Lung Cancer

Question 1

Which type of lung cancer leads to a shorter life expectancy due to rapid tumor growth and metastasis? (NSC vs SC)

Answer 1

SCLC

Question 2

What are common metastatic sites of lung cancer?

Answer 2

• Contralateral lung
• Lymph nodes
• Liver
• Adrenal glands
• Bone
• CNS*

Question 3

What are unique symptoms of lung cancer?

Answer 3

• SVC syndrome
• Neurologic symptoms due to CNS metastases
• Paraneoplastic syndromes (SIADH, hypercalcemia)

Question 4

How do you calculate pack years?

Answer 4

Years of smoking * Number of packs/day smoked
(1 pack = 20 cigarettes)

Question 5

Who should we screen for long cancer?

Answer 5

• Adults 50-80 years
• Smokers who quit within the last 15 years AND have a 20+ pack-year smoking history
• Without disqualifying comorbidity that shortens life expectancy

Question 6

How do we treat resectable stage 1 NSCLC?

Answer 6

Surgical resection

Question 7

How do we treat unresectable stage 1 NSCLC?

Answer 7

RT

Question 8

How do we treat resectable stage 2 NSCLC?

Answer 8

1. Surgical resection +/- neoadjuvant
2. Adjuvant therapy

Question 9

How do we treat unresectable stage 2 NSCLC?

Answer 9

Chemo + RT

Question 10

How do we treat resectable stage 3 NSCLC?

Answer 10

1. Surgical resection + neoadjuvant therapy +/- RT
2. Adjuvant therapy

Question 11

How do we treat unresectable stage 1 NSCLC?

Answer 11

1. Chemo + RT
2. Durvalumab maintenance

Question 12

What is the preferred platinum chemo regimen for non-squamous histology?

Answer 12

Cisplatin/pemetrexed

Question 13

Which drug can only be used for non-squamous histology?

Answer 13

Pemetrexed

Question 14

Which people are not candidates for cisplatin?

Answer 14

Poor performance status or significant comorbidities

Question 15

Which consideration does the Calvert equation take into account while dosing carboplatin?

Answer 15

Renal function

Question 16

Which specific ADE is more common in carboplatin than cisplatin?

Answer 16

Thrombocytopenia

Question 17

What are side effects of platinum-based chemotherapy agents?

Answer 17

• Myelosuppression
• N/V
• Diarrhea/constipation
• Nephrotoxicity
• Ototoxicity
• Peripheral neuropathy

Question 18

Which body weight should be used for obese patients?

Answer 18

AdjBW

Question 19

What is the Calvert equation?

Answer 19

Total dose (mg) = Target AUC x (CrCl + 25)

Question 19

How do you calculate the maximum carboplatin dose?

Answer 19

Target AUC x 150 mL/min

Question 20

What are side effects of taxanes (docetaxel, paclitaxel) that we should tell patients about?

Answer 20

Alopecia and peripheral neuropathy

Question 20

What is the maximum CrCl that should be used in the Calvert equation?

Answer 20

125 mL/min

Question 21

What should we give to patients taking taxanes to prevent hypersensitivity reactions?

Answer 21

Dexamethasone, famotidine, Benadryl

Question 22

Why do we give dexamethasone with pemetrexed?

Answer 22

To prevent skin rash

Question 23

Which ADEs are unique to osimertinib compared to other EGFR inhibitors?

Answer 23

- QTc prolongation - Mouth sores - Fatigue

Question 24

What sorts of dermatologic management should be used for patients on EGFR inhibitors?

Answer 24

- SPF 25 sunscreen - Gentle skin care (avoid OTC acne products) - Topical or systemic antibiotics/steroids

Question 25

What should we do if a patient develops grade 3 rashes on an EGFR inhibitor?

Answer 25

- Delay treatment 1-2 weeks - Consider dose reduction - Continue rash management and add prednisone 0.5 mg/kg for 7 days

Question 26

What are our preferred ALK inhibitors?

Answer 26

Brigatinib, Alectinib, Lorlatinib

Question 27

What are the common side effects between the preferred ALK inhibitors?

Answer 27

- Muscle/joint pains - Fatigue

Question 28

Why does lorlatinib have multiple neurological side effects?

Answer 28

It has more CNS penetration (common site of lung cancer metastasis)

Question 29

What are side effects of brigatinib?

Answer 29

- Diarrhea - Fatigue - Lung disease - Myalgia - HTN

Question 30

What are side effects of alectinib?

Answer 30

- Constipation - Fatigue - Liver problems - Peripheral edema - Myalgia - Anemia

Question 31

What are side effects of lorlatinib?

Answer 31

- Fatigue - Peripheral edema - Mood problems - Arthralgia - Dyslipidemia

Question 32

Which drug treats the exon 20 mutation?

Answer 32

Amivantamab

Question 33

(EGFR/KRAS) mutations are more commonly associated with cigarette smoking

Answer 33

KRAS

Question 34

Which drugs are approved for advanced or metastatic NSCLC with KRAS G12C mutation AFTER 1 prior therapy?

Answer 34

Sotorasib and Adagrasib

Question 35

Which KRAS inhibitor requires an acidic environment?

Answer 35

Sotorasib

Question 36

What are the monotherapy agents used for metastatic non-targetable NSCLC?

Answer 36

Pembrolizumab, Atezolizumab, Cemiplimab

Question 37

What is second line treatment for metastatic non-targetable NSCLC if a checkpoint inhibitor has been tried?

Answer 37

Docetaxel + Ramucirumab

Question 38

What is second line treatment for metastatic non-targetable NSCLC if a checkpoint inhibitor has not been tried?

Answer 38

- Pembrolizumab - Nivolumab - Atezolizumab

Question 39

How should we treat grade 1 immunologic ADEs?

Answer 39

Continue

Question 40

How should we treat grade 2 immunologic ADEs?

Answer 40

Hold immunotherapy and consider steroids

Question 41

How should we treat grade 3 immunologic ADEs?

Answer 41

Hold immunotherapy and give prednisone 0.5-2 mg/kg/day or equivalent until resolution to grade 1, then taper for at least 1 month

Question 42

How should we treat immunologic ADEs that are not resolved by steroids?

Answer 42

Mycophenolate, infliximab

Question 43

What VEGF inhibitors can we use for NSCLC?

Answer 43

Bevacizumab, ramucirumab

Question 44

How do we treat limited-stage SCLC?

Answer 44

Cisplatin/carboplatin + etoposide + concurrent RT

Question 45

How do we treat extensive-stage SCLC?

Answer 45

Carboplatin + etoposide + atezolizumab/durvalumab Cisplatin + etoposide + durvalumab

Question 46

What are second line options for SCLC?

Answer 46

- Topotecan - Lurbinectedin - Clinical trial

Question 47

What is the major side effect of etoposide, topotecan*, and lurbinectedin?

Answer 47

Myelosuppression

Question 48

What are unique side effects of lurbinectedin?

Answer 48

Fatigue, hepatic enzyme elevations, extravasation, nausea (pretreat with zofran)