Oncology I Flashcards
List ways on which adults can control their health and reduce their cancer risk
Stay away from tobacco (smoking cessation if needed)
Stay at a health weight
Get moving with regular physical activity
Eat healthy with plenty of fruits and vegetables
Limit how much alcohol u drink (if u drink at all)
Protect your skin
Know you’ll, ur FH and ur risks
Have regular check-ups and cancer screening tests
Most cancers will not relapse if a pt remains CA free for 5 yrs?
T
What’s most often the primary tx of CA?
Surgery (if CA is resectable)
Role of radiation or chemo?
Neoadjuvant therapy…. May be used b4 surgery to shrink tumor initially
What’s Neoadjuvant therapy?
Given B4 surgery
What’s adjuvant therapy?
Radiation and/or chemo done AFTER surgery (to eradicate residual dx and decease recurrence)
Chemo regimens are usually designed for synergy?
T
Chemo regimens are designed to complement each other (with different MOA, toxicities, and cell cycle specificity)
What’s the main cause of ADRs suffered by CA pts?
Damaging effects of chemo on rapidly dividing cells that are not cancerous
Where are the normal rapidly dividing cells? SEs from these?
GI, Hair follicles and bone marrow (blood cells)
T4, the most common SEs of chemo are
N/V; Alopecia; Myelosuppression
Why must the pts quality of Iife be accessed?
Bcuz of sever SEs of chemo
Is chemo advised during pregnacy (both males and females) and during breast feeding?
No
List the toxicities caused by chemo agents
Myelosuppression
Neuropathy
Cardiotoxicity
Pulmonary toxicity
Pneumonitis
Nephrotoxicity/Bladder toxicity (cystitis)
Acneform rash
Mucositis
Hand-foot syndrome
Hepatoxicity
Clotting risk
Alopecia
Extravasation
What’s Myelosuppression? Monitoring?
Bone marrow suppression => Decreased RBC, WBC, and platelets
CBC + differential (includes segs and bands, to calculate absolute neutrophil count (ANC))
Which drugs don’t cause Myelosuppression?
ABV
Asparaginase
Bleomycin
Vincristine
Classes with highest risk of Neuropathy?
PTV
Platinum agents
Taxanes
Vinca alkaloids
Monitoring for Cardiotoxicity? What should be avoided?
ECG or ECHO or MUGA monitoring
Chest radiation is avoided…causes more damage
Cardiotoxicity is more severe with what agents?
Cardiomyopathy:
- Anthracyclines* (think chemo man doxorubicin-heart)
- HER2-I’s
- fluorouracil
- lapatinib
QT Prolongation:
- Arenicic trioxide*
- TKIs
High risk agents for Pulmonary toxicity?
Pulmonary fibrosis:
- Belomycin and 3 specific alkylators: busulfan, carmustine, lomustine (think chemo man bleomycin lungs)*
Pneumonitis:
- Methotrexate
- Immune therapy MAB’s
What’s used to flush drug out and prevent bladder/renal toxicity?
Hydration
What may be used to reduce risk of Cisplatin-induced nal toxicity?
Amifostene (Ethyol)
What’s always given with Ifosfamide? Why?
MESNA (Mesnex) (also recommended in HIGH doses of cyclophosphamide)
To prevent hemorrhagic cystitis
Which agents cuz Acneiform rash?
Cetuximab
Erlotinib
Panitumumab
Sorafenib
Sunitinib
And all agents with EGFR inh MOA
What’s mucositis?
Painful inflammation of GI tract
Called oral mucositis if conc in mouth
High risk agents for Mucositis?
5- fluorouracil
Capecitabine
Irinotecan
Methotrexate
Which 2 agents are mist prone to causing Hand-foot syndrome?
Capecitabine
5-FU
Agents at mist risk of causing clotting risk?
SERMs (monitor for DVT/PE)
Some immunomodulators eg.
Thalidomide
Lenalidamide
Pomalidomide
Which agents cause the highest risk of alopecia?
Taxanes
Anthracyclines
These cause alopecia in nearly 100% of pts
What’s Extravasation?
Leakage of drug from vein into extravascular space.
How to deal with Extravasation? Exception?
Stop infusion
Elevate limb
Use cold compress (except with Vinca alkaloids and Etoposide - use warm compress)
Agents that have a high risk of Extravasation?
Anthracyclines
Ixabepilone
Mitomycin
Teniposide
Vinca alkaloids
Antidotes for Extravasation caused by Anthracyclines?
Dimethyl Sulfoxide (DMSO)
or
Dexrazoxane (Totect) - Main one
Or
Mitoxantrone
Antidotes for Extravasation caused by Vinca alkaloids?
Hyaluronidase
Antidotes for Extravasation caused by Mechlorethamine?
Sodium thiosulfate
When does the Nadir (lowest point that WBC and platelets reach) occur?
About 7-14 days after chemotherapy
RBC - 120 days after chemo cuz of long lifespans
When do cell lines gen recover post-tx?
3-4 weeks pits tx
Effect of ESA on some CA?
ESAs can shorten and increase tumor progression in some CA
What must be fulfilled b4 ESA is used in CA?
ESA APPRISE (REMS program)
Normal hgb levels?
F - 12-16 g/dL
M - 13.5-18g/dL
What’s ordered to access iron storage and transport?
Serum ferritin + Transferrin saturation + Total iron-binding capacity
(TIBC)
Why must iron storage and transport be measured b4 starting ESAs?
ESAs won’t work well to correct anemia if iron levels are inadequate
BBWs for use of ESAs in CA?
Can shorten overall survival and/or increase the risk of tumor progression or recurrence
Prescribers and hospitals must enroll in and comply with ESA APPRISE
Pt must receive ESA MedGuide (when therapy begins and at least monthly, if continuing)
ESAs shouldn’t be used if hgb level < 10g/dL
ESAs aren’t indicated for pts when anticipated outcome is cure, since tumor may progress and there’s thrombosis risk
At what level of hgb is ESA to recommended?
Hgb < 10g/dL
List ESA agents
Epoetin alfa (Epogen, Procrit)
Darbepoetin (Aranesp)
Brand name of Epoetin alfa (ESA)?
Epogen
Procrit
Brand name of Darbepoetin alfa (ESA)?
Aranesp
What may contribute to risk of ADRs with ESAs (Epoetin alfa (Epogen, Procrit) and Darbepoetin (Aranesp)) use?
Rapid rise in hemoglobin (> 1 g/dL over 2 wks)
SEs of ESAs (Epoetin alfa (Epogen, Procrit) and Darbepoetin (Aranesp))?
HTN
Thrombosis
Monitoring while on ESAs (Epoetin alfa (Epogen, Procrit) and Darbepoetin (Aranesp))?
Hgb
Hct
Transferrin saturation
Serum ferritin
BP
How do u categorize Neutropenia in CA?
< 1,000 mmol/L
How do u categorize Severe Neutropenia in CA?
< 500 mmol/L
How do u categorize Profound Neutropenia in CA?
< 100 mmol/L
Know how to calculate ANC?
Reviewed in calculations chapter
Role of CSFs (myeloid growth factors)?
When used prophylactically in pts with high risk of febrile neutropenia, that shorten risk of infection due to neutropenia and reduce mortality from inf
Agents under CSFs (myeloid growth factors)?
Sargramostim (Leukime) GM-SCG
Filgrastim (Neupogen) G-CSF
Pegfilgratim (Neulasta) Peglyated G-CSF
Brand name of Sargramostim - CSFs (myeloid growth factors)?
Leukine
Brand name of Filgrastim - CSFs (myeloid growth factors)?
Neupogen
Brand name of Pegfilgrastim - CSFs (myeloid growth factors)?
Neulasta
Ses of Filgrastim (Neupogen) & Pegfilgrastim (Neulasta)?
Bone pain
SEs of Sargramostim (Leukine)?
Fever
Bone pain
Arthralgias
Myalgias
Rash
When’s platelet transfusion recommended in thrombocytopenia?
When counts fall below 10,000/mm^3
20,000/mm^3 if pt has an active bleed
List agents with high emetic risk (> 90% freq)
Cisplatin
AC combo (Doxorubicin or Epirubici + Cyclophosphamide)
Epirubicin > 90mg/m2
Ifofsamide >= 2 g/m2 per dose
Cyclophosphamide > 1,500mg/m2
Doxorubicin >= 60 mg/m2
List agents with minimal emetic risk (< 10% freq)
Majority of monoclonal antibodies Bevacizumab Cetuximab Ipilimumab Panitumumab Pertuzumab Rituximab Trastuzumab
Bleomycin
Vinca alkaloids
List Anti-Emetic regimens for acute nausea and vomiting
Aprepitant (IV = Fosaprepitant) +
Dexamethasone + (1st two are for days 1-4)
Ondansetron (PO/IV) / Granisetron (PO/IV) / Dolasetron (PO only) / Palonosetron (IV preferred) (for day 1 only)
What’s the alternative for n/v?
Olanzapine-Containing regimen
Olanzapine (PO) + Dexamethasone (IV) + Palonosetron (IV)
What’s delayed emesis?
Vomiting occurring > 24 hrs after chemo
Prevention of delayed emesis?
Dexamethasone
Aprepitant
Palonosetron
( alone or in combo)
What may be added for anxiety/amnestic response?
Lorazepam (Ativan)
What could be used if upper GI sx similar to GERD are present?
H2RA or PPR
What’s the gold standard to moderate emergencies chemo?
Steroid + 5-HT3 receptor antagonist
Agents used in Low emetic risk chemo?
Single agents eg
Dexamethsone
Or
Prochlorperazine
Or
Metoclopramide
Concern with Phenothiazines and Metoclopramide use?
Dopamine-blocking agents… Could cause or worsen movement disorder
Sedating and can cause cognitive dysfunctions
When do u reduce Metoclopramide dose?
Renal dysfunction
SEs of centrally-acting antihistamines eg diphenhydramine? Why?
Can cause central and periphetal anticholinergic SEs
These may be intolerable in elderly pts
Which can be used a 2nd line agents in low emetic risk?
Dronabinol (Marinol)
Nabilone (Cesamet)
(These are delta-9-tetrahydrocannabinol…from cannabis (marijuana))
MOA of 5-HT3 antagonist?
Block serotonin, both peripherally on vagal nerve terminals and central in the chemoreceptor trigger zone
Agents under 5-HT3 antagonist?
All these can be used in high emetic risk
Ondasetron (Zofran, Zuplenz film)
Granisetron (Granisol soln, Sancuso transdermal patch)
Dolasetron (Anzemet)
Palonosetron (Aloxil)
Brand name of Ondansetron (5-HT3 antagonist)?
Zofran
Zuplenz film
IV, PO, ODT, soln
Brand name of Granisetron (5-HT3 antagonist)?
Granisol soln
Sancuso transdermal patch
IV, PO, soln
Brand name of Dolasetron (5-HT3 antagonist)?
Anzemet
Brand name of Palonosetron (5-HT3 antagonist)?
Aloxil
What’s the single max IV & PO dose of Ondansetron (Zofran, Zuplenz film)?
IV dose - 16mg
PO - 24mg
CIs to 5-HT3 antagonists use?
Don’t use Dolasetron (Anzemet) IV for acute CINV (due to QT prolongation)
SEs to 5-HT3 antagonists use?
HA
Fatigue
Dizziness
Constipation
Role of Sancuso patch (Granisetron) in therapy?
Useful if sores in mouth (mucositis)
Apply day before chemo and leave on at least 24 hrs after last session - lasts up to 7 days
What’s a risk associated with 5-HT3 antagonists use? What should be corrected b4 using 5-HT3 antagonist?
Risk of QT interval (torsades de Pointes)
Correct Mg and K and monitor ECG
MOA of Phenothiazines?
Block dopamine receptors in the CNS, including the chemoreceptor trigger zone (among other mechanisms)
Agents under Phenothiazines?
Prochlorperazine (Compro)
Chlorpromazine (Thorazine)
Promethazine (Phenergan, Phenadoz, Promethegan)
Brand name of Prochlorperazine - Phenothiazines?
Compro
Brand name of Promethazine - Phenothiazines?
Phenergan
Phenadoz
Promethegan
CI to Phenothiazines?
Don’t use in children < 2 yrs
Don’t admin Promethazine via SC route
SE to Phenothiazines?
Sedation
Lethargy
Acute EPS
List corticosteroid used in emetic?
Dexamethasone (Decadron) IV, PO
What’s the brand name of Dexamethasone?
Decadron
Cannabinoids used as emetic?
Dronabinol (Marinol) - C III
Nabilone (Cesamet) - C II
How should Dronabinol (Marinol) - C III be stored?
Refrigerate capsules
SEs to Cannabinoids (Dronabinol, Nabilone)?
Drowsiness
Euphoria
Increased appetite
Uses of Substance P/Neurokinin-1 receptor antagonist?
Acute and delayed emesis
Agents under Substance P/Neurokinin-1 receptor antagonist?
Aprepitant (Emend)
Fosaprepitant (Emend for inj)
Brand name of Aprepitant and Fosaprepitant? (Substance P/Neurokinin-1 receptor antagonist)
Aprepitant (Emend)
Fosaprepitant (Emend for inj
SEs of Substance P/Neurokinin-1 receptor antagonist (Aprepitant (Emend) and Fosaprepitant (Emend for inj))?
Dizziness
Fatigue
Constipation
Hiccups
What’s prophylaxis for mucositis that ALL pts can use? Which is FDA approved?
Saline rinse several times daily
Palifermin (Kepivance) is FDA-approved only for high dose chemo prior to stem cell transplant
What’s best to prevent hand-foot syndrome?
Emollients such as petrolatum, Udderly smooth cream and Bag Balm
Note: lotions don’t provide adequate protection
Whats used early in metastatic dx to PREVENT SKELETAL-RELATED EVENTS (bone pain, skeletal damage eg fracture)
Bisphosphonates
Or
Denosumab (Xgeva)
List tx of hypercalcemia of malignancy tx
Hydration with normal saline
Loos diuretics
Calcitonin
IV Bisphosphonates (Zoledronic acid (Zometa) or Pamidronate (Aredia))
How’s loop diuretics used in CA?
Only with hydration
Vaccinations and chemo?
Avoid vaccinations during chemo
Vaccinations must be given at least 2 wks b4 chemo starts
List the warning signs of cancer in adults
Change in bowel or bladder habits A sore that doesn't heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough or hoarseness
CAUTION
Cancer screening recommendations in women:
Once 21 yo: pap smear q3yr
Once 30 yo: pap smear + HPV test q5yr
Once 45 yo: mammograms yearly, AND [fecal occult blood test yearly OR stool DNA test q3yr], AND [colonoscopy q10yr OR sigmoidoscopy q5yr]
Once 55 yo: CT of chest yearly IF smoking Hx
Cancer screening recommendations in men:
Once 45 yo: [fecal occult blood test yearly OR stool DNA test q3yr], AND [colonoscopy q10yr OR sigmoidoscopy q5yr]
Once 50 yo: if patient opts to be treated: PSA +/- DRE
Once 55 yo: CT of chest yearly IF smoking Hx
Most important drugs regarding nephrotoxicity
Platinum agents, Cisplatin most importantly, and MTX.
Hemorragic cystitis is apparently considered a separate complication.
