Oncology: Oncology II: Common Cancer Types & Treatment Flashcards
Complete response is when
treatment has destroyed all known tumors
Partial response is when
at least 30% of tumor has been eliminated
BRCA1 and BRACA2 Gene mutations
normally genes suppress tumor growth
mutations prevent cell repair and inc breast cancer mutations
Klinefelter syndrome
Men with 1 Y, and multiple X
higher risk of breast cancer
Hormone-sensitive cancer treatment
treated with adjuvant (endocrine) therapy for 5-10yrs to suppress cancer recurrence
1st line adjuvant txm for premenopausal females with hormone-sensitive cancer
tamoxifen
SERM for breast cancer prevention in post menopausal females at risk for cancer?
Raloxifene
also inc bone density, indicated for osteoporosis prevention but not 1st line due to hot flashes/risk of blood clots
Why are Aromatase inhibitors not useful in premenopausal women
AIs reduce estrogen production by blocking aromatase enzyme, but dont block ovarian estradiol production
HER2 overexpression
oncogene that promotes breast tumor growth
20% of breast tumors over express HER2 on cell surface
SERMs Boxed warnings
inc risk of uterine or endometrial cancer
inc risk of thromboembolic events
QT prolongation
SERMs Contraindications
Dont use w/ warfarin = tamoxifen
Hx of DVT/PE = tamoxifen/raloxifene
pregnancy/breast feeding = raloxifene
QT prolongation = tamoxifen
SERMs side effects
Hot flashes
night sweats
vaginal bleeding/spotting
vaginal discharge/dryness/itchy
dec libido
weight gain
Dec bone density, supplement with calcium/vit D
Tamoxifen = teratogenic
Selective Estrogen Receptor Degrader (SERD)
Fulvestrant (Faslodex)
Fulvestrant (Faslodex) SE
SE: inc LFTS, hot flashes, injection site pain
Aromatase inhibitors
Anastrazole
Letrozole
Exemestane
Aromatase inhibitors info
Higher risk of osteoporosis
higher risk of CVS compared to SERMs
Aromatase inhibitors CI and SE
CI: pregnancy
SE: hot flashes/night sweats, arthralgia/myalgia
CDK4/6 inhibitors
Palbociclib
Abdemaciclib
Ribociclib
CDK4/6 inhibitors warnings & SE
Warnings: interstitial lung disease
SE: Neutropenia, anemia, nausea, diarrhea, fatigue, alopecia, blurred vision
Risk of TE events
Prostate Specific Antigen levels
> 4 = might be prostate cancer
4 - 10 = overlaps with BPH too
10 = prostate cancer likely
tumor flare in prostate cancer
When giving GnRH agonist, causes initial inc of T so its given with anti androgen, after awhile T drops and anti androgen can be stopped
due to negative feedback loop
GnRH agonists
Leuprolide (Lupin)
Goserelin (Zoladex)
Histrelin (Supprelin)
Triptorelin (Trelstar)
GnRH agonist Contraindications
Pregnancy
breastfeeding
GnRH agonist side effects
Hot flashes
impotence
gynecomastia
bone pain
QT prolongation
GnRH antagonist
Degarelix (Firmagon)
Relugolix (Orgovyx)
GnRH antagonist unique concerns
Osteoporosis. risk, consider vit D/calcium supp
No tumor flare, dont need anti androgen
GnRH antagonist CI and SE
CI: pregnancy
SE: similarly to GnRH agonist, Hot flashes, impotence, gyno, bone pain etc
1st gen anti androgen boxed warnings
Hepatotoxicity (Flutamide)
interstitial pneumonitis (nilutamide)
1st gen anti androgen meds
Bicalutamide
Flutamide
Nilutamide
1st gen anti androgen side effects
hot flashes
gyno
2nd gen anti androgen meds
Apalutamide (Erleada)
Darolutamide (Nubeqa)
Enzalutamide (Xtandi)
2nd gen Anti androgen warnings
seizures
myocardial ischemia
QT prolongation
can cause fetal harm
2nd gen Anti androgen side effects
HTN
peripheral edema
hot flashes
fatigue
Androgen Biosynthesis inhibitor
Abirateron (Zytiga)
Abirateron (Zytiga) side effects
mineralocorticoid excess
hepatotoxicity
Which patients body weight should be used for chemo dosing
their actual body weight
Cell cycle independent agents
Alkylating agents
platinum based compounds
Anthracyclines
Alkylating agents work by…..
cross-linking DNA strands and inhibiting protein synthesis and DNA synthesis
can cause DNA mutations and lead to secondary malignancies
Alkylating agents
Cyclophosphamide
Ifosfamide (Ifex)
Carmustine/Lomustine
Busulfan (Myleran)
Mitomycin
Cyclophosphamide and Ifosfamide unique concerns
Hemorrhagic cystitis = adequate hydration and use Mesna
Mesna given prophylactically with Ifosfamide and high dose cyclophosphamide
Alkylating agent boxed warnings
Myelosuppresion
Hemorrhagic cystitis
pulmonary toxicity = carmustine
neurotox = ifosfamide
hepatic necrosis = dacarbazine
Alkylating agents warnings
severe skin reactions, SJS/TEN
reactivation of infections = HBV, CMW, TB, HSV
hepatotoxicity
Alkylating agent side effects
Pulmonary toxicity = busulfan, carmustine/lomustine
Mod-high emetic potential
Mitomycin unique concerns
vesicant, antidote is DMSO and cool compresses
IV = hazy blue and make piss blue/green
Mitomycin Boxed warnings
bone marrow suppression
hemolytic uremia syndrome
Mitomycin CI
thrombocytopenia
coagulopathy
bleeding
Mitomycin SE
N/V
fatigue
alopecia
mucos membrane toxicity
leukopenia
Platinum based therapies
Cisplatin
Carboplatin
Oxaliplatin
Platinum based therapies common side effects
peripheral sensory neuropathy
ototoxicity
nephrotoxicity
Which platinum based therapy has highest risk of nephrotoxicity and CINV
Cisplatin
Cisplatin unique concerns
Nephro/Ototoxicity = cumulative
Amifostine = chemoprotectant used to prevent nephrotoxicity
highly emetic
Cisplatin boxed warnings
Anaphylactic like reactions, inc with repeated exposures, caution when > 6 cycles used
Cisplatin doses > 100mg/m2/cycle = check by provider
myelosuppresion
Oxaliplatin unique concerns
cold sensitivity = drinking cold beverages, eating ice cream etc
Platinum based therapies side effects
peripheral neuropathy
inc LFT
N/V
QT prolongation = oxaliplatin
Anthracyclines
Doxorubicin (Adriamycin)
Doxorubicin liposomal
Mitoxantrone
Doxorubicin unique concerns
potent vesicant
drug is red = discoloration of sweat, tears, urin
total lifetime dose not to exceed 450-550mg/m2
Dexrazoxane = for extravasation/chemoprotectant
Doxorubicin, other - ubicins boxed warnings
myocardial toxicity
vesicant
myelosuppresion
secondary malignancy
Doxorubicin, other -ubicins side effect
N/V - use antiemetics
Doxorubicin liposomal boxed warning and side effects
Boxed warning: myocardial toxicity
SE: hand-foot syndrome
Is liposomal doxorubicin interchangeable with regular?
no
Mitoxantrone boxed warning
myocardial toxicity
Cell-cycle specific agents
Topoisomerase I & II inhibitor,Vinca alkaloids, Texans, Pyrimidine Analog Antimetabolites, folate antimetabolites
Topoisomerase I inhibitors work by…..
block the coiling and uncoiling o the double stranded DNA helix during the S phase of the cell cycle
Topoisomerase I inhibitors
Irinotecan
Topotecan
Irinotecan boxed warnings
myelosuppresion
use only when ANC > 1500 and platelets > 100K
Diarrhea (Early and Late)
Irinotecan side effects
N/V/D
alopecia
diarrhea
abdominal pain
Topoisomerase II inhibitors
Etoposide
Bleuomycin
Topoisomerase II inhibitors work…
same as Topo I inhibitor, just work on Topo II
Etoposide unique concerns
Infusion rate related hypotension, give over atleast 30-60min
IV prep < 0.4 mg/ml to avoid precipitation
Etoposide boxed warnings
myelosuppression
Etoposide Side effects
Hypersensitivity reactions
anaphylaxis
secondary malignancies
Bleomycin unique concerns
max lifetime dose of 400 units due to pulmonary toxicity
not myelosuppresive
premedication used
Bleomycin boxed warnings
Pulmonary fibrosis
anaphylaxis
Bleomycin side effects
hypersensitivity reaction
pulmonary reactions
N/V
Chills
Fever
Vinca alkaloids work by….
inhibiting function of microtubules during the M phase of cell cycle
VinCrisitine is associated with….
more CNS toxicity than other vinca alakaloids
vinBlastine and vinorelBine are associated with….
more bone marrow suppression than vincristine
Vinca Alkaloids
Vincristine
Vinblastine
Vincristine is often capped at what dose?
2mg/dose
Vinca Alkaloid boxed warnings
Vesicants
IV admin only
Vinca Alkaloid side effects
peripheral sensory neuropathy
autonomic neuropathy
Taxanes work on…..
inhibit the function of microtubules during the M phase of the cell cycle
Taxanes include….
Paclitaxel (Abraxane)
Docetaxel
Cabazitxel (Jevtana)
Docetaxel unique concerns
premeditate w/ steroids for 3 days starting 1 day prior
severe fluid retention
Taxane boxed warnings
Severe hypersensitivity reactions = not Paclitaxel
myeliosuppresion
Pyrimidine analog antimetabolite mechanism
inhibits pyrimidine synthesis during the S phase of the cell cycle
Pyrimidine analog antimetabolites meds
Fluorouracil 5-FU
Capecitabine (Xeloda)
Gemcitabine
Fluorouracil, 5-FU unique concerns
Leucovorin given with to inc efficacy
Capecitabine Boxed warnings
Significant inv in INR and up to 1 month after treatment
Capecitabine contraindications
severe renal impairment, CrCl < 30
Pyrimidine analog antimetbolite side effects
Hand-foot syndrome
diarrhea
mucosities
caridotox
photosensitivtiy
dementia
Folate antimetabolites work by
interfering with enzymes involved in the folic acid cycle, blocking purine and pyrimidine biosynthesis during the S phase
Folate antimetabolite medications
Methotrexate (Trexail)
Pemetrexed (Alimta)
Pralatrexate (Folotyn)
Methotrexate Boxed warnings
myelosuppressio
renal dmage
hepatotoxicity
GI toxicity
teratogenic
Methotrexate side effects
Nephrotoxicity = dose related
hepatotoxicity
nausea
diarrhea
stomatitis
mucositis
Levoleucovorin vs Leucovorin dosing
Levoleucovorin is given at 1/2 the dose of Leucovorin
Methotrexate antidote
Glucarpidase
Methotrexate drug interactions
all dec clearance of methotrexate
NSAIDs
Salicylates
Beta lactase
PPI
sulfonamide ABX
probenacid
MAbs that target VEGFs
“ci”
Bevacizumab
Ramucirumab
MAbs that target EGFR
“Tu”
Cetuximab
Panitumumab
MAbs that target HER2
“Tu”
Trastuzumab
Pertuzumab
MAbs that target CD20/CD30
“Tu”
Rituximab
Brentuximab
MAbs that target immune system (PD-1, PD-L1, CTLA-4)
“li”
Ipilimumab
Pembrolizumab
Bevacizumab (Avastin) unique concerns (VEGF)
impairs wound healing, dont give 28 days prior or after surgery
Bevacizumab (Avastin) boxed warnings (VEGF)
Severe/fatal bleeding
GI perforation
Trastuzumab (Herceptin) unique concerns (HER2)
test for HER2 expression
monitor LVEF
Trastuzumab (Herceptin) boxed warnings (HER2)
HF
embryo-fetal death = avoid preg 7 months after txm
severe infusion related reasons
Cetuximab (Erbitux) unique concerns (EGFR)
test for EGFR expression and KRAS
KRAS wildtype = poor response colorectal cancer
Cetuximab (Erbitux) boxed warnings
Severe/fatal infusion related reactions
cardiac arrest
Cetuximab (Erbitux) side effects
acneiform rash
SJS/TEN
ocular toxicities
N/V/D
Cetuximab (Erbitux) notes
rash occurs in 1st 2 weeks of treatment, patient expected to have better response
avoid sunlight, use sunscreen
Rituximab (Rituxan) unique concerns
premeditate with Tylenol, Benadryl, steroid
Rituximab (Rituxan) boxed warnings
Hep B reactivation
SJS/TEN
severe/fatal infusion reactions
PD-1 inhibitors
Keytruda = Pembrolizumab
Opdivo = Nivolumab
PD-1 inhibitor unique concerns
immune mediated toxicities
PD-1 side effects
immune mediated toxicities
CTLA-4 inhibitor
Yervoy = ipilimumab
Ipilimumab (Yervoy) unique concerns
REMS program
Ipilimumab (Yervoy) boxed warnings & side effects
Boxed warning: fatal immune mediated reactions
SE: pneumonitis, nephrotoxicity, ocular toxicity
Tyrosine kinase info info
oral admin
have to before pharmacogenomic testing prior to starting
some TKIs have specific targets, others are multi-targeted
TKI used in Chronic myelogenous leukemia (CML) drugs
BCR-ABL inhibitors
Imatinib (Gleevec)
Dasatinib (Sprycel)
Nilotinib (Tasigna)
TKI used in Chronic myelogenous leukemia (CML) unique concerns
must be Philadelphia chromosome (BCR-ABL) positive for use
Imatinib, Dasatinib, Nilotinib boxed warnings
QT prolongation = nilotinib
vascular occlusions, HF
Imatinib, Dasatinib, Nilotinib Side effects
myelosuppression
N/V/D
QT porlongation
fluid retention
edema
skin rash
inc LFTs
HF
TKIs used in Melanoma
BRAF inhibitors
Vamurafenib (Zelboraf)
Dabrafenib (Tafinlar)
Vamurafenib, Dabrafenib unique concerns
Must be BRAF V600E or V600K mutation positive to use
Vamurafenib, Dabrafenib warnings
new malignancies
QT prolongation
MEK1 and 2 inhibitors
Cobimetinib (Cotellic)
Cobimetinib (Cotellic) unique concerns
used in combo with BRAF n patients with V600E/V600K mutations
Cobimetinib (Cotellic) side effects
HTN
HF
Hepatotoxicity
Hand-foot syndrome
Visual impairment
EGFR inhibitors, used in non-small cell lung cancer (NSCLC)
Afatinib (Gilotrif)
Erlotinib (Tarceva)
EGFR inhibitor unique concerns
must be EGFR mutation positive to use
EGFR inhibitor side effects
acneiform rash
dry skin
pruritus
N/V/D
mucositis
stomatitis
Acneiform rash from EGFR inhibitors indicates that patient will have what kind of response?
expected to be better
Anaplastic Lymphoma Kinase (ALK) inhibitors
Alectinib (Alecensa)
Brigatinib (Alunbrig)
ALK inhibitor unique concerns
must have ALK mutation to use
ALK inhibitor warnings and side effects
warning: QT prolong, hepatotoxicity, bradycardia, interstitial lung disease
Side effects: Skin rash N/V/D, edema
Lapatinib (Tykerb) Info, Warnings, Side effects
Info: HER2 inhibitor
Warning: Hepatotoxicity, GI toxicity, cardiotoxicity
Side effect: N/V/D, hand-foot syndrome
Neratinib (Nerlynx) Info, Warnings, Side effects
Info: HER2 inhibitor
Warning: Hepatotoxicity, GI toxicity = req premeditate w/ antidiarrheal meds
Side effect: N/V/D, hand-foot syndrome
Sorafenib (Nexavar) Info, Warning, Side effects
Info: TKI, multiple targets
Warnings: Hepatotoxicity, cardiac toxic, hen, SJS/TEN, impaired wound healing
Side effect: QT prolong, skin changes, hand-food syndrome, N/V/D, thyroid dysfunction
Sunitinib (Sutent) Info, Warnings, Side effects
Info: TKI, multiple targets
Boxed warning: Hepatotoxicity
Side effect: QT prolong, skin changes, hand-food syndrome, N/V/D, thyroid dysfunction
Common toxicities for TKIs
Hypothyroidism
QT prolongation
Diarrhea
Hepatic toxicity
Rash
Hand-foot syndrome
Which oral agents should be taken with food or within 1 hr after meal
Imatinib = Gleevec
Capecitabine = Xeloda
Thalidomide = Thalomid
Exemestane = Aromasin
Which oral agents should be taken on empty stomach, 1hr before or 2hrs after food
Nilotinib = Tasigna
Erlotinib = Tarceva
Sorafenib = Nexavar
Temozolomide = Temodar
Abiraterone = Zytiga
Pomalidomide = Pomyalyst
