Oncology I: Overview, Side Effect Mgmt, Oncologic Emergencies Flashcards by Bradley Wuthrich

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

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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)

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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.

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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.

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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

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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.

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Which chemotherapy agents do NOT cause myelosuppression?

bleomycin, vincristine, most biologics (“mabs”), TKIs, asparaginase

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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.

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Which chemo agents are most associated with N/V?

cyclophosphamide, doxorubicin, ifosfamide, cisplatin

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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

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Which chemo drugs are most associated with mucositis?

fluorouracil, methotrexate, many TKIs, capecitabine, irinotecan

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How is mucositis managed?

GI coating agents like sucralfate, topical anesthetics like lidocaine

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Which chemotherapy agents are most associated with diarrhea?

irinotecan (I run to the can), fluorouacil, capecitabine, methotrexate, most TKIs

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How is diarrhea associated with chemotherapy managed?

IV/PO hydration and antimotility (loperamide)

atropine can be used for early onset diarrhea associated with irinotecan

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Which two chemotherapy agents are most associated with constipation?

vincristine, thalidomides

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How is constipation in chemotherapy managed?

stimulant laxatives, PEG

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What are two options for chemo associated dry mouth?

artificial saliva, pilocarpine

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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

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To reduce the risk of cardiomyopathy, do not exceed a cumulative lifetime dose of ________mg/m^2 of doxorubicin.

450-550 mg/m^2

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Bleomycin is most associated with _______ toxicity and should not exceed a lifetime dose of _______.

pulmonary, 400 units

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Pulmonary toxicity associated with chemotherapy can manifest as pulmonary _______ and _________. Name the agents known to cause each.

fibrosis (bleomycin, busulfan, carmustine)

pneumonitis (methotrexate, MAbs)

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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)

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BUN/SCr monitoring are most necessary with what two chemo drugs, due to their potential for nephrotoxicity?

cisplatin and methotrexate

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Which agent, if given prophylactically with cisplatin, can reduce nephrotoxicity?

amifostine (Ethyol)

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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.