Oncology Flashcards
commonly associated ADR of patients undergoing chemotherapy
CINV
A group of disease characterized by uncontrolled and abnormal local cellular growth or reproduction, local
tissue invasion and distant spread to other location or
metastases
Cancer
Second cause of mortality in the United States
Cancer
growth of the tissues of the cells are malignant (reproduce on their own)
Cancer
A new and abnormal growth of tissue in some part of
the body, especially as a characteristic of cancer
Neoplasm
non-cancerous
benign neoplasm
cancer
malignant neoplasm
A multi-step process that includes initiation, promotion,
conversion and progression.
CARCINOGENESIS
exposure of normal cell to carcinogenic substances,
such as radiation, chemicals and other substances →
cellular damage → if not repaired, may lead to
irreversible mutation → promotion
Initiation
- cellular damage can be repaired on its own
● if cells are not severely damaged, it can be repaired
● unrepaired = progress to promotion
initiation
continuous division of mutated cells → alter the environment to favor the growth of the mutated cells
Promotion
If the body recognizes the mutated cell division → ____________
cell toxicity or apoptosis
If the body failed to recognize the mutated cell division
→ _____________
no production of immune cells → conversion
mutated cells are proliferated in the body as normal cells
conversion
involves further genetic changes leading to increased cell proliferation, tumor invasion into local tissue and
development of metastases (invasion of cancer cell), ultimately resulting to cancer
Progression
Growth of both normal and cancerous cells is genetically
controlled by the balance or imbalance of _______________, _____________, and___________.
(GENETIC BASIS OF CANCER)
oncogene, protooncogene and tumor suppressor gene protein product
● Develops from protooncogene or normal genes
● Present in all cells
● Essential regulator of normal cellular function including cell cycle and mitosis
Oncogene
● If there is cell mutation, __________ may increase
proliferation of mutated cells
● when activated → sends signals to cells to multiply
further
oncogene
● Regulates or inhibits the inappropriate cellular growth
and proliferation
Tumor suppressor gene
RISK FACTORS
- Environment
- Lifestyle
- Occupation
PREVENTION AND SCREENING
- Breast Cancer
- Colon/Rectal Cancer
- Prostate Cancer
- Cervical Cancer
● Annual mammogram
● Monthly SBE
Breast Cancer
● Colonoscopy
● Fecal Occult Blood Test
● Flexible Sigmoidoscopy
● Double Contrast Barium Enema
Colon/Rectal Cancer
● Prostate specific antigen (PSA)
● Digital rectal exam annually
Prostate Cancer
● Papanicolaou (Pap) test
● Pelvic exam
Cervical Cancer
○ X-ray picture of the breast
○ once a year, especially patients with history of breast cancer
○ may be done with or without symptoms
Annual mammogram
○ Look for any changes in the skin, like dimpling, and for lumps, which may feel hard or squishy
○ Best time: About 3 to 5 days after start of menstruation
■ breast is less swollen
Monthly SBE (self breast examination)
○ Especially in age 50 and above
○ camera inserted in the rectum/anus to visualize the large intestine
Colonoscopy
blood in the feces
Fecal Occult Blood Test
visualizing the lower portion of the colon (sigmoid)
Flexible Sigmoidoscopy
○ Checking for abnormalities of lower rectum, anus and prostate gland by palpation
Prostate Cancer (digital rectal exam annually)
○ Collection of sample from the surface of the cervix
○ For age 35 and above
○ a swab/small brush is inserted into the cervix/uterus to collect sample. The sample would then be subjected to microscopy for possibility of cancer progression.
Papanicolaou (Pap) test
○ Examine size, shape and position of ovaries and uterus
○ one hand/finger is inserted into the vagina, the other hand pushes down the abdomen.
Pelvic exam
Cancer treatment recommendation depends on the ___________
stage, severity of the cancer
CANCER TREATMENT
- Surgery
- Radiation therapy
- Chemotherapy
- Immunotherapy
- Hormone therapy
● if localized, depends on the stage and patient health; used with chemotherapy and radiation therapy
● may be curative (alam kung nasaan ang cancer) or diagnostic (di alam specific location)
Surgery
● subjects an area with tumor cell growth with high ionizing
radiation to kill cancer cells; used alone or with chemotherapy
● local therapy
● Radiation therapy to kill localized cancer cell, chemotherapy to kill the remaining/escaped cancer cell
Radiation therapy
● use of drugs as treatment; most common
● kills both mutated and healthy/normal cells
○ if healthy cells are killed, bone marrow is suppressed → no formation of new immune
cells/WBC
Chemotherapy
● boosting immune system to destroy cancer
● promote formation of immune cells
Immunotherapy
● slows growth of cancer cells that uses hormone to grow
Hormone therapy
CHEMOTHERAPY
- Curative
- Adjuvant
- Neoadjuvant
- Palliative care
destroy cancer cells that have spread from primary site
CHEMOTHERAPY
● entirely free of disease
● applicable to early stages of cancer detection
Curative
● keep it from spreading
● combination of chemotherapy and radiation therapy
Adjuvant
● reduces tumor burden or spare organ
Neoadjuvant
● relieve of symptoms and allow individual to live comfortably
● for end stage cancer diseases
● not aiming to cure/reverse the cancer, but improve the quality of life of the patient
Palliative care
- A condition of having unusually low levels of neutrophils, a type of white blood cells, responsible for fighting infections
NEUTROPENIA
- May be caused by cancer and cancer medications, genetic conditions, viral, bacterial and parasitic infections, nutritional deficiencies such as vitamin B12, folate or copper, and autoimmune deficiencies
NEUTROPENIA
no clear cause
Chronic idiopathic neutropenia
● the most common dose limiting toxicity associated with traditional cytotoxic chemotherapy
Bone marrow suppression
PRINCIPLES OF CHEMOTHERAPY
- Bone marrow suppression
- WBC count
- Decrease WBC
- risk
- computation of ANC
- Neutropenia
- Febrile Neutropenia
● normal range: 4,800 to 10,800 cells/mm3 with a circulating life span of 6 to 12 hours
WBC count
● neutropenia, leucopenia or granulocytopenia; the risk is
life-threatening infection
○ neutropenia = ↓neutrophils
○ granulocytopenia = ↓neutrophils, eosinophils,
basophils
○ leucopenia = ↓granulocytes
○ these are interchangeable
Decrease WBC
- Risk increase with Absolute Neutrophil Count (ANC) less
than __________ and the risk is greater with an ANC less
than ___________
500/mm3; 100/mm3
○ indicator if the patients can proceed with chemotherapy cycle
○ The total number of neutrophils in the WBC count
Absolute Neutrophil Count
Computation of ANC
ANC = WBC x % granulocytes or neutrophil (segmented
neutrophil + band neutrophil)
Before chemotherapy drug administration:
○ WBC: greater than 3000/mm3
○ ANC: greater than 1500/mm3
○ Platelet count: greater than 10,000/mm3
- An ANC of 500/mm3 or less or a count of less than 1000/mm3 with a predicted decrease to less than 500/mm3 during the next 48 hours
Neutropenia
- Neutropenia and a single oral temperature of 101ºF (38.3ºC) or more or a temperature of 100.4ºF (38ºC) or more for at least one hour
● ANC of less than 500/mm3 + fever
Febrile Neutropenia
- If chemotherapy administration has been delayed or the dose reduced because of prolonged neutropenia, ________________ can be considered for subsequent chemotherapy cycles as secondary prophylaxis
○ primary prophylaxis =_______ of the chemotherapy agent
○ w/ neutropenia = ________. Instead, either ↓the dose or give CSF (Filgrastim)
colony stimulating factor (CSF);
reduce the dose; do not proceed with chemotherapy
Dose reduction of chemotherapy should be considered the __________, instead of a CSF, after an episode of neutropenia in patients being treated with the intent to palliate.
first option
● Not recommended in patients who are neutropenic but
not febrile
● Consider in patients who are neutropenic AND febrile in
the presence of risk factors for complication (ANC < 100/mm3, pneumonia, hypotension, multiorgan dysfunction, invasive fungal infection), in addition to antibiotics to treat neutropenia in patients with these risk factors
Use of CSFs for Treatment of Established Neutropenia
● An unpleasant sensory and emotional experience associated with the actual or potential tissue damage or
described in terms of such damage
● Often subjective
Pain
Either somatic or visceral
Nociceptive Pain
arising from skin, bone, joint, muscle, or connective tissue
somatic
arising from the internal organs such as large intestine or pancreas
visceral
Pain sustained by abnormal processing of sensory input
by peripheral or CNS
Neuropathic Pain
- damaged nerves, generalized pain
● capable of signaling the body to activate nerves at different sites
● more difficult to treat
Neuropathic Pain
ANALGESIC MEDICATIONS
- Non-opioid Analgesic
- Opioid analgesic
- Non-Opioid – Opioid Combination
Pain medication should always be administered on a
schedule and not on PRN basis (t or f)
T
Cancer Pain Management: preferred route of administration
Oral
- Act peripherally to inhibit the activity of prostaglandin in the pathway
● first line of drug for patients with mild to moderate pain
● reduce inflammation and pain signals
Non-opioid Analgesic
- Act centrally in the brain and at the level of the spinal cord at specific opioid receptor
● for moderate to severe pain
Opioid analgesic
Medications that are not for pain, but they enhance the analgesic effect of other medications
adjuvant therapy
adjuvant therapy
- Antidepressant (Amitriptyline) and Anticonvulsant
- Transdermal Lidocaine
- Corticosteroid
- Benzodiazepine, Diazepam and Lorazepam
neuropathic pain
Antidepressant (Amitriptyline) and Anticonvulsant
- localized neuropathic pain
● topical anesthetic
Transdermal Lidocaine
● inflammation, bone pain, or increased intracranial pressure
Corticosteroid
muscle pain or muscle spasms
Benzodiazepine, Diazepam and Lorazepam
Ejection or expulsion of gastric content through the mouth
Vomiting
- Awareness of discomfort that may or may not proceed to vomiting; accompanied by decreased gastric tone and
decreased peristalsis
Nausea
CLASSIFICATION of N/V BASED ON ONSET
- Acute
- Delayed
- Anticipatory Vomiting
- Breakthrough Vomiting
Occurs 0 to 24 hours after chemotherapy
Acute
Occurs more than 24 hours after chemotherapy
Delayed
Caused by triggers, such as the sights, smells or sounds of the treatment room, even without the chemotherapy treatment yet
Anticipatory Vomiting
Occurs despite prophylaxis and may require rescue therapy of other antiemetics
Breakthrough Vomiting
Risk Factors for CINV
● Patient’s age (younger patients or younger than 50 years old)
● Female
● History of Morning Sickness
● History of Nausea and Vomiting in previous chemotherapy
● History of Alcoholism
Risk of producing emesis.
Emetogenic Potential
AC combo: Doxorubicin or
Epirubicin with Cyclophosphamide
Carboplatin ( AUC ≥ 4 )
Cisplatin
Cyclophosphamide ( > 1500
mg/m2 )
Doxorubicin ( > 50 mg/m2 )
HIGH
Carboplatin ( AUC < 4 )
Cyclophosphamide ( ≤ 50
mg/m2 )
Methotrexate ( ≥ 250 mg/m2)
MODERATE
Liposomal Doxorubicin
5-Fluorouracil
Methotrexate ( 50 < x < 250
mg/m2 )
Paclitaxel
LOW
Methotrexate ( ≤ 50 mg/m2 )
Vinblastine
Vincristine
MINIMAL
Management
- Serotonin (5HT3) Receptor Antagonists
- Corticosteroids
- Neurokinin-1 Receptor Antagonists
- Benzamide Analogs
- Butyrophenone
- Benzodiazepines
- Cannabinoid
Serotonin released from the gut in response to various stimuli acts on the ______ in the brainstem, initiating the vomiting reflex
- chemoreceptor trigger zone (CTZ)
Blocks serotonin receptor peripherally in the
gastrointestinal tract and centrally in the medulla
Serotonin (5HT3) Receptor Antagonists
Granisetron, Ondansetron, Palonosetron, Dolasetron
(DC)
Serotonin (5HT3) Receptor Antagonists
MOA: Unknown, thought to act by inhibiting prostaglandin synthesis in the cortex
Corticosteroids
Dexamethasone, Methylprednisone
Corticosteroids
- Used in combination with other antiemetic drug for
preventing acute and delayed nausea
● Neurokinin-1 Receptors are triggered by substance P in
the gut, which signals brainstem to induce forceful
expulsion of stomach contents
Neurokinin-1 Receptor Antagonists
Aprepitant or Fosaprepitant
Neurokinin-1 Receptor Antagonists
- Blocks dopamine receptor in the CTZ
● Stimulation of cholinergic activity in the gut
● Increasing gut motility
○ This promotes gastric contents to the small
intestine. Which in turn prevents regurgitation to
the esophagus and mouth. Hence, prevents vomiting.
● Antagonizes peripheral serotonin receptor in the intestine
Benzamide Analogs
Prochlorperazine, Chlorpromazine, Promethazine
Benzamide Analogs
Similar to and as effective as phenothiazine
Butyrophenone
antipsychotic medication with
antiemetic effects to treat transient nausea and vomiting
associated with viral infections, surgery or gastrointestinal illnesses
Phenothiazine
● Minimal antiemetic activity
● Used in combination with other antiemetic
● Anterograde amnesia helps prevent anticipatory N&V
● Relief of anxiety
Benzodiazepines
Lorazepam
Benzodiazepines
____________ receptor in the brain and gut may mediate at least some of the antiemetic activity
Cannabinoid
- Inhibition of prostaglandin and blockade of adrenergic
Cannabinoid
Heavy and long-term cannabinoid use can lead to
_______________ characterized with cyclic vomiting or repeated episodes of severe N&V
Cannabinoid Hyperemesis Syndrome
