Cancer Treatment Related Toxicities Flashcards by J G

What’re 3 possible goals of cancer tx?

adjuvant chemotx
curative chemotx
palliative chemotx

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T or F: Most chemotx pts experience AEs

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Why is it important to ensure that pts understand possible AEs and how to manage them?

to reduce anxiety, improve QoL, and maintain optimal chemo dose and schedule

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What is used to assess toxicity due to chemotx?

The National Cancer Institute (NCI) Common Toxicity Criteria

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How many grades of toxicity are there on the NCI Common Toxicity Criteria?

6 grades

0-5 (with 0 being no AEs, and 5 being death)

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NCI Common Toxicity Criteria Grade 4 refers to AEs that’re

a. mild
b. moderate
c. severe
d. life-threatening

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What is chemotx dosing based on?

BSA (body surface area)

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What kinds of cells will cytotoxic drugs preferentially attack in addition to tumor cells?

Rapidly-dividing healthy cells

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What’re the AEs of chemotx drugs due to?

They’re due to damage done to healthy cells

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What is the PRIMARY dose-limiting toxicity of cytotoxic drugs?

Myelosuppression, causing neutropenia, thrombocytopenia, and anemia

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Why is neutropenia predictable?

Bc we can easily measure absolute neutrophil count (ANC) in blood tests

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What value is considered neutropenia?

ANC (absolute neutrophil count) of less than 1.5 x 10^9 cells/L

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Define febrile neutropenia

Fever characterized by either…

a. single reading of >38.3ºC, or
b. >38ºC for >1h

…while being neutropenic (ANC <1.5x10^9 cells/L

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What should you do if febrile neutropenia develops?

Get to the emergency room right away!

And don’t take any antipyretics and just tx it as a normal fever!

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Define “nadir”

the lowest level of blood count after a cycle of chemotx

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When does a neutropenia nadir usually occur?

around 7-14 days after administration of cytotoxic drug(s)

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How do we manage a neutropenia nadir?

reduce dose OR delay tx

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What medication is used to tx febrile neutropenia?

filgrastim or pegfilgrastim

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MOA of filgrastim/pegfilgrastim?

growth factors that stimulate production of granulocytes such as neutrophils

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When would filgrastim/pegfilgrastim be used for 1º prophylaxis?

When a patient is at ≥20% risk of developing febrile neutropenia

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When should filgrastim be administered?

Greater than 24h before or after chemotx (otherwise, the anti-cancer drugs will have cytotoxic effects on the rapidly dividing myeloid cells)

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Tx for chemotx-induced anemia

infusion of packed RBC

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T or F: If packed RBCs aren’t working, then erythropoiesis-stimulating agents are recommended for chemotx-induced anemia

They are assoc w/ lower survival

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Tx for chemotx-induced thrombocytopenia

dose adjustment, tx delays, and/or platelet infusion

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When does chemotx-induced thrombocytopenia typically occur?

~2nd week after chemotx administration

When does the nadir of thrombocytopenia typically occur due to chemotx-induced?

Around day 14

When does chemotx-induced thrombocytopenia resolve?

~days 28-35

Why does mucositis often occur due to chemotx?

Because epithelial lining of the GIT has a rapid turnover rate

When does mucositis usually occur due to chemotx?

During the neutrophil nadir (7-10 days)

What can develop in the mouth as a result of chemotx or radiation tx?

Hyposalivation > mouth sores due to reduced mucosa regeneration

How to prevent mucositis-assoc mouth sores?

Good oral hygiene, salt/baking soda rinse, ice chips

Top 3 anti-cancer drugs assoc w/ mucositis?

MTX, etoposide, melphalan

Tx/prevention of mucositis-assoc mouth sores?

1. Rx mouth wash (steroids, local anesthetics, topical analgesics) 2. Nystatin/po fluconazole for fungal infection 3. analgesia

Chemotx-induced mouth sores can result in (choose all that apply) a. pain b. increased nutritional intake c. delayed/stopped tx d. infection

a. pain c. delayed/stopped tx d. infection (b. should've been DECREASED nutritional intake)

Why do pts feel stomach pain during cancer tx?

Due to cytotoxic drugs attacking cells directly and due to AEs of supportive care meds

How to manage cytotoxic med-induced dyspepsia/heartburn/stomach pain?

H2 blockers, PPIs, antacids avoid aggravating factors (e.g. smoking)

2 most common chemotx agents assoc w/ diarrhea

fluorouracil, capecitabine

How is chemotx-induced diarrhea tx'ed?

anti-spasmodics (e.g. loperamide, Lomotil)

Why is the GIT particularly susceptible to anti-cancer drugs?

Due to rapid cellular turnover

What is the risk of having prolonged diarrhea due to chemotx?

Dehydration that may require hospitalization

Irinotecan-induced ACUTE diarrhea tx

atropine

Irinotecan-induced ACUTE diarrhea - when does it occur?

Within 24h

Irinotecan-induced DELAYED diarrhea tx

Intensive loperamide regimen (doses higher than those found on label) until diarrhea-free for at least 12h

How can constipation develop in cancer pts undergoing tx?

It can be an AE of supportive tx's (e.g. ondansetron, opioids) It can also be chemotx-induced or radiation-induced

Non-pharm tx of constipation in cancer pts:

increase water, fibre, exercise

Pharm tx of constipation in cancer pts

stimulant antidiarrheals (e.g. senna, bisacodyl) osmotic antidiarrheals (e.g. lactulose)

What is NOT recommended for constipation tx in cancer pts?

Bulk-forming agents (e.g. metamucil)

Why aren't bulk-forming agents recommended for constipation in cancer pts?

Bc they need to take lots of fluid, and bc they're usually not effective for medication-induced constipation

When should you be worried wrt constipation?

if the pt isn't having a bowel movement for 3-5 days, not passing gas, blood in stool/tar-like stools, foul smelling vomit

Chemotx drugs most assoc w/ myalgia

Taxanes: paclitaxel and docetaxel

How to tx chemotx-induced myalgia?

Tylenol, opioids, prednisone, gabapentin *maybe* NSAIDs

Chemotx drugs most assoc w/ arthralgia?

aromatase inhibitors (letrozole, anastrazole), SERMs (tamoxifen)

Tx for chemotx-induced arthralgia?

glucosamine +/- chondroitin, po NSAIDs, po acetaminophen

Why're hair follicles susceptible to the effects of chemotx drugs?

Hair follicles possess rapidly dividing cells and are susceptible to the toxic effects of chemotherapy.

What's the most socially distressing AE of chemotx?

Alopecia

Anti-cancer drugs most assoc w/ alopecia

doxorubicin, paclitaxel

Anti-cancer drug assoc w/ irreversible hair loss.

docetaxel

Which drugs are assoc w/ trichomegaly (eyebrow/eyelash changes)?

EGFR inhibitors

What's the most common taste alteration due to chemotx?

Metallic or chemical taste

How can we possibly help w/ taste alterations due to chemotx?

use plastic utensils (to reduce metallic taste)

Most commonly reported AE of cancer tx w/ chemotx/radiation/specific biologic response modifiers?

cancer related fatigue (CRF)

T or F: Cancer related fatigue is often considered more distressing than N/V or pain

T or F: Cancer related fatigue usually completely reverses itself after cancer tx is d/c'ed.

F It may persist for months or years after tx

Which drugs are most assoc w/ photosensitivty?

anthracyclines, fluorouracil, MTX, vincas, dacarbazine, cyclophosphamide, 6-thioguanine (6TG), 6-merpatopurine (6MP)

Drugs assoc w/ nail changes

docetaxel, paclitaxel, doxorubicin

Drugs assoc w/ hyperpigmentation

5-fluorouracil, cyclophosphamide

Name all cutaneous rxns commonly assoc w/ anti-cancer chemotx drugs.

photosensitivity, nail changes, hyperpigmentation, dry skin, rashes, Hand Foot Skin Rxn (HFSR)

What is Hand Foot Skin Rxn?

Chemotx-induced cutaneous skin rxn characterized by dryness, redness, numbness, and tingling on the palms of the hand and soles of the feet that can progress to swelling, blistering, and severe pain

HFSR is most assoc w/ which chemotx drugs?

xeloda, capecitabine (po prodrug of fluorouracil), and caelyx (liposomal doxoribicin

What's the best approach to dealing Hand Foot Skin Reaction (HFSR)?

By PREVENTING it AVOID: tight fitting shoes, anything that may dry out hands MAKE SURE TO moisturize hands often

What kinds of drugs usually cause skin rashes?

EGFR inhibitors (monoclonal Abs and tyrosine kinase inhibitors)

T or F: EGFR-induced rashes should be tx'ed with benzoyl peroxide

F may make it worse + it's not acne

Tx for EGFR-induced rash?

Minocycline/doxycycline

What's paronychia?

painful inflammation at the edge of nailbeds of fingers and toes > caused by cancer chemotx drugs

Hypothyroidism is an AE most assoc w/ this cancer drug class.

VEGF inhibitors

How to tx cancer tx-induced hypothyroidism?

thyroid hormone (as usual)

T or F: Thyroid AEs are avoided with immune oncology drugs.

HTN is a v. common AE w/ this type of anti-cancer drug class.

VEGF receptor inhibitors

What chemo drugs are most assoc w/ neurotox?

platinum agents, taxanes, vinca alkaloids, new immunomodulating agents

How are neurotoxic effects usually exhibited in chemo pts?

As peripheral neuropathy

How are vinca alkaloids (vincristine) postulated to cause neurotox?

accumulation of vincristine in neuronal tissue > interferes w/ microtubular structure and transport fn in nerve cells

What medication is LETHAL if injected intrathecally?

Vinca alkaloids

What's used for tx'ing chemo-induced peripheral neuropathy?

antideps, opioids, and anticonvulsants

Which chemo drugs are most assoc w/ cardiotox?

anthracyclines (e.g doxorubicin), fluorouracil, and trastuzumab

how do anthracyclines cause cardiotox?

reactive free radicals form > damage myocardial cells

Why're there lifetime max doses for anthracyclines?

Due to delayed cardiotoxicity occurring years after anthracycline tx

2nd leading cause of death in cancer pts?

cancer-assoc thrombosis

Two cancer meds assoc w/ bladder tox?

ifosfamide, cyclophosphamide

What's the toxic metabolite of both ifosfamide and cyclophosphamide that causes bladder tox?

acrolein

What pharm tx is used to prevent bladder tox caused by alkylating agents like ifosfamide and cyclophosphamide?

mesna

What is tumor lysis syndrome?

Oncologic emergency where destruction of tumor cells increases uric acid (from DNA), which then precipitate acidic envir of urine > obstruction of urinary tract and renal blood vessels > acute renal failure

What's used to prevent tumor lysis syndrome?

hydration, urine alkalinization, allopurinol

Chemotx-induced nephrotox usually occurs with what which agents?

Platinum agents, methotrexate

How do we reduce nephrotox in chemotx pts receiving platinum agents?

Hydration and saline/mannitol diuresis

How do we reduce nephrotox in chemotx pts receiving methotrexate?

hydration and urine alkalinization

Chemo drug most commonly assoc w/ pulmonary tox?

bleomycin

How do we deal w/ chemo-induced pulmonary tox?

Recognizing the sx's and halting the drug right away

T or F: Chemotx-induced hypersensitivity rxns are dose-related.

F They are NOT dose related

Chemo drugs most commonly assoc w/ hypersensitivity rxns

taxanes, platinums, bleomycin, and monoclonal Abs

How to prevent infusion-related rxns in pts receiving chemotx?

give pt steroid + H2-antagonist + antihistamine +/- acetaminophen

Why is permanent or fatal liver damage usually not an issue for pts receiving chemotx?

bc of v. close monitoring

How would we tx hepatotox in chemo pts?

Either reduce dose, interrupt tx, or d/c drug completely (depends on severity)

Which class of chemo drugs have the most consistent negative effects on reproductive fn?

alkylating agents (e.g. cyclophosphamide, busulfan, etc.)

T or F: Chemotx drugs are all teratogenic.

T or F: Chemotx only affects reproductive health of women.

What's an ironic long term AE of chemotx cytotoxic drugs?

They can cause secondary malignanices

Most common secondary malignancies of cytotoxic chemo drugs?

acute myeloid leukemia (AMS) and acute myelogenous leukemia (AML)

Chemotx agents w/ highest risk of causing secondary malignancies?

alkylating agents and topoisomerase II inhibitors

Solid tumors more often show up as secondary malignancies w/ a. radiation tx b. chemotx c. both a. and b.

a. radiation tx | so chemo = blood cancer; radiation = solid tumor cancer AS SECONDARY MALIGNANCIES