Common Cancer Types and Treatment Flashcards
Treatment has destroyed all known tumors
complete response or complete remission
At least 30% of the tumor has been eliminated
partial response or partial remission
Given before surgery to shrink the tumor in order to make complete resection more likely
neoadjuvant therapy
Given after surgery in an attempt to eradicate residual disease and decrease recurrence
adjuvant therapy
Which type of cancer is the most common worldwide?
lung cancer
Which type of cancer is the most common in the US?
skin cancer
What medications can increase the risk of skin cancer?
immunosuppressants (post-transplant)
Warning signs of melanoma skin cancer: ABCDE
A = asymmetry (1/2 of the mole doesn’t match the other)
B = border (edges are irregular, notched)
C = color (color isn’t the same all over)
D = diameter (larger than 6 mm, or the size of the tip of a pencil eraser)
E = evolving (mole is changing in size, color, shape, or symptoms)
Modifiable risk factors of breast cancer
- Being overweight (in postmenopausal women)
- Low physical activity
- Poor nutrition
- Tobacco use
These genes normally suppress tumor growth. Inherited mutations in either gene prevents cell repair and causes a dramatic increase in breast cancer incidence.
BRCA1 and BRCA2
Less than __ percent of breast cancer occurs in males.
1
Congenital condition in which males have one Y chromosome and two or more X chromosomes, which leads to an increased production of estrogen.
Klinefelter syndrome
If a tumor expresses a high percentage of estrogen or progesterone, the tumor is referred to as ________-________, and classified as _______________, ______________, or both (____)
- Hormone-sensitive
- Estrogen receptor positive (ER+)
- Progesterone receptor positive (PR+)
- ER+/PR+
Hormone-sensitive cancers will be treated with adjuvant hormone (endocrine) therapy for _________ years to suppress cancer recurrence. The choice of treatment depends on _____________ of the patient.
5-10; menopausal status
First-line treatment for premenopausal females with hormone-sensitive cancer
tamoxifen, a selective estrogen receptor modulator (SERM) and antagonist in breast cells
Which chemotherapy agents are used in postmenopausal women, and why aren’t they effective in premenopausal women?
- Aromatase inhibitors
- Premenopausal females produce estradiol. Postmenopausal females produce very little estradiol and instead get most of their estrogen from the peripheral conversion of androgens. AIs don’t block ovarian estradiol production, which is why they aren’t useful in premenopausal females.
SERM used for breast cancer prophylaxis
raloxifene
What does raloxifene do and what is it indicated for?
increases bone density and is indicated for osteoporosis
Why isn’t raloxifene first line for osteoporosis?
It causes hot flashes and has a risk of blood clots.
Which drug class induces menopause in premenopausal females by decreasing LH and FSH, and makes AI treatment a reasonable option?
Gonadotropin-releasing hormone (GnRH) agonists: Goserelin and leuprolide
Protein that can turn a normal cell into a cancer cell
oncogene
Oncogene that promotes breast tumor growth
HER2
Monoclonal antibody that’s effective in treating tumors that overexpress HER2
Trastuzumab (Herceptin)
Which medication is preferred to treat hot flashes/night sweats caused by SERMs (tamoxifen, raloxifene, and toremifene)?
venlafaxine
Tamoxifen is a prodrug converted via CYP___.
CYP2D6
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMs)
BBW:
- Increases risk of ______ or ___________ cancer (tamoxifen)
- Increases risk of ______________ (tamoxifen, raloxifene)
- QT prolongation (___________)
Side Effects:
- __________ bleeding/spotting
- __________ discharge/dryness/pruritis
- _________ libido
- __________ decreases bone density (supplement with calcium/vitamin D) and is teratogenic
- uterine; endometrial
- thromboembolic events
- toremifene
- vaginal
- vaginal
- decreased
- tamoxifen
SELECTIVE ESTROGEN RECEPTOR DEGRADER (SERD)
Drug: _____________
Administration: ___________
Side effects: _______, injection-site pain, __________
- Fulvestrant
- IM injection
- Increased LFTs; hot flashes
Which drug class has the highest risk of osteoporosis and a higher risk of CVD compared to SERMs?
aromatase inhibitors
Name the main aromatase inhibitor that’s used
anastrozole (Arimidex)
Side effects of aromatase inhibitors
- Hot flashes/night sweats
- Arthralgia/myalgia
- Others: Lethargy/fatigue, N/V, rash, hepatotoxicity, hypertension, dyslipidemia
Cyclin-dependent kinase (CDK4/6) inhibitors
palbociclib (Ibrance), abemaciclib (Verzenio), and ribociclib (Kisqali)
Match the drug class with its MOA:
- Estrogen antagonist in breast tissue __
- Estrogen receptor antagonist that causes receptor degradation and downregulation __
- Block conversion of androgens to estrogens __
- Inhibit downstream signaling and tumor growth __
a. Aromatase inhibitors
b. Serotonin estrogen receptor modulator (SERM)
c. Cyclin-Dependent Kinase (CDK4/6) inhibitors
d. Serotonin estrogen receptor degrader (SERD)
- b
- d
- a
- d
Breast cancer metastases are often located where?
bone, lungs, liver, and brain
Primary chemo agents used for breast cancer
capecitabine, docetaxel, paclitaxel, carboplatin, cyclophosphamide, doxorubicin, methotrexate
What are 2 key counseling points for all patients with breast cancer?
- Don’t take any estrogen-containing medications. Estrogen is contraindicated with an hx of breast cancer.
- Take adequate calcium and vitamin D (unless calcium is high from metastases).
Match the chemo agent with its key counseling points:
- Tamoxifen __
- Raloxifene
- Aromatase inhibitors
a. Can cause hot flashes
b. Can cause hot flashes, night sweats, and muscle damage
c. Avoid in pregnancy (teratogenic); can cause blood clots and endometrial cancer
- c
- a
- b
What is the most common cancer in males in the US?
prostate cancer
Most prostate cancers can be felt with what exam?
digital rectum exam (DRE)
What is produced in the prostate gland by normal and cancerous cells and increases with most prostate cancers as well as in BPH?
prostate-specific antigen (PSA)
A PSA level of 4-10 ng/mL could be indicative of what?
BPH or prostate cancer
PSA level > 10 ng/mL
likely indicates prostate cancer
What are the primary hormones blocked when treating prostate cancer?
testosterone and dihydrotestosterone (DHT)
The hormonal treatment in prostate cancer is called what?
androgen deprivation therapy (chemical castration)
What are the side effects that can be seen with ADT?
impotence, weakness, hot flashes, and loss of bone density
What are the two treatment options for hormonal treatment of prostate cancer?
- Gonadotropin-releasing hormone (GnRH) antagonist alone OR
- GnHR agonist (initially taken with an antiandrogen)
T/F: GnHR antagonists initially causes a tumor flare.
False; GnRH AGONISTS initially cause a tumor flare, which is why an antiandrogen is given with them to block the tumor flare.
Fill in the blanks:
Normally, the hypothalamus releases ______________ hormone, which stimulates the ____ receptor in the pituitary to release ___ and __. These hormones stimulate testosterone (T) production in the testes.
Initially, the GnRH ___________ cause the pituitary to release __ and ___ to increase testosterone, causing a _______________. They are given with an _________ to block this effect by blocking the initial T _______ effect on the cancer cells.
After a few weeks, feedback _________ suppresses FSH and LH output from the pituitary, which ______ T, and the _______________ can be discontinued.
- luteinizing hormone-releasing hormone (LHRH); GnRH; FSH; LH
- agonists; LH; FSH; tumor flare; antiandrogen; surge
- inhibition; decreases; antiandrogen
GnRH agonists are also known as what?
LHRH agonists
Match the hormonal treatments used for prostate cancer with their correct MOA/description:
- GnRH agonists __
- GnRH antagonists __
- 1st generation antiandrogens __
- 2nd generation antiandrogens __
- Androgen biosynthesis inhibitor __
a. Don’t cause upregulation of androgen receptors and can be used as a single treatment
b. Block GnRH receptors directly causing a rapid decrease in testosterone production
c. Interferes with a specific CYP-17 enzyme involved in the synthesis of steroid hormones in the testes and adrenal glands to decrease testosterone production
d. Reduce testosterone through a negative feedback mechanism, causing an initial surge in testosterone, followed by a gradual reduction
e. Competitively inhibit testosterone from binding to prostate cancer cells
- d
- b
- e
- a
- c
Androgen biosynthesis inhibitors must be taken with __________ to cause negative feedback on the production of ________ and prevent symptoms of ________________ (HTN, fluid retention, hypokalemia).
prednisone; aldosterone; hyperaldosteronism
Match the chemo agents used in prostate cancer to their correct drug class:
- Degarelix, relugolix __
- Apalutamide, darolutamide, enzalutamide __
- Leuprolide (Lupron Depot), goserelin (Zoladex), histrelin, triptorelin __
- Bicalutamide, flutamide, nilutamide __
- Abiraterone __
a. GnRH agonists
b. GnRH antagonists
c. 1st generation antiandrogens
d. 2nd generation antiandrogens
e. Androgen biosynthesis inhibitors
- b
- d
- a
- c
- e
Which hormonal treatment for prostate cancer should be taken with calcium/vitamin D supplementation d/t a decrease in bone density?
GnRH agonists (leuprolide, goserelin)
What are the side effects of GnRH agonists?
hot flashes, impotence, gynecomastia, bone pain, QT prolongation
Which drug class used in prostate cancer has an osteoporosis risk?
GnRH antagonists
The 2nd generation antiandrogen, abalutamide, has a side effect of what?
QT prolongation
Why are chemo regimens usually given in combination?
to take advantage of synergistic mechanisms by targeting cells with different resistance mechanisms and at different stages of replication
Why are chemo regimens usually given in 2-6 week cycles?
to all the patient time to recover from the adverse effects, especially myelosuppression
What cells in the body are rapidly dividing and why are these particular cells important to remember?
cells in the GI tract, hair follicles, and bone marrow
This is why many cytotoxic drugs cause diarrhea, mucositis, nausea, alopecia, and myelosuppression.
Which chemo agents target the M-phase of the cell cycle?
Taxanes (paclitaxel, docetaxel)
Vinca alkaloids (vincristine, vinblastine)
Which chemo agents target the G1 phase of the cell cycle?
asparaginase, interferons, steroids
Which chemo agents target the S-phase of the cell cycle?
Antimetabolites
- Methotrexate, pemetrexed (folate antimetabolites)
- Fluorouracil (5-FU)
- Capecitabine
Topoisomerase I inhibitors (irinotecan, topotecan)
REMEMBER: AT the S-phase, the DNA replicATes
Which chemo agents target the G2 phase of the cell cycle?
Topoisomerase II inhibitors - block DNA coiling and uncoiling, causing the DNA to break
- Etoposide
- Bleomycin
Which chemo agents are cell-cycle independent?
REMEMBER: All Awesome Pharmacists
A = Alkylating agents (cyclophosphamide, ifosfamide)
A = Anthracyclines (doxorubicin, mitoxantrone)
P = Platinum compounds (cisplatin, carboplatin)
Why are most traditional cytotoxic chemotherapy drugs more effective at killing rapidly dividing cancer cells?
They work by interfering with DNA replication.
This chemotherapy drug class work by cross-linking DNA strands and inhibiting protein and DNA synthesis
alkylating agents
Match the alkylating agent with its correct unique concern (there may be more than one answer):
- Hemorrhagic cystitis
- Use non-PVC bag and tubing
- Fatal toxicity occurs with overdosage; don’t dispense more than 1 dose at a time and emphasize to the pt that only 1 dose is taken every 6 weeks
- Protect from light to avoid drug degradation
- MAO inhibitor, avoid interacting drugs/food
- Vesicant
a. Carmustine
b. Procarbazine
c. Cyclophosphamide
d. Lomustine
e. Mitomycin
f. Ifosfamide
g. Dacarbazine
- c, f
- a
- d
- g
- b
- e
Cyclophosphamide and ifosfamide produce what metabolite that concentrates in the bladder and can cause hemorrhagic cystitis?
acrolein
Chemoprotectant that inactivates acrolein in the bladder without interfering with the cytotoxic effects of cyclophosphamide and ifosfamide
mesna
_________ is always dispensed with mesna. High doses of ______________ may require mesna.
Ifosfamide; cyclophosphamide
Match the alkylating drug with its correct BBW:
- Hemorrhagic cystitis
- Pulmonary toxicity
- Neurotoxicity
- Hepatic necrosis
a. Ifosfamide
b. Carmustine
c. Cyclophosphamide
d. Dacarbazine
- a, c
- b
- a
- d
What is a key side effect for busulfan?
pulmonary toxicity
Which drug class can cause symptoms that are similar to heavy metal poisoning, such as peripheral sensory neuropathy, ototoxicity, and nephrotoxicity?
platinum chemo agents
_________ is associated with the highest incidence of nephrotoxicity and CINV.
Cisplatin
Chemoprotectant used with cisplatin and can be given prophylactically to prevent nephrotoxicity.
amifostine (Ethyol)
Doses for adults of this platinum agent is commonly calculated by target AUC using the Calvert Formula
carboplatin
What is the primary concern for patients treated with oxaliplatin and what exacerbates this effect?
acute sensory neuropathy; exposure to cold (including drinking cold beverages)
What is the BBW assigned to platinum agents?
anaphylactic reactions - risk increases with repeated exposure
What is a side effect specific to oxaliplatin?
QT prolongation
What are the 3 main MOAs of anthracyclines?
- Intercalation into DNA
- Inhibition of topoisomerase II
- Creation of oxygen-free radicals that damage cells
All anthracyclines are associated with what?
cardiotoxicity
Anthracyclines are strong ____________.
vesicants, except for the liposomal formulations
How do you calculate the cumulative dose of doxorubicin?
[doxorubicin dose in mg/m2/cycle] x [total # of cycles received] = cumulative doxorubicin dose in mg/m2
What is the lifetime maximum cumulative doxorubicin dose?
450-550 mg/m2
What should be monitored before and after doxorubicin treatment?
left ventricular ejection fraction (LVEF)
Dexrazoxane (Totect) may be considered when the doxorubicin cumulative dose is > ___ mg/m2.
300
Most anthracyclines, including doxorubicin, causes urine, tears, sweat, and saliva to be what color?
red
T/F: The liposomal formulations of doxorubicin and daunorubicin are not interchangeable with non-liposomal formulations.
true
Which anthracycline causes blue discoloration of urine, sclera, and other bodily fluids?
mitoxanthone
These chemo agents work by blocking the coiling and uncoiling of the DNA helix during the S phase of the cell cycle, causing single and double-strand breaks in the DNA and preventing religation (sealing the DNA strands back together again) of single-strand breaks.
topoisomerase I inhibitors
Name the topoisomerase I inhibitors
irinotecan and topotecan
Irinotecan can cause what type of symptoms?
acute cholinergic symptoms
Patients homozygous for the ____________ allele are at increased risk for neutropenia and delayed diarrhea with irinotecan therapy.
UGT1A1*2B
Name the topoisomerase II inhibitors
etoposide and bleomycin
IV etoposide:
- _______________________: Infuse over at least 30-60 minutes
- IV preparation: Prepare solution to a concentration </= ___ mg/mL to avoid _____________________.
- Use non-PVC IV bag and tubing d/t to leaching of ____
- Infusion rate-related hypotension
- 0.4; precipitation
- DEHP
Does not have solution concentration limits like etoposide (primarily used if the concentration needs to be >/= 0.4 mg/mL)
etoposide phosphate
Which topoisomerase II inhibitor is helpful in patients with fluid restriction?
etoposide phosphate
Etoposide capsules should be kept where?
in the fridge
What should be done before initial bleomycin administration and why?
a test dose; risk of anaphylactic reactions
T/F: Bleomycin is the most myelosuppressive chemo agent.
false; bleomycin does not cause myelosuppression
What is the maximum dose of bleomycin and why?
400 units; pulmonary toxicity
Vinca alkaloids inhibit the function of ________________ during the __ phase of the cell cycle.
microtubules; M
What 2 side effects are common with vinca alkaloids?
peripheral and autonomic neuropathies (constipation)
Which vinca alkaloid is associated with more CNS toxicity (neuropathy)?
vincristine
vinCristine = Cns toxicity
Which vinca alkaloids are associated with more bone marrow suppression (myelosuppression)?
vinblastine and vinorelbine
vinBlastine & vinorelBine = Bone marrow suppression
T/F: Vinca alkaloids are potent vesicants.
true
What should be administered if extravasation occurs with vinca alkaloids?
warm compresses and hyaluronidase
T/F: Vinca alkaloids can be administered via any route.
false; vinca alkaloids can only be delivered via IV administration. Accidental intrathecal administration will cause progressive paralysis and death.
To prevent inadvertent intrathecal administration, prepare vincristine in a __________________ (_____________) rather than in a ______________.
small IV bag (piggyback); syringe
Taxanes inhibit the function of _______ during the __ phase of the cell cycle.
microtubules; M
________________ are common side effects since the microtubules play an important role in axonal transport in neurons.
Peripheral sensory neuropathies
What 2 things can occur with taxanes?
severe infusion-related hypersensitivity reactions (HSR) and fatal anaphylaxis
Elimination of taxanes is reduced when given after ______/___________. Give taxanes BEFORE _____________________.
cisplatin/carboplatin; platinum-based compounds
What should given with docetaxel to prevent HSR?
steroids for 3 days, starting 1 day before docetaxel
What is a BBW for docetaxel?
severe fluid retention
T/F: Hypersensitivity reactions from taxanes are d/t the taxane itself.
false; they are d/t the solvent systems
Which taxane does not require premedication?
Abraxane (paclitaxel bound to albumin)
T/F: Taxanes can be administered via PVC bag and tubing.
false; non-PVC bag and tubing should be used
These taxanes require a 0.22 micron filter for administration.
paclitaxel and cabazitaxel
Pyrimidine analog antimetabolites inhibit pyrimidine synthesis during the __ phase of the cell cycle.
S
Name the pyrimidine analog antimetabolites.
5-FU, capecitabine, cytarabine, gemcitabine
What is commonly given with 5-FU and why?
leucovorin; to increase 5-FU’s efficacy
Oral prodrug of fluorouracil
capecitabine
How is capecitabine administered?
taken orally in 2 divided doses 12 hours apart with water within 30 min after a meal
_______________________ deficiency increases risk of severe toxicity with 5-FU and capecitabine.
Dihydropyrimidine dehydrogenase (DPD)
Capecitabine is contraindicated when CrCl < __ mL/min. It also has a BBW for significant ____________ in INR during and up to 1 month after treatment.
30; increase
Folate antimetabolites interfere with the enzymes involved in the folic acid cycle, blocking purine and pyrimidine biosynthesis during the __ phase of the cell cycle.
S
Active form of folic acid
leucovorin
Leucovorin must be given when high-dose methotrexate (>/= ____ mg/m2) is used.
500
______________ and IV _________________ must be given to ____________ the urine and decrease the risk of nephrotoxicity caused by high-dose methotrexate.
Hydration; sodium bicarbonate; alkalinize
Antidote that will rapidly lower methotrexate levels that remain high despite adequate hydration and urinary alkalinization.
glucaripase (Voraxaze)
Name 2 drugs that have major drug interactions wit methotrexate.
NSAIDs, salicylates
1st line therapy for acute promyelocytic leukemia (APL)
tretinoin
What is the pegylated form of asparaginase and what are its benefits?
pegaspargase; less frequent dosing and less allergic reactions
MOA: Inhibit downstream regulation of vascular endothelial growth factor (VEGF) reducing cell growth, metabolism, proliferation, and angiogenesis
mTOR inhibitors
What are the major side effects of everolimus?
mouth ulcers/stomatitis, rash, interstitial lung disease, peripheral edema, dyslipidemia, increased BP
Bevacizumab should not be administered __ days before or after surgery.
28
A patient must be ____ wild type to use cetuximab.
KRAS
When on rituximab treatment, patients need to be premedicated with what medications?
diphenhydramine and a steroid
Name the BCR-ABL tyrosine kinase inhibitors
imatinib (Gleevec), dasatinib, nilotinib
Oral chemo agents that should be taken with food or within 1 hour after a meal
imatinib and capecitabine
Oral chemo agents that can be taken without regard to food
anastrozole (Armidex) and tamoxifen
Which of the following reactions is not associated with the tyrosine kinase inhibitors?
a. An acneiform rash that indicates the drug is working
b. QT prolongation
c. Hyperthyroidism
d. Oral bioavailability may be altered if taken with food
e. Hypertension
c
In addition to the others listed, TKIs may be associated with hypothyroidism and diarrhea.
