common toxicities in systemic anticancer treatment

Question 1

what are the hormone sensitive tumors

Answer 1

sex hormone positive:
breast cancer
endometrial cancer
prostate cancer

TSH positive :
differentiated thyroid cancer

steroids:
lymphoma
leukemia

Question 2

what are the AE of steroids

Answer 2

GOT steroids

gastritis
Elevation of blood glucose
osteoporosis with prolonged use

Question 3

what are the diffeerent typees of hormonal therapies

Answer 3

selective estrogen receptor modulator - Tamoxifen and Raloxifen
Aromatase inhibitors
GnRH agonists
Anti-Androgens - flutamide

Question 4

what are the types of aromatase inhibiitors

Answer 4

Letrozole.
Anastrozole.
Exemestane

Question 5

what ar the types of GnRh agonsits

Answer 5

Leuprolide, goserelin, triptorelin and histrelin

Question 6

what are the AE associated with Tamoxifen

Answer 6

tamoxifen - selective oestrogen receptor modulator
Hot flushes
VTE
Endometrial carcinoma

Question 7

what are the management strategies for thee AE of tamoxifen

Answer 7

Hot flushes - life style changes and SSRI , paroxetine and fluxetine to be avoided - opt for Venlafaxine

VTE- caution with other risk factors and treat accordingly

Endometrial carcinoma - routine screening is not recommended, investigate any irregular vaginal bleeding in premenopausal patients or any postmenopausal bleeding with endometrial biopsy

Question 8

management of cardiovascular events , arthralgia and osteoporosis , sexual dysfunction in tamoxifen use

Answer 8

CVD - routinee sccreeniing , checkk HTN, lipids and metabolic syndrome

Osteoprosis - BMD follow up , administration of Vitt D 800 iu and CA 1200 iu , exeersice and NSAIDs

Sexual dysfunction - biopsychosocial approach , education
lubricants and lidocaiine

Question 9

mngmnt of toxicities in ET in prostate cancer

Answer 9

CVD and embolic events - life style modification , consider GnRh agonists if significantly affected

osteoporosis - as with females

Sexual dysfunction - including decreased libido, erectile dysfunction , consider intermittent ET drug therapy with phosphodiesterase 5 inhibitors

Question 10

what are the common AEs associated with targeted therapies

Answer 10

Anti-EGFR: erlotinib gefitinib
skin toxicity tx: skin moisturizers

Anti VEGF : bevacizumab
Bleeding
HTN
VTE
delayed wound healing
GI perforation

Question 11

what is the treatment for AE due to anti-VEGF ?

Answer 11

for HTN : daily BP measurements
the goal is less than 150/100
treat with ACE inhibitors and angiotensin II receptor blocker
severe HTN of over 200/100 is an indication for permanent treatment cessation

for GI perforation - discontinue bevicazimub for 60 days before surgery and can continue again 28 days after the surgery

Question 12

what are thee AEs of immuno-therapy

Answer 12

pneumonitis
hepatitis
thyroid dysfunction

Question 13

what aree the classifications of AE associated with systemic anti cancer treatments according to timing

Answer 13

immediate adverse effects - within 30 minutes
short term adverse effect - within hours to days
medium to long term adverse effects - after 7 days of administration

Question 14

what are the types of immediate adverse effects ?

Answer 14

local site reaction - local irritation , thrombophlebitis
systemic reactions - flushing, hypotension, anaphylaxis

Question 15

what are the types of short term adverse effects ?

Answer 15

gastrointestinal side effects - mucositis , nausea and vomiting , constip diarrhea and anorexia
hematopoetic side effects - myelosuppression causing cytopenia

Question 16

most important short term adverse side effects

Answer 16

tumor lysis syndrome

Question 17

what canceers aree highly associatedd with TLS

Answer 17

leukemia and lymphoma

Question 18

what are the labs for TLS

Answer 18

in sensitive bulky tumors
hyperuricemia,
hyperkalemia - arrythmia
hyperphosphatemia - kiidney affection
hypocalcemia.

Question 19

what are the medium to long term adverse effects

Answer 19

alopecia
liver dysfunction
nephrotoxicity
cardiac toxicity
gonadal damage
pulmonary fibrosis

Question 20

Tx for TLS

Answer 20

hydration in prophylaxis and in treatment
along with allopurinol
dialysis may need to be initiated

Question 21

what are the types of cardiotoxicity associated with cancer treatment

Answer 21

cardiotoxicity type I and type II
type I - early irreversible and dose dependent
type II - delayed reversible and dose independent

Question 22

cancer treatments associated with type I vs type II cardiotoxicity

Answer 22

type I - chemoth such as doxorubicin (anthracycline )
type II - targeted such as trastuzumab (herceeptin )

Question 23

methods off prevention of cardiotoxicity in cancer treatment

Answer 23

1- avoid anthracyclines in the elderly
2- proper dose calculation
3- avoid adding 2 cardioitoxic agents together - ( radiotherapy and anthracyclines
or
trastuzumab and anthracyclines )

3- use of beta blockers and acee inhibitors

Question 24

when should trastizumab be discontinued ?

Answer 24

if LEVF is reduced by 10% or more
or if it reaches a level below 55%

Question 25

treatment of cytopenia

Answer 25

1- Dose reductions or modifications of chemoth/ prompt ttt in acute leukaemias.
2- If thrombocytopenia is due to hypersplenism then perform splenectomy.
3- Use of growth factors (GFs).
4- If severe transfusion therapies are needed.

Question 26

tx of anemia duee to cancer ?

Answer 26

1- pRBCs transfusion
2- Vit B12, Fe
3- rHuEPO

Question 27

what is febrile neutropenia ?

Answer 27

Defined as Fever > 38.5° C on two or more occasions with neutropenia < 500/mL

associated with herpetic lesions and sites of absceess

Question 28

treatment for grade I+II diarrhea vs grades above II diarrhea

Answer 28

grade I and II :
1- Oral hydration
2- Dietary modifications (e.g. eliminating all lactose-containing products and high-osmolar dietary supplements)
3- Anti diarrheal as Loperamide (GI morphine receptors +++)

Grades above II :
1- Hospital admission & IV fluids
2- Anti diarrhea as Octreotide
3- Antibiotics (e.g. fluoroquinolone).
4- These patients should be evaluated with CBC, electrolytes & a stool work-up evaluation for blood, Cl.difficile, Salmonella, E.coli, Campylobacter and infectious colitis