Oncology (focus on SE and management, and key drug info) Flashcards
carcinoma
starts in skin or on tissues that line internal organs
leukemia
cancer of leukocytes (blood cancer)
multiple myeloma
cancer of bone marrow
sarcoma
cancer of connective tissue including fat, muscle, blood vessels, and bone
basal and squamous cell carcinomas are unlikely to metastasize and we can do surgery or topical treatment
adjuvant treatment
given after or along with primary therapy. longer in duration
neoadjuvant treatment
treatment given before the primary therapy to shrink the size of the tumor and make surgery more effective
palliative
treatment with intention not to cure, but to slow down growth or reduce symptoms
remission
disappearance of symptoms of cancer and signs, but not necessarily that the disease is completely gone.
Cancer staging (TNM)
describes the size and the extent (whether its metastasized)
TNM staging , where the T = size and extent, N = spread of cancer to lymph nodes, M= whether the cancer metastasized
7 warning signs of cancer (CAUTION)
change in bowel/bladder habits
a sore that does not heal
unusual bleeding or discharge
thickening or lump in breast or anywhere
indigestion or difficulty swallowing
obvious wart or mole
nagging cough or hoarseness
low dose aspirin is recommended for patients with
to prevent colorectal cancer and CVD in patients who are 50-59 years old, have ASCVD ris k> 10 %, have a >/= 10 year life expectancy and are at low risk of bleeding
wear spf 15-30, hat w/ at least 2 in brim, stay out of sun 10 am - 4pm, wear sunglasses, and wear a shirt
to prevent skin cancer
Screening for breast cancer
yearly mammogram at 45-54 yrs
55 or older, can do it yearly or every two years
earlier than 45 is optional
Cervical cancer screening
21 - 29 pap smear q3yrs
30 - 65 pap smear + HPV test every 5 years
Colon cancer screening (male and female)
starts at age 45
stool based test can be yearly or every 3 yrs or colonoscopy can be every 10 years
or virtual colonoscopy or flexible sigmoidoscopy q5 yrs
lung cancer screening in pts in good health, AND with at least 30 pack yr smoking history, AND still smoking or quit smoking within the past 15 years
age 55-74 years , get annual chest CT scan
prostate cancer screening in pts who choose to be tested
50 or older, PSA or digital rectal exam
contraception is required during chemotherapy to prevent issues with baby
max lifetime dose of bleomycin and why
400 u max
to avoid pulmonary toxicity
max lifetime dose of doxorubicin and why
450-550 mg/m^2 max
to avoid cardiomyopathy. also give with dexrazoxane (totect) to prevent
max dose per cycle of cisplatin and why
100 mg/m^2 max/ cycle
to avoid nephrotoxicity. always give hydration and amifostine (ethyol) to prevent
vincristine max single dose and why
2 mg max at once
to prevent neuropathy
almost all chemo drugs cause myelosuppression. which dont?
asparaginase, bleomycin, vincristine, mAbs, TKIs
how to manage myelosuppression
monitor CBC
neutropenic (wbcs <1,000 cells/mm^3) (sx: fever or infection) –> give CSF’s (filgrastim IV/SC daily- neupogen, or pegfilgrastim SC once per chemo cycle-neulasta, pegylation extends half life)
- severe <500 , profound < 100
- CSFs prevent infx after chemo (prophylactic not tx). if any pt has > 20% chance of getting neutropenia, give CSF
if anemic: sometimes resolves on its own. RBC blood transfusions or ESA’s if palliative pt. ESA’s are rarely used. (ESAs shorten survival and increase tumor progression so avoid in pts receiving chemo with curative intent) only start lowest dose ESAs if at least 2 mo. chemo left and pt Hgb<10, but always make sure the TSAT and TIBC and B12 and folate are good otherwise ESA wont work well
if thrombocytopenia: give platelet transfusions if < 10,000 cell/mm^3, esp. if bleeding
Common drugs that cause N/C
and management
cisplatin, cyclophosphamide, ifosfamide, doxorubicin, epirubicin
monitor: dehydration
give: NK1-RA (Neurokinin 1 antagonists), 5HT-RA (antagonists), dexamethasone, olanzapine, metoclopramide, prochlorperazine, IV or PO hydration
Mucositis is caused by which drugs (same ones that cause diarrhea) and how to manage
fluorouracil, methotrexate, capecitabine, ironotecan, many TKIs
monitor: s&s of HSV infection or oral thrush
give symptomatic tx: mucosal coating agensts, topic anesthetics, antifungals, antivirals
diarrhea is caused by which drugs (same as mucositis) fand how to manage
irinotecan, capecitabine, fluoruracil, MTX, many TKIs
monitor: fluids, electrolytes esp. K+
give: IV/PO fluids, antimotility meds (loperamide). if caused by irinotecan, give atropine for early onset diarrhea
constipation caused by vincristine, pomalidomide, thalidomide
monitor: BMs
give stimulant laxative, PEG 3350, miralax
xerostomia (dry mouth) is caused by radiation therapy to head and neck regions
give: artificial saliva, pilocarpine, amifostine
cardiotoxicity caused by anthracyclines, fluorouracil, and HER2 inhibitors (adotraztuzumab,trastuzumab,pertuzumab, lapatinib) (these cause cardiomyopathy)
and QT prolongation happens with arsenic trioxide, many TKIs, leuprolide (droperadol used for post op N/V increases QT prolongation)
in cardiomyopathy- monitor LVEF, lifetime cumulative dose of anthracycline
treat: doxorubicin lifetime max 450-550 mg/m^2 should not be exceeded and give dexrazoxane
in QT prolongation:
monitor K+, Mg, Ca 2+ to make sure all normal
consider holding therapy if QTc is > 500 msec
Lung issues and how to manage
Pulmonary toxicity is caused by bleomycin, busulfan, carmustine, and lomustine
pneumonitis is caused by chronic use of MTX, mAbs that target CTLA-4 or PD-1
monitor O2 sat, ABGs, symptoms (SOB, etc)
treat symptoms, use steroids for immunotherapy agents
do not exceed max 400 u of bleomycin in life
hepatoxicity is caused by
antiandrogens (bicalutamide, flutamide, nilutamide) folate antimetabolites (MTX), pyrimidine analog metabolites (cytarabine), many TKI’s, some mAbs
monitoring: LFTs, jaundice, ascites
treat their sx but consider stopping tx
use steroids if using a mAb, atezolizumab, durvalumab, ipilimumab, nivolumab, and pembrolizumab
nephrotoxicity is caused by cisplatin, MTX at high doses, and pemetrexed and pralatrexte, and some mAbs
monitor BUN, SCr, urinalysis, CrCl
treat:
give amifostine (ethyol) prophylactically with cistplatin to reduce nephrotox.
hydration
never exceed 100 mg/m^2/cycle of cisplatin
hemorrhagic cystitis caused by ifosphamide (all doses), cyclophosphamide at higher doses > 1 gram/m^2
monitor: urinalysis for blood, sx of dysuria
tx:
always give mesna with ifosphamide prophylactically to reduce the risk of hemorrhagic cystitis. give proper hydration
neuropathy is caused by which meds
peripheral neuropathy
vinca alkaloids (vincristine, vinblastine, vinorelbine) - they also cause autonomic neuropathy
platinums (cisplatin, oxaliplatin)
taxanes (paclitaxel, docetaxel, cabazitaxel)
preoteasome inhibitors (bortezomib, carflizomib), thalidomide, ado-traztuzumab, cytarabine (high doses), brentuximab
monitor for s/sx of paresthesias (pain, tingling, numbness) for peripheral neuropathy
for autonomic neuropathy monitor for constipation
sx treatment with drugs:
vincristine - limit to 2 mg per dose max (regardless of BSA)
oxaliplatin
causes an acute cold mediated sensory neuropathy - pts should avoid cold temps/cold beverages
bortezomib
SC administration assoc. with less peripheral neuropathy than IV
drugs that cause thromboembolic risk
aromatase inhibitors (anastrozole, letrozole), SERMS (e.g. tamoxifen, raloxifene), immunomodulators (thalidomide, lenalidomide, pomalidomide)
tx: consider prophylaxis tx
give 5-FU (fluorouracil) with leucovorin or levoleucovorin (they are cofactors) to enhance efficacy
if pt ever overdoses or toxicity, give uridine triacetate within 96 hrs
if pt on capecitabine overdoses or toxicity, give uridine triacetate within 96 hrs
always give mesna and hydration with ifosfamide to prevent hemorrhagic cystitis
always give irinotecan with atropine and loperimide to prevent or treat diarrhea
always give high dose MTX with leucovorin or levoleucovorin or to prevent myelosuppression and mucositis
use glucarpidase with MTX as an antidote to decrease excessive MTX levels due to acute renal failure
nadir
the lowest point the WBCs and platelets reach 7-14 days after chemo . Nadir period lasts 5-7 days and pts are at highest risk of infection. RBCs take later since life cycle is 120 days
takes WBCs 3-4 weeks to recover - we give next chemo dose then if numbers are better. sometimes need to give drugs or transfusions to speed up recovery
kinase inhibitor: trilaciclib (Cosela) used to decrease myelosuppresion in pts on extensive stage small cell lung cancer tx
CSF facts
filgrastim/pegfilgrastim
MUST ADMINISTER WITHIN 96 HOURS OF CHEMO, but no sooner than 24 hrs after.
SE: bone pain, fever ,rash, glomerulonephritis , patients should report sx of enlarged spleen, RDS, or upper left abdomen pain)
Sargramostim (used only for stell cell transplants) - fever, bone pain, arthralgias, myalgias, rash, dyspnea, HTN, chest pain, peripheral edema, pericardial effusion
always document when pegfilgrastim is given - MUST be at least 12 days before next chemo cycle
monitor: CBC, pulmonary fx, weight, vital signs
STORE IN FRIDGE AND PROTECT FROM LIGHT
empiric antibiotics are started immediately if chemo pt is neutropenic and has FEVER
gram+ and gram- offenders, but gram- have highest risk for causes sepsis SO we must cover gram - including pseudomonas
diagnosis of neutropenic fever:
(oral: > 38.3 C/101F AND > 38 C/100.4 for > 1 hr) AND ANC < 500 or ANC is expected to decrease more in next 48 hrs
IF low risk (ANC expected to drop <500 within 7 days), give oral coverage: cipro or levo PLUS augmentin or (clindamycin if allergic to penicillin)
IF high risk (ANC expected to drop < 100 for over 7 days) or if they have renal or hepatic impairment or comorbidities - use IV
cefepime OR ceftazadime OR meropenem OR imipenem/cilastatin OR zosyn
risk for spontaneous bleeding occurs when plts <10,000 cells/mm^3 so this is when we would give plt transfusions (we can also do <30,000 cells/mm^3 if active bleeding is present)
AVOID IM injections of NSAIDs bc they affect platelet function
Pts at increased risk of N/V
females
< 50 yrs
anxiety
depression
dehydration
Hx of motion sickness
Hx of N/V with prior regimens
for CINV, give antiemetics at least 30 min before chemo and give take home meds too (ondansetron, prochlorperazine, or metoclopramide)
risk for N/V lasts for 3 days post high emetic drug and 2 days post moderate emetic drug
acute CINV - within 24 hours after chemo. targeting serotonin and substance P by using 5HT-3 antagonists or NK1 antagonists, dexamethasone or olanzapine
delayed CINV - 24 hrs after chemo (common with anthracyclines, platinum analogs, cyclophosphamide, ifosfamide, any regimens with high risk for acute CINV.) use 4 DRUG combo of NK1 anagonists (netupitant) AND corticosteroids AND 5HT3 RA (e.g. palonosetron or granisetron ER SC), AND olanzapine.
anticipatory CINV - usually in ppl with hx of CINV in previous regimen. targetting GABA receptor we use benzos in the evening before chemo
drugs with high emetic risk
- cisplatin
Drug options for antiemesis
5HT3 RA
- ondansetron
- granisteron
- palonosetron
NK1 RA
aprepitant
fosaprepitant IV
rolapitant
combo:
netupitant/palonsetron - (akynzeo) - PO
fonetupitant/palonsetron IV (akynzeo)
Benzo:
Olanzapine
steroid: dexamethasone
sometimes can use dopamine receptor antagonists or cannabinoids (dronabinol or nabilone- 2nd line and schedule 1 drug), or olanzapine, lorazepam, or scopolamine
droperidol use to be used but it causes QT prolongation so not any more
high emetic risk chemo: (4 or 3 combo)
NK1RA + 5HT3 RA + olanzapine + dexamethasone preferred
or
palonosetron + olanzapine + dexamethasone
or
NK1 RA + 5HT3 RA + dexamethasone
moderate emetic risk chemo: (2 or 3 combo)
NK1RA + 5HT3 RA + dexamethasone
or
5HT3 RA + dexamethasone
or
palonosetron + olanzapine + dexamethasone
low emetic risk chemo: no benzo needed, no N1K options
-5HT3 or steroid (granisetron or ondansetron), or prochlorperazine, or metoclopramide
migraine like HA and constipation and EPS (extrapyramidal sx) are SE of 5HT3 RAs
treat EPS with anticholinergics like benztropine or benadryl
Types of substance P/Neurokinin-1 Receptor antagonists (NK1-RAs)
inhibit the substance p/neurokinin 1 receptor and prevent acute and delayed emesis
aprepitant (emend)
fosaprepitant (emend) - IV
netupitant + palonsetron (Akynzeo)
fosnetupitant + palonsetron (akynzeo) IV
rolapitant (varubi) tab and inj.
give all 1 hr before chemo
CI: don’t use aprepitant or fosaprepitant with cisapride or pimozide (CYP 3a4 SUBSTRATES)
SE: dizziness, fatigue, constipation, weakness, hiccups, infusion RXNS with fosaprepitant
if using aprepitant/fosaprepiant or netupitant (CYP3a4 inhibitors) use lower dexamethasone dose UNLESS using rolapitant because its a CYP 2d6 inhibitor
5HT - RAs ( block serotonin in Chemoreceptor trigger zone)
ondansetron (zofran, zuplenz film) PO (8-24 mg) and IV (8-16 mg)
granisetron (sancuso) - PO, inj, and patch- patch should be applied 24-48 hrs before chemo - leave in place for up to 7 days
Palonosetron (aloxi) injection or PO, comes in combo with NKR1’s
all should be given on chemo day one before chemo, except granisetron patch
SE: HA, constipation, fatigue, dizziness,
Warnings: serotonin syndrome in combo with other serotonin drugs, dose dependent increase QT interval is more common with IV.
CI with apomorphine (apokyn) due to severe hypotension and loss of concsiousness
Corticosteroid for CINV
dexamethasone (decadron)
tab, iv, PO
12 mg PO or IV on day 1 generally and then may decrease to 8 mg on day 2-4
if low risk, just 12 mg for all chemo days
SE: short term increased appetite/weight gain, fluid retention, emotional instability, insomnia, GI Upset. high doses will increase BP and BG
CI: systemic fungal infections, cerebral malaria
Dopamine receptor antagonists
prochlorperazine (compazine) 10 mg IV/PO, tab, supp, inj. - boxed warning: increased mortality in elderly pts with psychosis related to dementia
promethazine (phenergan, promethegan) tab, PO sol., supp., inj. 12.5 - 25 mg - don’t use with kids < 2 d/t risk of respiratory depression. boxed warning: DON’T give intra-arterial or SC administration, and IV causes extravasation. PREFERRED: GIVE DEEP IM!!!
Metoclopramide (reglan) tab, ODT, inj., nasal spray for diabetic gastroperesis 10 - 20 mg - dose adj . for creatinine clearance 40. boxed warning: tardive dyskinesia can be irreversible esp. with long tx - avoid > 12 wk long therapy
olanzapine (zyprexa) 10 mg PO , ODT, or inj. (works through dopamine and 5HT, and histamine MOA)
Droperidol inj. only for POST OP N/V NOT FOR CHEMO. boxed warning: increased QT prolonging and serious arrhythmias
SE: lethargy, acute EPS (esp. in kids, use benztropine or benadryl), can decrease seizure threshold, increase QT interval, strong anticholinergic SE except metoclopramide (diarrhea)
Olanzapine - se: mild sedation, orthostasis when used for CINV,
cannabinoids work by inhibiting vomiting control mechanism in the medulla oblongata
Dronabinol (marinol) - must refrigerate
C3 - capsules
C2 - oral sol. (this contains alcohol)
Nabilone (cesamet) - no need to refrigerate
SE: somnolence, euphoria, increase appetite, orthostatic HTN, dysphoria, lowered seizure threshold, caution in pts with subs. abuse hx
Benzos for CINV
enhances the GABA inhibitory neurotransmitter to decrease neuronal excitability = relieves anxiety and anticipatory NV
lorazepam (ativan) a C4
0.5-2 mg PO or IV q6hrs MUST START THE EVENING BEFORE CHEMO
chemo can cause xerostomia (dry mouth) and mucositis (5FU or MTX) because of damage to the rapidly dividing cells of the GI tract
pilocarpine (cholinergic) can relieve dry mouth and dry eyes
irinotecan cause cholinergic excess, which leads to (SLUDD) and early onset diarrhea and abd. cramping. 5FU and capecitabine (5Fu’s prodrug) cause diarrhea too esp. if 5FU + leucovorin or pts has rare DPD deficiency
atropine (anti-cholinergic) can help with SLUDD and prevent diarrhea. also, loperamide, (max: 16 mg/day) diphenoxylate/atropine.
Xerostomia
good oral hygeine, soft brush and viscous lidocaine 2% magic mouthwash (don’t use <3 yrs bc of cardio/pulm arrest and death, dose is 15 ml q3hrs PRN), frequent swishing with NaCl helps retain moisture, and the nystatin oral susp. or clotrimazole troches are used to treat oral thrush if it occurs. could use artificial saliva
warnings for lidocaine: dont exceed dose recommendation d/t seizures, cardio/pulm arrest, methemoglobinemia
SE: dizziness, drowsiness, confusion, hypotension
AVOID EATING FOR 60 MIN AFTER lidocaine mouthwash DOSE BC OF RISK OF IMPAIRED SWALLOWING AND ASPIRATION
warning for pilocarpine for xerostomia - use cautiously in cholesthiasis, nephrolithiasis, CVD, lung conditions. avoid giving with high fat meal.
hand foot syndrome (palmar plantar erythrodysethesia - PPE)can happen after capecitabine , fluorouracil, cytarabine, liposomal doxorubicin, and TKIs (sorafenib and sunitinib)
small amounts of chemo leak out of capillaries and into palms of hands and soles of feet , so heat and friction on palms and feet can increases drug leakage = tenderness, pain, inflammation, peeling of palms and soles
cool hands and feet with cold compresses
use emolients (aquaphor, udder cream, bug balm)
use steroids or pain meds
limit activities that cause friction or increase pressure (jogging, jumping, powerwalking, aerobics)
limit heat exposure (hot water in shower or while washing dishes, but they should avoid gloves while washing dishes cause this traps heat)
avoid any task where you have to squeeze your hand or push hand on hard surface
tumor lysis syndrome
most common with leukemia and hodgkins lymphoma
chemo leads to cells lysing and release of their intracellular contents into blood
TLS causes
hyperkalemia = arrythmias,
hyperphosphatemia = binding to calcium and precipitating in soft tissues
hypocalcemia = anorexia, nausea, seizures
and hyperuricemia (when purines from dna are catalyzed by xanthine oxidase to produce uric acid) = acute renal failure or acute gout
hyperuricemia ->
allopurinol (xanthine oxidase inhibitor) + hydration
400-800 mg/day continued 10-14 days after chemo (much larger dose than gout- 100 mg/day)
if allopurinol + hydration dont work or pt cant use allopurinol, rasburicase ($$) can be added or used alone (it converts uric acid to water soluble metabolite. RASBURICASE CI: IN G6PD DEFICIENCY and if pt develops hemolysis DC
we give rasburicase and allopurinol always with IV NS to help increase urine output and speed up excretion of things
certain cancers lead to calcium leaking from the bone into blood
mild hypercalemia (corrected Ca 2+ < 12) can be asymptomatic and tx with loop diuretics and hydration
mod (Corr. Ca2+ 12-14) - severe (>14) : sx (N/V fatigue, dehydration, confusion) and tx with NS, and calcitonin (used for up to 48 hrs bc tachyphylaxis/tolerance develops quick)
calcitonin (miacalcin) 4-8 u/kg/IM or SC q12h; this inhibits bone resorption within 2-6 hrs . used for mod-severe
IV bisphosphonates like zolendronic acid (zometa) - works by stopping osteoclast fx (stops bone resorption too). DONT CONFUSE WITH RECLAST which is a yearly inj. for osteo.
zolendronic acid 4 mg IV once or pamidronate 60-90 mg IV over 2-24 hrs once and can repeat in a week if needed (these are for mild - severe)
loop diuretics and hydration with normal saline (work within minutes) for mild-severe
denosumab (Xgeva) 120 mg SC on days 1, 8, and 15 of first month, then monthly. DONT CONFUSE WITH PROLIA (that one is 60 mg SC q6 months for osteo -
mabs are proteins recognized by human immune system as a foreign substance. risk is higher for immune reaction if murine (mouse components) is in the mAb
cytokine release syndrome (CRS) can occur with few doses of mABs that target T or B cells.
other risk factors:
- high WBC tumor burden
- pre-existing cardiac conditions
always premedicate with mAbs : apap (650 mg PO) and benadryl (IV or PO) and another antihistamine. if needed H2 blockers can be used, steroids, and or meperidine for rigors
anthracyclines and vinca alkaloids are major vesicants that cause extravastation
cold compresses for most drugs, but warm compresses for vinca alkaloids and etoposide
antidotes for extravasation
anthracyclines: dexrazoxane (totect) or dimethyl sulfate
vinca alkaloids and etoposide: hyaluronidasae
chemo meds that are given intrathecally (into spinal fluid) must be preservative free!!!
(cytarabine, methotrexate, hydrocortisone, thiotepa)
NEVER GIVE VINCRISTINE INTRATHECALLY
we do not vaccinate pts during chemo because immune sys. is down
vaccination should precede chemo tx by at least 2 wks
AVOID ANY LIVE VACCINES unless patient has discontinued chemo for at least 3 months
