Oncology I: Overview, Side Effect Mgmt, Oncologic Emergencies Flashcards
What are some risk factors for developing cancer?
chemicals/radiation diet low physical activity genetics (BRCA gene, etc.) excessive alcohol intake hormones age sunlight exposure tobacco obesity
At what age should women begin receiving annual mammograms?
45 years (can start as early as 40, probably good for those with a family history)
screening guidelines for cervical cancer
Starting at age 21, a PAP smear is recommended every 3 years until age 30. Then, a PAP smear and an HPV test are recommended every 5 years.
colon cancer screening guidelines
Stool based tests should begin every year at age 45. Colonoscopy every 10 years, or CT colonography/flexible sigmoidoscopy every 5 years.
Who should be screened for lung cancer? How?
Patients who meet the following 3 criteria should receive a yearly CT chest starting at age 55:
1) in good health
2) have at least 30 pack year history
3) still smoking or quit within last 15 years
Prostate cancer involves what two tests, starting at what age (for those who elect)?
Starting at age 50, prostate cancer screening involves a PSA test and a DRE.
Which chemotherapy agents do NOT cause myelosuppression?
bleomycin, vincristine, most biologics (“mabs”), TKIs, asparaginase
How is myelosuppression in chemotherapy managed?
Mostly, infusions of whatever is missing (RBCs, platelets). Anemia can also be treated with ESAs. Neutropenia is treated with colony stimulating factors.
Which chemo agents are most associated with N/V?
cyclophosphamide, doxorubicin, ifosfamide, cisplatin
Which drug classes are used in CANV management?
NK1 antagonists ((fos)aprepitant)
serotonin receptor antagonists (-setrons)
dexamethasone
phenothiazines (prochlorperazine)
dopamine antagonists (metoclopramide, haldol, chlorpromazine)
benzodiazepines for anticipatory N/V
Which chemo drugs are most associated with mucositis?
fluorouracil, methotrexate, many TKIs, capecitabine, irinotecan
How is mucositis managed?
GI coating agents like sucralfate, topical anesthetics like lidocaine
Which chemotherapy agents are most associated with diarrhea?
irinotecan (I run to the can), fluorouacil, capecitabine, methotrexate, most TKIs
How is diarrhea associated with chemotherapy managed?
IV/PO hydration and antimotility (loperamide)
atropine can be used for early onset diarrhea associated with irinotecan
Which two chemotherapy agents are most associated with constipation?
vincristine, thalidomides
How is constipation in chemotherapy managed?
stimulant laxatives, PEG
What are two options for chemo associated dry mouth?
artificial saliva, pilocarpine
Which class of chemo agents is most frequently associated with cardiomyopathy? Which medication can be used in combination with one of them to reduce cardiotoxicity?
anthracyclines (rubicins)
dexrazoxane can be used with doxorubicin
To reduce the risk of cardiomyopathy, do not exceed a cumulative lifetime dose of ________mg/m^2 of doxorubicin.
450-550 mg/m^2
Bleomycin is most associated with _______ toxicity and should not exceed a lifetime dose of _______.
pulmonary, 400 units
Pulmonary toxicity associated with chemotherapy can manifest as pulmonary _______ and _________. Name the agents known to cause each.
fibrosis (bleomycin, busulfan, carmustine)
pneumonitis (methotrexate, MAbs)
The 4 classes of chemotherapy agents for which you should monitor LFTs are:
1) folate antimetabolites
2) antiandrogens
3) TKIs
4) pyrimidine analog antimetabolites (cytarabine)
BUN/SCr monitoring are most necessary with what two chemo drugs, due to their potential for nephrotoxicity?
cisplatin and methotrexate
Which agent, if given prophylactically with cisplatin, can reduce nephrotoxicity?
amifostine (Ethyol)
The max dose per cycle of cisplatin should not exceed _______.
100 mg/m^2
Ifosfamide can cause _______ at any dose, and is often given with _______ to reduce the occurrence.
hemorrhagic cystitis, mesna
cyclophosphamide can also cause HC, but usually only at higher doses. it is only sometimes given with mesna.
Vinca alkaloids, platinum agents, and taxanes are all associated with what adverse effect?
peripheral neuropathy
Because of its neurotoxicity, the single dose cap of _______ is ________.
vincristine, 2mg
Describe the unique neuropathy and subsequent patient counseling that should occur with oxaliplatin.
Oxaliplatin causes an acute, cold-mediated sensory neuropathy. Tell patients to avoid cold temperatures and drinking cold beverages.
What is the hallmark side effect of proteasome inhibitors?
neuropathy
Which chemotherapy agents carry a thromboembolic risk?
aromatase inhibitors (anastro/letrozole), SERMs, thalidomides
Which agent is given with methotrexate to reduce its toxicities? (myelosuppression, renal toxicity, mucositis)
leucovorin/levoleucovorin
glucarpidase (recombinant enzyme that inactivates serum methotrexate - used for overdose, must be given within 48-60 hours)
Leucovorin can be used to reduce the toxicity of _______ and to enhance the efficacy of _______.
methotrexate, fluorouracil
Acute diarrhea is mediated by _______ effects, while delayed is mediated by _______.
cholinergic effects (why atropine is effective)
toxicity on the intestinal lumen of metabolites
The _____ is the term used to describe the lowest WBC count after chemotherapy, and usually occurs ______ days after administration.
nadir, 7-14
What are the ANC cutoffs for the definitions of neutropenia and severe neutropenia?
neutropenia = ANC <1000 severe = <500
Filgrastim is administered daily, while pegfilgrastim is given only _____ every ______ ______.
once every chemo cycle
What are the common side effects of colony stimulating factors?
bone pain, fever
sargramostim (stem cell transplant) - arthralgias, myalgias, rash
CSFs can cause an enlargement of this organ, which should prompt patients to report to their provider.
spleen
signs of enlargement would be pain in the upper left abdomen, rarely respiratory distress syndrome
Which groups of organisms are neutropenic patients susceptible to infections from?
enteric Gram negatives, fungi, potentially skin flora if they have a port
At what ANC should a patient receive oral antibiotics for neutropenic fever? IV?
<500 = oral antipseudomonal <100 = IV antipseudomonal
Which organism must be included in the spectrum of activity of antibiotics used for neutropenic fever?
pseudomonas
What is the risk associated with ESA use in malignancy?
They can increase tumor progression and contribute to recurrence.
What is the place in therapy of ESAs for anemia of malignancy?
Since they carry the risk of increasing tumor progression and shortening survival, they are only used in patients with cancer receiving chemotherapy without a curative intent. They are only used for palliation.
The major neurotransmitter implicated in acute N/V is _____, while delayed vomiting is more due to _____.
5HT3, NK-1
Which 3 classes of drugs are most commonly used for breakthrough N/V?
5TH3 RAs
dopamine antagonists
cannabinoids
side effects of 5HT3 RAs
migraine headache, constipation
minimal sedation compared to other agents used for breakthrough
examples of and side effects of dopamine antagonists
prochlorperazine, promethazine, metoclopramide
sedation, acute dystonia, anticholinergic side effects
side effects of cannabinoids
similar to weed - increased appetite, euphoria or dysphoria, sedation
used 2nd-line
aprepitant/fosaprepitant are inhibitors of ______, and warrant a reduced dose of _______ if given together.
3A4, dexamethasone
How long before chemotherapy should antiemetics be given?
at least 30 minutes
What are the four ways granisetron can be administered?
PO, IV, SC, and transdermal
Which two medications are coformulated in Akynzeo?
palonosetron and netupitant/fosnetupitant (same brand name for both)
What are some short term side effects of dexamathesone infusion?
increased appetite, increased blood sugar, mood swings/irritability, insomnia, fluid retention
5-HT3 RAs carry two warnings: _______ and _______ _______.
QTc prolongation and serotonin syndrome
All dopamine receptor antagonists used for CINV can cause constipation due to their anticholinergic effects except ________.
metoclopramide - works by increasing gastric motility, so can cause diarrhea instead
Which dopamine antagonist is associated with serious tissue injury if extravasated?
promethazine (Phenergan)
Which dopamine antagonist can cause irreversible TD?
metoclopramide
Why would using a dopamine antagonist be a concern in a patient with epilepsy?
they decrease the seizure threshold
What is one important counseling point regarding ondansetron ODT?
Do not push the pill through the foil pack, and administer with dry hands.
Which medication is contraindicated with 5-HT3 RAs?
apomorphine (causes serious hypotension and LOC)
brand name of oral pilocarpine used for chemo induced xerostomia
Salagen (like saliva generation)
Hand-foot syndrome (palmar plantar erythrodysesthesia or PPE) is a side effect of which 6 chemo drugs?
1) capecitabine
2) sorafenib
3) sunitinib
4) liposomal doxorubicin
5) fluorouracil
6) cytarabine
What measures can be taken to reduce the severity of hand-foot syndrome?
avoid anything that will increase friction/heat on surfaces of hands and feet (jogging, work involving the hands, wearing gloves, long exposure to hot water)
What are two ways hand-foot syndrome is managed?
symptomatically - emollients can trap moisture in the hands and feet to prevent peeling of skin, and pain meds/steroids can help reduce pain
How does the dosing of allopurinol in TLS differ from gout prophylaxis?
much higher - can use 400-800 mg daily
Allopurinol and rasburicase are both given with what else to help get rid of uric acid?
IV NS helps flush the excess uric acid out of serum
The dosing of bisphosphonates in hypercalcemia of malignancy is [higher/lower] than in osteoporosis?
higher
What are the two mainstays of hypercalcemia of malignancy treatment?
IV fluids to increase excretion as well as loop diuretics
What two classes of chemo drugs are major vesicants?
anthracyclines, vinca alkaloids
How is extravasation managed with each of the following drugs: etoposide, vinca alkaloids, anthracyclines
etoposide and vinca alkaloids: WARM compress and hyaluronidase
anthracyclines: COLD compress and dexrazoxane or dimethyl sulfoxide
Why are cold compresses preferred in cases of vinca alkaloid and etoposide extravasation?
The goal with these agents is to disperse and dilute - cold compresses can cause vasoconstriction that keeps the drug in tissue longer and can further tissue damage.
How should the timing of vaccinations be navigated in a patient undergoing chemotherapy?
Immune responses will likely not be as robust during chemo, so patients should avoid receiving vaccines if possible. Vaccines that must be given during chemo treatment should precede the next chemo dose by at least 2 weeks. However, if the vaccine is live, it should not be given until 3 months after discontinuation of chemo. The inactivated flu vaccine is fine on a yearly basis in between chemo cycles.
Which antiemetic capsules must be kept under refrigeration?
Dronabinol
What are the 3 regimens approved for prophylaxis of CINV in highly emetogenic regimens?
at least 3 drugs - combination of 5-HT3 RA/NK-1 antagonist/dexamethasone or olanzapine/palonosetron/dexamethasone
4 drugs - 5-HT3 RA/NK-1 RA/dex/olanzapine
Which subset of patients may receive low dose aspirin for prevention of colorectal cancer?
patients aged 50-59 with ASCVD risk > 10% and life expectancy of at least 10 years
What is the difference between neoadjuvant and adjuvant therapy?
While both are terms used to describe cancer treatment other than the primary treatment (which is often surgery), neoadjuvant therapy occurs before primary (eg. radiation to reduce tumor size before resection) and adjuvant occurs with or after primary therapy.
