Oncology Flashcards
External factors causing cancer
Chemical
Radiation
Bacteria
Viruses
Internal factors causing cancers
Genetic mutations
Hormones
Sunlight exposure
Tobacco use
Excessive EtOH intake
Obesity
Older age
Poor diet
Low physical activity
Warning signs of cancer
CAUTION
Change in bowel or bladder habits
A sore throat that does not heal
Unusual bleeding/discharge
Thickening or lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
Breast cancer screening
Begin yearly mammograms at age 45–54
Mammograms every 2 years or annually at ages ≥ 54 yrs
Cervical cancer screening
Pap smear every 3 years
HPV DNA test every 5 years
PAP smear + HPV DNA test every 5 years
For years 25-65 years
Colorectal cancer screening
Stool-based tests (if +, f/u with colonoscopy): FIT yearly, gFOBT yearly, or MT-sDNA every 3 years
Visual exams: colonoscopy every 10 years, CT colonography every 5 years, FSIG every 5 years
For M/F ≥ 45 yrs old
Lung cancer screening
Annual CT scan if all of the following:
1. 20 pack-year+ smoking history
2. Still smoking or quit smoking in the past 15 years
For F/M ≥ 50 years
Prostate cancer screening
If a patient chooses to be tested:
- PSA blood test with/without DRE
Bleomycin: dosing considerations
Lifetime cumulative dose: 400 units
Pulmonary toxicity
Doxorubicin: dosing considerations
Lifetime cumulative dose: 450-550 mg/m2
Cardiotoxicity
Cisplatin: dosing considerations
Dose per cycle not to exceed 100 mg/m2
Nephrotoxicity
Vincristine: dosing considerations
Single dose “capped” at 2 mg
Neuropathy
Medication given to prevent cardiotoxicity from doxorubicin
Dexrazoxane
Chemotherapy agents that don’t cause myelosuppression
Bleomycin
Vincristine
Asparaginase
Chemotherapies MOST known to cause N/V
Cisplatin
Ifosfamide
Cyclophosphamide
Chemotherapies MOST known to cause Mucositis
Fluorouracil
Methotrexate
Chemotherapies MOST known to cause Cardiotoxicity
Anthracyclines
HER2 inhibitors
Arsenic Trioxide
Many TKIs
Chemotherapies MOST known to cause pulmonary toxicity
Bleomycin
Busulfan
Carmustine/Lomustine
Methotrexate & MAbs (pneumonitis)
Chemotherapies MOST known to cause Nephrotoxicity
Cisplatin
Methotrexate (high doses)
Chemotherapies MOST known to cause constipation
Vincristine
Chemotherapies MOST known to cause diarrhea
Irinotecan
Capecitabine/5-FU
Methotrexate
Chemotherapies MOST known to cause neuropathy
Vinca alkaloids
Platinums
Taxanes
Chemotherapies MOST known to cause clotting
SERMs
Aromatase inhibitors
Immunomodulators
Chemotherapies MOST known to cause Hepatotoxicity
Anti-androgens (bicalutamide, flutamide, nilutamide)
Methotrexate
Drug to give prophylactically with cisplatin to prevent nephrotoxicity
Amifostine (Ethyol)
Also, maintain adequate hydration and do not exceed max dose of 100 mg/m2/cycle
Nadir: defination
Lowest point that WBCs & RBCs reach
WBC/platelet nadir
How many days after chemotherapy?
7-14 days after chemotherapy
RBC nadir
Much later, usually months d/t long lifespan of RBCs (~120 days)
How long does it generally take for WBCs & platelets to recover?
3-4 weeks post-treatment
Neutropenia & severe neutropenia definitions
Neutropenia: < 1,000 cells/mm3
Severe neutropenia: < 500 cells/mm3
Filgrastim (Neupogen) side effects
Bone pain, fever
Febrile neutropenia diagnosis requirements
Fever of > 38.3 degrees Celsius and ANC < 500 cells/mm3
Issues with ESAs and cancer
Can shorten survival and inc tumor progression. For this reason, they are NOT recommended in a patient pursuing curative intent
When to initiate ESAs
Hgb < 10 mg/dL
Use the lowest dose needed to avoid RBC transfusions
When to initiate platelet transfusions for thrombocytopenia
PLT count < 10,000 or
< 30,000 and active bleeding is present
Droperidol: issue
QTc prolongation
Cannabinoids (e.g. dronabinol, nabilone) side effects
Inc. appetite
Sedation
Dysphoria
Euphoria
Aprepitant & dexamethasone DI
Aprepitant is an CYP3A4 inhibitor
**decrease dexamethasone dose
Max dose of Loperamide under medical supervision
16mg/day
Hand-foot syndrome management
Limit daily activities to reduce friction and heat exposure to hands/feet
Avoid prolonged exposure to hot water
Avoid use of dishwashing gloves
Avoid inc. pressure on the soles of feet & palm of hands
TLS complications
Hyperkalemia (arrhythmias)
Hypercalcemia (anorexia, nausea, seizures)
Hyperuricemia (Uric acid crystallizes, causing acute renal failure)
TLS treatment
Hyperuricemia: allopurinol, rasburicase for high-risk patients, and NS for all
Hypercalcemia: mild (hydration), moderate-severe (IV hydration with NS, IV bisphosphonates (Zometa), and calcitonin (up to 2 days) for severe cases. Xgeva for hypercalcemia refractory to bisphosphonates
Major vesicants
anthracyclines & vinca alkaloids
Anthracyclines extravasation management
Dexrazoxane or dimethyl suloxide plus cold compresses
Vinca alkaloids: Extravasation treatment
Hyaluronidase plus warm compresses
Warning signs of melanoma skin cancer
ABCDE
Asymmetry
Border
Color
Diameter
Evolving
Klinefelter syndrome
When males have 1 Y chromosome and 2+ X chromosomes
Males with this genetic condition have a higher risk of breast cancer
Adjuvant treatment for breast cancer in a premenopausal women
Tamoxifen, SERM, antagonist in the breast cells
GnRH agonist (gosereline or leuprolide) to induce menopause IF this then AI is a reasonable option
Adjuvant treatment for breast cancer in a postmenopausal women
Aromatase inhibitors (anastrozole)
Raloxifene for breast cancer prevention in post-menopausal females
Raloxifene: issues
Blood clots & hot flashes
Oncogene
Protein that turns a normal cell into a cancer cell (e.g. HER2)
What supplements to take with tamoxifen (soltamax)
Ca/Vit D
Tamoxifen metabolism
Prodrug, metabolized by CYP2D6
why venlafaxine is preferred for hot flashes instead of fluoxetine & paroxetine
Prostate cancer treatments
GnRH antagonists: examples
Degarelix (Firmagon)
Relugolix (Orgovyx)
GnRH agonists: examples
Leuprolide (Lupon, Depot)
Gosereline (Zoladex)
Anti-androgens (first-generation): examples
Bicalutamide (Casodex)
Flutamide
Nilutamide (Nilandron)
Antiandrogen (2nd generation) examples
Apalutamide (Erleada)
Darolutamide (Nabeqa)
Enzalutamide (Xtandi)
Which prostate chemo drugs can cause an initial surge in testosterone (Tumor flare), and thus must be given with an anti-androgen for several weeks?
GnRH agonists
Androgen deprivation therapy (ADT) side effects
Impotence
Weakness
Hot flashes
Loss of bone density
Mesna (Mesnex) use
Given prophylactically with ifosfamide and high doses of cyclophosphamide to prevent hemorrhagic cystitis
Platinums: issues
Peripheral sensory neuropathy
Ototoxicity
Nephrotoxicity
Carboplatin dosing
Use the Calvert formula
(Target AUC) * (GFR + 25)
Oxaliplatin: unique issues
Cold sensitivity
QT prolongation
Topoisomase I example
Irinotecan
Topotecan
Mtoxantrone: discoloration
Blue
Topoisomase II examples
Etoposide
Bleomycin
Etoposide IV concerns
Infusion-related hypotension (infuse over atleast 30-60 minutes)
Prepare concentration to ≤ 0.4mg/mL to avoid precipitation
Vinca alkaloids concerns (all)
peripheral sensory and autonomic neuropathies (constipation)
Vinca alkaloid most associated with CNS toxicity
Vincristine
Vincaalkaloids most associated with BMS
Vinblastine
Vinorelbine
Vincristine: DI
Major substrate of CYP3A4
Caution with Azole antifungals
Taxanes: DI
Elimination reduced when given after cisplatin/carboplatin. Give taxanes BEFORE platinum-based compounds
Taxanes: common side effects
Peripheral sensory neuropathies
HSR and fatal anaphylaxis
Require adjustment for hepatic impairment
Paclitaxel: premedication
Benadryl, steroid, H2RA
Docetaxel: premedication
Premedicate with steorids for 3 days, starting 1 day prior to docetaxel
Docetaxel: unique concern
severe fluid retention
Abraxane: characteristics
Paclitaxel bound to albumin
No need to premedicate
Pyrimidine Analog Antimetabolites: MOA
active metabolite (F-UMP) is incorporated into RNA to replace uracil & inhibit cell growth while another active metabolite (5-dUMP) inhibits thymidylate synthetase
Capecitabine Boxed Warning/Contraindication
BW: Significant increase in INR during and up to 1 month after treatment
C/I: CrCl < 30 mL/min
What is given with fluorouracil to increase efficacy?
Leucovorin
Dihydropyrimidine dehydrogenase (DPD) deficiency increases toxicity from which drugs?
Capecitabine
Fluorouracil
What drug is the active form of folic acid?
Leucovorin
What is given to rapidly lower MTX levels in patients with MTX-induced AKI & delayed clearance?
Glucarpidase (Voraxane)
If given intrathecally, what formulation of MTX must be used?
Preservative-free
Lenalidomide: Boxed warning
Severe birth defects
Thrombosis
Common characteristics of MAbs
All given as IV infusions
Most associated with infusion related reactions
Agents conjugated to cytotoxic drugs are associated with additional side effects d/t the conjugate
Agents that activate the immune system can be associated with life-threatening autoimmune-mediated side effects
Bevacizumab/Ramucirumab: MoA + common toxicities
MoA: inhibits blood vessel growth
HTN, leading to proteinuria, hemorrhage, thrombosis, impaired wound healing
Cetuximab/Panitumumab: MoA + common toxicities
EGFR antagonist, inhibits growth factor binding to the surface of tumor cells.
EGFR > Epidermis > Skin toxicity (acneform rash)
Rash = working!
Trastuzumab/Pertuzumab: MoA + common toxicity
HER2 receptor antagonist.
Cardiotoxicity
Rituximab/Brentuximab: MoA + common toxicities
Bind to antigens (CD20, CD30, etc) expressed in specific hematopoietic cells & cause cell death.
BMS, inc. risk of viral infection reactivation
Ipilimumab/Pembrolizumab: MoA + common toxicities
Increases immune recognition of tumor antigens.
Over-active immune system = colitis, hepatotoxicity, thyroid dysfunction, myocarditis
Bevacizumab (Avastin): unique concerns
Impairs wound healing: do not administer 28 days before or after surgery
Trastuzumab (Herceptin): monitoring
LVEF (using ECHO or MUGA) at baseline and during treatment
Pharmacogenomics: test for HER2 gene expression
Cetuximab: genomics
Test for EGFR gene expression and KRAS mutation. Must be KRAS wild-type to use in colorectal cancer.
Rituximab: unique concerns
MUST premedicate with Benadryl, Tylenol & steroid.
Must be CD20 positive to use
Hep B reactivation and PML are boxed warnings
Check Hep B panel prior to administration
TKI examples
Imatinib (Gleevic)
All end in “nib”
TKI common characteristics
Require pharmaogenomic testing
Oral bioavailability may be altered with food
TKI: common toxicities
Hypothyroidism
QT prolongation
Rash Correlated with efficacy
Hepatic toxicity
Diarrhea
Those that are multi-targeted may cause HTN, hand-foot syndrome d/t interference with growth of blood vessels (VEGF)
Which oral chemo drugs should be taken with meals or within 1 hour after food?
Imatinib
Capecitabine