneal cancer patient, they can develop subcut bowel obstruction. Uh, steroids can be helpful, but obviously, if they develop mechanical obstruction, they would need surgery. Um, if surgery is not visible or patient's not fit for surgery, uh, sometimes we do start the patient or commonly we start the patient with a syringe driver with steroids and poor kinetics like metoclopramide. Uh, this combination can be actually very effective. Um, uh, but be careful though as you need to investigate first and make sure that they do not have mechanical obstruction before starting the mimetic. Oh, provide, um, if the nose and vomiting due to chemotherapy or radiotherapy dexamethasone and or on the Citron can be very, very effective. Um, if, uh, the cause of uh nausea, vomiting is, is their chemotherapy. Sometimes you do have to stop their chemotherapy if they're sick or they're nauseous or because of um increased intracranial pressure because they got brain metastases and then there's lots and lots of swelling arriving the brain metastases. Steroids can be very helpful because steroid, reduce the inflammation around the cancer and can reduce the swelling and release some of the pressure in the brain. Okay. Uh Again, nose and vomiting could be one of these symptoms that could be very difficult to manage and you may need the help of palliative care team. And I'm going to keep emphasizing this. Um don't forget other potential causes of nausea and vomiting such as, you know, uti gastroenteritis, reflux and everything and, and so on. Okay. Right. Um Next, fatigue and anorexia, again, very common. Um when I say anorexia, I don't mean anorexia, nervosa that um you know, eating disorder, it's more unready is the lack of appetite. The patient's not eating because they haven't got appetite. Uh Most of the symptoms that I'm going to talk about or the two that I've talked about today, I will say rule number one treat the symptoms, but fatigue and anorexia are different. Um taken under next year are not really, there's not really a treatment that can quickly alleviate the symptoms. So you may need to investigate the cause uh and treat it okay. So in this, in case, you might have to go straight to finding out why they're fatigue and why they're not eating and drinking. Probably sometimes though. Uh sorry, a lot of times we and including you steroids to boost their appetite, energy, it can be very effective but it doesn't work or don't work for everyone. And remember trying the side effects of steroids, but once you found the cause, then you have to cheat if they're fatigued because of the cancer that we need to treat the cancer. If it's due to cancer treatment, you might want to either stop them, provide supportive measures such as steroids and nutritional sport or reduce those. Sometimes it can so fatigue with the cancer treatment that it affects the quality of life. Much stop cancer treatment all together. Um If they have pain treatment, pain, a lot of people don't realize that being in pain is exhausting. Absolutely exhausting. So, so it's important that you treat them have poor appetite and weight loss or if they have high must score. I don't know if you had a mask or M U S T. What's mes taken? Malnutrition, universal screening tools. I think if they've got Moscow two or above, patient's need to be referred to the dietician to see if they need a nutritional support. Um So uh steroids can sometimes help with appetite. Um how many times of the steroids on this slides alone. Um Just what I mean when I say we love steroids, right? The other thing about fatigue and anorexia. When patient's approach in the life, um they will have fatigue anorexia. So if you, you investigated the patient and you can't find any other cause of fatigue and anorexia apart a progression of their cancer and you can't do anything more for the cancer. Then there's no point in trying to reverse it. Just keep the patient comfortable and communicate to the patient's and the relatives so that they know what is happening and we're providing that you're providing end of life care to keep them comfortable. Again. This, this is another situation where you might want to the patient care team, right? Um Oh More scans great on the left is an MRI scan of a patient with initially, she had a locally advanced lung cancer and she was finishing her radical treatment when she got a reported that she had been experiencing early morning hitting your head and the MRI showed a mass in the occipital lobe um which is very unlucky with surrounding visit, any edema, I think. Um I don't know if you can see that the edema or the swelling around where you see a dark great around with the country. So the cancer is um in the observe it'll lobe um on, on right, an MRI head of a patient of mine with metastatic triple negative breast cancer. Uh It's a solitary metastases at the peel body of the penal area of the brain and it's causing a degree of hydrocephalus. So this patient presented with headaches, visual disturbances and poor balance. She is going to start her radio Thet the whole I think on Friday. So um headaches and other neurological symptoms. Again. Roll number one, treat the pain, treat the symptoms. So, treat the headaches okay. Uh If the headache is due to brain metastases, you then investigate uh if the headaches is due to brain metastases with a lot of edema or a lot of swelling around the cancer in the brain. Um then steroids help to use the swelling. And you might want to consider definitive treatment for the brain metastases either with surgery, radiotherapy or suck if they have leptomeningeal disease or sometimes we see the leptomeningeal carcinomatosis or meningitis cussing mitosis. Um This is when you have metastases in the meninges, the lining of your brain and your spinal cord, it's an awful awful disease. If patient have leptomeningeal disease, the diagnosis is straightforward either usually see the head, uh doesn't normally show anything. The MRI head can sometimes show some men angel enhancement, but a lot of that I don't. Um and sometimes you need to do a lumbar puncture to come from the diagnosis. I I had a patient once when I was working down south in England had a patriot was extremely sore and agitated. CT was normal. MRI was normal. So I had to get help from an aesthetic to do an LP and see examples of malignant cells which come from diagnosis of leptomeningeal carcinomatosis. Uh and as I said, her CT an MRI scan. So, um leptomeningeal disease can be very, very sore and patient can be very agitated up to a point that if they are approaching enough life care, sometimes the most main thing you can do is to not the night with lots and lots of old period sensation. It sounds rough. It's just horrible me saying that you knock out the patient, you know, just make them unconscious with lots and lots of medication. But um I remember when I was a junior doctor, when I was working in Aberdeen, I saw a patient with metastatic melanoma who you could hear him shout and how from the end of the corridor because he was so uncomfortable and so agitated. So we took pretty much sedate him with lots of morphine, lots of the diazePAM because it was just terrible for the family to see the relative suffering like that. It was horrible. But you don't, it's, it's, it's, yeah, but it's the, it's the most, the main thing you can do. Um Finally remember again, other causes of uh symptoms which could be not related to the cancer or the cancer treatment. Um because you know, other causes of headaches and neurological deficit, um for example, patient can still have migraines, they can still have tension headaches. Uh If cancer patient developed any sudden onset neurological deficit, it's more likely that they're still going to be rather than the metastases. The spring metastases then too grew slowly rather than, you know, rapidly and causing a rapid or sudden on the sentence. Uh Next, oh I like this status epilepticus Liberte last. Uh So I'm going to talk about seizure. So, seizures, I said that we love steroids and in the context of brain tacit vasogenic edema steroids can reduce the swelling and reduce the pressure in the brain. But if they had a seizure, you need to start them on anti epileptics. Okay. Because antiepileptics is thing going to prevent further seizures to reduce the risk of them developing new seizures, steroids only reduce the swelling event, the answer will grow. So you do need to start them on anti epileptics. And uh like the meme that I showed you just before Keppra levetiracetam is usually our epileptic of choice as long as there's no translations. So treat symptoms first, okay. Uh LORazepam if you need to to stop seizures, antiepileptics to prevent further seizures. And also at the next episode, if on the scan, there's evidence of lots of playing in the brain. Uh then obviously, if the patient, the patient is fit enough and the patient has brain metastases. You treat the cancer. Ok. Surgery you that b or sad uh neck symptoms, um mucositis, sore math or oral thrush these symptoms that sore math mucositis, oral thrush almost exclusively the results of cancer treatment rather than cancer. So a lot of times it's iatrogenic rather than a bit of cancer. Uh patient's can develop mucositis when they're the stomach. After recent high dose radiotherapy to the head neck with consular cancer, for example, they get high dose radiotherapy to the head neck. They can develop mucositis. One in you sedation and prolonged use of steroids because we love steroids so much. They can also cause oral thrush. Um so while with other symptoms, cheating, the cancer can help the symptoms. Um But when the mucus itis or oral thrust, because these conditions developed due to the cancer treatment, self, okay. It doesn't mean that if they have mucositis, you have to stop the cancer treatment. It means that you must support them with, you know, mouthwash and antifungal. So the mouthwash, mouthwash that we normally use the phlegm calf sol uh use antifungals that just nice that and sometimes you can use Gelclair as well. Uh Invest you investigate if they've got ulcers or infection uh because sometimes they can get herpes simplex infection and that can cause a lot of mouth ulcers and can be quite sore. Right next. We've got uh sorry, my slides. So oh scan, it's good on left an image of a normal scan. It's a normal CT scan. Um Oh, this is really difficult. I've, I've now got a cursor to show you but you can see posterior to the trachea. You can see where the esophagus is. So the esophagus, it looks really small, but that's what a normal esophagus usually looks like on an actual scan. An actual CT scan is um that is on the right at the top and the bottom, the top is a pet scan. The bottom is the CT scan of the same pain. If you look at the bottom itch, you can see the esophagus is thicken. Uh There's this soft tissue mass uh and it suggests that there's a mass filling. The lumen of the software gives an image on top is a scan again of the same patient. And you can see there's an uptick. So it looks bright, it looks that like bright yellow color. Uh in the middle of the scan is actually high metabolic activity, uh which is likely due to cancer and in this case, it is due to cancer because it's proven um with a biopsy. Uh So, um that's uh just a patient with esophageal cancer, dysphasia. Rule number one, treat the symptoms. So, um if they are sore, give them analgesia, if they're dehydrated, give them IV fluids. Uh you might want to refer the patient to the dietician as they may need artificial nutrition such as defeating DPN while you investigate and while you treat the cause of the dysphagia, okay, you can, can you see, can you see a theme so far, uh you've got symptoms, you treat the symptom to stabilize the patient investigate the course. And then, uh of course, although it's not 100% correct. For example, like if it doesn't normally works that way. But anyway, um if the page is due to cancer, treat the cancer, treat, you treat the cancer. Uh If it's radiation stricture, which happen if they have a new therapy to their esophagus, they may need a dilatation or a stent if they had radiotherapy recently. And you think they might have radiation esophagitis. Remember radiation causes lots of inflammation, then they can have esophagitis secondary to radiotherapy steroids might help. If they have oral thrush, then you know, give them antifungal and remember other causes of feature as well, right? Um uh hematemesis and hemoptysis is again, rule number one, treat the symptoms, stabilize the patient, um their symptoms, but usually you can't itself either in the upper gi tract or in the long or sometimes we give them chemotherapy would make them thrown like they can develop human temp STIs or hemoptysis, this or that. Uh So treat the symptoms first, stabilize the patient. If they're vomiting, you might want to give them anti emetic. If they're anemic, you might want to transfuse them if the sore, obviously give them analgesia. Uh then obviously you need to try and stop the bleeding or prevent further bleeding either industry quickly or medically using stomach acid, for example, or PPI if you think they've got human te missus or occasionally a single fractions of can we use for huma stasis. Uh Once you've investigated the course, then treat the course of its cancer. Again, treat the cancer if it's stronger cytopenia because they've had chemotherapy recently, then you might want to give them completely a transfusion. Um Right. Um Next slide is uh more scans, uh slides on the left or image on the left is a patient with a metastatic, your endocrine carcinoma of the lung. You can see there's a lot, a massive mass in the mediastinum and it's growing on into the right lung. Um You can see, I haven't gotten worse, but it's definitely you can see the arch of the aorta there. Okay. That's on the left side, but on the right side, which is on the other side, you can see the S V C is actually being, being, you know, compressed. So this patient has to be developing sec obstruction and the patient presented breathlessness and also um swelling in the face and host voice. Um The two X rays on the right are off the same patient. The patient immunotherapy as part of her lung cancer treatment. Um uh with the hospital cough and shortness of breath uh on the top showed might spread opacities uh compared to the previous X ray, which is the uh can do her even do therapy. So an example how um cancer treatment can cause problems, side effects toxicities which can lead to symptoms, right? So, breathlessness or shortness of breath number one, treat the symptoms or if they're breathless, then give them some oxygen and uh investigate or if it's due to the cancer, obviously treat the cancer. If they've got lymphangitis, lymphangitis and inflammation of the fattest in your lungs. Um Cancer one cwas of cancer you see is that cancer causes lots of inflammation. That's why you get a lot of swelling with cancer around cancer because there's a lot of inflammation around cancer with the information you get better swelling. So lymphangitis um can make the patient quite breakfast. Steps can be very helpful. But ultimately, if the lymphocyte is due to the cancer, you do need to treat cancer. Uh patient can have pneumonitis like the X ray that I've showed. Um pneumonitis is inflammation along. So you give them steroids to help with the inflammations and you stop the culprit drugs more often than not. Nowadays, with our cancer patient, they have pneumonitis because of immunotherapy. Um I don't know if you've heard about, you know, therapies, chemotherapy is different from chemotherapy. Chemotherapy goes into your body and then it attacks the cancer even the therapy in the hand, they work like a like a middle person. There's a theory to say that each and every one of us have got cancer um or develop cancers in our body. But our immune system is clear enough to find these cancer cells and attack them and destroy them. When somebody get diagnosed with cancer is when they've got cancer cells that grows is usually because these cancer cells have become clever. So they've managed to hide themselves from your immune system or they managed to present themselves S A R U normal cells, uh, the immune system to attack the cancer immunotherapy works by telling you immune system that these are cancer, you have to attack the cancer. So they work by, by, by boosting union systems. The immune system knows these are cancer attack, the cancer, uh do that. Uh, Even if they can sometimes make your immune system goes to on a bit of an overdrive. Um So you get symptoms, you get autoimmune symptoms because your immune system attack your own normal cells. That's why they can get pneumonitis. Um So if you ever encountered a patient who got history of lung cancer or any other cancer and their own treatment, uh their own immunotherapy and they come in with breathlessness, then you might want to think about, you know, that could they have pneumonitis. For example, if they did have pneumonitis from either their exhale with a CT scan, they need to give them hydro steroids to dampen down the immune system. Cancer patient's uh and paste on cancer treatment, high risk of P E. So if investigating that you find out they got pe then you need to start them on article calculation. Remember other causes of shortness of breath, for example, pneumothorax or heart failure uh problem in the fatima um and patient cancer. Uh cancer patient's just because of cancer does mean that they can do other causes of shortness of breath. Okay. Um Next symptoms uh scan more scans, uh scan on the left. The two scans on the left are of the same patient. Um The patient with again, metastatic breast cancer uh picture uh the image on the bottom. You can see uh patient pelvis and you can see lots of, lots of bowels and maybe some, some uh feces in the bowels as well. But the image on the top, the same patient a few weeks later, uh this patient has got um paratonia metastases. You can see you can't see the bubble much what you can see. It's all these grey fuzzier and that society. So this patient presented with abdominal pain, abdominal distension because she's got lots of societies in about uh image on the right. Um You can see on the top as a, as a man with sigmoid adenocarcinoma. So this man presented when I was on call when they with abdominal pain uh and and vomiting. Obviously, a patient can develop vomiting or nausea because of the chemotherapy and he was on chemotherapy. But I did an abdominal X ray and you can see that he's got a distended transfers cool on, on the abdominal scan. We did a CT scan which confirmed that he's got bowel obstruction because of a stricture in his sigmoid colon because of the cancer. So, uh this one ended up having a to release the obstruction and improve his symptoms, uh when it comes to abdominal poor abdominal distension. Again, rule, number one, treat the symptoms, they're in pain. You give them people ear's um and treat the cause if it's cancer. Obviously, you know, treat the cancer. One of the main causes of abdominal pain and cancer patient, particularly those with liver metastases, you can get liver capsule of pain. Your liver sits in the, in the capsule. So they've got lots and lots of cancer that stretches the capsule and that can be quite sore. You can give them analgesia, steroids can be very helpful in these patient's. If they got ascites, then you might want to drain the site is if they go obstruction, again, they might need surgery or if they're not fit for surgery, sometimes steroids can be helpful, usually accepted. Remember, uh the cause of abdominal pain, abdominal distension, they could have kasserine treat this, for example, that can cause abdominal pain. Um I think this is uh constipation again, treat the symptoms if they're, they've got diarrhea and constipation. They, if they got the idea, they're dehydrated, give them my great if they've got them until it easier. If they're constipated, uh cause them a lot of pain. Again, analgesia. Uh and then you investigate the cause if it's treatment related, for example, a lot of chemotherapy causes die and constipation, diarrhea more. So the constipation, then you might want to cheat them with motive measures. IV fluids. Sometimes if you want to rule that it's not gastroenteritis or infective gastroenteritis, then you can give them the IV fluids and sometimes you can give them like not IV fluid, you can give them a little Parramatta to try and slow down the diarrhea. Uh patient can develop colitis either from chemotherapy or nowadays, more commonly from immunotherapy. Again, radiation can cause colitis as well. So, colitis, by definition as inflammation. So anything that ends with the itis in the end, we know we treat with steroids. So it even steroids or you can stop the treatment if it's the treatment that cause the colitis. Again, if the causes cancer, then treat cancer, surgeries, act or radiotherapy and remember other causes of diarrhea and constipation. Um Right. I think this is going to be the last symptoms. I'm going to talk about a couple more scans on the left. If you look at it in the right kidney, there's a mass uh like it is a patient with uh renal cell carcinoma on the right. You can see that's a ct urogram. You can see there's thing defect in the patient's bladder, there's a mask and the blood of all posteriorly on the right side. Um That's um that's a patient with transitional cell carcinoma or urothelium, several carcinoma of the bladder. Right? Though hematuria and other urological or urinary symptoms again, treat the symptoms if they're sore, given papers, if they're bleeding, stabilized the patient and then you investigate, um, what, what causes the symptoms. You're practically might need to be catheterized because they've got, you know, urinary retention or if they've got hydrin focuses, sometimes can cause a lot of pain, flat pain, for example, might need to stand on the first time. If it's the cancer that's causing the bleeding or the pain, sometimes we can give radiotherapy for homeostasis of pain control or we can give chemotherapy or a systemic treatment because their breeding because recently the heart communitarian, it's thrombocytopenia. Again, they might want to give them a platelet transfusion and then wait for a few days. Hopefully they platelet cultural, then start to improve. Remember are the causes of him to Julia, for example, Union infection and you just causing material, right? Uh I think it's all the symptoms I'm gonna talk about as I say, I'm not, I've not covered all symptoms. Uh but if there's anything you want to ask, please do. But in somebody uh symptoms in cancer patient's can be caused by cancer itself or cancer treatment, but they can still develop symptoms, not related to the cancer, all kinds of treats. Remember that um was on global treatment which is radiotherapy or sacked can be very, very effective in treating cancer and alleviate symptoms caused by cancer. They take time to the office and they take time to work. So it's very, very important to remember that like any other patient's that present to you with any symptoms, treat the symptoms, stabilize. The patient has to investigate the course of their symptoms and treat the courses. And also remember palliative care team that can be very, very helpful, especially enterprising too much cancer patient's with complex symptoms. So that's me. Thanks so much traffic. If anyone's got any questions, please just pop them in the chat. I'm also going to be posting a link to the feedback form in the chat. Really appreciate if everyone can fill that out for traffic. Yeah, no questions yet. Okay. It's gonna probably linked to the next uh web around issues as well. Feel free to make sure that one if you're interested if you want, I'm just gonna book the last like because that's um, well, we'll talk on the 15. Yeah. Okay. Well, hang on for a few minutes. If anyone's got any questions, just pop them in the cat. That's like there. You can also see a QR code for the feedback link if you can't click the link in the shop. Um, to the guy for a bit of a general question, which seems do you feel are most poorly managed by kind of, you know, usable doctors on the ward? Uh I miss that. So which symptoms that normally probably managed to say? Yeah, it's the most common and I, I would say it's the most poorly managed because um uh I mean, it's easy for me to say this because we use, we use morphine to type. I'm not saying that. Um I'm not saying that we are uh we're very gung ho but because we use it all the time, day in, day out, we're a bit braver and doing that. And as I said before is, it's quite common when I get further patient because they go pain because because of the cancer and they wonder whether we should give this patient some radiotherapy. I go and see the patient to get their card decks. Um They were only on part I item on either the P R N just even just regular paracetamol, they haven't got anything else. Um And you see the patient's suffering, uh The patient's in agony, the patient can really talk to you because they're sore. Um So I think, I think pain is, is number one, I think one of the benefits of me when I was, when I was a junior doctor was my rotation was uh oncology. So I did four months uh oncology in Aberdeen and we, we, we work very closely with palliative care team. I think uh palliative care teams so lovely. They're so nice. Um And I learned a lot from them and that's how I got to be brave uh in, in managing pain. I mean, I think partly why it's so probably managed is probably because people are not comfortable with stronger pain killers. Uh Sometimes, um I did say my presentations, uh some of these gain control issue can be quite complex that you might want to speak to the public Aid team. But sometimes you do need to put a bit more effort in terms of managing their symptoms. Don't just say, oh, they've got cancer, they got pain. It's just on College electric to palliative care team. And then when we come and see the patient, they're only an perceptible pr, uh, anything else. Um, I think, yeah, they should not ask a question and I think pain is probably one of the symptoms that I think, uh, poorly managed. Um, and it's not just not just anywhere else, even in oncology, even in oncology, that is the case. And even in oncology, we do ask a lot of help from our political colleagues. Yeah. Thank you dot Brick. Not seeing any other questions come in yet. Just hang about for a couple of minutes and then there's no other questions. All right, I think we'll end it there. Thank you, everyone for attending. Thank you again. We'll pick for very interesting talk and if everyone could please fill out the feedback farms that be, I really appreciate it. Anything you want to our topic. Uh No, not really. Um Well, I'm glad there's no questions, not very answering questions, but, uh, but you know, as I said, this, I've not covered all of the symptoms that we deal with, particularly in cancellations. So hopefully the ones that I have covered, uh, the common ones and hopefully, as I said, these are helpful. They're, they're very, very straightforward and then there's, there's no, no complicated statistics or anything like that. I've shown it's more, a lot of them is actually common sentence. And hopefully for junior doctors out there, you won't be, you won't be answers to answers are scared when you get presented with a cancer patient and it got symptoms, treat like any other patient. Manage the symptoms do as best as you can and then investigate and then treat the cause. But if you be quite a few, sure get in touch with oncology or get the quality of care. Uh part security teams. Very lovely, really nice oncology, registrars normally. Uh really nice. So they're not as nice as me. But yeah, uh hopefully that the presentation has been very, very helpful. So, yeah. Anything else now? All right. Thanks again. Ok. Everyone have a good evening.