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PHRM 864 > Exam 2 Oncology > Flashcards

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
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2
Q

Acute Nausea/Vomiting

A
  • usually within 24 hours of receiving chemo
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3
Q

Delayed Nausea/Vomiting

A
  • occurs > 24 hours following completion of chemo
  • NK-1 receptor and substance P binding
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4
Q

Breakthrough Nausea/Vomiting

A
  • occurs even if on scheduled anti-emetics prior to chemo
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5
Q

Refractory

A
  • nausea/vomiting that persists despite appropriate anti-emetics
  • failed other therapies
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6
Q

Receptor involved in Nausea/Vomiting

A

chemoreceptor trigger zone (CTZ)

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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

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8
Q

Wretching

A

the labored movement of abdominal and thoracic muscles before vomiting

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9
Q

Vomiting

A

the ejection or forced expulsion of gastric contents through the mouth

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10
Q

Highly Emetogenic Chemotherapy

A
  • > 90% Frequency of Emesis
  • Level 5
  • cisplatin
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11
Q

Moderately Emetogenic Chemotherapy

A
  • > 30 - 90% frequency of emesis
  • level 3-4
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12
Q

Low Emetic Risk

A
  • 10-30% frequency of emesis
  • level 2
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13
Q

Minimial Emetic Risk

A
  • < 10% frequency of emesis
  • level 1
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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
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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
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16
Q

Prophylaxis for acute N/V is based on what?

A

emetogenic potential of chemotherapy

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17
Q

Highly Emetogenic: Regimen A

A
  • NK-1 antagonist ( -pitant)
  • Dexamethasone
  • 5-HT3 antagonist (-setron)
  • Olanzapine
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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
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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
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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
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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
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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
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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
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24
Q

Breakthrough Nausea and Vomiting Treatment

A
  • PICK ONE
  • Haloperidol
  • Metoclopramide +/- diphenhydramine
  • prochlorperazine
  • promethazine
  • olanzapine
  • benzodiazepines
  • cannabinoids
  • 5-HT3 antagonist
  • dexamethasone
  • scopolamine
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25
Q

Delayed Nausea/Vomiting Treatment

A
  • One of the following
  • Dexamethasone
  • NK-1 antagonist
  • olanzapine
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26
Q

Anticipatory Nausea and Vomiting Treatment

A
  • optimal antiemetic therapy during every cycle of treatment
  • behavioral
  • acupuncture/acupressure
  • lorazepam
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27
Q

Oral Chemo High to Moderate Emetogenic Risk

A
  • start before chemo and continue daily
  • 5-HT3 antagonists
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28
Q

Oral Chemo Low to Minimal Emetogenic Risk

A
  • start before chemo and maybe given daily or as needed
  • metoclopramide
  • 5-HT3 antagonists
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29
Q

Total Body Irradiation Emesis Pretreatment

A
  • start for each day of radiation
  • granisetron PO +/- dex
  • ondansetron PO +/- dex
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30
Q

Common Toxicities: 5-HT3 Antagonists

A
  • headache (not class effect)
  • asymptomatic and transient EKG changes at max doses
  • constipation
  • increased transaminases
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31
Q

Common Toxicities: Corticosteroids

A
  • anxiety
  • euphoria
  • insomnia
  • hyperglycemia
  • increased appetite
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32
Q

Common Toxicities: Substance P Antagonists

A
  • hiccups
  • worry about drug interactions
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33
Q

Common Toxicities: Dopamine Antagonists (chlorpromazine, haloperidol, metoclopramide)

A
  • EPS
  • diarrhea
  • sedation
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34
Q

Common Toxicities: Olanzapine

A
  • dystonic reactions
  • sedation
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35
Q

Common Toxicities: Phenothiazines (prochlorperazine, promethazine)

A
  • sedation
  • akathesia
  • dystonia
  • IV promethazine = tissue damage
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36
Q

Common Toxicities: Cannibanoids

A
  • drowsiness
  • dizziness
  • euphoria
  • mood changes
  • hallucinations
  • increased appetite
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37
Q

Common Toxicities: Benzos

A
  • sedation
  • hypotension
  • urinary incontinence
  • hallucinations
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38
Q

Common Toxicities: Scopolamine

A
  • anticholinergic side effects
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39
Q

When are anti-emetics most effective?

A
  • prophylaxis
  • 5-30 minutes prior to chemo and around-the-clock until chemo is complete
  • provide PRN agents for breakthrough
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40
Q

Mucositis Progression

A
  • paralleles the neutrophil nadir and begins on day 5 to 7 after chemotherapy and improves as the neutrophil count increases
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41
Q

Mucositis: continuous infusions __ short IV infusions

A

>

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42
Q

Risk factors for mucositis?

A
  • pre-existing oral lesions
  • poor dental hygiene or ill-fitting dentures
  • patients receiving both chemo and radiation
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43
Q

Mucositis: Diet Recommendations

A
  • avoid rough food, spices, salt, acidic fruit
  • mainly eat soft or liquid foods, nonacidic fruits, soft cheeses, and eggs
  • avoid smoking and alcohol
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44
Q

Mucositis: Pretreatment

A
  • baking soda rinses BID-QID
  • soft bristled toothbrush to minimize gingival irritation
  • saliva sub for radiation induced xerostomia
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45
Q

Mucositis: Oral Cryotherapy

A
  • 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
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46
Q

Mucositis: Sucralfate

A
  • 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
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47
Q

Mucositis: Oral and PR Opioids

A
  • moderate to severe mucositis
  • many oral solutions contain a high percentage of alcohol, which may burn
  • best administered around the clock
  • PCA is common
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48
Q

Neutropenia: WBCs

A
  • < 0.5 x 10^3/uL
  • risk of life-threatening infections
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49
Q

Neutropenia: Platelets

A
  • thrombocytopenia = < 100 x10^3/uL
  • risk of bleeding increases when platelet count is ≤ 20 x 10^3/uL and therefore may require transfusion
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50
Q

Neutropenia: RBCs

A
  • anemia
  • risk of hypoxia and fatigue
  • Hgb z, 11 g/dL or >2g/dL drop from baseline should undergo work-up
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51
Q

What is the most common dose-limiting toxicity of chemo?

A

bone marrow suppression

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52
Q

What is the nadir?

A
  • 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
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53
Q

Guidelines to administer chemo safely in patient’s with neutropenia

A
  • WBC > 3000 OR
  • ANC of >1500 AND
  • Platelet count ≥ 100 x 10^3/uL
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54
Q

Severe Neutropenia

A
  • ANC < 0.5 x 10^3/uL
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55
Q

Febrile Neutropenia Definition

A
  • 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
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56
Q

Prophylactic Use of CSFs

A

decreased
- incidence of febrile neutropenia
- LOS
- confirmed infections
- Duration of antibiotics

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57
Q

When to administer primary CSF prophylaxis?

A
  • if the patient is to receive a chemo regiment that is expected to cause ≥ 20% incidence of febrile neutropenia
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58
Q

High Risk Patients of FN

A
  • preexisting neutropenia due to disease
  • extensive prior chemo
  • previous irradation to the pelvis or other areas containing large amounts of bone marrow
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59
Q

Secondary Prophylaxis using CSF

A
  • 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
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60
Q

Other Uses for CSFs

A
  • 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
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61
Q

Filgrastim (Neupogen) G-CSF and Sargramostim (Leukine) GM-CSF

A
  • dose dependent elevation in ANCE
  • rapid drop in WBC and neutrophil count following discontinuation
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62
Q

Pegfilgrastim (Neulasta)

A
  • non-linear PK
  • clearance increases with increasing neutrophil count
  • longer half life
  • much more expensive
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63
Q

Filgrastim: Dosing

A
  • 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)
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64
Q

Pegfilgrastim: Dosing

A
  • 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
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65
Q

GSF Adverse Effects

A
  • flu like symptoms
  • bone and joint pain due to rapid proliferation of the bone myeloid cells
  • DVT
  • splenic enlargement with long term CSF use
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66
Q

General Causes of Anemia

A
  • decreased RBC production
  • decreased erythropoietin production (renal dysfunction)
  • decreased body stores of b12, iron, folic acid
  • blood loss
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67
Q

Significance of Anemia in Cancer

A
  • fatigue
  • low hemoglobin correlated with poor performance status –> decreased survival
  • decreased quality of life
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68
Q

Treatment of Chemo Induced Anemia

A
  • if the patient is symptomatic
  • tranfuse as indicated
  • consider ESA (not indicated for patients receiving myelosuppressive chemo when anticipated outcome is cure)
  • iron studies
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69
Q

ESAs are not recommended when:

A
  • curative intent
  • patients not receiving chemo
  • patients receiving non-myelosuppressive chemo
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70
Q

Epoeitin Alpha Clinical Pearls

A
  • 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
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71
Q

Darbepoetin Clinical Pearls

A
  • Starting Dose: weekly
  • Maintenence: every 3 weeks
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72
Q

Iron in Anemic Cancer Patients

A
  • 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
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73
Q

Chemos that cause Myalgias/Arthralgias

A
  • Taxanes
  • ARs
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74
Q

Treatment for myalgias/arthralgias

A
  • nsaids
  • maya require opioids
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75
Q

Chemos that cause hemorrhagic cytitis

A
  • high dose cyclophos
  • ifosfamide
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76
Q

Treatment for hemorrhagic cystitis

A
  • hydration (prevention)
  • mesna (used to prevent)
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77
Q

Chemos that cause HF

A
  • anthracyclines
  • high dose cyclophosphamide
  • trastuzumab (other HER2 targeted therapies)
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78
Q

Treatment of HF

A
  • monitor cumulative dose
  • assess for risk factors
  • dexrazoxane (chemoprotectant)
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79
Q

Chemos that cause peripheral neuropathy

A
  • taxanes
  • vinca alkaloids
  • platinums
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80
Q

Treatment of Peripheral Neuropathy

A
  • change infusion rate (ie paclitaxel)
  • adjunctive pain medications (gabapentin, amitriptyline)
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81
Q

Chemos that cause pulmonary toxicities

A
  • bleomycin
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82
Q

Treatment of pulmonary toxicities

A
  • corticosteroids (no good treatment once it happens)
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83
Q

Mesna

A
  • should be used with standard ifosfamide doses of < 2.5 g/m2/day to decreas risk of hemorrhagic cystitis
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84
Q

Cardiac Toxicity

A
  • formation of iron-dependent oxygen free radicals due to stable AC-iron complexes, which cause catalysis of electron transfer
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85
Q

Type I Chemo Related Cardiac Dysfunction: Acute

A
  • 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
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86
Q

Type I Chemo Related Cardiac Dysfunction

A
  • onset usually within a year of receiving AC therapy
  • rapid onset and progression
  • common and life threatening
  • related to cumulative dose patient received
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87
Q

Type I Chemo Related Cardiac Dysfunction: Late- onset

A
  • develops several years or even decades after therapy
  • manifests as ventricular dysfunction, CHF, conduction disturbances, and arrhythmias
  • pediatric cancer survivors who received AC
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88
Q

Which drug causes Type II Chemo Related Cardiac Dysfunction?

A

Trastuzumab

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89
Q

Type II Chemo Related Cardiac Dysfunction

A
  • 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)
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90
Q

Assessment of Pain

A

O: onset
P: provokes
Q: quality
R: radiate
S: severe
T: time
U: understanding

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91
Q

Principles of Pain Management

A
  • 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
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92
Q

Mild Pain Regimen

A
  • non-opioid ± adjuvent
93
Q

Moderate Pain Treatment

A
  • opioid for mild-to-moderate pain
  • ± non-opioid
  • ± adjuvant
94
Q

Severe Pain

A
  • opioid for moderate-to-severe pain
  • ± non-opioid
  • ± adjuvant
95
Q

Common Non-Opioids

A
  • scale 1-3
  • APAP
  • Advil
  • Aspirin
96
Q

Combo Products/Mild Opioids

A
  • 4-6
  • Hydrocodone/APAP
  • Oxycodone/APAP
  • Hydrocodone/Ibuprofen
  • Oxycodone/Ibuprofen
  • Tramadol
  • Oxycodone/Aspirin
  • Condeine/APAP
97
Q

Opioids

A
  • 7-10
  • morphine
  • hydromorphone
  • methadone
  • oxycodone
  • fentanyl
  • no max dose
98
Q

Morphine

A
  • metabolized in the liver
  • excreted renally and will accumulate in renal insufficiency
99
Q

Morphine Dosage Forms

A
  • short acting
  • long acting
  • solutions
  • IV
  • PR
100
Q

Hydromorphone

A
  • metabolized in liver
  • all renally excreted
  • lower dose or longer dosing intervals in renal insufficency
101
Q

Hydromorphone Dosage Forms

A
  • short acting
  • long acting
  • solution
  • IV
  • PR
102
Q

Oxycodone

A
  • CYP2D6
  • over sedation and CNS toxicity in renal failure patients
  • use in caution in liver dysfunction
103
Q

Oxycodone Dosage Forms

A
  • short acting tablets
  • long acting tablets
  • solutions
  • NO IV
104
Q

Fentanyl

A
  • 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
Q

Fentanly: Dosage Forms

A
  • patch
  • IV
  • buccal
  • nasal spray
  • lozenges
106
Q

Fentanyl: REMS

A
  • 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
Q

Methadone: When to Consider

A
  • 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
Q

Methadone: Avoid

A
  • numerous drug interactions
  • risks for syncope or arrhythmias
  • history of unpredictable adherance
  • poor cognition
109
Q

Methadone Clearance

A
  • 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
Q

Administration of Opioids

A
  • oral is the preferred route
  • must consider long-acting and short-acting agents and allow for overlapping effects
111
Q

Opioids: Constipation

A
  • always add a bowel regimen
  • mild stimulant ± stool softener)
112
Q

Opioids: Sedation

A
  • tolerance typically develops within a few days
  • hold sedatives and/or anxiolytics
  • consider a dosage reduction
113
Q

Opioids: N/V

A
  • change opioid
  • take with food
  • consider addition of scheduled anti-emetic therapy
114
Q

Opioids: Pruritus

A
  • most seen with morphine administration
  • decrease the dose or change opioid
  • consider the addition of anti-histamine such as diphenhydramine
115
Q

Opioids: Hallucinations

A
  • decrease dose or change opioid
  • consider neuroleptic medication
116
Q

Opioids: Confusion/Delirium

A
  • decrease dose or change opioid
  • consider neuroleptic medication
117
Q

Opioids: Myoclonic Jerking

A
  • may be a sign of toxicity
  • consider changing opioid or treating underlying cause
118
Q

Opioids: Respiratory Depression

A
  • give low dose Narcan
  • hold opioids
  • sedation precedes respiratory depression
119
Q

PCA

A
  • 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
Q

PCA Basal Rate

A
  • 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
Q

Adjusting PCA

A
  • cut or stop basal rate when patient no longer needs it
  • if they have received multiple boluses then increase the basal rate
122
Q

Changing from PCA to Oral

A
  • 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
Q

Intrathecal Pain Pump

A
  • use in patients who are refractory to other opioid therapy or increased toxicities
  • use much smaller doses
  • can use baclofen and clonidine
124
Q

Radiation Therapy Indication

A
  • painful bony metastases, brain metastases, spinal cord compression
125
Q

Adjuvant Pain Alternatives

A
  • dex
  • NSAIDs
  • neuropathic pain
  • dont treat anxiety/depression with opioids
126
Q

Breast Cancer: Risk Factors

A
  • 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
Q

BRCA-1

A
  • Tumor suppressor gene involved in DNA repair
128
Q

Ductal Carcinoma in Situ

A
  • normal cells have undergone pre-malignant genetic transformation
  • typically seen as microcalcifications on a mammogram
129
Q

Lobular Carcinoma in Situ

A
  • 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
Q

Inflammatory Breast Cancer

A
  • aggressive form with rapid onset and poor prognosis
131
Q

Presentation of Breast Cancer

A
  • > 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
Q

Diagnosis of Breast Cancer

A
  • History and PE
  • Clinical breast exM
  • Mammogram
  • breast ultrasound
133
Q

FISH Testing

A
  • can test for HER2 status
  • IHC detects protein expression (1+, 2+, 3+)
  • FISH detects gene amp
134
Q

OncotypeDx

A
  • 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
Q

Oncotype Dx Scoring: TAILORx

A
  • Low risk (<26) = hormonal therapy only
  • high risk (≥26) = chemo and hormonal therapy
136
Q

RXPonder

A
  • 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
Q

Sites of Metastasis in Breast Cancer

A
  • Bone
  • Liver
  • Lungs
  • Brain
  • distant lymph nodes
  • skin
138
Q

Neoadjuvant and Adjuvant Therapy: Breast Cancer

A
  • Stage I, IIA, III disease
  • cure
  • neoadjuvant for patients with larger tumors > 1 cm
139
Q

Breast Cancer: RS ≤ 15

A

adjuvant endocrine therapy ± OS

140
Q

Breast Cancer: RS 16-25

A

Adjuvant endocrine therapy ± or adjuvant chemo followed by endocrine therapy

141
Q

Breast Cancer: RS ≥ 26

A

adjuvant chemo followed by endocrine

142
Q

Systemic Adjuvant Therapy: HER2 Positive

A
  • 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
Q

Adjuvant Hormonal Therapy: Surgical Ablation

A
  • ooherectomy
  • remoes the largest source of estrogen
144
Q

Adjuvant Hormonal Therapy: SERMS

A
  • tamoxifen
  • anti-estrogenic effects in breast but estrogenic properties in other tissues
  • major toxicities: hot flashes
145
Q

Adjuvant Hormonal Therapy: LHRH Analogs

A
  • 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
Q

Aromatase Inhibitors

A
  • only in postmenopausal status
  • no dvt/ endometrial cancer, not protective on bone
147
Q

Premenopausal at Diagnosis of Breast Cancer

A
  • Tamoxifen x 5 years ± OS
  • AI x 5 years +/- OS
148
Q

Postmenopausal treatment for a patient who was premenopausal at diagnosis

A
  • could consider an additional 5 years of AI to total 10 years

OR

  • consider T x 5 more years to complete 10 years
149
Q

Premenopausal treatment for a patient who was premenopausal at diagnosis

A
  • T x 5 more years to complete a total of 10 years

OR

  • no further endocrine therapy
150
Q

Adjuvant Hormonal Therapy for a patient who is Postmenopausal at Diagnosis

A

-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
Q

Adjuvant Chemo for HER2 Negative

A

Dose Dense AC –> Paclitaxel
- Doxorubicin
- Cyclophosphamide
- Paclitaxel
- Filgrastim

OR

TC
- Docetaxel
- Cyclophosphamide

152
Q

Dose Dense AC: CALBG Trial Group 4

A

every 2 weeks plus filgrastim = concurrent doxorubicin and cyclophosphamide followed by paclitaxel

153
Q

Cardiotoxicity in Chemo

A
  • if cardiac problems, can consider docetaxel and cyclophosphamide (TC) chemo regimen to avoid Anthracyclines
154
Q

What should patients receive as pre-medications with paclitaxel?

A
  • dexamethasone
  • diphenhydramine
  • H2 antagonist
155
Q

What does HER2 positive disease greatly benefit from?

A

The incorporation of HER2 targeted therapies in the regiment such as trastuzumab

156
Q

What are the preferred adjuvant HER2+ regimens?

A

APT
- paclitaxel
- trastuzumab

TCH
- docetaxel
- carboplatin
- trastuzumab

TCHP
- docetaxel
- carboplatin
- trastuzumab
- pertuzumab

157
Q

What is the Triple Negative Breast Cancer standard of care?

A

Pembrolizumab + Paclitaxel + Carboplatin

158
Q

Breast Cancer Metastatic Disease Goal

A
  • 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
Q

ER/PR+, Bone Mets, Asymptomatic Visceral Disease

A
  • Endocrine Therapy +/- bisphosphonate or denosumab

OR
- Clinical Trials

160
Q

ER/PR-, Symptomatic Visceral Disease or Hormone Refractory, HER2+

A
  • anti-HER2 therapy ± chemo
161
Q

ER/PR-, Symptomatic Visceral Disease or Hormone Refractory, HER2-

162
Q

When to give hormonal therapy in breast cancer patients?

A
  • ER and/or PR positive disease
  • long disease-free survival
  • prior response to therapy
  • bone only disease
163
Q

When to give chemotherapy in breast cancer patients?

A
  • ER/PR negative disease
  • short disease-free interval
  • rapidly progressing disease
  • disease refractive to hormonal therapy
164
Q

If the patient has a shorter disease-free interval with hormonal therapy, what should you do?

A
  • switch to chemo as hormonal therapy is likely not working
165
Q

Which patients respond better to chemo?

A
  • better performance status
  • less extensive prior treatment and/or disease
  • prolonged disease-free interval
166
Q

What are the options for chemotherapy for breast cancer?

A
  • single vs combination
  • TNBC
  • PD-L1 status
  • HER2(+)
  • BRCA status
167
Q

The recommended 1st line options for HER2+ metastatic disease

A
  • Trastuzumab
  • Pertuzumab
  • Docetaxel (or paclitaxel)
168
Q

What is the recommended treatment in HER2 low patients?

A
  • Fam-trastuzumab deruxtecan
169
Q

Hormone positive, LN- and +, HER2 -, tumor ≤ 0.5 cm

A

consider adjuvant endocrine therapy

169
Q

1st line treatment for TNBC

A
  • carboplatin or cisplantin single agent
  • however, pembrolizumab + chemo is better in chemo alone in patients with a combined positive score ≥ 10
170
Q

Hormone positive, LN- and +, HER2 -, tumor > 0.5 cm or 1-3 positive nodes, RT-PCR not done

A

adjuvant endocrine therapy or adjuvant chemo followed by endocrine therapy

170
Q

Hormone positive, LN- and +, HER2 -, tumor > 0.5 cm or 1-3 positive nodes, RS < 26

A

adjuvant endocrine therapy

171
Q

Hormone positive, LN- and +, HER2 -, tumor > 0.5 cm or 1-3 positive nodes, ≥ 26

A

adjuvant chemo followed by adjuvant endocrine therapy

172
Q

HER2-, postmenopausal or premenopausal receiving OS metastatic hormonal therapy first line

A
  • AI + CDK 4/6 Inhibitor (-clib)
173
Q

Abemaciclib Monitoring Parameters

A
  • CBC, diarrhea
174
Q

Palbociclib Monitoring Parameters

175
Q

Ribociclib Monitoring Parameters

A
  • CBC, QTc prolongation
176
Q

Mammogram Screening

A
  • Age 40-44 opportunity for annual exams
  • Age 45-54 annual mammograms
177
Q

Breast Cancer Prevention

A
  • prophylactic mastectomy
  • bilateral oophorectomy
  • Tamoxifen and Raloxifene
178
Q

Etiology/Patho of Prostate Cancer

A
  • Hormonal: testosterone is a growth signal to the prostate
  • Androgen receptor alterations
179
Q

Risk Factors of Prostate cancer

A
  • age
  • AA, less common in Asians
180
Q

Signs and Symptoms of Prostate Cancer

A
  • asymptomatic with early disease
  • alterations in urinary habits
  • impotence
  • lower extremity edema
  • weight loss
  • anemia
181
Q

Prostate cancer metastasizes to what?

A
  • the bone (most common)
  • lung
  • liver
182
Q

Diagnosis of Prostate Cancer

A
  • physical exam
  • PSA
  • transrectal ultrasound
  • via biopsy of prostate
183
Q

Importance of Gleason Score

A
  • the higher the score, the higher the risk of extracapsular spread (increased growth rate)
184
Q

PSA Diagnosis

A
  • 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
Q

m1

A

metastatic prostate cancer

186
Q

m0

A

non-metastatic on scans (PSA only)

187
Q

HSPC

A

hormone sensitive prostate cancer

188
Q

CRPC

A

castrate resistant prostate cancer

189
Q

Localized Observation treatment for Prostate Cancer

A
  • 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
Q

When to check DRE and PSA in localized observation

191
Q

Localized active surveillance for prostate cancer

A
  • based on the premise that prostate cancer is a benign and indolent disease
  • if cancer noted to progress, will initiate potentially curative therapy
192
Q

Monitoring for active surveillance treatment: prostate cancer

A
  • PSA, digital rectal exam, and symptoms
193
Q

When to initiate treatment in prostate cancer?

A
  • rising PSA or the development of symptoms
194
Q

What are the three types of localized treatment for prostate cancer

A
  • active surveillance
  • radiation therapy
  • surgery
195
Q

Localized radiation therapy for prostate cancer

A
  • reasonable alternative for patients who are not surgical candidates
  • diarrhea, ED
  • can add adjuvant ADT if intermediate or poor risk
196
Q

locally advanced/high risk prostate cancer treatment

A
  • 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
Q

Radial Prostatectomy + Pelvic lymph node dissection (PLND)

A
  • definite curative therapy
198
Q

Androgen deprivation therapy

A
  • LHRH agonist ± anti-angdrogen or orchiectomy
  • goal is to induce castrate levels of testosterone ≤ 50 ng/dL after 1 month
200
Q

LHRH Agonist

A
  • reversible and as effective as orchiectomy
  • leuprolide (IM, SQ)
    goserelin (SQ)
201
Q

Acute LHRH agonist toxicities

A
  • tumor flair (in the metastatic setting)
  • gynecomastia
  • hot flashes
  • ED
  • injection site reaction
  • edema
202
Q

Long term toxicities of LHRH agonists

A
  • osteoporosis
  • fracture
  • obesity
  • changes in lipids
  • CV events
  • increased risk of both diabetes
203
Q

Relugolix

A
  • compared to LHRH agonists and had less CV events
204
Q

Anti Androgen Drugs

A
  • flutamide
  • bicalutamide (most common)
  • nilutamide
  • diarrhea
205
Q

General first line for metastatic prostate cancer

A
  • palliation of disease
  • suppress testosterone
  • need to determine whether this is a PSA recurrence or overt metastatic disease
206
Q

metastatic disease m0HSPC with PSA doubling time < 6 months

A

can give ADT

207
Q

metastatic disease m0HSPC with PSA doubling time > 6 months

A

can observe

208
Q

Orchiectomy

A
  • immediate drop in testosterone levels
  • addition of anti-androgen therapy is of unknown benefit
  • toxicities: impotence, hot flashes
208
Q

What medication in prostate cancer causes disease flare?

A
  • LHRH agonists
  • anti-androgen should be administered to prevent disease flare
209
Q

Intermittent ADT in m0HSPC

A
  • 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
Q

m0CRPC therapy

A
  • continue ADT (usually an LHRH agonist)
  • Add one of the following (Enzalutamide, aptalutamide, darolutamide)
211
Q

Enzalutamide (Xtandi)

A
  • blocks androgen binding and translocation of the androgen receptor
212
Q

Enzalutamide Interactions

A
  • avoid CYP2C8
  • can decrease concentrations that are substrates for CYP3A4, 2C9, 2C19 (warfarin)
  • caution in patients with a seizure history
  • enzalutamide syndrome
213
Q

Which medication does not have an indication in the M0 setting of prostate cancer

A

abiraterone

214
Q

Apalutamide

A
  • non steroidal androgen receptor inhibitor
  • CYP 3A4 CYP 2C8
  • use caution in patients with seizure disorder, QT prolongation
215
Q

Darolutamide

A
  • structurally unique androgen receptor antagonist
  • offers potentially less toxicities and less severe toxicities
  • less fractures, falls, seizures, weight loss
216
Q

m1HSPC

A
  • patient now has visceral metastasis
  • hormone sensitive disease
217
Q

Low volume m1HSPC treatment

A
  1. ADT: LHRH agonist or antagonists
  2. Continue ADT and add any of the following
    - abiraterone + prednisone
    - enzalutamide
    - apalutamide
218
Q

Abiraterone

A
  • selectively and irreversible inhibits CYP17
  • must give prednisone for adrenal insufficiency
219
Q

High volume m1HSPC

A

Could do
- ADT
- ADT + Abiraterone + Prednisone
- ADT + Enzalutamide
- ADT + Apalutamide

or

chemo becomes an option

220
Q

First line treatment for high volume m1HSPC

A
  • Docetaxel + ADT (abiraterone or darolutamide)
  • visceral metastasis
  • 4 or more bone metastases
  • at least one metastasis beyond the pelvis vertebral column
221
Q

Docetaxel in M1HSPC

A
  • more neutropenic fevers
  • more neuropathy
222
Q

m1CRPC

A
  • hormone refractory
  • Sipuleucel-T
  • Docetaxel (alone or in combo with abiraterone or darolutamide)
  • Cabazitaxel (second line if already on docetaxel)
223
Q

Cabazitaxel

A
  • poor affinity for MDR proteins, conferring activity in resistant tumors
  • more severe neutropenia, more diarrhea, more febrile neutropenia
224
Q

Prostate Cancer Screening Options

A
  • DRE
  • PSA
  • transrectal ultrasonography
225
Q

ACS Screening guidelines Prostate Cancer

A
  • men ≥ 50
  • PSA±DRE
  • annual screening if PSA ≥ 2.5 ng/mL
  • PSA ≥ 4.0 ng/mL refer
226
Q

Prostate cancer prevention

A
  • finasteride
  • those who are on finasteride that developed prostate cancer had disease wit increased Gleason score

PHRM 864 (11 decks)

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