Oncology Flashcards
What is a malignant tumor?
cancerous
What is a benign tumor?
non-cancerous
What is a malignant tumor?
travel of primary cancer tissue through the lymphatic system or blood to invade other tissues; can form a second tumor with the same cancerous cells at the primary tumor
What are the main types of genes involved in cancer?
- oncogenes (HER2, EGFR,) promote cancer cell growth
- DNA repair genes usually fix the mutations
- Tumor suppressor genes (BRCA1, BRCA2) which normally regulate cell division
What are internal and external factors that promote cancer?
- smoking
- sunlight
- chemicals
- radiation
- hormones (internal)
What are risk factors for skin cancer?
- UV light exposure
- Immunosuppressant drugs/disease (immune system can eliminate some early cancers)
- light skin/hair color
What are counseling points for skin protection?
- Shade between 10am-4pm
- Shirt tightly woven fabric
- Sunscreen SPF 30 and reapply every 2 hours
- Hat with 2-3 “ brim
- sunglasses
What is the ABCDE mnemonic for skin cancer?
A-asymmetry
B- border irregular
C-color is different
D- diameter >6mm
E- evolving
At what ages should females be screened for breast cancer and how often?
40-44: annual mammogram (optional)
45-54: yearly mammogram
≥55: mammogram every 2 years (annual optional)
At what ages should females be screened for cervical cancer and how often?
25-65:
Pap smear Q 3 years
HPV DNA test Q 5 years
Pap smear + HPV DNA test Q 5 years
What ages should colorectal screening start and how often?
≥ 45:
(Stool Based)
Fecal occult blood test yearly
Stool DNA test Q 3 years
(Visual Based)
Colonoscopy Q 10 years
Flexible sigmoidoscopy Q 5 years
What ages should lung CA screening start and how often?
≥ 50 with both criteria met:
1. 20-pack-year smoking history
2. Still smokes OR quit smoking in the last 15 years
Annual CT scan of the chest
What ages should prostate screening start and how often?
Individualized decision:
PSA blood test +/- digital rectal exam
What are the warning signs of cancer (CAUTION)?
C- change in bowel/bladder habits
A- a sore that does not heal
U-unusual bleeding/discharge
T-thickening/lump in the breast/ elsewhere
I-indigestion/difficulty swallowing
O-obvious change in wart/mole
N-nagging cough/hoarseness
What is the TNM staging system?
T- tumor size and location
N- lymph node involvement
M- metastasis
How is cancer diagnosis evaluated?
- Biopsy
- Imaging tests
- Biomarker tests: detects genes, proteins, or other substances released by cancer cells
- genetic tests: cancer genes/ mutations
- H and P, CBC, CMP
What are cancer treatment decisions based on?
- cancer type/characteristics
- stage/metastasis
- physical functioning
- efficacy vs. tolerability
- goals (curative vs. palliative)
What is neoadjuvant therapy?
radiation/chemotherapy is used before surgery to shrink the tumor and make complete resection more likely
What is adjuvant therapy?
chemotherapy/radiation is used after surgery to eradicate residual disease
What is a complete treatment response/remission?
the cancer responded to treatment and cannot be detected
What is a partial treatment response/remission?
substantial reduction in cancer burden, but it is still present
How do traditional chemotherapy agents work?
cytotoxic drugs interfere with cell division and DNA replication; more effective at killing active rapidly dividing cells like the GI tract, hair follicles, and bone marrow (causes common SEs like N/V/D, mucositis, alopecia, myelosuppression)
Which chemotherapy agents work on the M phase (mitosis; division of 2 daughter cells) of the cell cycle?
- Taxanes (Paclitaxel, Docetaxel)
- Vinka alkaloids (Vincristine, Vinblastine)
Which chemotherapy agents work on the S phase (DNA replication) of the cell cycle?
- Antimetabolites (methotrexate, fluorouracil)
- Topoisomerase I inhibitors (irinotecan, topotecan)
AT the s-phase DNA replacATes
Which chemotherapy agents work on the G1 phase?
Pegaspsrgase
Which chemotherapy agents work on the G2 phase?
- Etoposide
- Bleomycin
What chemotherapy agents are non-cell cycle specific?
- alkylating agents (cyclophosphamide, ifosfamide)
- anthracycline (doxorubicin, daunorubicin)
- platinum compounds (cisplatin, carboplatin)
What does a typical chemotherapy regimens look like?
multiple agents increases efficacy via synergistic effects (targeting cells at different stages of replication) usually administered in 2-6 week followed by days to weeks without treatment to allow for recovery of adverse effects
What are chemoprotectants?
reduce toxicity without compromising chemotherapeutic effect
What is the MOA of alkylating agents?
Cross-linking DNA strands which inhibit protein synthesis resulting in cell death; cell cycle non-specific
What are the alkylating agents?
- Cyclophosphamide
- Ifosfamide
- Busulfan
- Carmustine and others
What are safety concerns with cyclophosphamide/ifosfamide?
Hemorrhagic cystitis due to Acrolein concentration in the bladder
What should be monitored with cyclophosphamide/ifosfamide?
- Hematuria
- Dysuria
- urinalysis for RBCs
- lower urinary tract infection
What are safety concerns specific to ifosfamide?
neurotoxicity including encephalopathy and cerebellar dysfunction
How is hemorrhagic cyctisis with cyclophosphamide/ifosfamide prevented and treated?
Prevent:
1. Mesna with all ifosfamide doses and high-dose cyclophosphamide
2. Hydration
Treat: NS bladder irrigation
How is neurotoxicity with ifosfamide prevented/treated?
Methylene Blue
What are the safety concerns with Busulfan?
- Pulmonary toxicity (pulmonary fibrosis)
- seizures
How is Busulfan pulmonary toxicity/ seizure treated?
pulmonary: supportive care (oxygen)
seizure: antiseizure medication (levetiracetam)
What are safety concerns with Carmustine?
- Neurotoxicity (Seizures, cerebral edema)
- Pulmonary toxicity (pulmonary fibrosis)
Ifosfamide
Ifex
Busulfan
Busufex
Myleran
Carmustine
BiCNU
Gliadel Wafer
What is the MOA of platinum-based (platin) chemo?
cross-link DNA interfering with DNA synthesis/cell replication; cell cycle nonspecific
What are the safety concerns with platinum (platin) agents?
- HSR
- Nephrotoxicity
- Ototoxicity
- Peripheral neuropathy
What are safety concerns specific to Oxaliplatin?
Acute sensory neuropathy exacerbated by cold
Which platin has greatest risk of nephrotoxicity and ototoxicity?
Cisplatin
What should be monitored while on platin therapy?
- s/sx Anaphylaxis
- Renal function/ electrolytes
- Audiogram at baseline; s/sx Hearing loss, Tinnitus
- s/sx neuropathy (Extremity Numbness, Paresthesia, Pain)
- oxaliplatin: Abnormal Sensations in hands, feet, perioral area, jaw spasm, chest pressure
How is nephrotoxicity managed with platins?
- Amifostine (Ethyol) reduces cumulative renal toxicity with Cisplatin
- Limit Cisplatin dose per cycle ≤100 mg/m2
- Hydration
How is acute sensory neuropathy with oxaliplatin prevented?
Avoid cold exposure (cold temperatures, consumption of cold food/beverages)
Carboplatin
Paraplatin
What is the MOA of anthracyclines?
Inhibition of Topoisomerase II and creation of ROS
What are the safety concerns with Doxorubicin?
- Cardiotoxicity (cardiomyopathy, HF)
- Red discoloration of body fluids
What should be monitored with Doxorubicin (all anthracyclines)?
LVEF fraction
How is cardiotoxicity with Doxorubicin prevented?
- Limit total lifetime cumulative dose to 450-500mg/m2 (lower end of dose range if CV risk or previous mediastinal radiation)
- Dexrazoxane considered when cumulative doxorubicin dose is ≥300 mg/m2 with planned continued treatment
- Monitor LVEF before and after treatment
Doxorubicin
Adriamycin (brand D/C but name used)
How should red body fluids be prevented with doxorubicin?
N/A not harmful
What is a safety concern with Mitoxantrone (related to anthracyclines)?
Blue discoloration of sclera and body fluids
What is the MOA of irinotecan/ topotecan?
Topoisomerase I inhibitors;
block coiling/uncoiling of double stranded DNA helix during the S phase
What are the safety concerns with irinotecan?
- Acute diarrhea (during/after infusion)
- Cholinergic symptoms (abdominal cramping, lacrimation, salivation)
- Delayed diarrhea (>24 hours after infusion)
What should be monitored with irinotecan?
- frequency of bowel movements
- electrolytes
- dehydration (dizziness, decreased skin turgor)
How are irinotecan SEs treated?
Acute diarrhea: Atropine
Delayed diarrhea: Loperamide
Hydration/electrolyte replacement
Irinotecan
Camptosar
What is the MOA of etoposide?
Topoisomerase II inhibitors;
block coiling/uncoiling of double-stranded DNA helix during the G2 phase
What are safety concerns with etoposide?
infusion rate-related hypotension; infuse over 30-60 min
What is the MOA of vinca alkaloids (vincristine, vinblastine, vinorelbine)?
inhibit microtubule formation during the M phase; microtubules play a role in axon transport causing neuropathy to be common)
What are the safety concerns with vinca alkaloids?
- Peripheral neuropathy
- Autonomic neuropathy (constipation)
- Paralysis and death if given intrathecally
What should be monitored with vinca alkaloids?
- s/sx neuropathy (Extremity numbness, Paresthesia, Pain)
- s/sx constipation (bowel movement frequency, hard stools)- fiber/laxatives
- appropriate administration of product (IV only)
How can peripheral neuropathy be prevented/treated with vinca alkaloids?
- Limit single vincristine dose to 2mg (regardless of BSA dose)
- symptomatic care (neuropathic pain meds)
How can intrathecal administration resulting in death be prevented with vinca alkaloids?
- Prepare in a small IV piggyback that cannot be administered intrathecally
- label products
What drugs have interactions with vincristine?
azole antifungals etc; vincristine is a major CYP3A4 substrate
What is the MOA of taxanes? (Paclitaxel, Docetaxel, Cabazitaxel)
Inhibit depolymerization of tubulin (stabilizes microtubules) during the M phase of the cell cycle
What are safety concerns with taxanes (Paclitaxel, Docetaxel, Cabazitaxel)?
- peripheral neuropathy
- HSR reactions
- Docetaxel: severe fluid retention
What should be monitored with taxanes (Paclitaxel, Docetaxel, Cabazitaxel)?
- Extremity numbness, Paresthesia, Pain, and other s/sx of neuropathy
- Anaphylaxis (angioedema, dyspepsia, urticaria, vital signs, BP,HR)
- s/sx fluid retention (dyspnea at rest, abdominal distention, edema)
How can safety concerns with What are safety concerns with taxanes (Paclitaxel, Docetaxel, Cabazitaxel) be prevented/treated?
- Premedication with systemic steroid (dexamethasone), diphenhydramine, and H2RA (famotidine)
- symptomatic care
- stop therapy and do not rechallenge if HSR is severe
What are important administration instructions for taxanes
- Use non-PVC tubing (except albumin-bound paclitaxel (Abraxane))
- Use 0.22 micron filter (cabazitaxel and paclitaxel)
Cabazitaxel
Jevtana
What is the MOA of pyrimidine analog antimetabolites (fluorouracil 5-FU, capecitabine, cytarabine)?
inhibit pyrimidine DNA synthesis at the S phase
What drug is given with fluorouracil to increase efficacy?
leucovorin or levoleucovorin
What are the safety concerns with pyrimidine analog antimetabolites fluorouracil (5-FU) and capecitabine?
- Hand-foot Syndrome (Plamar Plantar Erythrodysesthesia) capillary drug leakage in the palms/soles of feet/hands
- Diarrhea
- Mucositis
- Dihydropyrimidine dehydrogenase (DPD) Deficiency: Increased Risk of Severe Toxicity (myelosuppression, GI toxicity)
- Increase INR with warfarin significantly
What are safety concerns with pyrimidine analog antimetabolite (Cytarabine)?
- neurotoxicity: acute cerebellar toxicity at high doses (seizure, slurred speech, confusion, incoordination)
- cytarabine syndrome hours after administration (fever, weakness, bone pain, chest pain
How is hand-foot syndrome managed?
- reduce friction/pressure on hands/fees (loose socks, avoid tools that require squeezing)
- avoid heat on hands/feet (lukewarm shower)
- cold compress
- Emollients (ammonium lactate, urea cream, Aquaphor) retain moisture of hands/feet
- topical steroids (clobetasol)/ pain meds
- dose modification/disruption for severe cases
How is DPD deficiency with pyrimidine analog antimetabolites fluorouracil (5-FU) and capecitabine managed?
Antidote: Uridine Triacetate
Capecitabine
Xeloda; Oral prodrug of fluorouracil
What is the MOA of folate antimetabolites (methotrexate, pemetrexed, pralatrexate)?
interfere with enzymes in the folic acid cycle during S phase of the cell cycle
Whata are safety concerns with methotrexate?
- Nephrotoxicity
- GI toxicity: Diarrhea, Mucositis
- hepatotoxicity
- photoxicity
How is nephrotoxicity with methotrexate managed?
Antidote: Glucarpidase lowers MTX levels
1. Leucovorin/ levoleucovorin rescue
2. IV Sodium Bicarb Hydration to Alkalinize the Urine (improve methotrexate solubility)
3. Avoid NSAIDs, salicylates, etc
4. Renal Function Monitoring
5. caution in patients with 3rd spacing (ascites, pleural effusions) have delayed drug clearance
How is diarrhea and mucositis with high methotrexate doses managed?
Leucovorin/levoleucovorin rescue
How is mucositis managed?
- Good oral hygiene (soft toothbrush)
- Frequent bland rinses with NaCl or Na bicarb
- ice chips
- Viscous lidocaine 2%, Magic Mouthwash
- thrush: Nystatin oral suspension, Clotrimazole Troches
How is methotrexate dosed for autoimmune disease (psoriasis/rheumatoid arthritis)?
2-25mg WEEKLY with folic acid 1-5mg daily to reduce SEs
How is methotrexate dosed for oncologic disease?
≥ 40mg/m2 per dose; Leucovorin/levoleucovorin is required at doses ≥500mg/m2 to reduce toxicity (allows DNA synthesis to begin again by competing with MTX for transport into tissues and replenishing folate metabolites displaced by MTX)
What is the MOA of tretinoin (retinoic acid derivative)?
decreases proliferation and increase differentiation of acute promyelocytic leukemia (APL) cells
What are safety concerns with tretinoin?
