cancer survivorship endometrial cancer module

Cancer Survivorship

Endometrial Cancer ModulePart 2

StartCase©2007. David Geffen School of Medicine, UCLA

Goal of this Module

This is an interactive and self-directed learning module intended to build a foundation of knowledge around the epidemiology and late effects of cancer survival. This is one of several educational modules you will complete during your core clinical clerkships. Themes emphasized in this, and other modules, are:

Epidemiology of survival Late effects Psychosocial concerns Secondary prevention Strategies for behavior change

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Part 2 Case Summary

Ms. Johnson, an obese (BMI =37), 64 year-old, Caucasian woman, gravida 1, para 1, came to see you because she was having post menopausal bleeding over the past month. She had no other symptoms. She did not receive hormone replacement therapy with estrogen or progesterone. Endometrial biopsy revealed endometrial cancer.

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Summary Continued

Ms. Johnson was treated with an exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH & BSO) pelvic and para-aortic lymphadenectomy and adjuvant chemotherapy (paclitaxel, doxorubicin and cisplatin (CAP) chemotherapy). She was staged as endometrial cancer stage 2A.

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Paclitaxel

Licensed to University of California ©2006 UpToDate ® U.S. BRAND NAMES — Abraxane® PHARMACOLOGIC CATEGORY

Antineoplastic Agent, AntimicrotubularAntineoplastic Agent, Natural Source (Plant) Derivative

USE — Treatment of relapsed or refractory breast cancer Adverse reactions

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Paclitaxel (Adverse Reactions)

>10%: Cardiovascular: EKG abnormal (60%) Dermatologic: Alopecia (90%) Gastrointestinal: Nausea (30%; grades 3/4: 3%), diarrhea (27%; grades 3/4: <1%), vomiting (18%; grades 3/4: 4%) Hematologic: Neutropenia (80%; grade 4: 9%), anemia (33%; grades 3/4: 1%) Hepatic: AST increased (39%), alkaline phosphatase increased (36%), GGT increased (grades 3/4: 14%) Neuromuscular & skeletal: Sensory neuropathy (71%; grades 3/4: 10%; dose dependent; may be cumulative), weakness (47%), myalgia/arthralgia (44%) Ocular: Vision disturbance (13%; severe [keratitis, blurred vision]: 1%) Respiratory: Dyspnea (12%) Miscellaneous: Infection (24%; primarily included oral candidiasis, respiratory tract infection, and pneumonia)

1% to 10%: Cardiovascular: Edema (10%), hypotension (5%), cardiovascular events (grades 3/4: 3%; included chest pain, cardiac arrest, supraventricular tachycardia, edema, thrombosis, pulmonary thromboembolism, pulmonary emboli, and hypertension) Gastrointestinal: Mucositis (7%; grades 3/4: <1%) Hematologic: Bleeding (2%), neutropenic fever (2%), thrombocytopenia (2%; grades 3/4: 1%) Hepatic: Bilirubin increased (7%) Neuromuscular and skeletal: Peripheral neuropathy (grade 3: 10%) Renal: Creatinine increased (11%; severe 1%) Respiratory: Cough (7%) Miscellaneous: Hypersensitivity reaction (4%)

<1% (Limited to important or life-threatening): Bradycardia, cardiac ischemia, cerebrovascular attack, cranial nerve palsies, embolism, erythema, hand-foot syndrome (in patients previously exposed to capecitabine), injection site reaction, maculopapular rash, MI, motor neuropathy, nail discoloration, nail pigmentation changes, photosensitivity reaction, pneumothorax, pruritus, radiation recall, stroke, thrombosis, transient ischemic attack

Adverse reactions reported with paclitaxel, which may occur with paclitaxel (protein bound): Autonomic neuropathy, cellulitis, conjunctivitis, extravasation recall, fibrosis, hepatic necrosis, hepatic encephalopathy, induration, intestinal obstruction, intestinal perforation, interstitial pneumonia, ischemic colitis, lacrimation increased, lung fibrosis, necrosis, neutropenic enterocolitis (typhlitis), optic nerve damage (persistent), pancreatitis, paralytic ileus, phlebitis, radiation pneumonitis with concurrent radiation therapy, skin exfoliation, Stevens-Johnson syndrome, toxic epidermal necrolysis

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Doxorubicin

Licensed to University of California ©2006 UpToDate ® U.S. BRAND NAMES — Adriamycin PFS®; Adriamycin

RDF®; Rubex® PHARMACOLOGIC CATEGORY

Antineoplastic Agent, Anthracycline USE — Treatment of leukemias, lymphomas, multiple

myeloma, osseous and nonosseous sarcomas, mesotheliomas, germ cell tumors of the ovary or testis, and carcinomas of the head and neck, thyroid, lung, breast, stomach, pancreas, liver, ovary, bladder, prostate, uterus, and neuroblastoma

Adverse reactions

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Doxorubicin(Adverse Reactions)

>10%: Cardiovascular: Transient ECG abnormalities (supraventricular tachycardia, S-T wave changes, atrial or ventricular extrasystoles); generally asymptomatic and self-limiting. CHF, dose related, may be delayed for 7-8 years after treatment. Cumulative dose, mediastinal/pericardial radiation therapy, cardiovascular disease, age, and use of cyclophosphamide (or other cardiotoxic agents) all increase the risk. Recommended maximum cumulative doses: No risk factors: 550 mg/m2 Concurrent radiation: 450 mg/m2 Note: Regardless of cumulative dose, if the left ventricular ejection fraction is <30% to 40%, the drug is usually not given. Dermatologic: Alopecia Gastrointestinal: Acute nausea and vomiting (21% to 55%), mucositis, ulceration, and necrosis of the colon, anorexia, and diarrhea, stomatitis, esophagitis Genitourinary: Discoloration of urine (red) Hematologic: Myelosuppression, leukopenia (75%), dose-limiting toxicity WBC: Moderate Platelets: Moderate Onset (days): 7 Nadir (days): 10-14 Recovery (days): 21-28 Local: Vesicant chemotherapy

1% to 10%: Cardiovascular: Acute: Arrhythmias, heart block, pericarditis-myocarditis, facial flushing; Delayed: CHF (related to cumulative dose; usually a maximum total lifetime dose of 450-550 mg/m2; possibly higher if given by continuous infusion) Dermatologic: Hyperpigmentation of nail beds, erythematous streaking along the vein if administered rapidly Endocrine & metabolic: Hyperuricemia

<1% (Limited to important or life-threatening): Pediatric patients may be at increased risk of later neoplastic disease, particularly acute myeloid leukemia (pediatric patients). Prepubertal growth failure may result from intensive chemotherapy regimens. Radiation recall: Noticed in patients who have had prior irradiation; reactions include redness, warmth, erythema, and dermatitis in the radiation port. Can progress to severe desquamation and ulceration. Occurs 5-7 days after doxorubicin administration; local therapy with topical corticosteroids and cooling have given the best relief.

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Cisplatin

Licensed to University of California ©2006 UpToDate ® U.S. BRAND NAMES — Platinol®-AQ [DSC] PHARMACOLOGIC CATEGORY

Antineoplastic Agent, Alkylating Agent USE — Treatment of bladder, testicular, and ovarian cancer USE - UNLABELED / INVESTIGATIONAL —

Treatment of head and neck, breast, gastric, lung, esophageal, cervical, prostate and small cell lung cancer; Hodgkin's and non-Hodgkin's lymphoma; neuroblastoma; sarcomas, myeloma, melanoma, mesothelioma, and osteosarcoma

Adverse reactions

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Cisplatin(Adverse Reactions)

>10%: Central nervous system: Neurotoxicity: Peripheral neuropathy is dose- and duration-dependent. Dermatologic: Mild alopecia Gastrointestinal: Nausea and vomiting (76% to 100%) Hematologic: Myelosuppression (25% to 30%; mild with moderate doses, mild to moderate with high-dose therapy) WBC: Mild Platelets: Mild Onset: 10 days Nadir: 14-23 days Recovery: 21-39 days Hepatic: Liver enzymes increased Renal: Nephrotoxicity (acute renal failure and chronic renal insufficiency) Otic: Ototoxicity (10% to 30%; manifested as high frequency hearing loss; ototoxicity is especially pronounced in children)

1% to 10%: Gastrointestinal: Diarrhea Local: Tissue irritation

<1% (Limited to important or life-threatening): Anaphylactic reaction, arrhythmias, blurred vision, bradycardia, cerebral blindness, hemolytic anemia, liver enzymes increased, mild alopecia, mouth sores, optic neuritis, papilledema

Central nervous system: Peripheral and autonomic neuropathy, ototoxicity Endocrine & metabolic: Hypokalemia, hypomagnesemia Gastrointestinal: Highly emetogenic Hematologic: Myelosuppression Renal: Acute renal failure, increased serum creatinine, azotemia Miscellaneous: Transient pain at tumor, transient autoimmune disorders

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Presenting Complaint

Four weeks into her treatment and 8 weeks after her diagnosis, Ms Johnson notices her bed is full of hair when she wakes up. She also loses a lot of hair when she brushes. She is very agitated because she is very proud of her wavy curly blonde hair.

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Question #1

She comes to your office seeking an explanation about her hair loss. What is the most likely diagnosis?

A. Alopecia areata

B. Telogen effluvium

C. Cicatricial alopecia

D. Traumatic alopecia

E. Drug induced alopecia

Incorrect. Question #1

B. Alopecia areata Alopecia areata causes one or more patches of scalp hair loss. Tends to affect younger individuals, both male and female. It is an autoimmune disorder, in which the immune system

attacks hair follicles. The condition resolves without treatment within a year, but

hair loss is sometimes permanent. Treatments may be steroid injections and cream (such as

clobetasol or fluocinonide), minoxidil, irritants (anthralin or topical coal tar), and topical immunotherapy (cyclosporine).

Back toQuestion 1


B. Alopecia areata Alopecia areata causes one or more patches of scalp hair loss. Tends to affect younger individuals, both male and female. It is an autoimmune disorder, in which the immune system

attacks hair follicles. The condition resolves without treatment within a year, but hair

loss is sometimes permanent. Treatments may be steroid injections and cream (such as

clobetasol or fluocinonide), minoxidil, irritants (anthralin or topical coal tar), and topical immunotherapy (cyclosporine).

Continue Case

Teaching Points for Incorrect Answers

Minoxidil BRAND NAME: Rogaine DRUG CLASS AND MECHANISM: Oral minoxidil, a medication that originally was used

to treat high blood pressure, has been found to increase hair growth. This lead to the development of topical (solution applied to the skin) minoxidil. Topical minoxidil (Rogaine) has been shown to stimulate hair growth on the bald spot of the back of the head in men. In women, Rogaine can increase hair growth in the forehead areas. Minoxidil is in a class of drugs called hair growth stimulants.

DRUG INTERACTIONS: Oral minoxidil can cause a fall in blood pressure, an increase in the heart rate, and weight gain (fluid retention). An increase in the absorption of minoxidil from the scalp can occur in patients with inflamed or abnormal scalps, leading to side effects mentioned above. Patients with heart failure or significant coronary heart disease should avoid Rogaine because of these side effects. Rogaine's alcohol base can irritate the eyes. Rogaine should not be used with other topical medications because they may increase its absorption and side effects. Rogaine should be used with caution in those with high blood pressure.

PREGNANCY: Rogaine should not be used in pregnancy. NURSING MOTHERS: Rogaine should not be used by nursing women. SIDE EFFECTS: Skin side effects are seen at times with Rogaine, including irritation, itch,

contact dermatitis, hives, swelling, and sensitivity.

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Minoxidil BRAND NAME: Rogaine DRUG CLASS AND MECHANISM: Oral minoxidil, a medication that originally was used

to treat high blood pressure, has been found to increase hair growth. This lead to the development of topical (solution applied to the skin) minoxidil. Topical minoxidil (Rogaine) has been shown to stimulate hair growth on the bald spot of the back of the head in men. In women, Rogaine can increase hair growth in the forehead areas. Minoxidil is in a class of drugs called hair growth stimulants.

DRUG INTERACTIONS: Oral minoxidil can cause a fall in blood pressure, an increase in the heart rate, and weight gain (fluid retention). An increase in the absorption of minoxidil from the scalp can occur in patients with inflamed or abnormal scalps, leading to side effects mentioned above. Patients with heart failure or significant coronary heart disease should avoid Rogaine because of these side effects. Rogaine's alcohol base can irritate the eyes. Rogaine should not be used with other topical medications because they may increase its absorption and side effects. Rogaine should be used with caution in those with high blood pressure.

PREGNANCY: Rogaine should not be used in pregnancy. NURSING MOTHERS: Rogaine should not be used by nursing women. SIDE EFFECTS: Skin side effects are seen at times with Rogaine, including irritation, itch,

contact dermatitis, hives, swelling, and sensitivity.

Back to Incorrect Answers


C. Telogen effluvium Telogen effluvium is nonscarring alopecia with diffuse hair

shedding. A reactive process caused by a metabolic, hormonal stress or

medications that shifts follicles in anagen to a telogen-predominant distribution.

Generally, recovery is spontaneous and occurs by 6 months. Acute telogen effluvium is hair shedding lasting < 6 months. Usually initiated by metabolic or physiologic stressors. Papulosquamous diseases of the scalp, such as psoriasis and

seborrheic dermatitis, can produce telogen effluvium. Chronic telogen effluvium is hair shedding lasting > 6 months.

Back toQuestion 1


C. Telogen effluvium Telogen effluvium is nonscarring alopecia with diffuse hair

shedding. A reactive process caused by a metabolic, hormonal stress or

medications that shifts follicles in anagen to a telogen-predominant distribution.

Generally, recovery is spontaneous and occurs by 6 months. Acute telogen effluvium is hair shedding lasting < 6 months. Usually initiated by metabolic or physiologic stressors. Papulosquamous diseases of the scalp, such as psoriasis and

seborrheic dermatitis, can produce telogen effluvium. Chronic telogen effluvium is hair shedding lasting > 6 months.

Continue Case



D. Cicatricial alopecia Cicatricial alopecia is hair loss from scalp and hair

follicle damage. The scalp usually has an abnormal appearance. Plaques of erythema, scaling or pustules occur. Associations include infections (e.g., syphilis,

tuberculosis, acquired immunodeficiency syndrome, herpes zoster), autoimmune disease (discoid lupus erythematosus), sarcoidosis, scalp trauma (e.g., injuries, burns), and radiation therapy.

Back toQuestion 1


D. Cicatricial alopecia Cicatricial alopecia is hair loss from scalp and hair

follicle damage. The scalp usually has an abnormal appearance. Plaques of erythema, scaling or pustules occur. Associations include infections (e.g., syphilis,

tuberculosis, acquired immunodeficiency syndrome, herpes zoster), autoimmune disease (discoid lupus erythematosus), sarcoidosis, scalp trauma (e.g., injuries, burns), and radiation therapy.

Continue Case



E. Traumatic alopecia Traumatic alopecia is caused by cosmetic

practices that damage hair follicles over time. Cosmetic alopecia has been linked to the use of

brush rollers, curling irons, hair brushes with square or angular tips, and tight braiding of the hair.

Back toQuestion 1


E. Traumatic alopecia Traumatic alopecia is caused by cosmetic

practices that damage hair follicles over time. Cosmetic alopecia has been linked to the use of

brush rollers, curling irons, hair brushes with square or angular tips, and tight braiding of the hair.

Continue Case


Correct. Question #1F. Drug induced alopecia Anagen effluvium occurs after insult to hair follicle that impairs mitotic or

metabolic activity. Due to exposure to chemotherapeutic agents Inhibition of cell division in the hair matrix leads to thin, weakened hair

shaft likely to fracture with minimal trauma May cause complete failure of hair formation. Worse with combination chemotherapy and higher doses. Hair loss usually begins 7-14 days after exposure and is clinically most

apparent after 1-2 months. Reversible; hair growth resumes few weeks after treatment cessation;

regrows in 3-5 months; color or texture of new hair may differ from

original hair. Continue

CaseTeaching Points

for Incorrect Answers

Question #1 Incorrect Answers

Alopecia areata Telogen effluvium Cicatricial alopecia Traumatic alopecia

ContinueCase

Case Continued

After discussing her options Ms Johnson is fitted with a wig.

Four months after her treatment and 5 months after diagnosis. Mrs. Johnson comes to see you and states: “ I have noticed that over the last 2 months my shoes don’t fit and I can only wear bathroom slippers. Both my legs feel tight and appear very swollen but I don’t feel much pain. What is happening to me?”

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Question #2

What is the most likely diagnosis?

A. Deep venous thrombosis

B. Lymphedema

C. Compartment syndrome

D. Femoral artery ligation

E. Necrotizing fascitis

Incorrect. Question #2A. Deep venous thrombosis Cancer results in a hypercoagulable state. Deep venous thrombosis occurs in up to 11% of

cancer patients and is an important cause of death Usually unilateral and about half are asymptomatic. Symptoms of include swelling, pain, and

discoloration. Physical examination may reveal a palpable cord

(reflecting a thrombosed vein), ipsilateral edema, warmth, and/or superficial venous dilation.

Diagnosed by: venography of the legs, Doppler ultrasound, plethysmography, D-dimer blood test

Back toQuestion 2

Incorrect. Question #2A. Deep venous thrombosis Cancer results in a hypercoagulable state. Deep venous thrombosis occurs in up to 11% of cancer

patients and is an important cause of death Usually unilateral and about half are asymptomatic. Symptoms of include swelling, pain, and discoloration. Physical examination may reveal a palpable cord

(reflecting a thrombosed vein), ipsilateral edema, warmth, and/or superficial venous dilation.

Diagnosed by: venography of the legs, Doppler ultrasound, plethysmography, D-dimer blood test

Continue Case


Correct. Question #2

B. Lymphedema Lymphedema is nonpitting swelling of an extremity,

usually bilateral. In cancer is due to lymphatic obstruction from node

dissection, radiation or malignant obstruction. Treated by exercise, gradient pressure garments,

massage or external pneumatic compression. Patients undergoing dissection or radiation of lymph

nodes should be counseled on preventing lymphedema; which are: elevating limb, avoiding constricting garments that cause a tourniquet effect, meticulous skin hygiene and nail care.

Continue Module

Stage 3



C. Compartment syndrome Compartment syndrome is increased tissue

pressure in a closed muscle compartment compromising local circulation and neuromuscular function.

Requires 1:constricting envelope (fascia or cast) 2: increase in volume (blood, edema).

Fascia of leg muscles do not allow muscle expansion when significant edema occurs.

Due to a direct blow, usually to an unpadded soft-tissue area. Causes pain that is more severe than physical findings.

Treatment is fasciotomy: longitudinal incisions in affected compartments.

Back toQuestion 2


C. Compartment syndrome Compartment syndrome is increased tissue

pressure in a closed muscle compartment compromising local circulation and neuromuscular function.

Requires 1:constricting envelope (fascia or cast) 2: increase in volume (blood, edema).

Fascia of leg muscles do not allow muscle expansion when significant edema occurs.

Due to a direct blow, usually to an unpadded soft-tissue area. Causes pain that is more severe than physical findings.

Treatment is fasciotomy: longitudinal incisions in affected compartments.

Continue Case



D. Femoral artery ligation Femoral artery ligation will result in

pulselessness and lower extremity ischemia. If not corrected, will result in lower limb

ischemia and necrosis necessitating amputation.

It may occurs as an inadvertent injury following extensive and difficult surgery for extensive cancer.

Back toQuestion 2


D. Femoral artery ligation Femoral artery ligation will result in

pulselessness and lower extremity ischemia. If not corrected, will result in lower limb

ischemia and necrosis necessitating amputation.

It may occurs as an inadvertent injury following extensive and difficult surgery for extensive cancer.

Continue Case


Incorrect. Question #2E. Necrotizing fascitis Necrotizing fasciitis is an insidiously advancing soft

tissue infection with widespread fascial necrosis. Mixed infection after surgery with diabetes or

peripheral vascular disease. Systemic toxicity and high mortality. Extensive tissue destruction, thrombosis of blood

vessels, bacteria spread along fascial planes. Unexplained pain. Erythema darken to a reddish-

purple color, with blisters and bullae. Treatment is early and aggressive surgical

exploration and debridement of necrotic tissue, antibiotics, and hemodynamic support.

Back toQuestion 2

Incorrect. Question #2E. Necrotizing fascitis Necrotizing fasciitis is an insidiously advancing soft

tissue infection with widespread fascial necrosis. Mixed infection after surgery with diabetes or

peripheral vascular disease. Systemic toxicity and high mortality. Extensive tissue destruction, thrombosis of blood

vessels, bacteria spread along fascial planes. Unexplained pain. Erythema darken to a reddish-

purple color, with blisters and bullae. Treatment is early and aggressive surgical

exploration and debridement of necrotic tissue, antibiotics, and hemodynamic support.

Continue Case



A. Deep venous thrombosis

C. Compartment syndrome

D. Femoral artery ligation

E. Necrotizing fascitis

Continue Case

Case Continued

She is started on an exercise program, fitted with gradient pressure garments and diuretics were prescribed.

Three months later and seven months after diagnosis she comes to see you. She is very distraught and agitated. She tells you “I cry a lot and have lost interest in almost everything. I don’t sleep well and I don’t want to eat. I’ve lost weight. I think the cancer has come back.”

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Question #3

Of the following, what is the most likely explanation?

A. Insomnia

B. Nutritional imbalance

C. Depression

D. Recurrence of the cancer

Incorrect. Question #3A. Work-up for insomnia is helpful but does not explain all the other

symptoms that she has.

Sedatives should be used with caution since tolerance or dependence can develop. Time and effort should be spent in finding the cause of insomnia.

Causes of insomnia include:

Back toQuestion 3

Psychiatric disease: SchizophreniaAnxietyDepression

Medical disease:Alcoholism Degenerative Neurological Disorders Alzheimer’s diseaseParkinson’s disease Fatal Familial Insomnia (FFI)Headaches

Medical disease cont.Chronic Obstructive Pulmonary Disease (COPD) Sleep apneaAsthma Gastroesophageal Reflux Fibromyalgia HypothyriodismMedications

Incorrect. Question #3A. Work-up for insomnia is helpful but does not explain all the other

symptoms that she has.

Sedatives should be used with caution since tolerance or dependence can develop. Time and effort should be spent in finding the cause of insomnia.

Causes of insomnia include:

Continue Case

Psychiatric disease: Schizophrenia AnxietyDepression

Medical disease:Alcoholism Degenerative Neurological Disorders Alzheimer’s diseaseParkinson’s Disease Fatal Familial Insomnia (FFI)Headaches

Medical disease cont.Chronic Obstructive Pulmonary Disease (COPD) Sleep apneaAsthma Gastroesophageal Reflux Fibromyalgia HypothyriodismMedications


Alcoholism

Alcoholism Alcohol may induce sleep for up to four hours, but after that it can lead to frequent awakenings and sleep fragmentation. Insomnia is a common symptom of alcoholism.

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Alcoholism

Alcoholism Alcohol may induce sleep for up to four hours, but after that it can lead to frequent awakenings and sleep fragmentation. Insomnia is a common symptom of alcoholism.


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Degenerative Neurological Disorders

Insomnia is often associated with degenerative neurological disorders, such as Alzheimer's disease, Pick's disease, and hydrocephalus. People with dementia who require institutionalization typically have insomnia.

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Degenerative Neurological Disorders

Insomnia is often associated with degenerative neurological disorders, such as Alzheimer's disease, Pick's disease, and hydrocephalus. People with dementia who require institutionalization typically have insomnia.


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Alzheimer’s disease

Alzheimer's disease (AD) is an irreversible, progressive disorder in which brain cells (neurons) deteriorate, resulting in the loss of cognitive functions, primarily memory, judgment and reasoning, movement coordination, and pattern recognition. In advanced stages of the disease, all memory and mental functioning may be lost.

The condition predominantly affects the cerebral cortex and hippocampus, which lose mass and shrink (atrophy) as the disease advances.

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Alzheimer’s disease

Alzheimer's disease (AD) is an irreversible, progressive disorder in which brain cells (neurons) deteriorate, resulting in the loss of cognitive functions, primarily memory, judgment and reasoning, movement coordination, and pattern recognition. In advanced stages of the disease, all memory and mental functioning may be lost.

The condition predominantly affects the cerebral cortex and hippocampus, which lose mass and shrink (atrophy) as the disease advances.


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Parkinson's Disease

Insomnia is a common complication of Parkinson's disease and of the medications used to treat it. Other causes of insomnia in people with Parkinson's disease include periodic limb movements and sleep-related breathing disorders. Parkinson's patients also don't move much in bed and experience pain from agitated pressure-point arousal. Rapid eye movement disorder is thought to precede Parkinson's disease.

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Parkinson's Disease

Insomnia is a common complication of Parkinson's disease and of the medications used to treat it. Other causes of insomnia in people with Parkinson's disease include periodic limb movements and sleep-related breathing disorders. Parkinson's patients also don't move much in bed and experience pain from agitated pressure-point arousal. Rapid eye movement disorder is thought to precede Parkinson's disease.


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Fatal Familial Insomnia

Fatal familial insomnia is an extremely rare, infectious prion disease. It involves proteinaceous cells, probably of the thalamus, that lack the ability to produce nucleic acid. It is a progressive disorder that begins with difficulty initiating sleep and leads to total lack of sleep within a few months. It can be fatal within 7 to 13 months after symptoms begin but may last longer.

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Prion

A microscopic protein particle similar to a virus but lacking nucleic acid, responsible for certain degenerative diseases of the nervous system.

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Fatal Familial Insomnia

Fatal familial insomnia is an extremely rare, infectious prion disease. It involves proteinaceous cells, probably of the thalamus, that lack the ability to produce nucleic acid. It is a progressive disorder that begins with difficulty initiating sleep and leads to total lack of sleep within a few months. It can be fatal within 7 to 13 months after symptoms begin but may last longer.


Back to Insomnia

Prion

A microscopic protein particle similar to a virus but lacking nucleic acid, responsible for certain degenerative diseases of the nervous system.

Back to FFI

Headaches

Any type of headache that occurs during sleep may wake a person up. For example, hypnic (sleep-inducing) headaches are characterized by generalized pulsating pain and may occur three times a night for 30 minutes for several consecutive nights. They are benign and usually affect people over the age of 60. They sometimes respond to lithium treatment

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Headaches

Any type of headache that occurs during sleep may wake a person up. For example, hypnic (sleep-inducing) headaches are characterized by generalized pulsating pain and may occur three times a night for 30 minutes for several consecutive nights. They are benign and usually affect people over the age of 60. They sometimes respond to lithium treatment


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Chronic Obstructive Pulmonary Disease (COPD)

Many aspects of COPD can disturb one's sleep. Low blood oxygen levels, coughing to clear secretions from the lungs, bronchospasm (narrowing and obstruction of airways), and the side effects of the medications used to treat the condition can create a night of broken sleep.

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Chronic Obstructive Pulmonary Disease (COPD)

Many aspects of COPD can disturb one's sleep. Low blood oxygen levels, coughing to clear secretions from the lungs, bronchospasm (narrowing and obstruction of airways), and the side effects of the medications used to treat the condition can create a night of broken sleep.


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Asthma

Asthma-related bronchospasm and subsequent airway obstruction is often worse during the night. This may lead to shortness of breath that causes a person to wake up. As with COPD, many asthma medications can cause insomnia, including theophylline, beta agonists (used as inhalants), and corticosteroids.

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Asthma

Asthma-related bronchospasm and subsequent airway obstruction is often worse during the night. This may lead to shortness of breath that causes a person to wake up. As with COPD, many asthma medications can cause insomnia, including theophylline, beta agonists (used as inhalants), and corticosteroids.


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Gastroesophageal Reflux and Heartburn

Nocturnal acid reflux and its characteristic chronic burning sensation in the lower esophagus can arouse one from sleep. If the symptoms are pronounced before going to sleep, they may cause sleep-onset difficulties. Heartburn often wakes people up and makes it difficult to go back to sleep. Avoiding fatty foods before sleep may help reduce heartburn and sleep disturbance.

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Gastroesophageal Reflux and Heartburn

Nocturnal acid reflux and its characteristic chronic burning sensation in the lower esophagus can arouse one from sleep. If the symptoms are pronounced before going to sleep, they may cause sleep-onset difficulties. Heartburn often wakes people up and makes it difficult to go back to sleep. Avoiding fatty foods before sleep may help reduce heartburn and sleep disturbance.


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Fibromyalgia

People with fibromyalgia often complain of light sleep and nonrestorative sleep. Fibromyalgia causes chronic pain in muscles and joint tissue, which can significantly disrupt or prevent sleep.

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Fibromyalgia

People with fibromyalgia often complain of light sleep and nonrestorative sleep. Fibromyalgia causes chronic pain in muscles and joint tissue, which can significantly disrupt or prevent sleep.


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Medications There are numerous medications for which insomnia is a predictable

side effect. The most common ones are listed below:

Decongestants (pseudoephedrine) Bronchodilators (beta-2 agonists, theophylline) Antihypertensives (hydrochlorothiazide, nifedipine, methyldopa, propranolol) Antidepressants (fluoxetine, bupropion, sertraline) Antidepressants that may cause daytime drowsiness (desipramine, imipramine,

nortriptyline) Diuretics (furosemide) Antiepileptics (phenytoin) Antiarrhythmic agents (quinidine, propranolol, verapamil) Histamine H2 inhibitors (cimetidine -for gastrointestinal conditions) Thyroid medications Alcohol, caffeine, nicotine

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Medications There are numerous medications for which insomnia is a predictable

side effect. The most common ones are listed below:

Decongestants (pseudoephedrine) Bronchodilators (beta-2 agonists, theophylline) Antihypertensives (hydrochlorothiazide, nifedipine, methyldopa, propranolol) Antidepressants (fluoxetine, bupropion, sertraline) Antidepressants that may cause daytime drowsiness (desipramine, imipramine,

nortriptyline) Diuretics (furosemide) Antiepileptics (phenytoin) Antiarrhythmic agents (quinidine, propranolol, verapamil) Histamine H2 inhibitors (cimetidine -for gastrointestinal conditions) Thyroid medications Alcohol, caffeine, nicotine


Back to Insomnia


B. Nutritional Imbalance

Nutrition evaluation is always important but must not prevent physicians from making a diagnosis that maybe potentially life-threatening and treatable.

Back to Question 3


B. Nutritional Imbalance

Nutrition evaluation is always important but must not prevent physicians from making a diagnosis that maybe potentially life-threatening and treatable.

Continue Case



C. Depression Clinical depression occurs in about 25% with

cancer, causing distress, impaired functioning, and less ability to follow treatment and is treatable. Symptoms of clinical depression that our patient has are:

Sad or "empty" mood Loss of interest or pleasure Significant weight changes “Slowed down" or restless and agitated Sleeping disorders Continue

CaseTeaching Points



D. Recurrence of the cancerCancer recurrence is always a concern. A thorough physical examination would be the first step, including an MRI. However the patient has other symptoms that need to be evaluated.

Back toQuestion 3


D. Recurrence of the cancerCancer recurrence is always a concern. A thorough physical examination would be the first step, including an MRI. However the patient has other symptoms that need to be evaluated.

Continue Case



A. Insomnia

B. Nutritional imbalance

D. Recurrence of the cancer

Continue Case

Case Continued

She is started on an SSRI, psychotherapy sessions are initiated and she joins a cancer support group.

A year after her diagnosis, Ms. Johnson, comes for her check-up with her oncologist. Clinical evaluation and follow-up MRI shows that she has a suspicious enlarged para-aortic lymph node. Further therapy is suggested.

Next

Question #4

Of the following, which is the best management?

A. Surgical removal of lymph node

B. Combined chemotherapy

C. Brachytherapy

D. External pelvic and abdominal radiation

E. Tamoxifen


A. Surgical removal of lymph nodeSurgical removal of the lymph node will increase the risk of disseminating cancerous tissue. It is not curative since the exact extent of local spread cannot be determined.

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A. Surgical removal of lymph nodeSurgical removal of the lymph node will increase the risk of disseminating cancerous tissue. It is not curative since the exact extent of local spread cannot be determined.

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B. Combined chemotherapyPatient has previously been treated with chemotherapy. Repeat chemotherapy is not felt to be effective and will increase morbidity with little or no benefit.

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B. Combined chemotherapyPatient has previously been treated with chemotherapy. Repeat chemotherapy is not felt to be effective and will increase morbidity with little or no benefit.

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Incorrect. Question #4C. Brachytherapy

Brachyterapy is, giving a high radiation dose to the tumor while reducing the radiation exposure in the surrounding healthy tissues by using radioactive seeds or applicators placed in or near the tumor itself. It allows use of a higher total dose of radiation to treat a smaller area and in a shorter time than is possible with external radiation treatment. It is given at a short distance: internally, localized, precise, and high-tech. This is not possible with lymph nodes. Some of the tumors treated with: Breast , Lung, Esophageal, cervical, Anal/Rectal, head and neck cancers and Sarcomas

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Incorrect. Question #4C. Brachytherapy

Brachyterapy is, giving a high radiation dose to the tumor while reducing the radiation exposure in the surrounding healthy tissues by using radioactive seeds or applicators placed in or near the tumor itself. It allows use of a higher total dose of radiation to treat a smaller area and in a shorter time than is possible with external radiation treatment. It is given at a short distance: internally, localized, precise, and high-tech. This is not possible with lymph nodes. Some of the tumors treated with: Breast , Lung, Esophageal, Cervical, Anal/Rectal, head and neck cancers and Sarcomas

Back toQuestion 4


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D. External pelvic and abdominal radiation

Radiation therapy may be used in combination with other forms of cancer treatment, or when surgery is not an option.

Radiotherapy uses high-energy rays to destroy or impede tumor growth. External Beam Radiation Therapy, or EBRT involves focusing a “beam” of radiation from an external source on the cancerous internal organ and/or tissue.

Radiotherapy should be considered for women with endometrial cancer who suffer a localized relapse following surgery. It can be curative in a select group of previously non-irradiated women.

In the literature, long-term survival rates in women who undergo irradiation after relapse range from 25 to 71 percent, with most reporting five-year survival rates between 40 and 55 percent.

Continue Case

Teaching Points for Incorrect Answer


E. Tamoxifen Tamoxifen, a selective estrogen receptor modulator

(SERM), appears to have some efficacy in women with advanced endometrial cancer as a single agent, with response rates of 10 to 22 percent .

It is inactive in women who are resistant to progestins or chemotherapy.

Low-grade endometrial cancers are far more likely to respond to tamoxifen than are high-grade tumors. There is a more effective therapy for this patient

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E. Tamoxifen Tamoxifen, a selective estrogen receptor modulator

(SERM), appears to have some efficacy in women with advanced endometrial cancer as a single agent, with response rates of 10 to 22 percent .

It is inactive in women who are resistant to progestins or chemotherapy.

Low-grade endometrial cancers are far more likely to respond to tamoxifen than are high-grade tumors. There is a more effective therapy for this patient

Back to Question 4


Continue Case

Tamoxifen

Licensed to University of California ©2006 UpToDate ® U.S. BRAND NAMES — Nolvadex®; Soltamox™ PHARMACOLOGIC CATEGORY

Antineoplastic Agent, Estrogen Receptor Antagonist USE — Palliative or adjunctive treatment of advanced

breast cancer; reduce the incidence of breast cancer in women at high risk; reduce risk of invasive breast cancer in women with ductal carcinoma in situ (DCIS); metastatic female and male breast cancer

Back to Case

Tamoxifen

Licensed to University of California ©2006 UpToDate ® U.S. BRAND NAMES — Nolvadex®; Soltamox™ PHARMACOLOGIC CATEGORY

Antineoplastic Agent, Estrogen Receptor Antagonist USE — Palliative or adjunctive treatment of advanced

breast cancer; reduce the incidence of breast cancer in women at high risk; reduce risk of invasive breast cancer in women with ductal carcinoma in situ (DCIS); metastatic female and male breast cancer



A. Surgical removal of lymph node

B. Combined chemotherapy

C. Brachytherapy

E. Tamoxifen

Continue Case

Case Continued

Six months later and 18 months after her diagnosis, Ms Johnson receives external pelvic and abdominal radiation.

A repeat MRI shows resolution of the enlarged lymph node.

Mrs Johnson returns to your office and states; “ My bladder is very painful, I have strong urgency with frequent urination and sometimes lose my urine before I get to the bathroom. Also my urine is very bloody. Is it happening again?

Next

Question #5

What is the most likely diagnosis?

A. Urinary tract infectionB. Estrogen loss cystitisC. Irradiation cystitis D. Recurrence of endometrial cancerE. Detrusor instability


A. Urinary tract infectionBecause of a short urethra, urinary tract infection is common in women but is usually not associated with hematuria.

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A. Urinary tract infectionBecause of a short urethra, urinary tract infection is common in women but is usually not associated with hematuria

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B. Estrogen loss cystitis Estrogen deficiency may lead to vaginal atrophy

resulting in vaginal dryness and dyspareunia. The mucosal lining of the vagina and urethra are

very sensitive to estrogen, and thinning of the vaginal epithelium occurs after the menopause. Estrogen deprivation is unlikely to cause bladder inflammation.

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B. Estrogen loss cystitis Estrogen deficiency may lead to vaginal atrophy

resulting in vaginal dryness and dyspareunia. The mucosal lining of the vagina and urethra are

very sensitive to estrogen, and thinning of the vaginal epithelium occurs after the menopause. Estrogen deprivation is unlikely to cause bladder inflammation.

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C. Irradiation cystitis

Continue Case

Radiation results in cell death, vasculitis, fibrosis and neuritis. Early findings (<12 mo) are submucosal inflammation and fibrosis, perineural inflammation, surface ulceration, and epithelial atypiaLate findings (>12 mo) include luminal occlusion, vascular ectasia, and necrosis of vessel walls. Acute symptoms consist of urgency, frequency, dysuria, and hematuria. Chronic symptoms are due to ischemia and fibrosis resulting in contracted bladders, ulcer formation, fistulas, and bladder dysfunction; therefore, clinical presentation can include frequency, urgency, dysuria, hematuria, incontinence, hydronephrosis,

pneumaturia, and fecaluria. Teaching Points for Incorrect Answers


D. Recurrence of endometrial cancerSince the lymph node has resolved, recurrence of the endometrial cancer is less likely. Also endometrial cancer does not commonly present as heamturia.

Back toQuestion 5


D. Recurrence of endometrial cancerSince the lymph node has resolved, recurrence of the endometrial cancer is less likely. Also endometrial cancer does not commonly present as heamturia.

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Incorrect. Question # 5

E. Detrusor instability

Detrusor instability is due to uninhibited bladder contractions of detrusor overactivity resulting in urgency, frequency, and nocturia, and urge incontinence but does not cause heamturia.

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Detrusor instability is due to uninhibited bladder contractions of detrusor overactivity resulting in urgency, frequency, and nocturia, and urge incontinence but does not cause heamturia.

Continue Case



A. Urinary tract infection

B. Estrogen loss cystitis

D. Recurrence of endometrial cancer


Continue Case

Case Continued

She is treated with hyperbaric oxygen and alum irrigation with good results.

Six months, later and 20 months after her diagnosis, Ms Johnson calls your office. “I am really mad. My daughter, who takes care of me, is being threatened with termination from her job because of all the time she has taken off work to help me during my treatment.”

Next

Question #6

Which federal law best protects her caregiver?

A. American with disabilities act of 1990(ADA), P.L. 101-336B. Family medical Leave Act of 1993 (FMLA), P.L. 103-3C. Federal Rehabilitation Act of 1973, P.L. 93-112(amended 19

98)D. Employee Retirement Income Security Act of 1974E. Consolidated Omnibus Budget Reconciliation Act of 1985 (C

OBRA), P.L. 99-272F. Health Insurance Portability and Accountability Act of 1996


A. American with disabilities act of 1990(ADA), P.L. 101-336The ADA prohibits employers with 15 or more employees from treating a cancer survivor or the family of a cancer survivor differently from other employees. The ADA requires employees to make reasonable accommodations to the survivor’s work schedule, work environment or duties if needed.

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A. American with disabilities act of 1990(ADA), P.L. 101-336The ADA prohibits employers with 15 or more employees from treating a cancer survivor or the family of a cancer survivor differently from other employees. The ADA requires employees to make reasonable accommodations to the survivor’s work schedule, work environment or duties if needed.

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B. Family medical Leave Act of 1993 (FMLA), P.L. 103-3 FMLA states: Subject to section 103, an eligible employee shall be entitled

to a total of 12 work weeks of leave during any 12-month period for any of the following:

A) Birth of a son or daughter of the employee and in order to care for such son or daughter.

(B) Placement of a son or daughter with the employee for adoption or foster care.

(C) In order to care for the spouse, or a son, daughter, or parent, of the employee, if such spouse, son, daughter, or parent has a serious health condition.

(D) Serious health condition that makes the employee unable to perform the functions of the position of such employee.

Employers with at least 50 employees are required to provide up to 12 weeks of unpaid leave to care for a spouse, child or oneself with a serious medical condition. The leave need not be taken at once. The person is entitled to health benefits and must be allowed to return to his or her job or an equivalent position. Continue

CaseTeaching Points for Incorrect Answers


C. Federal Rehabilitation Act of 1973, P.L. 93-112(amended 1998)

This legislation bans discrimination of employees that are not covered under the ADA. These include the Federal Government, Federal contract receivers who have less than 15 employees and Federal assistance receivers who have less than 15 employees.

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This legislation bans discrimination of employees that are not covered under the ADA. These include the Federal Government, Federal contract receivers who have less than 15 employees and Federal assistance receivers who have less than 15 employees.

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D. Employee Retirement Income Security Act of 1974

ERISA sets minimum standards for established pensions and health plans in private industry and protects the individuals in these plans. It stipulates that a person cannot be fired because the employer thinks the individual’s health care will cost too much.

Back toQuestion 6


D. Employee Retirement Income Security Act of 1974

ERISA sets minimum standards for established pensions and health plans in private industry and protects the individuals in these plans. It stipulates that a person cannot be fired because the employer thinks the individual’s health care will cost too much.

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E. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), P.L. 99-272Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), P.L. 99-272 is the legislation that enables a worker at a company of more than 20 employees who must leave his/her job for health reasons to continue to participate in the employer’s group health plan. The employee must pay the full monthly premium plus an administrative fee.

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E. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), P.L. 99-272Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), P.L. 99-272 is the legislation that enables a worker at a company of more than 20 employees who must leave his/her job for health reasons to continue to participate in the employer’s group health plan. The employee must pay the full monthly premium plus an administrative fee.

Continue Case



F. Health Insurance Portability and Accountability Act of 1996

Employees must be allowed to join a group health plan without an exclusion or waiting period for coverage of pre-existing conditions as long as they have had continuous “credible” coverage without a break for 63 days.

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Employees must be allowed to join a group health plan without an exclusion or waiting period for coverage of pre-existing conditions as long as they have had continuous “credible” coverage without a break for 63 days.

Continue Case



A. American with disabilities act of 1990(ADA), P.L. 101-336


D. Employee Retirement Income Security Act of 1974E.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), P.L. 99-272


Continue Case

Case Continued

With the assistance of an employment attorney, her daughter is able to retain her job.You have a counseling session with Mrs. Johnson. At the end of the visit she responds; “I was concerned about the status of my cancer. My diagnosis of cancer was made about 3 years ago. I am relieved that you state that I am in remission. I am now ready to face the fact that I am a cancer survivor.”

Next

Question #7

How can her current status be best categorized?

A. Acute survivor

B. Extended survivor

C. Permanent survivor

D. End of life survivor


A. Acute survivorBegins at diagnosis and continues till end of treatment. This “season of life” is dominated by cancer treatment including medical, surgical and radiological. Fear and anxiety are important elements of this phase. Pain is common and the person for the first time may have to deal with the fact that they may die.

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A. Acute survivorBegins at diagnosis and continues till end of treatment. This “season of life” is dominated by cancer treatment including medical, surgical and radiological. Fear and anxiety are important elements of this phase. Pain is common and the person for the first time may have to deal with the fact that they may die.

NextTeaching Points



B. Extended Survivor Begins at the conclusion of treatment and lasts until

the risk of recurrence has decreased. This is the period of watchful waiting, periodic examinations and intermittent therapy. This phase is dominated by the fear of recurrence.

The 5 year survival for endometrial cancer stage 2A is about 78%. There is probably an increased of risk till 5 years after diagnosis, thus this patient is most likely an extended survivor.

NextTeaching Points for Incorrect Answers


C. Permanent Survivor The period when the activity of the disease or the

likelihood of its recurrence is sufficiently small that the cancer can now be considered permanently arrested.

This encompasses the duration of survivor’s life. This is the period that the individual deals with employment; insurance and discrimination issues. Secondary effects such as sterility, secondary tumors, and radiation effects are a concern.

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C. Permanent Survivor The period when the activity of the disease or the

likelihood of its recurrence is sufficiently small that the cancer can now be considered permanently arrested.

This encompasses the duration of survivor’s life. This is the period that the individual deals with employment; insurance and discrimination issues. Secondary effects such as sterility, secondary tumors, and radiation effects are a concern.

NextTeaching Points



D. End of Life Survivor

Weeks or months at the end of life associated with palliative care.

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Weeks or months at the end of life associated with palliative care.

NextTeaching Points



A. Acute Survivor

C. Permanent Survivor


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cancer survivorship endometrial cancer module

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