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Pharm 401 Midterm #2 > Lec 19: Cancer Survivorship > Flashcards

Lec 19: Cancer Survivorship Flashcards

1
Q

What does “net survival” mean?

A

Def:
* “The survival probability that would be observed in the hypothetical situation
where the cancer of interest is the only possible cause of death” (CCS,
Canadian Cancer Statistics, 2019)

–> basically, refers to the propability that they would die of their cancer ONLY, nothing else.

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2
Q

Waht is the def of “cancer survivor”?

A

“An individual is considered a cancer survivor from the time of diagnosis,
through the balance of his or her life”

–> Cancer survivor: is ANY indivdiual from time of dx throughout life. Does not mean they are cancer free. May be living with cancer or not, but still called a cancer survivor.

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3
Q

What are 4 big canccer survivorship issues?

A

Cancer Survivorship Issues:

1) Cancer:
- recurrence of primary cancer.
- Secondary malignancies from cancer treatment (radiation, chemo etc).

2) Infertility

3) Neurologic complications:
- cognitive problems
- neuropathies

4) Mental Health
- depression/anxiety big ones

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4
Q

Chemotherapy Induced Neurotoxicity
* Can be _______,______, and/or _____neurotoxicity

A

Chemotherapy Induced Neurotoxicity
* Can be peripheral, autonomic, and/or central neurotoxicity

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5
Q

What are some long term considerations regarding CHEMO-INDUCED NEUROTOXICITY?

  • _________ Neuropathy
  • ________ disorders, changes in gate/posture, risk of ___
  • Estimated that 30% of cancer survivors _____ every year
  • Evaluations for ______ (esp for cisplatin)
A

Long term considerations:
* Peripheral Neuropathy
* Movement disorders, changes in gate/posture, risk of falls
* Estimated that 30% of cancer survivors fall every year
* Evaluations for tinnitus and hearing loss (eg cisplatin)

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6
Q

What are the 2 biggest culprits for CIPN (chemo induced neurotoxicity)?

  • What are the other anticancer drugs of concern asociatedw ith cipn?
A

Taxanes (paclitaxel, docetaxel) and Vinca Alkaloids (vincristine, vinlastine, vinorelbine).

  • Platinums (carbooplatin, cisplatin), IMIDs (thalidomides, lenalidomide), Bortezomib, and Brentuximab vedotin.
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7
Q

How does CIPN present?

  • caused by what?
A

Present as tingles, pins and needls, sensitivity to hot/cold, pain/burning/numness, difficulty with ifne motor skills (usually statrs symetrically at the fingers and toes, progressing towards the body).

  • caused by chemo induced damagae ot nerves away from brain and spinal cord.
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8
Q

CIPN DURATION:

When does CIPN usually BEGIN TO APPEAR?

  • CIPN can persist up to how long with the non-taxane/vincas?
  • what about for taxanes/ vincas?
  • can platinum toxicty lead to permanent damage?
A

~ 3 months after stopping treatment.

 Can persist up to a year or longer with
some medications (IMIDs, brentuximab)

 Taxanes/Vincas CIPN duration can last up to 5-7 years

yes, Platinum toxicity can progress for several
months and lead to permanent damage

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9
Q

Waht are risk factors for CIPN?

 Prior ______
 waht chronic disease?
 ____/____ deficiencies
 ______ history
 Decreased ____

A

 Prior chemotherapy
 Diabetes
 Folate/Vit B12 deficiencies
 Smoking history
 Decreased creatinine clearance

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10
Q

What is the pain reduction goal for CIPN?

A

pain reduction by at least 30%.

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11
Q

What is first line pharmacotherapy for CIPN? alternatives?

A

DULOXETINE!! only agent shown in a RCT to be effective for CIPN

Other agents where efficacy has been established in other forms of
neuropathic pain can be used as adjunct or if duloxetine ineffective or not
tolerated:
* Gabapentin, pregabalin
* TCAs (amitriptyline, nortriptyline, desipramine, or imipramine)

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12
Q

How does CHEMO BRAIN present?

  • mechanism?
A

AS :
 ↓ in memory
 Word-finding difficulty
 Difficulty concentrating
 ↑ time to complete tasks

moa:  DNA damage & oxidative stress from cytotoxics

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13
Q

Prevalence and Duration of CHEMO BRAIN:

  • what is the percentage of perceived brain fog in cancer surivors?
  • can it go away after treatnebt?
  • may persist up to 5-10 years in waht proportion of cancer pts?
A

 46% prevalence of perceived cognitive
dysfunction in cancer survivors

 May go away at end of treatment

 In ~ 1/3 patients, may persist for 5-10 years

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14
Q

Is there an effective BRIEF SCREENING TOOL for chemo-related COGNITIVE DYSFXN?

A

No! Mini-mental state examination (MMSE) lacks adequate sensitivity for the more subtle decline
in cognitive performance commonly seen in survivors

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15
Q

Describe the management of chemo cog dysfxn…

  • _______ of sx exp.
    • Keep in mind the implications to ________ with medications
  • Provide strategies for ______.
  • _________and understanding from friends/family is important
  • ______: routine physical activity, limiting use of alcohol, stress management, relaxation
  • Consider ________.
A
  • Validation of symptom experience
  • Keep in mind the implications to compliance with medications
  • Provide strategies for forgetfulness
  • Social support and understanding from friends/family is important
  • Lifestyle: routine physical activity, limiting use of alcohol, stress management, relaxation
  • Consider meditation, yoga, cognitive training (brain games)
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16
Q

MENTAL HEALTH AND CANCER:

A

Psychological Challenges:

  • Dealing with fear
    –> Can have constant and intrusive thoughts (disease, control,
    independence, dying)
  • Managing anger
    –> Disease, delays, obstacles in health care system
  • Guilt
    —> Cause of illness, impact on family, hereditary component
  • Stress
    –> diagnosis, finances, loss of work, away from school
  • Identity and Self Image
    –> Cancer stigma, changes in appearance
  • Pain
  • Clinical Mental Health Diagnosis
    –> Depression, Anxiety, Adjustment Disorder, PTSD
    –> Cancer survivors use medication for anxiety and depression at a
    rate about twice that of the general population
17
Q

DEPRESSION is highest in pts WHEN during their cancer journey?

  • what about ANXIETY?
A

highest less than 2 years since diagnosis.

  • anxiety highest for pts dx with cancer more than 10 YEARS out. they hope it doesnt come back.
18
Q

What is the non pharm trx for DEPRESSION/ANXIETY associated wtih cancer?

A

Supportive Services:

  • Psychologists
  • Social Workers
  • Support Groups
  • Counselling
19
Q

What are the 2 pharmacotherapy options for cancer related depression/anxiety?

A

Options:
* SNRIs (consider if concomitant pain
or hot flashes)
* SSRIs (watch for drug interactions,
example with tamoxifen)

20
Q

What are the 3 biggest anticancer agents responsible for INFERTILITY?

A

1) ALKYLATING AGENTS (cyclophosphamide biggest culprit)

2) Platinum agents (cisplatin, cabroplatin)
- Infertility assocaiton more conclusive with men; controversial in womn.

2) Hormonal agents (i..e Tamoxifen):
- may cause amenorrhea.
- may be teratogenic.
- is usually long term therapy.

21
Q

What are some methods for FERTILITY PRESERVATION for MEN?

is HORMONAL GONadoprotection considered effective?

A
  • Sperm Banking (semen cryopreservation)
  • Testicular shielding (gonadal shielding): Protective cover placed on the body to shield testicles from scatter radiation
  • Testicular sperm extraction
  • Testicular tissue freezing (this is experimental and ONLY For boys that have NOT gone through puberty and at high risk of infertility.
  • Hormonal gonadoprotection
  • NOT effective (ASCO guidelines)
22
Q

What are some methods for FERTILITY PRESERVATION for WOMEN?

A
  • Oocyte cryopreservation (egg freezing)
  • Embryo banking/cryopreservation: Eggs are fertilized with sperm and then frozen
  • Ovarian shielding
    : where a Protective cover placed on outside of the body to shield ovaries from scatter radiation
  • Ovarian tissue freezing
    : this is an EXPERIMENTAL procedure for girls who HAVE NOT YET gone through puberty (and don’t have mature eggs)
  • Ovarian transposition (oophorpexy)
    : refers to Surgical repositioning of the ovaries away from radiation field
  • Gonadotropin-releasing hormone agonist (GnRHa)
  • Example goserelin
23
Q

What is the ASCO recommendation regarding OVARIAN SUPPRESION WITH GNRH AGONISTS as a method for fertility suppression for women?

A

ONLY use as a LAST RESORT..

 There is conflicting evidence to recommend GnRHa and
other means of ovarian suppression for fertility
preservation.

 When proven fertility preservation methods such as oocyte,
embryo, or ovarian tissue cryopreservation are not feasible,
and in the setting of young women with breast cancer,
GnRHa may be offered to patients in the hope of reducing
the likelihood of chemotherapy-induced ovarian
insufficiency.

 However, GnRHa should not be used in place of proven
fertility preservation methods

24
Q

What are the Chemotherapy agents most implicated in SEcondary Malignancies?

A
  • Anthracycliens (the - rubicins: doxorubuicin, daunorubicin).
  • Topoisomerase inhibitros: ETOPoside.
  • Alkylating agents:
     Bendamustine
     Busulfan
     Carmustine
     Chlorambucil
     Cyclophosphamide
     Melphalan
  • Immunomodulators:
    aka the - thalidomides.
  • PARP inhibitors: i..e Olaparib, Niraparib (the -ribs)
25
Q

Is amenorrhea a good predictor fo fertility? Which makrer is more correlated with follicle count?

A

no!

  • Anti-mullerian hormoen (AMH): it’s a good estimate of follicle count. good to get pretreatment basline, then monitor as trx continues.
26
Q

Women should be counselled to avoid conception for up to how many years after COMPELTING TRX?

A

up to 2 yrs!

27
Q

What are the 4 populations at highest risk of developing secondary malignancies?

A

Breast , Testicular, Lymphoma nad Pediatric pts. {think: a child eating a BLT}

28
Q

What are the 3 subtypes of women’s cancer that are high risk for dvlping secondary malignancies?

  • acute myeoloid -_____.
  • _____ breast cancer.
  • ______ cancer
A

 Acute Myeloid Leukemia
–> cuz of Cyclophosphamide + Doxorubicin as part
of breast cancer treatment regimen.

 Contralateral Breast Cancer
–> Radiation to breast
–> Genetic predisposition
–> Dormant nature of disease

 Endometrial Cancer
–: Tamoxifen use increases risk

29
Q

wHY IS Acute Myeloid Leukemia rates secondary to Testicular Cancer so high?

A

Cuz of the trx for it:

BEP (bleomycin, ETOPOSIDE HUGE CULRIT, and cisplatin).

  • and regimens associated with etoposide > 2g/m^2 were associated with a sig higher risk fo dvlping a secondary leukemia.
30
Q
  • What is the trx regimen for HODGKIN LYMPHOMA? what is the biggest culprit for secondary malignancy?
    • What is the trx regimen for NON- HODGKIN LYMPHOMA? what are the two biggest culprits for secondary malignancy?
A
  • Hodgkin: ABVD. Doxorubicin.
  • Non Hodgkin: R-CHOP. Cyclophosphamide and doxorubicin.
31
Q

What are the 3 anticancer agents most commonly used in pediatric pts that are most responsible for secondary malignancies?

A

Cyclphosphamide, etoposide and anthracycliens. –> Acute myeloid luekemia Usually occurs within 10 years of treatment

ACE

32
Q

How do we SCREEN for secondary malignancies for all cancers except breast?

A
  • All undergo same screening as per population guideliens except breast cancer.
  • With BC, Anyone who’se had radiation ot chest or axilla, they need ot get mammographs starting 8 yrs after radiation, but no earlier than 25. and don’t wait till age 40.
33
Q

What are some non-pharm prevention measures pts can take to reduce chacne of developing secondary malignancies?

the classic….

  • _____ cessaiton.
  • reduce ______Nconsumption
  • have a good _____
  • reduce ___ exposure
  • get vaccines for ____ and ____
A

Prevention:
- the classic….

  • smoking cessaiton.
  • reduce alcohol consumption
  • have a good diet*
  • reduce sun exposure and uyse suncreen.
  • get vaccines for Hep B nad HPV.
34
Q

Does physical activity improves CIPN, chemo induced fatigue,
myalgias/arthralgias from hormonal therapies for breast cancer?

A

Yes, growing body of evidence showing this.

  • Exercise and Cancer Prevention:
    i) Physical activity is linked to decreased cancer incidence, recurrence and increased survival time (in
    certain tumour types)
    ii) Possible link between inactivity/sendentary lifestyle with higher mortality (cohort study of nonmetastatic colorectal cancer patients)
35
Q

What are some chronic mouth problems associated with head and neck radiation? (4)?

  • which is the only short term one?
A
  • Mucositis (short term)
  • Damage to salivary glands (long term)
  • Swallowing disorders (can be long term)
  • Taste/smell disorders (con be short or long term)
36
Q

Waht is the consequecne of damage to salivary glands? hence imp to emphasize what with patients regarding mouth care?

A
  • Damage to salivary glands can lead to dry mouth, severe tooth decay. imp to emphasize:
  • Dental visits very important
  • Fluoride treatments
  • Artificial Saliva

Pharm 401 Midterm #2 (6 decks)

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