Lung Cancer Flashcards
1
Q
*What is the #1 cause of lung cancer?
What are the #2 and #3 causes of lung cancer?
A
cigarette smoking!
Radon
Asbestos exposure
2
Q
*Which type of cancers are most associated with smoking?
A
squamous cell
small cell
3
Q
What is the average age of diagnosis of lung cancer?
A
70
4
Q
T/F the risk of lung cancer decreases with age
A
false
Increases with age
5
Q
There is an 80-90% reduction in risk for lung cancer after _____ years smoking cessation
A
15
6
Q
*What is the only prevention for lung cancer?
A
Smoking cessation
7
Q
*When is screening recommended for lung cancer and what?
A
annual low-dose CT imagining for HIGH risk patients
8
Q
*Who are high risk patients for lung cancer?
A
- Age 55-77
- > /= 30 pack year history
- Smoking cessation < 15 years
9
Q
S/S of lung cancer
A
chest pain, cough, hoarseness, weight loss, dyspnea
10
Q
T/F most lung cancer is metastatic disease at diagnosis
A
True!
NSCLC 55%
SCLC 66%
11
Q
Where does lung cancer like to travel? (4)
A
- brain
- bone
- liver
- adrenal glands
12
Q
S/S of distant spread in lung cancer
A
Neurologic deficits
Bone pain
Jaundice
13
Q
Common paraneoplastic syndromes in SCLC
A
- SIADH
- Cushing’s syndrome
- Eaton-Lambert Syndrome
14
Q
Common paraneoplastic syndromes in NSCLC
A
Hypercalcemia
15
Q
Other S/s of paraneoplastic syndromes in lung cancer
A
nail clubbing
hypercoagulability
16
Q
What can be used for diagnosis in lung cancer surgical candidates?
A
Chest X ray
Chest CT
PET scan
17
Q
Why is molecular testing done in lung cancer?
A
establish prognosis and treatment course
18
Q
How do you confirm diagnosis in lung cancer?
A
tissue biopsy
19
Q
*T/F SCLC is more common than NSCLC
A
false!
80-85% = NSCLC
20
Q
*T/F SCLC and NSCLC are rapid growing
A
False!
SCLC = rapid
NSCLC = slow
21
Q
*What are the 3 histologic subtypes of NSCLC?
A
- Adenocarcinoma (40%)
- Squamous cell (30%)
- Large cell (10%)
22
Q
What are the 2 stages for SCLC?
A
Limited stage
Extensive stage
23
Q
Limited stage in SCLC
A
tumor confined to 1 radiation field
stage I-III
24
Q
Extensive stage in SCLC
A
Multiple lung nodules or distant spread
Stage IV
25
T/F surgery is the mainstay treatment in SCLC
False!
| It is a fast growing tumor, so has limited role!
26
What is definitive treatment for limited stage SCLC?
radiation
27
Radiation in extensive stage SCLC
palliation of symptoms
28
T/F maintenance therapy of chemo is used in limited stage and not extensive stage
false!
| only in extensive stage!
29
*Treatment for limited stage SCLC
cisplatin + etoposide + radiation
30
*Treatment for extensive stage SCLC
Same as limited + CPI
CPI = atezolizumab or durvalumab
31
*What 2 check point inhibitors are used in extensive stage SCLC?
atezolizumab
| durvalumab
32
*Treatment for relapse <6 months in SCLC
Topotecan or clinical trial
33
*Treatment for relapse >6 months in SCLC
Use original regimen
34
Carboplatin dosing
use Calvert equation
| based on AUC
35
Squamous cell NSCLC is more common in who?
Male, smokers
36
Adenocarcinoma NSCLC is more common in who?
Women, non-smokers
37
What is staging based on in NSCLC?
TNM system
38
Testing for KRAS is important for what in NSCLC?
predicts resistance
39
Testing for EGFR is important for what in NSCLC?
predicts response to EGFR TKIs
40
What is a common EGFR mutation in NSCLC?
T790M
41
ALK mutations in NSCLC are common in who?
97% adenocarcinoma
No/light smokers
Young age
Men
42
ROS-1 mutations in NSCLC are common in who?
Adenocarcinoma
No/light smokers
Women
43
What is the most common BRAF mutation in NSCLC?
V600E
44
Who are BRAF mutations in NSCLC common in?
Current or former smokers
45
T/F if you have a PD-L1 expression you typically have other rearrangements
False!
Typically do not
Same with BRAF!
46
*T/F surgery is the initial treatment for resectable tumors in NSCLC
True
47
Radiation in NSCLC
alternative to surgery or with chemo in stage III
48
Chemotherapy in NSCLC
can be in all stages but mainly in II-IV
49
*Non-squamous stage I-III treatment
cisplatin + pemetrexed
50
*Squamous cell stage I-III treatment
cisplatin + gemcitabine
| cisplatin + docetaxel
51
*T/F pemetrexed can be used in any type of NSCLC
false!
| NEVER in squamous cell
52
*Supportive care with pemetrexed and why given
folic acid: GI and myelosuppression
vitamin B12: GI and myelosuppression
dexamethasone: rash
53
Other ades of pemetrexed
nephrotoxicity
| pulm toxicity
54
*Stage IV NSCLC what is the mainstay treatment?
chemo
55
*When deciding chemo in stage IV NSCLC what factors do you consider?
1. performance status
2. histology (squamous/non-squamous)
3. molecular/biomarker testing
56
*PS 3-4 treatment NSCLC
best supportive care
57
PS 0-2 treatment
chemo
targeted therapy
immunotherapy
58
*Treatment (-) or unknown mutational status for non-squamous PS 0-2
pemetrexed + platinum +/- pembrolizumab
*carboplatin/cisplatin
59
(-) or unknown mutational status for non-squamous PS 0-2 maintenance therapy
Continuation maintenance
| Switch maintenance: pemetrexed
60
Treatment (-) or unknown mutational status for non-squamous/squamous progressive disease PS 0-2
*immune checkpoint inhibitors (no previous PD-1/PD-L1 inhibitor)
only exception: NO pemetrexed in squamous!
61
*Bevacizumab indication in NSCLC
combo therapy for non-squamous NSCLC
62
*When do you hold bevacizumab?
4 weeks prior to elective surgery
| at least 4 weeks after
63
BBW of bevacizumab
hemorrhage
GI perforation
wound healing complications
64
Other ADEs of bevacizumab
HTN: hold in uncontrolled
Proteinuria: hold if >/= 2 g/24 hours
65
*Treatment (-) or unknown mutational status for squamous PS 0-2
Platinum + 2nd agent
paclitaxel + carboplatin +/- pembrolizumb
carboplatin + gemcitabine (PS 2)
66
*In squamous cell carcinoma what drugs have NO role? (3)
pemetrexed
bevacizumab
atezolizumab
67
Negative or unknown mutational status for squamous PS 0-2 maintenance therapy
```
continuation maintenance
switch maintenance (docetaxel)
```
68
*Treatment EGFR+ NSCLC
Osimertinib
| *squamous or non-squamous
69
*Treatment EGFR+ NSCLC progression T790M+
Osimertinib
70
*Treatment EGFR+ NSCLC progression T790M(-)
Switch TKI agent
71
*Which EGFR inhibitors are used in NSCLC?
OAGED
```
Osimertinib
Afatinib
Geftinib
Erlotinib
Dacomitinib
```
72
*T/F all of the EGFRs in NSCLC are oral
true
73
Class reactions of EGFRs
rash
| diarrhea
74
Which EGR has risk of QT prolongation?
Osimertinib
75
When would you reduce EGFR dose in rash?
severe!
76
*Treatment ALK rearrangement NSCLC
Alectinib
| *squamous or non-squamous
77
T/F you can use standard acne therapies for EGFR associated rash
false!
| May worsen rash
78
*ALK inhibitors in NSCLC
ABCCL
```
Alectinib
Brigatinib
Certinib
Crizotinib
Loriatinib
```
79
ALK inhibitor class ADEs
```
hepatotoxicity (except briga)
pulmonary toxicity (rare)
```
80
ADE of alectinib
photosensitivity
| nephrotoxicity
81
ADE of brigatinib
arthralgia/myalgia
| hyperglycemia, pancreatitis (IGF-IR)
82
ADE of certitinib
hyperglycemia, pancreatitis (IGF-IR)
83
MOLA of ceritinib
inhibits ALK, ROS1, IGF-IR
84
*Treatment ROS1 rearrangement + NSCLC
Crizotinib
Entrectinib
*squamous or non-squamous
85
*Treatment BRAF V600E+ NSCLC
Dabrafenib + trametinib
86
What type of drug is trametinib?
MEK inhibitor
87
*ADE of trametinib
retinal detachment
| retinal vein occlusion
88
ADE of dabrafenib
fever
89
*Treatment PD-L1+ non-squamous NSCLC
| PD-L1 >50%
pembrolizumb
90
*Treatment PD-L1+ non-squamous NSCLC
| PD-L1 <50%
platinum + pemetrexed + pembrolizumab
*cis/carb
91
*Treatment PD-L1+ squamous NSCLC
| PD-L1 >50%
pembrolizumab
92
*Treatment PD-L1+ squamous NSCLC
| PD-L1 <50%
carboplatin + paclitaxel + pembrolizumab
93
T/F chemotherapy ADEs are usually acute onset and immunotherapy typically delayed onset
true!
94
ADE of immunotherapy
inflammatory or autoimmune effects
| *any organ system involved
95
Common ADE of immunotherapy
dermatitis
colitis
endocrine toxicities
hepatitis
96
Life threatening ADE of immunotherapy
Neurologic effects
Cardiac toxicity
Pneumonitis
Colitis
97
Grade I ADE with immunotherapy tx
continue ICI
98
Grade II ADE with immunotherapy tx
hold ICI
| resume at grade I
99
Grade III ADE with immunotherapy tx
Hold ICI
| High dose steroids
100
Grade IV ADE with immunotherapy tx
Permanently discontinue ICI
| High dose steroids
101
*High dose steroids for immunotherapy ADEs
prednisone/methylpred 1-2 mg/kg/day
| taper over 4-6 weeks
