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PHRM 864 > Exam 2: Colorectal Cancer > Flashcards

Exam 2: Colorectal Cancer Flashcards

1
Q

Presentation of Colorectal

A
  • Asymptomatic
  • rectal bleeding
  • change in bowel habit
  • N/V
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2
Q

Cause of CRC

A

DNA mismatch repair system

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3
Q

dMMR or MSI-H tumor predicts a _____ benefit from adjuvant 5-FU therapy for stage __ disease

A

decreased, II

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4
Q

_____ patients with dMMR or MSI-H disease can _______ from adjuvant 5-FU

A

Stage III, benefit

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5
Q

Which patients with colon cancer should be tested for mismatch repair or microsatellite instability

A

all patients

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6
Q

When is surgery an option in CRC

A
  • early stage disease
  • palliative setting
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7
Q

When is radiation a treatment option in CRC

A
  • more controversal
  • can be used to alleviate pain
  • can decrease bleeding
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8
Q

Which stages are considered potentially curable

A

I - III

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9
Q

Which stages is localized therapy indicated for

A

I and II

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10
Q

Treatment for localized therapy

A
  • surgery alone is definitive therapy
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11
Q

Chemo in stage I and II

A
  • recommended against
  • can recommend if patient is high risk
  • if MSI-H or dMMR, then will not benefit from chemo
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12
Q

Chemo options for high risk or intermediate risk stable II patients

A

FOLFOX
CapeOXF

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13
Q

FOLFOX

A
  • 5-FU
  • Leucovorin
  • Oxaliplatin
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14
Q

CapeOX

A
  • capecitabine
  • oxaliplatin
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15
Q

Standard therapy for Stage III disease

A
  • surgery including regional lymph node removal AND
  • chemo
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16
Q

What medications do not play a role in Stage III disease

A
  • bevacizumab
  • cetuximab
  • panitumumab
  • rinotecan
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17
Q

Ajuvant Chemo options for Stage II disease

A
  • mFOLFOX6
  • CapeOX
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18
Q

IDEA trial

A

CapeOX for 3 months was noninferior to 6 months

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19
Q

Stage III Low risk

A
  • CapeOx x 3 months
  • FOLFOX x 6 months, consider 3 months
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20
Q

Stage III High Risk

A
  • CapeOx 6 months, consider 3 months
  • FOLFOX x 6 months
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21
Q

Regimen Considerations FOLFOX

A
  • requires port
  • 2 day pump
  • more infusions
  • increased myelosuppression and mouth sores
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22
Q

CapeOx Regiment Considerations

A
  • Port not required
  • less infusions overall
  • increased hand foot syndrome
  • increased diarrhea
  • Capecitabine needs renal dose adjustments, more expensive, more interactions
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23
Q

Mainstay of therapy for metastatic disease

A
  • chemo
  • palliative RT
  • surgery can play a role in isolated
24
Q

Co-morbities that may determine therapy

A
  • neuropathy
  • UGT1A1 deficiency (irinotecan)
  • 1 vs 2 vs 3 drug
25
Q

PDL-1 Inhibitor benefit

A
  • pembro and nivolumab shown benefit in metastatic setting
    -should be tested for dMMR/MSI status first
26
Q

KRAS

A
  • mutations predict lack of response to anti-EGFR monoclonal antiboidies
27
Q

Which medications should you not use in the setting of a KRAS mutation

A
  • cetuximab and panitumumab
28
Q

BRAF

A
  • test all patients in metastatic setting
29
Q

1st line metastatic disease with no targetable mutations

A
  • FOLFOX
  • CapeOx
  • FOLFIRI
  • FOLFIRINOX
    + bevacizumab
30
Q

1st line metastatic disease with Kras wild type, left sided

A
  • FOLFOX OR
  • CapeOx + Cetuximab or Panitumumab OR
  • FOLFIRI Cetuximab or Panitumumab
31
Q

1st line metastatic disease with dMMR/MSI-H

A
  • Nivolumab + ipilimumab OR
  • Pembrolizumab
32
Q

1st line metastatic disease with HER2+

A

trastuzumab + pertuzumab or lapatinib

OR

fam-trastuzumab deruxtecan-nxki

33
Q

FOLFIRI

A
  • Irinotecan
  • Leucovorin
  • Fluorouracil
34
Q

FOLFIRINOX

A
  • oxaliplatin
  • Leucovorin
  • Irinotecan
  • Fluorouracil
35
Q

1st Line Metastatic Disease with no targetable mutations in someone who can not tolerate intensive chemo

A
  • Infusional 5-FU + leucovorin
    OR
  • capecitabine ± bevacizumab
36
Q

1st Line Metastatic Disease with KRAS WT, left sided in someone who can not tolerate intensive chemo

A
  • Cetuximab OR
  • Panitumumab
37
Q

1st Line Metastatic Disease with dMMR/MSI-H in someone who can not tolerate intensive chemo

A
  • nivolumab ± ipilimumab OR
  • pembro
38
Q

1st Line Metastatic Disease with HER2+ in someone who can not tolerate intensive chemo

A

trastuzumab + (pertuzumab or lapatinib or tucatinib)

39
Q

Second line therapy for metastatic Disease progression with prior oxaliplatin therapy

A

FOLFIRI or irinotecan based

40
Q

Second line therapy for metastatic Disease progression with prior irinotecan-based therapy

A

FOLFOX or Capox regiments
+ bevacizumab or cetuximab or panitumumab

41
Q

Tests to primarily detect colon cancer

A
  • fecal immunochemical test (FIT)
  • FIT DNA
  • Endoscopy
42
Q

Colon Cancer Screening

A
  • > 45 years old
  • Family history = 40
  • HNPCC = 20-25
  • FAP = 10-12
43
Q

If BRAF Positive Second line therapy metastatic

A
  • Encorafenib + cetuximab or panitumuab
44
Q

Average Risk Screening

A
  • Annual FOBT or
  • annual FIT or
  • multi-target stool DNA test every 3 years

OR

  • flexible sigmoidoscopy every 5 years
  • colonoscopy every 10 years or
  • CT colonography every 5 years
45
Q

Colon Cancer Prevention

A
  • celecoxib
  • NSAIDs
  • aspirin
  • colectomy
46
Q

F-FU

A
  • converted to FUTP and FdUMP
  • FdUMP binds to thymidylate synthase and reduces rate of DNA synthesis, replication, and repair
47
Q

Leucovorin

A
  • given in combo with 5-FU to enhance binding of FdUMP to TS
48
Q

Irinotecan

A
  • pro-drug of SN-38
  • topo I
  • Diarrhea
  • UGT1A1 increases diarrhea by preventing SN-38 conversion
49
Q

Oxaliplatin

A
  • cross links DNA, inhibiting DNA replication
  • cold intolerances
50
Q

Capecitabine

A
  • oral pro-drug of 5-FU
  • hand foot syndrome
  • diarrhea
51
Q

Cetuximab

A
  • binds to extracellular domain of the EGFR
  • only in KRAS wild type
  • acneform rash
  • hypomagnesemia
  • premedicate with H1 antagonist
52
Q

Panitumumab

A
  • binds to EGFR
  • acneform rash
  • hypomagnesemia
53
Q

Bevacizumab

A
  • binds to VEGF
  • given in combo with 5-FU, leucovorin, irinotecan
  • signficant toxicity: bleeding
  • many black box warnings
54
Q

Regorafenib

A
  • Multi-kinase inhibitor targeting angiogenesis (VEGF 1-3, BRAF)
  • can use in patients with KRAS mutations
  • take with high fat meals
55
Q

TAS-102 (Trifluridine/Tipiracil)

A
  • used after patients fail
  • better tolerated than regorafenib

PHRM 864 (10 decks)

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