Chapter 61: Oncology I: Overview and Side Effect Management Flashcards
What is an adjuvant
Treatment given AFTER the primary therapy (usually surgery) or CONCURRENT with other therapy (usually radiation) to eradicate residual disease and decrease recurrence
A tumor that is not cancerous is also called
benign
What is used to make a definitive diagnosis of cancer
Biopsy
What is a neoadjuvant
Treatment given BEFORE the primary therapy to shrink the size of the tumor and make surgery more effective
Cancer that has returned after a period during which it could not be detected is called
recurrence
The disappearance of the signs and symptoms of cancer, but not necessarily the presence of the disease is called
Remission
How is cancer staged
T - size and extent
N - spread to lymph nodes
M - whether the cancer has metastasized
Cancer that cannot be cured and leads to death is called
Terminal or end-stage
What are the warning signs that warrant referral to a physician (if suspected cancer)
CAUTION: Change in bowel or bladder habits A sore throat that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough or hoarseness
____ is recommended for prevention of colorectal cancer and CVD in patients who are 50-59 years old, have ASCVD risk ≥ 10%, have ≥ 10-year life expectancy and are at low risk of bleeding
Low-dose ASA
To reduce risk of developing skin cancer, you should use a broad-spectrum sunscreen with an SPF of at least ____ and reapply every __ hours
15-30
2 hours
Mammograms should begin ____ in women age 45-54
Yearly
Mammograms should be done ____ at age 55
every 2 years or yearly
Women age 21-29 should have a PAP smear every ___
3 years
At what age should women have a pap smear and HPV DNA test?
How often?
age 30-65
every 5 years
Men and women over ____ years should have stool-based tests done (i.e., fecal occult blood test, stool DNA test) and colonoscopy every ____ or flexible sigmoidoscopy every ___
45 years
10 years
5 years
Men and women age 55-74 should complete an annual ____ if all of the following:
- In good health
- Have ____
- Still smoking or quit smoking within the past 15 years
annual CT scan of the chest
at least a 30-pack year smoking hx
If a patient ops to be tested for prostate, it involves:
what age?
PSA test (blood test) \+/- digital rectal exam
for ≥ 50
Max dose for bleomycin and reason
Lifetime cumulative dose: 400 units
Pulmonary toxicity
(Lungs have 4 lobes – 400)
Max dose for doxorubicin and reason
Lifetime cumulative dose: 450-550 mg/m2
Cardiotoxicity
Max dose for Cisplatin and reason
Dose per cycle not to exceed 100 mg/m2
Nephrotoxicity
Max dose for Vincristine and reason
Single dose “capped” at 2 mg
Neurotoxicity
Almost all classic chemo drugs can cause myelpsuppression EXCEPT:
asparginase, bleomycin, vincristine
How to manage neutropenia in myelosuppression:
CSFs
How to manage anemia in myelosuppression:
RBC transfusions and (in palliation only) ESAs
How to manage thrombocytopenia in myelosuppression:
platelet transfusions
Which chemo drugs commonly cause nausea/vomiting
Cisplatin, cyclophosphamide, ifosfamide
Management of N/V with chemotherapy
NK1-RA
5HT3-RA
dexamethasone
IV/PO fluid hydration
Which chemo drugs commonly cause mucositis
Fluorouracil, MTX
Management of mucositis with chemotherapy
Symptomatic treatment: mucosal coating agents, topical local anesthetics, antifungals, antivirals
Which chemo drugs commonly cause diarrhea
Irinotecan, capecitabine, FU, MTX
Management of diarrhea with chemotherapy
IV/PO fluid hydration, antimotility meds (e.g., loperamide)
Irinotecan: atropine for early-onset diarrhea
(loperamide for delayed diarrhea)
Which chemo drug commonly causes constipation
Vincristine
Management of constipation with chemotherapy
Stimulant laxatives, Miralax
Management of xerostomia with radiation
artificial saliva substitutes, pilocarpine
Which chemo drug class commonly causes cardiomyopathy
Anthracyclines
Which chemo drugs commonly cause QT prolongation
Arsenic trioxide, many TKIs
What can be given prophylactically in select patients receiving doxorubicin
dexrazoxane (Zinecard) to prevent cardiomyopathy
Which chemo drugs can cause pulmonary fibrosis
Bleomycin, busulfan, carmustine, lomustine
Which chemo drugs can cause pneumonitis
Immune therapy MABs targeting PD-1 and CTLA-4
Management of pulmonary toxicity/ pneumonitis
stop drug
Steroids for immune therapy agents
DNE lifetime cumulative dose of 400 units for bleomycin
Which chemo drugs can cause hepatotoxicity
Antiandrogens (bicalutamide, flutamide, nilutamide)
Management of hepatotoxicity
Steroids for immunotherapy agents
Which chemo drugs can cause nephrotoxicity
Cisplatin, MTX
What drug can be given prophylactically with cisplatin to reduce the risk of nephrotoxicity
Amifostine (Ethyol)
Ensure adequate hydration
DNE max cycle dose of 100 for cisplatin
Which chemo drugs can cause hemorrhagic cystitis
Ifosfamide (all doses), cyclophosphamide (higher doses)
What drug is always given prophylactically with ifosfamide (and sometimes with cyclophosphamide) to reduce risk of hemorrhagic cystitis
Mesna (Mesnex)
ensure adequate hydration
Which chemo drug classes can cause peripheral neuropathy
Vinca alkaloids (vincristine, vinblastine, vinorelbine) Platinums (cisplatin, oxaliplatin) Taxanes (paclitaxed, docetaxel, cabazitaxel)
Management of neuropathy with vincristine and oxaliplatin
symptomatic treatment
vincristine: limit dose to 2mg/dose
oxaliplatin: avoid cold temperatures and avoid cold beverages (cold-mediated neuropathy)
Which chemo drugs have clotting risk
Aromatase inhibitors (i.e., anastrazole, letrozole), SERMs (e.g., tamoxifen, raloxifene)
What adjunctive treatment can be given with fluorouracil to enhance efficacy
Leucovorin
What adjunctive treatment can be given with fluorouracil or capecitabine as an antidote within 96 hours for an OD or to treat severe, life-threatening or early-onset toxicity
Uridine triacetate (Vistogard)
What adjunctive treatment can be given with MTX prophylactically after MTX to decrease myelosuppression and mucositis in high-dose therapy
Leucovorin or levoleucovorin (Fusilev)
What adjunctive treatment can be given with MTX as an antidote to decrease excessive MTX levels d/t acute renal failure
Glucarpidase (Voraxaze)
what is nadir?
lowest point that WBCs and platelets reach after chemo
When does nadir occur
7-14 days after chemo
WBCs and platelets generally recover ____ post treatment
3-4 weeks
All drugs used for myelosuppression (e.g., EPO, filgrastim) are kept ____ and are given by ____
refrigerated
SC injection
What ANC is considered neutropenia
< 1000 cells/mm3
What ANC is considered severe neutropenia
profound neutropenia?
< 500 cells/mm3
<100
What are G-CSFs used for
To prevent neutropenia
by stimulating production of WBCs
Filgrastin brand name
Neupogen
Pegfilgrastim brand name
Neulasta
How often is filgrastim dosed
daily
How often is pegfilgrastim dosed
1 syringe once per chemo cycle
Side effects of filgrastim & pegfilgrastim
Bone pain
SE of sargramostim
fever, bone pain, arthralgias, myalgias, rash
While using filgrastim or pegfilgrastim, patients should report any signs of ______
Enlarged spleen (pain in the left upper abdomen)
Which drug has to be documented when it was given since it should have at least 12 days from dose to the next cycle of chemo: filgrastim or pegfilgrastim
Pegfilgrastim
T/F: empiric antibiotics are started immediately if a fever occurs after chemo
True
Neutropenia diagnosis requirements
Oral temp > 38.3C (101F) x 1 reading
and ANC < 500 cells/mm3
Which bacteria have the highest risk for causing sepsis
Gram-negative
The initial empiric abx for neutropenia must provide adequate ____ coverage, including _____
Gram-negative
Pseudomonas aeruginosa
Treatment of neutropenia, low risk patients
(expected ANC < 500 for ≤ 7 days, no comorbidities)
ORAL
cipro/levo + augmentin
clindamycin can replace augmentin in pcn allergy
Treatment of neutropenia, high risk patients
(expected ANC < 500 for > 7 days, comorbidities present, renal or hepatic impairment)
INTRAVENOUS anti-pseudomonal beta-lactam
ESAs should only be initiated when Hgb is
< 10 g/dL
ESA’s risk in cancer
can shorten survival and increase tumor progression - ONLY for palliation
What needs to be assessed when using ESAs since they will not work well to correct anemia if these levels are inadequate
Serum ferritin, transferrin saturation (TSAT) and total iron-binding capacity (TIBC)
When are platelet transfusions indicated
When platelet count is < 10,000 cells/mm3
or < 30K with bleeding present
What patient factors increase the risk of N/V
female age < 50 anxiety, depression dehydration history of motion sickness history of N/V with prior regimens
For CINV, when should antiemetics be administered
30 min prior to chemo and provide take-home antiemetic therapy
What is the onset of acute, delayed, and anticipatory CINV
acute - within 24 hrs after chemo
delayed - > 24 hours after chemo
anticipatory - before chemo
Drug therapy for acute CINV
5HT3-RA
Drug therapy for delayed CINV
NK1-RA, corticosteroids, palonosetron, olanzapine
Drug therapy for anticipatory CINV
BZDs; start evening prior to chemo
Which drug has the highest emetic risk
Cisplatin
Antiemetic regimen for high-emetic risk chemo
3 or 4 drugs:
- NK1RA + 5HT3RA + Olanzapine + Dexamethasone (preferred)
- Olanzapine + Palonosetron + Dexa
- NK1RA + 5HT3RA + Dexa
What meds can be used for breakthrough CINV
5HT3-RA, dopamine RA, cannabinoids, olanzapine
Common SE of 5HT3-RAs
migraine-like headaches and constipation
minimal sedation
dopamine receptor antagonists common SE
sedation
(prochlorperazine, promethazine, metoclopramide)
management of extrapyramidal symptoms like acute dystonic reactions should be managed with
anticholinergics (benztropine, diphenhydramine)
Droperidol has restricted use due to
QT prolongation
Cannabinoids like dronabinol and nabilone can be used as second-line agents and are synthetic analogs of
delta-9-THC
Aprepitant brand name
(PO) Emend
Fosaprepitant brand name
(IV) Emend
What formulation does fosaprepitant come in
Injection
Aprepitant/Fosaprepitant/netupitant are CYP3A4 inhibitors; dose of ____ should be decreased
Dexamethasone
Ondansetron brand name
Zofran, Zuplenz film
Granisetron brand name
Sancuso
Palonosetron brand name
Aloxi
5HT3-RA should not be used with ____ d/t severe ____ and loss of consciousness
apomorphine
hypotension
5HT3-RA warnings
risk of serotonin syndrome when used in combination with other serotonergic agents
Short-term SE of dexamethasone
increased appetite/weight gain, fluid retention, insomnia
Higher doses increase BP and blood glucose
Prochlorperazine brand name
Compazine
Promethazine brand name
Phenergan
Metoclopramide brand name
Reglan
Olanzapine brand name
Zyprexa
Promethazine should not be used in children < ___ years of age d/t risk of ____ depression
2 years
respiratory
Promethazine given IV route can cause
Serious tissue injury if extravasation occurs
deep IM preferred
Boxed warning for metoclopramide
tardive dyskinesia that can be irreversible
Side effects of dopamine receptor antagonists
Sedation, lethargy, acute EPS, can decrease seizure threshold
Dronabinol brand name
Marinol
Dronabinol must be
refrigerated
Nabilone brand name
Cesamet
Side effects of cannabinoids
Somnolence, euphoria, increased appetite
What is the max dose of loperamide when treating chemo induced diarrhea
16 mg/day
What is the classic med that blocks acute diarrhea
Atropine
What is the classic med used for xerostomia (dry mouth)
Pilocarpine
What drugs are used to treat Candida infection with oral mucositis
Nystatin oral suspension or clotrimazole troches
Which drugs can cause hand-foot syndrome, or PPE
Capecitabine and FU
How can you treat hand-foot syndrome
Cooling with cold compresses
Emollients to retain moisture
Steroids and pain meds to lessen inflammation and pain
What medications are used to treat hyperuricemia in tumor lysis syndrome
Allopurinol and rasburicase
Treatment for mild hypercalcemia of malignancy
hydration and loop diuretics
IV bisphosphonates
Treatment for mod-severe hypercalcemia of malignancy
- IV hydration with NS
- Calcitonin is sometimes used initially for up to 48 hrs
- IV bisphosphonate (e.g., pamidronate, zoledronic acid)
- denosumab - can build bone density and reduce fraction
Calcitonin brand name
Miacalcin
Zoledronic acid brand name for hypercalcemia of malignancy
brand name for osteoporosis
Zometa
Reclast
Denosumab brand name for hypercalcemia of malignancy
brand name for osteoporosis
Xgeva
Prolia
Denosumab MOA
Monoclonal antibody that block the interaction between RANKL and RANK
To prevent immunologic reactions, most monoclonal antibodies require the following premeds:
APAP and diphenhydramine
Major chemo vesicants include
anthracyclines and vinca alkaloids
If extravasation occurs, what can be done
apply cold compresses (except with vinca alkaloids and etoposide, use warm compresses)
Antidotes:
- Anthracyclines: dexrazoxane (Totect) or dimethyl sulfoxide
- Vinca alkaloids and etoposide: hyaluronidase
Drugs that can be given intrathecally include:
and must be ______
Cytarabine, MTX, hydrocortisone and thiotepa
Preservative-free
Which chemo drug can be fatal if given intrathecally
Vincristine
Do not dispense in a syringe
When chemo is being planned, vaccination should precede chemo by ≥ ____
2 weeks
