Onc key points Flashcards
What classification is used in staging most solid tumors?
TNM
What does each letter represent in TNM and what numbers can each have?
T: extent of local invasion, 1-4
N: degree of locoregional lymph node involvement, 0-3
M: presence or absence of mets, 0-1
What term refers to a patient’s well-being and ability to perform ADL?
Performance status
How often is chronologic age a major contraindication to aggressive cancer therapy?
Rarely, if ever
Why is it so important to acknowledge that the disease in incurable in patients with incurable cancer?
This is a dumb question… sorry. But really it leads to appropriate use of analgesics and other comfort-oriented measures.
What does overall survival refer to?
Time from initiation of therapy until death
Overall survival is often quoted as what statistic from a published study?
Medial survival time for a population of pts
What does progression free survival refer to?
Time from initiation of therapy until time therapy is no longer controlling tumor growth
What’s another name for progression free survival?
Progression free interval
Can you correlate PFS w/ OS?
Not really- PFS doesn’t intrinsically indicate improved OS
What does overall response rate mean?
Percentage of pts in a clinical trial whose tumor undergoes a prespecified degree of shrinkage on imaging
What is the primary treatment for locoregional solid tumor malignancies? What 2 things can it be combined with to potentially increase cure rate?
Surgical resection.
Chemo or XRT
When is adjuvant therapy given in relation to definitive surgery? What about neoadjuvant?
Adjuvant is given after, neo before
What is the purpose of giving adjuvant or neoadjuvant therapy with definitive surgery with curative intent in solid tumor patients?
To eradicate micrometastatic disease
What’s the difference btwn predictive assays and prognostic assays for cancer?
Predictive assays ID who’s at risk for CA recurrence and who will benefit from Tx, while prognostic assays can ID who’s at risk for recurrence, but not who will benefit from treatment.
What’s the goal of personalized medicine in onc?
To direct therapeutic approached that are optimally beneficial to an individual patient through a better understanding of the molecular makeup of the individual and the tumor.
What percent of women with breast cancer are older than 40?
95%
Which ethnic group has the highest incidence of breast cancer? Second highest?
First: non-hispanic white women. Second: black women
What additional referral should you make in women with a strong family history of breast cancer?
Genetic counselor for possible genetic testing for breast cancer susceptibility genes
What groups of women are candidates for medical breast cancer Ppx (3)?
Women older than 35 with either
- 5 yr breast cancer risk of 1.7% or higher
- LCIS
- Atypical ductal hyperplasia
For women who are candidates for medical breast cancer Ppx, what drug would you give to the premenopausal ones? What are the 3 options for postmenopausal ones?
Pre: tamoxifen
Post: tamoxifen, raloxifene, or exemestane
What are 2 prophylactic surgical options for BRCA1/2 mutation carriers?
BL mastectomy
BSO
By how much will a prophylactic BL mastectomy decrease breast cancer risk in women who are BRCA1/2 carriers?
90% decreased risk
By how much will a prophylactic BSO decrease ovarian cancer risk in women who are BRCA1/2 carriers?
80% decreased risk
4 clinical features a/w a more favorable prognosis of early-stage breast cancer?
- Hormone-receptor positive cancer
- Small tumor size
- Low tumor grade
- Negative nodes
In women with stage 1 or 2 breast cancer, when would you perform imaging to ID occult metastatic disease?
If they have Sx worrisome for mets
How is early-stage breast cancer defined?
Stage 1 or 2
2 general treatment options for DCIS?
Breast-conserving therapy or mastectomy
What are 2 scenarios in which you’d use mastectomy instead of breast-conserving therapy for DCIS?
Extensive disease
Clear margins can’t be obtained by a wide excision
What drug is useful as adjuvant therapy in ER+ DCIS?
Tamoxifen
In ER+ DCIS, how does adjuvant tamoxifen affect:
- risk of local recurrence of DCIS
- risk of invasive cancer
- risk of contralateral breast cancer
- overall survival
- risk of local recurrence of DCIS: decrease by 20-25%
- risk of invasive cancer: decrease by 20-25%
- risk of contralateral breast cancer: decrease by 50%
- overall survival: no change
For breast-conserving therapy to be effective in invasive breast cancer, describe the size requirements, quadrant involvement, and margins?
Tumor of 5 cm or less; involves a single quadrant of the breast; clear margins s/p excision
Which women with invasive breast cancer require mastectomy instead of breast cancer (5)?
- Tumor involvement of skin or chest wall
- Tumor greater than 5 cm that can’t be shrunk preop with other methods
- Tumor in more than one quadrant
- Inflammatory breast cancer
- Women unable to undergo XRT
Which invasive breast cancer patients need chest wall XRT s/p mastectomy?
- Tumor greater than 5 cm
- Positive margins
- Skin or chest wall involvement
- Inflammatory breast cancer
- Positive axillary nodes
In women with ER or PR+ breast cancer, by how much does antiestrogen therapy decrease risk of local and distant recurrence and of contralateral breast cancer?
Local and distant recurrence: by 40-50%
Contralateral breast cancer: by 50-65%
How long should women with hormone-receptor positive breast cancer take adjuvant tamoxifen?
10 yr
What additional drug should be included in women with hormone-receptor positive breast cancer who are either postmenopausal at diagnosis or become postmenopausal after first 2-3 yr of tamoxifen therapy?
Aromatase inhibitor
Which breast cancer patients benefit most from adjuvant chemo: those with hormone receptor + or - cancer?
Hormone receptor negative cancer benefit most
A combo of two medical therapies are needed in patients w/ a HER2+ breast tumor 0.5 cm or larger?
Adjuvant chemo plus trastuzumab
In women with HER2+ breast tumor 0.5 cm or larger, the addition of trastuzumab to standard adjuvant chemo decreases the risk of recurrence by ___ and the risk of breast cancer-related death by ___.
53%, 34%
Which subtype of breast cancer is characterized by erythema and edema of the skin of the breast, resembling an orange peel?
Inflammatory breast cancer
How is inflammatory breast cancer diagnosed?
Based on the clinical appearance of the breast
What additional staging is done in patients with inflammatory breast cancer (vs only in some w/ invasive breast CA) due to the high risk of mets (2)?
CT and bone scan
Describe treatment of inflammatory breast cancer (super general)
Neoadjuvant chemo-> surgery-> XRT
How often should follow-up monitoring occur in pts w/ early-stage breast CA?
First 2 yr: q3-6 mo
Years 2-5: q6 mo
After 5 yr: annually
Describe frequency of follow-up mammograms in breast cancer survivors? Who gets MRI?
Annual mammos for all. Only do MRI in those @ high risk of recurrence.
Which breast cancer survivors get surveillance blood tests and imaging other than mammo or MRI?
Only those with Sx or findings of disease
Which two classes of drugs are helpful in treatment of therapy-related hot flushes in breast cancer survivors?
SSRIs or SNRIs
When treating hot flushes 2/2 tamoxifen in breast cancer survivors, what subgroup of SSRIs/SNRIs must you avoid? Why?
Strong to moderately strong CYP2D6 inhibitors bc they can inhibit tamoxifen activation
Name two symptoms to monitor for in the upper extremities of breast cancer survivors
Decreased arm mobility and lymphedema
If you notice decreased arm mobility and/or lymphedema in a breast cancer survivor, who should you sent them to?
PT
What are the 3 goals of treatment of recurrent breast cancer with distant mets?
Because this scenario isn’t curable, the goals are…
- Improve survival
- Palliate Sx
- Minimize treatment toxicity
In patients w/ Hx of early-stage breast cancer who develop Sx of mets, what’s the optimal method to confirm the diagnosis (not necessarily the initial step though)? What else will this method allow you to do that imaging wouldn’t?
Bx of suspected metastatic lesion- in addition to confirming Dx, it allows repeat assessment of hormone receptor and HER2 status
What class of drug is usually used in initial Tx of recurrent metastatic hormone receptor+ breast cancer?
Anti-estrogen therapy
When using anti-estrogen therapy as initial Tx of recurrent metastatic hormone receptor+ breast cancer, which 2 groups of patients benefit the most?
Those with bone and soft tissue mets, and those with a longer disease-free interval since the initial breast cancer Dx
Which ovarian cancer patients are eligible for BRCA 1/2 testing?
All of them
How does OCP use affect risk of ovarian cancer?
Use for 15 yr or more decreases the risk by 50% (protective effect lasting for 30 yr s/p OCP cessation), but even shorter use results in some protection
We know not to screen average risk women for ovarian cancer. This is because the predictive values for both CA-125 testing and US are each less than what?
3%
In women with hereditary syndromes predisposing to ovarian cancer, a Ppx BSO reduces ovarian cancer risk by what percent? What is the residual risk of primary peritoneal cancer?
Reduces it by 80%, leaving a 1-3% risk of primary peritoneal cancer
Suspect ovarian cancer in postmenopausal women with which 4 severe and/or persistent Sx?
Abdominal/pelvic pain, bloating, early satiety, anorexia
3 US findings suggestive of malignant ovarian mass?
- Solid component that’s often nodular or papillary
- Ascites
- Peritoneal masses
In pts w/o advanced disease, how do you confirm ovarian cancer diagnosis?
Surgical exploration
In pts w/ advanced disease, what are 2 alternates to surgical exploration for the diagnosis of ovarian cancer?
- Ascites or pleural fluid cytology
2. Image-guided Bx of peritoneal masses
Describe the surgical treatment of ovarian cancer
TAH/BSO, peritoneal washings, lymph node evaluation, and optimal debulking
Which two groups of ovarian cancer patients should consider intraperitoneal chemo over IV due to the 16 month OS benefit?
Stage II and optimally debulked stage III
What has more toxicity in the treatment of ovarian cancer: intraperitoneal or IV chemo?
Intraperitoneal
2 goals of Tx in recurrent ovarian cancer?
Extend survival and improve cancer-related Sx
Secondary cytoreductive surgery is best for ovarian cancer patients meeting what 3 criteria?
PFS interval of at least 12 months
Good performance status
A local recurrence that can potentially be rendered free of gross disease w/ surgery
Which two types of HPV lead to almost all cases of cervical cancer?
16 and 18
If the HPV vaccine is given before infection develops, it’s ___% effective at preventing infection and __-__% effective at presenting CIN and invasive cervical cancer
90, 97-100
3 MC presenting Sx of cervical cancer?
- Abnormal vaginal discharge
- Postcoital bleeding
- Vaginal bleeding btwn cycles or after menopause
When must chemo be given in relation to XRT in order to improve survival in intermediate or high risk cervical cancer?
Concurrently! Adjuvant or neoadjuvant chemo doesn’t imrpove survival
Describe frequency of surveillance evaluations in pts w/ cervical cancer
First 2 yr: q3-6mo
Years 2-5: q6 mo
After 5 yr: annually
Beside H&P, what testing do you do at surveillance exams for cervical cancer?
Pelvic exam w/ cervicovaginal cytology
What is a specific, common, and unfounded fear in the majority of patients just diagnosed with CRC?
The need for a permanent colostomy
Describe use of pre-op PET scans for staging in pts w/ CRC?
Don’t improve pre-op staging, so don’t routinely use
Initial treatment of all pts w/ colon cancer w/o preop evidence of mets?
Surgical resection of the primary and regional nodes
Which group of patients w/ rectal tumors can be treated with surgery alone?
When the tumor is not full-thickness and doesn’t have nodal involvement on pretreatment imaging (stage 1)
In stage 3 colon cancer, you can reduce risk of recurrence and death by giving 6 months of adjuvant chemo based around what drug?
5-FU
Patients with stage II colon cancer and a high risk of recurrence have a prognosis similar to what stage?
Stage III colon cancer
Because pts w/ stage II colon cancer plus a high risk of recurrence have a prognosis similar to stage 3 colon cancer, it may be appropriate to treat them with one of which two drugs?
5FU/leucovorin or capecitabine
Patients with which stage(s) of rectal cancer get neoadjuvant and adjuvant chemo?
3 and 4
Which patients with metastatic CRC may be curable? What procedure is required?
Those with mets confined to a single organ. Surgical resection of the primary + the met.
3 chemo agents (along with one supplement) used to treat metastatic CRC?
5FU, leucovorin, irinotecan, oxaliplatin
How does bevacizumab affect outcome in when added to standard chemo in pts w/ metastatic colon CA?
Modest improvement in outcome
Why should all pts w/ metastatic CRC get tumor genotyping for K-ras and N-ras?
Because the anti-EGFR mAbs are inactive in tumors that harbor these mutations
What percent of metastatic CRC has mutations in N-ras or K-ras?
50%
Name the 2 main anti-EGFR mAbs
Cetuximab and panitumumab
How frequently should CRC patients get post-op surveillance with CT chest/abd/pelvis?
Annually for at least the first 3 years postop
How frequently should CRC patients get post-op surveillance with colonoscopy?
1 yr s/p resection, 3 yr after that, and then q5yr
What’s the goal of post-op surveillance with colonoscopy in pts w/ CRC?
Identification of surgically curable resection
How does treatment of small volume, widely metastatic, ASx recurrent CRC discovered on surveillance impact outcomes?
It doesn’t improve outcome and may subject pts to significant treatment toxicity
When would PET scanning be employed in the post-op screening of CRC patients?
Further evaluation of an equivocal finding on CT
Anal cancer is often curable with XRT plus what 2 chemo agents given concurrently?
Mitomycin + 5-FU
For how long can anal tumors continue to regress after completion of XRT?
6 months to 1 yr
Because anal tumors can continue to regress for 6 mo to a year after completion of XRT, treatment failure may not be declared as soon as it would be in other cases. When would you declare treatment failure?
If unequivocal growth or mets are documented after completion of XRT
What is the only potentially curable option for pancreatic CA?
Surgical resection
Which patients with pancreatic cancer are eligible for surgical resection (with curative intent)?
Pts w/ no evidence of mets and with technically resectable disease
Patients with what stage(s) of gastroesophageal cancer are typically treated surgically?
1-3
General treatment intent of metastatic gastroesophageal cancer?
Palliative
Describe the two general therapeutic approaches to metastatic gastroesophageal cancer (both medical)
Cisplatin-based therapy alone vs cisplatin-based therapy + trastuzumab (used in pts w/ HER2 expression)
What percent of neuroendocrine tumors are functional?
25%
Describe the aggressiveness of well-differentiated neuroendocrine tumors
Indolent
Because well-differentiated neuroendocrine tumors are often very indolent, what is a low-key way that you can manage them?
Expectant obs and serial imaging
If you choose to manage a well-differentiated neuroendocrine tumor with expectant observation and serial imaging, what are the two best options for imaging?
Triple-phase contrast-enhanced CT or MRI with gad
Name 2 small-molecule inhibitors active in PNETs
Sunitinib and everolimus
The cytotoxic combo of what two drugs is active in PNETs?
Capecitabine + temozolomide
Initial management of localized GIST?
Surgical resection
After surgical resection of localized GIST, how do you treat pts w/ favorable RFs?
No further Tx required
After surgical resection of localized GIST, how do you treat pts w/ high risk tumors?
Extended course of imatinib
Management of metastatic GIST?
Lifelong imatinib until disease progresses or treatment toxicity is no longer tolerable
The initial step in development of a therapeutic plan to treat lung cancer is getting a tissue diagnosis. What 2 key things will this tell you?
Small cell vs non-small cell
R/o met from another location
How extensive is lung cancer at diagnosis (typically)?
Advanced, often incurable
Name 3 paraneoplastic manifestations of non-small cell lung cancer
Hypercalcemia, hypertrophic pulmonary osteoarthropathy, and inflammatory myopathies
What is the MC mechanism of paraneoplastic hypercalcemia in NSCLC?
Parathyroid hormone-related peptide
Why is it important to determine subtype of metastatic NSCLC?
Allows determination of proper Tx
Initial treatment of stage I and II NSCLC?
Surgery
Which patients with surgically resected NSCLC get adjuvant chemo?
Stage 2 and 3
Preferred treatment for majority of pts w/ stage III NSCLC?
Combo chemo + XRT
