Oncology (focus on SE and management, and key drug info)

Question 1

carcinoma

Answer 1

starts in skin or on tissues that line internal organs

Question 2

leukemia

Answer 2

cancer of leukocytes (blood cancer)

Question 3

multiple myeloma

Answer 3

cancer of bone marrow

Question 4

sarcoma

Answer 4

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

Question 5

adjuvant treatment

Answer 5

given after or along with primary therapy. longer in duration

Question 6

neoadjuvant treatment

Answer 6

treatment given before the primary therapy to shrink the size of the tumor and make surgery more effective

Question 7

palliative

Answer 7

treatment with intention not to cure, but to slow down growth or reduce symptoms

Question 8

remission

Answer 8

disappearance of symptoms of cancer and signs, but not necessarily that the disease is completely gone.

Question 9

Cancer staging (TNM)

Answer 9

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

Question 10

7 warning signs of cancer (CAUTION)

Answer 10

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

Question 11

low dose aspirin is recommended for patients with

Answer 11

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

Question 12

wear spf 15-30, hat w/ at least 2 in brim, stay out of sun 10 am - 4pm, wear sunglasses, and wear a shirt

Answer 12

to prevent skin cancer

Question 13

Screening for breast cancer

Answer 13

yearly mammogram at 45-54 yrs
55 or older, can do it yearly or every two years

earlier than 45 is optional

Question 14

Cervical cancer screening

Answer 14

21 - 29 pap smear q3yrs
30 - 65 pap smear + HPV test every 5 years

Question 15

Colon cancer screening (male and female)

Answer 15

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

Question 16

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

Answer 16

age 55-74 years , get annual chest CT scan

Question 17

prostate cancer screening in pts who choose to be tested

Answer 17

50 or older, PSA or digital rectal exam

Question 18

contraception is required during chemotherapy to prevent issues with baby

Question 19

max lifetime dose of bleomycin and why

Answer 19

400 u max

to avoid pulmonary toxicity

Question 20

max lifetime dose of doxorubicin and why

Answer 20

450-550 mg/m^2 max

to avoid cardiomyopathy. also give with dexrazoxane (totect) to prevent

Question 21

max dose per cycle of cisplatin and why

Answer 21

100 mg/m^2 max/ cycle

to avoid nephrotoxicity. always give hydration and amifostine (ethyol) to prevent

Question 22

vincristine max single dose and why

Answer 22

2 mg max at once

to prevent neuropathy

Question 23

almost all chemo drugs cause myelosuppression. which dont?

Answer 23

asparaginase, bleomycin, vincristine, mAbs, TKIs

Question 24

how to manage myelosuppression

Answer 24

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

Question 25

Common drugs that cause N/C

and management

Answer 25

cisplatin, cyclophosphamide, ifosfamide, doxorubicin, epirubicin

monitor: dehydration

give: NK1-RA (Neurokinin 1 antagonists), 5HT-RA (antagonists), dexamethasone, olanzapine, metoclopramide, prochlorperazine, IV or PO hydration

Question 26

Mucositis is caused by which drugs (same ones that cause diarrhea) and how to manage

Answer 26

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

Question 27

diarrhea is caused by which drugs (same as mucositis) fand how to manage

Answer 27

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

Question 28

constipation caused by vincristine, pomalidomide, thalidomide

Answer 28

monitor: BMs

give stimulant laxative, PEG 3350, miralax

Question 29

xerostomia (dry mouth) is caused by radiation therapy to head and neck regions

Answer 29

give: artificial saliva, pilocarpine, amifostine

Question 30

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)

Answer 30

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

Question 31

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

Answer 31

monitor O2 sat, ABGs, symptoms (SOB, etc)

treat symptoms, use steroids for immunotherapy agents

do not exceed max 400 u of bleomycin in life

Question 32

hepatoxicity is caused by

antiandrogens (bicalutamide, flutamide, nilutamide) folate antimetabolites (MTX), pyrimidine analog metabolites (cytarabine), many TKI’s, some mAbs

Answer 32

monitoring: LFTs, jaundice, ascites

treat their sx but consider stopping tx

use steroids if using a mAb, atezolizumab, durvalumab, ipilimumab, nivolumab, and pembrolizumab

Question 33

nephrotoxicity is caused by cisplatin, MTX at high doses, and pemetrexed and pralatrexte, and some mAbs

Answer 33

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

Question 34

hemorrhagic cystitis caused by ifosphamide (all doses), cyclophosphamide at higher doses > 1 gram/m^2

Answer 34

monitor: urinalysis for blood, sx of dysuria

tx:
always give mesna with ifosphamide prophylactically to reduce the risk of hemorrhagic cystitis. give proper hydration

Question 35

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

Answer 35

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

Question 36

drugs that cause thromboembolic risk

aromatase inhibitors (anastrozole, letrozole), SERMS (e.g. tamoxifen, raloxifene), immunomodulators (thalidomide, lenalidomide, pomalidomide)

Answer 36

tx: consider prophylaxis tx

Question 37

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

Answer 37

if pt on capecitabine overdoses or toxicity, give uridine triacetate within 96 hrs

Question 38

always give mesna and hydration with ifosfamide to prevent hemorrhagic cystitis

Answer 38

always give irinotecan with atropine and loperimide to prevent or treat diarrhea

Question 39

always give high dose MTX with leucovorin or levoleucovorin or to prevent myelosuppression and mucositis

Answer 39

use glucarpidase with MTX as an antidote to decrease excessive MTX levels due to acute renal failure

Question 40

nadir

Answer 40

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

Question 41

kinase inhibitor: trilaciclib (Cosela) used to decrease myelosuppresion in pts on extensive stage small cell lung cancer tx

Question 42

CSF facts
filgrastim/pegfilgrastim

Answer 42

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

Question 43

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

Answer 43

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

Question 44

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

Question 45

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

Answer 45

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

Question 46

drugs with high emetic risk
- cisplatin

Question 47

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

Answer 47

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

Question 48

migraine like HA and constipation and EPS (extrapyramidal sx) are SE of 5HT3 RAs

treat EPS with anticholinergics like benztropine or benadryl

Question 49

Types of substance P/Neurokinin-1 Receptor antagonists (NK1-RAs)

inhibit the substance p/neurokinin 1 receptor and prevent acute and delayed emesis

Answer 49

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

Question 50

5HT - RAs ( block serotonin in Chemoreceptor trigger zone)

Answer 50

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

Question 51

Corticosteroid for CINV

dexamethasone (decadron)
tab, iv, PO

Answer 51

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

Question 52

Dopamine receptor antagonists

Answer 52

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,

Question 53

cannabinoids work by inhibiting vomiting control mechanism in the medulla oblongata

Answer 53

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

Question 54

Benzos for CINV

enhances the GABA inhibitory neurotransmitter to decrease neuronal excitability = relieves anxiety and anticipatory NV

Answer 54

lorazepam (ativan) a C4
0.5-2 mg PO or IV q6hrs MUST START THE EVENING BEFORE CHEMO

Question 55

chemo can cause xerostomia (dry mouth) and mucositis (5FU or MTX) because of damage to the rapidly dividing cells of the GI tract

Answer 55

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.

Question 56

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

Answer 56

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

Question 57

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

Answer 57

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

Question 58

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)

Answer 58

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 -

Question 59

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

Answer 59

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

Question 60

anthracyclines and vinca alkaloids are major vesicants that cause extravastation

Answer 60

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

Question 61

chemo meds that are given intrathecally (into spinal fluid) must be preservative free!!!
(cytarabine, methotrexate, hydrocortisone, thiotepa)

NEVER GIVE VINCRISTINE INTRATHECALLY

Question 62

we do not vaccinate pts during chemo because immune sys. is down

Answer 62

vaccination should precede chemo tx by at least 2 wks

AVOID ANY LIVE VACCINES unless patient has discontinued chemo for at least 3 months