Exam 2 Oncology Flashcards
1
Q
Anticipatory Nausea/Vomiting
A
- learned response conditioned by severity and duration of previous emetic reactions from prior cycles of chemo
- can be provoked by sight, sound, or smell
2
Q
Acute Nausea/Vomiting
A
- usually within 24 hours of receiving chemo
3
Q
Delayed Nausea/Vomiting
A
- occurs > 24 hours following completion of chemo
- NK-1 receptor and substance P binding
4
Q
Breakthrough Nausea/Vomiting
A
- occurs even if on scheduled anti-emetics prior to chemo
5
Q
Refractory
A
- nausea/vomiting that persists despite appropriate anti-emetics
- failed other therapies
6
Q
Receptor involved in Nausea/Vomiting
A
chemoreceptor trigger zone (CTZ)
7
Q
Nausea
A
the inclination to vomit or as a feeling in the throat or epigastric region alerting an individual that vomiting is imminent
8
Q
Wretching
A
the labored movement of abdominal and thoracic muscles before vomiting
9
Q
Vomiting
A
the ejection or forced expulsion of gastric contents through the mouth
10
Q
Highly Emetogenic Chemotherapy
A
- > 90% Frequency of Emesis
- Level 5
- cisplatin
11
Q
Moderately Emetogenic Chemotherapy
A
- > 30 - 90% frequency of emesis
- level 3-4
12
Q
Low Emetic Risk
A
- 10-30% frequency of emesis
- level 2
13
Q
Minimial Emetic Risk
A
- < 10% frequency of emesis
- level 1
14
Q
Combination Chemotherapy Emetogenic Risk
A
- level 1 and 2 agents do not contribute to the emetogenicity of the regiment
- adding level 3-4 agents increases the emetogenicity of the combination regimen by 1 level per agent
15
Q
Risk Factors for CINV
A
- women > men
- younger patients > older patients
- prior history of motion sickness
- previous CINV tend to do worse
- anxiety/high pretreatment anticipation of nausea
- chronic ethanol can be protective
16
Q
Prophylaxis for acute N/V is based on what?
A
emetogenic potential of chemotherapy
17
Q
Highly Emetogenic: Regimen A
A
- NK-1 antagonist ( -pitant)
- Dexamethasone
- 5-HT3 antagonist (-setron)
- Olanzapine
18
Q
Highly Emetogenic: Regimen B
A
- Olanzapine
- Palonosetron
- Dexamethasone
- +/- lorazepam 0.5 mg-2mg po or iv or sublingual every 4-6 hours PRN
- +/- H2 blocker or PPI
19
Q
Highly Emetogenic: Regimen C
A
- NK-1 antagonist
- steroid
- 5-HT3 antagonist
- +/- lorazepam 0.5 mg-2mg po or iv or sublingual every 4-6 hours PRN
- +/- H2 blocker or PPI
20
Q
Moderately Emetogenic: Regimen A
A
- Dexamethasone
- 5HT3 antagonist
- +/- lorazepam 0.5 mg-2mg po or iv or sublingual every 4-6 hours PRN
- +/- H2 blocker or PPI
21
Q
Moderately Emetogenic: Regimen B
A
- Olanzapine
- Palonosetron
- Dexamethasone
- +/- lorazepam 0.5 mg-2mg po or iv or sublingual every 4-6 hours PRN
- +/- H2 blocker or PPI
22
Q
Moderately Emetogenic: Regimen C
A
- NK-1 Antagonist
- Dexamethasone
- 5-HT3 Antagonist
- +/- lorazepam 0.5 mg-2mg po or iv or sublingual every 4-6 hours PRN
- +/- H2 blocker or PPPI
23
Q
Low Emetogenic Regimens
A
- PICK ONE
- Dexamethasone
- Metoclopramide +/- diphenhydramine
- Prochlorperazine
- 5-HT3 Antagonist
- +/- lorazepam 0.5 mg-2mg po or iv or sublingual every 4-6 hours PRN
- +/- H2 blocker or PPPI
24
Q
Breakthrough Nausea and Vomiting Treatment
A
- PICK ONE
- Haloperidol
- Metoclopramide +/- diphenhydramine
- prochlorperazine
- promethazine
- olanzapine
- benzodiazepines
- cannabinoids
- 5-HT3 antagonist
- dexamethasone
- scopolamine
25
Delayed Nausea/Vomiting Treatment
- One of the following
- Dexamethasone
- NK-1 antagonist
- olanzapine
26
Anticipatory Nausea and Vomiting Treatment
- optimal antiemetic therapy during every cycle of treatment
- behavioral
- acupuncture/acupressure
- lorazepam
27
Oral Chemo High to Moderate Emetogenic Risk
- start before chemo and continue daily
- 5-HT3 antagonists
28
Oral Chemo Low to Minimal Emetogenic Risk
- start before chemo and maybe given daily or as needed
- metoclopramide
- 5-HT3 antagonists
29
Total Body Irradiation Emesis Pretreatment
- start for each day of radiation
- granisetron PO +/- dex
- ondansetron PO +/- dex
30
Common Toxicities: 5-HT3 Antagonists
- headache (not class effect)
- asymptomatic and transient EKG changes at max doses
- constipation
- increased transaminases
31
Common Toxicities: Corticosteroids
- anxiety
- euphoria
- insomnia
- hyperglycemia
- increased appetite
32
Common Toxicities: Substance P Antagonists
- hiccups
- worry about drug interactions
33
Common Toxicities: Dopamine Antagonists (chlorpromazine, haloperidol, metoclopramide)
- EPS
- diarrhea
- sedation
34
Common Toxicities: Olanzapine
- dystonic reactions
- sedation
35
Common Toxicities: Phenothiazines (prochlorperazine, promethazine)
- sedation
- akathesia
- dystonia
- IV promethazine = tissue damage
36
Common Toxicities: Cannibanoids
- drowsiness
- dizziness
- euphoria
- mood changes
- hallucinations
- increased appetite
37
Common Toxicities: Benzos
- sedation
- hypotension
- urinary incontinence
- hallucinations
38
Common Toxicities: Scopolamine
- anticholinergic side effects
39
When are anti-emetics most effective?
- prophylaxis
- 5-30 minutes prior to chemo and around-the-clock until chemo is complete
- provide PRN agents for breakthrough
40
Mucositis Progression
- paralleles the neutrophil nadir and begins on day 5 to 7 after chemotherapy and improves as the neutrophil count increases
41
Mucositis: continuous infusions __ short IV infusions
>
42
Risk factors for mucositis?
- pre-existing oral lesions
- poor dental hygiene or ill-fitting dentures
- patients receiving both chemo and radiation
43
Mucositis: Diet Recommendations
- avoid rough food, spices, salt, acidic fruit
- mainly eat soft or liquid foods, nonacidic fruits, soft cheeses, and eggs
- avoid smoking and alcohol
44
Mucositis: Pretreatment
- baking soda rinses BID-QID
- soft bristled toothbrush to minimize gingival irritation
- saliva sub for radiation induced xerostomia
45
Mucositis: Oral Cryotherapy
- vasoconstriction may decrease chemotherapy delivery to the oropharyngeaal mucosa
- use of ice chips 30 minutes prior to 5-FU doses has been shown to decrease mucositis incidence
46
Mucositis: Sucralfate
- forms protective barrier
- swish and swallow (1 gm PO QID) has been shown in some trials to significantly decrease pain
- some patients find the taste and texture of sucralfate to be nauseating; not good data to support use
47
Mucositis: Oral and PR Opioids
- moderate to severe mucositis
- many oral solutions contain a high percentage of alcohol, which may burn
- best administered around the clock
- PCA is common
48
Neutropenia: WBCs
- < 0.5 x 10^3/uL
- risk of life-threatening infections
49
Neutropenia: Platelets
- thrombocytopenia = < 100 x10^3/uL
- risk of bleeding increases when platelet count is ≤ 20 x 10^3/uL and therefore may require transfusion
50
Neutropenia: RBCs
- anemia
- risk of hypoxia and fatigue
- Hgb z, 11 g/dL or >2g/dL drop from baseline should undergo work-up
51
What is the most common dose-limiting toxicity of chemo?
bone marrow suppression
52
What is the nadir?
- the absolute neutrophil count or ANC
- the lowest value the blood counts fall to during a cycle of chemotherapy
- occurs 10-14 days after chemo administration
- counts usually recover by 3 to 4 weeks after chemo
53
Guidelines to administer chemo safely in patient's with neutropenia
- WBC > 3000 OR
- ANC of >1500 AND
- Platelet count ≥ 100 x 10^3/uL
54
Severe Neutropenia
- ANC < 0.5 x 10^3/uL
55
Febrile Neutropenia Definition
- ANC < 0.5 x 10^3/uL AND
- single oral temp > 101ºF or ≥ 100.4ºF for at least an hour
- other signs/symptoms of infection are absent with fever being the only reliable indicator
56
Prophylactic Use of CSFs
decreased
- incidence of febrile neutropenia
- LOS
- confirmed infections
- Duration of antibiotics
57
When to administer primary CSF prophylaxis?
- if the patient is to receive a chemo regiment that is expected to cause ≥ 20% incidence of febrile neutropenia
58
High Risk Patients of FN
- preexisting neutropenia due to disease
- extensive prior chemo
- previous irradation to the pelvis or other areas containing large amounts of bone marrow
59
Secondary Prophylaxis using CSF
- patient experienced a neutropenic complication from a previous cycle of chemo and you want to prevent that again
- use a CSF preventatively with the next cycle of chemo
60
Other Uses for CSFs
- support patients through dose dense chemo
- can be used alone, after chemo, or in combination with plerixafor to mobilize peripheral blood progenitor cells
- after a stem cell transplant to reduce the duration of severe neutropenia
- guidelines for pediatric use are available and should be followed
61
Filgrastim (Neupogen) G-CSF and Sargramostim (Leukine) GM-CSF
- dose dependent elevation in ANCE
- rapid drop in WBC and neutrophil count following discontinuation
62
Pegfilgrastim (Neulasta)
- non-linear PK
- clearance increases with increasing neutrophil count
- longer half life
- much more expensive
63
Filgrastim: Dosing
- start up to 3-4 days after completion of chemo and continue until post-nadir ANC recovery to normal or near normal levels
- 5 mcg/kg/day
- come in 300 and 480 mcg single use vials (round dose to the nearest vial size)
64
Pegfilgrastim: Dosing
- start at least 24 hours after chemo and can be given up to 3-4 days after chemo (same day administration is not recommended)
- 6 mg SQ x 1 dose
65
GSF Adverse Effects
- flu like symptoms
- bone and joint pain due to rapid proliferation of the bone myeloid cells
- DVT
- splenic enlargement with long term CSF use
66
General Causes of Anemia
- decreased RBC production
- decreased erythropoietin production (renal dysfunction)
- decreased body stores of b12, iron, folic acid
- blood loss
67
Significance of Anemia in Cancer
- fatigue
- low hemoglobin correlated with poor performance status --> decreased survival
- decreased quality of life
68
Treatment of Chemo Induced Anemia
- if the patient is symptomatic
- tranfuse as indicated
- consider ESA (not indicated for patients receiving myelosuppressive chemo when anticipated outcome is cure)
- iron studies
69
ESAs are not recommended when:
- curative intent
- patients not receiving chemo
- patients receiving non-myelosuppressive chemo
70
Epoeitin Alpha Clinical Pearls
- if the Hgb increases > 1 g/dL in a 2-week period, the dose should be decreased by 25% for epoetin alpha and 40% for darbepoeitin
- Starting dose: TID SQ
- maintenence: Weekly SQ
71
Darbepoetin Clinical Pearls
- Starting Dose: weekly
- Maintenence: every 3 weeks
72
Iron in Anemic Cancer Patients
- all oncology patients who are prescribed ESA therapy should have baseline iron studies performed
- serum ferritin, iron, iron sat
- Iron Dextran, Iron Sucrose, Ferric Gluconate
73
Chemos that cause Myalgias/Arthralgias
- Taxanes
- ARs
74
Treatment for myalgias/arthralgias
- nsaids
- maya require opioids
75
Chemos that cause hemorrhagic cytitis
- high dose cyclophos
- ifosfamide
76
Treatment for hemorrhagic cystitis
- hydration (prevention)
- mesna (used to prevent)
77
Chemos that cause HF
- anthracyclines
- high dose cyclophosphamide
- trastuzumab (other HER2 targeted therapies)
78
Treatment of HF
- monitor cumulative dose
- assess for risk factors
- dexrazoxane (chemoprotectant)
79
Chemos that cause peripheral neuropathy
- taxanes
- vinca alkaloids
- platinums
80
Treatment of Peripheral Neuropathy
- change infusion rate (ie paclitaxel)
- adjunctive pain medications (gabapentin, amitriptyline)
81
Chemos that cause pulmonary toxicities
- bleomycin
82
Treatment of pulmonary toxicities
- corticosteroids (no good treatment once it happens)
83
Mesna
- should be used with standard ifosfamide doses of < 2.5 g/m2/day to decreas risk of hemorrhagic cystitis
84
Cardiac Toxicity
- formation of iron-dependent oxygen free radicals due to stable AC-iron complexes, which cause catalysis of electron transfer
85
Type I Chemo Related Cardiac Dysfunction: Acute
- occurs immediately after a single dose or course of therapy with AC
- may involve abnormal ECG findings
- not related to cumulative dose and is uncommon
86
Type I Chemo Related Cardiac Dysfunction
- onset usually within a year of receiving AC therapy
- rapid onset and progression
- common and life threatening
- related to cumulative dose patient received
87
Type I Chemo Related Cardiac Dysfunction: Late- onset
- develops several years or even decades after therapy
- manifests as ventricular dysfunction, CHF, conduction disturbances, and arrhythmias
- pediatric cancer survivors who received AC
88
Which drug causes Type II Chemo Related Cardiac Dysfunction?
Trastuzumab
89
Type II Chemo Related Cardiac Dysfunction
- appears to be largely reversible and short lived
- lower incidence in non-AC treated patients
- if trastuzumab given with AC, incidence can increase up to 27% cardiac toxicity (NYHA class III/IV)
90
Assessment of Pain
O: onset
P: provokes
Q: quality
R: radiate
S: severe
T: time
U: understanding
91
Principles of Pain Management
- understand the cause of pain
- regular administration of around the clock agents combined with PRN agents
- individualized therapy
- necessary to monitor for therapeutic and adverse effects
- use the lowest dose necessary
- pain assessment is subjective
92
Mild Pain Regimen
- non-opioid ± adjuvent
93
Moderate Pain Treatment
- opioid for mild-to-moderate pain
- ± non-opioid
- ± adjuvant
94
Severe Pain
- opioid for moderate-to-severe pain
- ± non-opioid
- ± adjuvant
95
Common Non-Opioids
- scale 1-3
- APAP
- Advil
- Aspirin
96
Combo Products/Mild Opioids
- 4-6
- Hydrocodone/APAP
- Oxycodone/APAP
- Hydrocodone/Ibuprofen
- Oxycodone/Ibuprofen
- Tramadol
- Oxycodone/Aspirin
- Condeine/APAP
97
Opioids
- 7-10
- morphine
- hydromorphone
- methadone
- oxycodone
- fentanyl
- no max dose
98
Morphine
- metabolized in the liver
- excreted renally and will accumulate in renal insufficiency
99
Morphine Dosage Forms
- short acting
- long acting
- solutions
- IV
- PR
100
Hydromorphone
- metabolized in liver
- all renally excreted
- lower dose or longer dosing intervals in renal insufficency
101
Hydromorphone Dosage Forms
- short acting
- long acting
- solution
- IV
- PR
102
Oxycodone
- CYP2D6
- over sedation and CNS toxicity in renal failure patients
- use in caution in liver dysfunction
103
Oxycodone Dosage Forms
- short acting tablets
- long acting tablets
- solutions
- NO IV
104
Fentanyl
- metabolized in liver
- safe in renal dysfunction
- great for refractory N/V and head/neck/esophageal cancers who may not be able to maintain PO intake
105
Fentanly: Dosage Forms
- patch
- IV
- buccal
- nasal spray
- lozenges
106
Fentanyl: REMS
- exposes users to risks of addiction, abuse, misuse, which can lead to overdose
- not good for patients who are opioid naive
- accidently exposure in children can result in fatal overdose
- avoid exposing patch and surrounding area to direct external heat
107
Methadone: When to Consider
- true morphine allergy
- with opioid induced ADRs
- with pain refractory to other opioids
- with neuropathic pain
- who need long-acting oral dosage form at low cost
108
Methadone: Avoid
- numerous drug interactions
- risks for syncope or arrhythmias
- history of unpredictable adherance
- poor cognition
109
Methadone Clearance
- exreted in the urine and feces
- no ADR related to methadone in patients with renal failure
- not advised in severe liver dysfunction
- QT prolongation
110
Administration of Opioids
- oral is the preferred route
- must consider long-acting and short-acting agents and allow for overlapping effects
111
Opioids: Constipation
- always add a bowel regimen
- mild stimulant ± stool softener)
112
Opioids: Sedation
- tolerance typically develops within a few days
- hold sedatives and/or anxiolytics
- consider a dosage reduction
113
Opioids: N/V
- change opioid
- take with food
- consider addition of scheduled anti-emetic therapy
114
Opioids: Pruritus
- most seen with morphine administration
- decrease the dose or change opioid
- consider the addition of anti-histamine such as diphenhydramine
115
Opioids: Hallucinations
- decrease dose or change opioid
- consider neuroleptic medication
116
Opioids: Confusion/Delirium
- decrease dose or change opioid
- consider neuroleptic medication
117
Opioids: Myoclonic Jerking
- may be a sign of toxicity
- consider changing opioid or treating underlying cause
118
Opioids: Respiratory Depression
- give low dose Narcan
- hold opioids
- sedation precedes respiratory depression
119
PCA
- patient demand ± basal infusion of opioid with lockout interval
- patient must be awake and oriented to self administer their doses (only the patient is to press the button)
- use with caution in patients with sleep apnea
120
PCA Basal Rate
- can be added once it becomes more clear that the patient requires frequent PCA use over several hours
- use caution with opioid naive patients
121
Adjusting PCA
- cut or stop basal rate when patient no longer needs it
- if they have received multiple boluses then increase the basal rate
122
Changing from PCA to Oral
- calculate 24 hour dose
- convert to equi-analgesic 24 hour dose of the new agent using the conversion chart above
- reduce dose by ~25% to account for incomplete cross-tolerance
- divide total 24 hour dose into the appropriate dose
- always add breakthrough PRN dosing, generally 10-20% of total 24 hour oral dose available q4h if oral and more often if IV
123
Intrathecal Pain Pump
- use in patients who are refractory to other opioid therapy or increased toxicities
- use much smaller doses
- can use baclofen and clonidine
124
Radiation Therapy Indication
- painful bony metastases, brain metastases, spinal cord compression
125
Adjuvant Pain Alternatives
- dex
- NSAIDs
- neuropathic pain
- dont treat anxiety/depression with opioids
126
Breast Cancer: Risk Factors
- age
- family history
- personal history
- Radiation treatment
- estrogen exposure (early menarche or late menopause)
- exogenous estrogen
- alcohol
- prior breast biopsies with proliferative histology
- nulliparity or age > 30 years old before first birth
- elevated body mass and diet
- more than 60% of patients will not have any risk factors
127
BRCA-1
- Tumor suppressor gene involved in DNA repair
128
Ductal Carcinoma in Situ
- normal cells have undergone pre-malignant genetic transformation
- typically seen as microcalcifications on a mammogram
129
Lobular Carcinoma in Situ
- has not invaded beyond the lobule basement membrane
- usually, an incidental finding on biopsy specimen obtained because of symptoms or mammographic findings consistent with benign lesions
130
Inflammatory Breast Cancer
- aggressive form with rapid onset and poor prognosis
131
Presentation of Breast Cancer
- > 90% with painless bump on breast
- nipple discharge, retraction, or aching
- asymptomatic disease may be detected on screening mammography
- 50% of patients with an initial diagnosis of breast cancer
132
Diagnosis of Breast Cancer
- History and PE
- Clinical breast exM
- Mammogram
- breast ultrasound
133
FISH Testing
- can test for HER2 status
- IHC detects protein expression (1+, 2+, 3+)
- FISH detects gene amp
134
OncotypeDx
- genetic test for expression of 21 genes which give a recurrence score
- can determine the likelihood that the breast cancer will return and whether the patient is likely to benefit from chemo
135
Oncotype Dx Scoring: TAILORx
- Low risk (<26) = hormonal therapy only
- high risk (≥26) = chemo and hormonal therapy
136
RXPonder
- lymph node+ disease
- Low risk (<26) = hormonal therapy only
- high risk (≥26) = chemo and hormonal therapy
- both pre-menopausal and post menopausal patients LN+ disease
137
Sites of Metastasis in Breast Cancer
- Bone
- Liver
- Lungs
- Brain
- distant lymph nodes
- skin
138
Neoadjuvant and Adjuvant Therapy: Breast Cancer
- Stage I, IIA, III disease
- cure
- neoadjuvant for patients with larger tumors > 1 cm
139
Breast Cancer: RS ≤ 15
adjuvant endocrine therapy ± OS
140
Breast Cancer: RS 16-25
Adjuvant endocrine therapy ± or adjuvant chemo followed by endocrine therapy
141
Breast Cancer: RS ≥ 26
adjuvant chemo followed by endocrine
142
Systemic Adjuvant Therapy: HER2 Positive
- Tumor ≤ 0.5 cm: consider adjuvant endocrine therapy ± chemo with HER2 targeted therapy
- Tumor > 0.6 cm: adjuvant chem with HER2 therapy followed by endocrine therapy
143
Adjuvant Hormonal Therapy: Surgical Ablation
- ooherectomy
- remoes the largest source of estrogen
144
Adjuvant Hormonal Therapy: SERMS
- tamoxifen
- anti-estrogenic effects in breast but estrogenic properties in other tissues
- major toxicities: hot flashes
145
Adjuvant Hormonal Therapy: LHRH Analogs
- leuprolide and Goserelin
- initially increases release of FSH and LH
- long term sustained exposure inhibits LH and FSH by inhibits estrogen production by the ovaries
146
Aromatase Inhibitors
- only in postmenopausal status
- no dvt/ endometrial cancer, not protective on bone
147
Premenopausal at Diagnosis of Breast Cancer
- Tamoxifen x 5 years ± OS
- AI x 5 years +/- OS
148
Postmenopausal treatment for a patient who was premenopausal at diagnosis
- could consider an additional 5 years of AI to total 10 years
OR
- consider T x 5 more years to complete 10 years
149
Premenopausal treatment for a patient who was premenopausal at diagnosis
- T x 5 more years to complete a total of 10 years
OR
- no further endocrine therapy
150
Adjuvant Hormonal Therapy for a patient who is Postmenopausal at Diagnosis
-AI x 5 years then consider AI for additional 5 more years
OR
T x 2-3 years then followed by AI to complete a total of 5 years or vice versa
OR
T x 4.5-6 years then AI x 5 years or T x 5 more years to complete a total of 10 years
151
Adjuvant Chemo for HER2 Negative
Dose Dense AC --> Paclitaxel
- Doxorubicin
- Cyclophosphamide
- Paclitaxel
- Filgrastim
OR
TC
- Docetaxel
- Cyclophosphamide
152
Dose Dense AC: CALBG Trial Group 4
every 2 weeks plus filgrastim = concurrent doxorubicin and cyclophosphamide followed by paclitaxel
153
Cardiotoxicity in Chemo
- if cardiac problems, can consider docetaxel and cyclophosphamide (TC) chemo regimen to avoid Anthracyclines
154
What should patients receive as pre-medications with paclitaxel?
- dexamethasone
- diphenhydramine
- H2 antagonist
155
What does HER2 positive disease greatly benefit from?
The incorporation of HER2 targeted therapies in the regiment such as trastuzumab
156
What are the preferred adjuvant HER2+ regimens?
APT
- paclitaxel
- trastuzumab
TCH
- docetaxel
- carboplatin
- trastuzumab
TCHP
- docetaxel
- carboplatin
- trastuzumab
- pertuzumab
157
What is the Triple Negative Breast Cancer standard of care?
Pembrolizumab + Paclitaxel + Carboplatin
158
Breast Cancer Metastatic Disease Goal
- palliation
- bone and soft tissue metastases tend to have a better prognosis and respond to hormonal therapy
- ER/PR+ tend to be more indolent
- Symptomatic = chemo
159
ER/PR+, Bone Mets, Asymptomatic Visceral Disease
- Endocrine Therapy +/- bisphosphonate or denosumab
OR
- Clinical Trials
160
ER/PR-, Symptomatic Visceral Disease or Hormone Refractory, HER2+
- anti-HER2 therapy ± chemo
161
ER/PR-, Symptomatic Visceral Disease or Hormone Refractory, HER2-
Chemo
162
When to give hormonal therapy in breast cancer patients?
- ER and/or PR positive disease
- long disease-free survival
- prior response to therapy
- bone only disease
163
When to give chemotherapy in breast cancer patients?
- ER/PR negative disease
- short disease-free interval
- rapidly progressing disease
- disease refractive to hormonal therapy
164
If the patient has a shorter disease-free interval with hormonal therapy, what should you do?
- switch to chemo as hormonal therapy is likely not working
165
Which patients respond better to chemo?
- better performance status
- less extensive prior treatment and/or disease
- prolonged disease-free interval
166
What are the options for chemotherapy for breast cancer?
- single vs combination
- TNBC
- PD-L1 status
- HER2(+)
- BRCA status
167
The recommended 1st line options for HER2+ metastatic disease
- Trastuzumab
- Pertuzumab
- Docetaxel (or paclitaxel)
168
What is the recommended treatment in HER2 low patients?
- Fam-trastuzumab deruxtecan
169
Hormone positive, LN- and +, HER2 -, tumor ≤ 0.5 cm
consider adjuvant endocrine therapy
169
1st line treatment for TNBC
- carboplatin or cisplantin single agent
- however, pembrolizumab + chemo is better in chemo alone in patients with a combined positive score ≥ 10
170
Hormone positive, LN- and +, HER2 -, tumor > 0.5 cm or 1-3 positive nodes, RT-PCR not done
adjuvant endocrine therapy or adjuvant chemo followed by endocrine therapy
170
Hormone positive, LN- and +, HER2 -, tumor > 0.5 cm or 1-3 positive nodes, RS < 26
adjuvant endocrine therapy
171
Hormone positive, LN- and +, HER2 -, tumor > 0.5 cm or 1-3 positive nodes, ≥ 26
adjuvant chemo followed by adjuvant endocrine therapy
172
HER2-, postmenopausal or premenopausal receiving OS metastatic hormonal therapy first line
- AI + CDK 4/6 Inhibitor (-clib)
173
Abemaciclib Monitoring Parameters
- CBC, diarrhea
174
Palbociclib Monitoring Parameters
- CBC
175
Ribociclib Monitoring Parameters
- CBC, QTc prolongation
176
Mammogram Screening
- Age 40-44 opportunity for annual exams
- Age 45-54 annual mammograms
177
Breast Cancer Prevention
- prophylactic mastectomy
- bilateral oophorectomy
- Tamoxifen and Raloxifene
178
Etiology/Patho of Prostate Cancer
- Hormonal: testosterone is a growth signal to the prostate
- Androgen receptor alterations
179
Risk Factors of Prostate cancer
- age
- AA, less common in Asians
180
Signs and Symptoms of Prostate Cancer
- asymptomatic with early disease
- alterations in urinary habits
- impotence
- lower extremity edema
- weight loss
- anemia
181
Prostate cancer metastasizes to what?
- the bone (most common)
- lung
- liver
182
Diagnosis of Prostate Cancer
- physical exam
- PSA
- transrectal ultrasound
- via biopsy of prostate
183
Importance of Gleason Score
- the higher the score, the higher the risk of extracapsular spread (increased growth rate)
184
PSA Diagnosis
- Normal range is 0-4 ng/mL
- > 10 ng/mL highly sus for malignancy
- PSA velocity: >0,5 ng/mL rise per year sus for malignancy
185
m1
metastatic prostate cancer
186
m0
non-metastatic on scans (PSA only)
187
HSPC
hormone sensitive prostate cancer
188
CRPC
castrate resistant prostate cancer
189
Localized Observation treatment for Prostate Cancer
- monitoring the course of disease with the expectation to deliver palliative therapy for the development of symptoms, a change in exam or PSA that suggests symptoms are imminent
190
When to check DRE and PSA in localized observation
q6months
191
Localized active surveillance for prostate cancer
- based on the premise that prostate cancer is a benign and indolent disease
- if cancer noted to progress, will initiate potentially curative therapy
192
Monitoring for active surveillance treatment: prostate cancer
- PSA, digital rectal exam, and symptoms
193
When to initiate treatment in prostate cancer?
- rising PSA or the development of symptoms
194
What are the three types of localized treatment for prostate cancer
- active surveillance
- radiation therapy
- surgery
195
Localized radiation therapy for prostate cancer
- reasonable alternative for patients who are not surgical candidates
- diarrhea, ED
- can add adjuvant ADT if intermediate or poor risk
196
locally advanced/high risk prostate cancer treatment
- ADT in combo with external beam radiation therapy
- Start ADT prior to RT and then continue during RT and for 1-3 years after radiation
197
Radial Prostatectomy + Pelvic lymph node dissection (PLND)
- definite curative therapy
198
Androgen deprivation therapy
- LHRH agonist ± anti-angdrogen or orchiectomy
- goal is to induce castrate levels of testosterone ≤ 50 ng/dL after 1 month
199
200
LHRH Agonist
- reversible and as effective as orchiectomy
- leuprolide (IM, SQ)
goserelin (SQ)
201
Acute LHRH agonist toxicities
- tumor flair (in the metastatic setting)
- gynecomastia
- hot flashes
- ED
- injection site reaction
- edema
202
Long term toxicities of LHRH agonists
- osteoporosis
- fracture
- obesity
- changes in lipids
- CV events
- increased risk of both diabetes
203
Relugolix
- compared to LHRH agonists and had less CV events
204
Anti Androgen Drugs
- flutamide
- bicalutamide (most common)
- nilutamide
- diarrhea
205
General first line for metastatic prostate cancer
- palliation of disease
- suppress testosterone
- need to determine whether this is a PSA recurrence or overt metastatic disease
206
metastatic disease m0HSPC with PSA doubling time < 6 months
can give ADT
207
metastatic disease m0HSPC with PSA doubling time > 6 months
can observe
208
Orchiectomy
- immediate drop in testosterone levels
- addition of anti-androgen therapy is of unknown benefit
- toxicities: impotence, hot flashes
208
What medication in prostate cancer causes disease flare?
- LHRH agonists
- anti-androgen should be administered to prevent disease flare
209
Intermittent ADT in m0HSPC
- can start on LHRN agonist alone or with oral ADT
- d/c when PSA level has returned to baaseline
- men with biochemical failure only
210
m0CRPC therapy
- continue ADT (usually an LHRH agonist)
- Add one of the following (Enzalutamide, aptalutamide, darolutamide)
211
Enzalutamide (Xtandi)
- blocks androgen binding and translocation of the androgen receptor
212
Enzalutamide Interactions
- avoid CYP2C8
- can decrease concentrations that are substrates for CYP3A4, 2C9, 2C19 (warfarin)
- caution in patients with a seizure history
- enzalutamide syndrome
213
Which medication does not have an indication in the M0 setting of prostate cancer
abiraterone
214
Apalutamide
- non steroidal androgen receptor inhibitor
- CYP 3A4 CYP 2C8
- use caution in patients with seizure disorder, QT prolongation
215
Darolutamide
- structurally unique androgen receptor antagonist
- offers potentially less toxicities and less severe toxicities
- less fractures, falls, seizures, weight loss
216
m1HSPC
- patient now has visceral metastasis
- hormone sensitive disease
217
Low volume m1HSPC treatment
1. ADT: LHRH agonist or antagonists
2. Continue ADT and add any of the following
- abiraterone + prednisone
- enzalutamide
- apalutamide
218
Abiraterone
- selectively and irreversible inhibits CYP17
- must give prednisone for adrenal insufficiency
219
High volume m1HSPC
Could do
- ADT
- ADT + Abiraterone + Prednisone
- ADT + Enzalutamide
- ADT + Apalutamide
or
chemo becomes an option
220
First line treatment for high volume m1HSPC
- Docetaxel + ADT (abiraterone or darolutamide)
- visceral metastasis
- 4 or more bone metastases
- at least one metastasis beyond the pelvis vertebral column
221
Docetaxel in M1HSPC
- more neutropenic fevers
- more neuropathy
222
m1CRPC
- hormone refractory
- Sipuleucel-T
- Docetaxel (alone or in combo with abiraterone or darolutamide)
- Cabazitaxel (second line if already on docetaxel)
223
Cabazitaxel
- poor affinity for MDR proteins, conferring activity in resistant tumors
- more severe neutropenia, more diarrhea, more febrile neutropenia
224
Prostate Cancer Screening Options
- DRE
- PSA
- transrectal ultrasonography
225
ACS Screening guidelines Prostate Cancer
- men ≥ 50
- PSA±DRE
- annual screening if PSA ≥ 2.5 ng/mL
- PSA ≥ 4.0 ng/mL refer
226
Prostate cancer prevention
- finasteride
- those who are on finasteride that developed prostate cancer had disease wit increased Gleason score
