Supportive Care, Symptom Control and Palliative Care
What this domain tests
This domain tests proactive management of treatment toxicity and cancer symptoms, with correct drug doses and conversions. It rewards practical prescribing detail: antiemetic combinations, opioid arithmetic, prophylaxis thresholds.
Core rules
- Pain: follow the WHO analgesic ladder. Start a long-acting opioid with a short-acting breakthrough dose of roughly one-sixth of the total daily dose, prescribed as needed. Always co-prescribe a laxative with opioids; consider metoclopramide or haloperidol for opioid-induced nausea.
- Opioid conversion: oral morphine to subcutaneous morphine approximately 3:1; oral morphine to oral oxycodone approximately 1.5–2:1; reduce the calculated dose by about 25–30% for incomplete cross-tolerance when rotating.
- Antiemetics: highly emetogenic regimens (e.g., cisplatin) need an NK1 antagonist plus a 5-HT3 antagonist plus dexamethasone, with olanzapine as an option. Moderately emetogenic regimens need a 5-HT3 antagonist plus dexamethasone.
- Febrile neutropenia prophylaxis: primary G-CSF when the regimen carries a febrile neutropenia risk of 20% or more, or 10% or more with patient risk factors.
- Bone health: offer bone-modifying agents in castration-sensitive prostate cancer and in myeloma; supplement calcium and vitamin D and monitor renal function with bisphosphonates.
- Palliative care is concurrent, not terminal: early integration improves quality of life and can extend survival. Advance care planning and DNACPR decisions are discussed with the patient while they retain capacity.
Worked example
A patient on oral morphine 60 mg per day has uncontrolled pain and cannot swallow. Convert to subcutaneous morphine: 60 ÷ 3 = 20 mg per 24 hours by continuous subcutaneous infusion. Breakthrough dose: about one-sixth of the daily dose, so 5 mg subcutaneously as needed, reviewed after 24 hours. Reasoning: the 3:1 ratio reflects reduced first-pass metabolism parenterally; keeping the breakthrough dose proportional prevents both under-treatment and stacking.
Traps
Increasing the long-acting opioid without reviewing adherence and absorption; forgetting laxatives; using a 1:1 oral-to-subcutaneous conversion, which over-sedates; referring to palliative care only in the final days.