Oncology Overview and Side Effect Management Flashcards by Payton Dennis

Cancer risk factors

Sunlight exposure, tobacco use, excessive alcohol intake, obesity, older age, poor diet, and low physical activity

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External factors of cancer

chemicals, radiation

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Internal factors of cancer

hormones, genetic disorders

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These 2 types of skin cancer are common and unlikely to metastizie

basal cell and squamous cell carcinoma

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_____ is the least prevalent type of skin cancer but is the most deadly.

melanoma

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Treatment given after the primary therapy (usually surgery) or concurrent with other therapy (usually radiation) to eradicate residual disease and decrease recurrence

adjuvant

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Treatment given before the primary therapy (which is usually surgery) to shrink the size of the tumor and make surgery more effective

neoadjuvant

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The disappearance of the signs and symptoms of cancer, but not necessarily the presence of the disease (cancer could be undetectable but still present)

remission

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TNM staging: T refers to…

tumor size and extent

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TNM staging: N refers to…

spread of cancer to lymph nodes

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TNM staging: M refers to…

whether the cancer has metastasized

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Type of tumor marker common in colon cancer

carcinoembryonic antigen (CEA)

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CAUTION warning signs of cancer that warrant referral to a physician

Change in bowel or bladder habits
A sore that doesn’t heal
Unusual bleeding or discharge
Thickening of lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness

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What medication is recommended for prevention of colorectal cancer?

low-dose aspirin

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Using a broad-spectrum sunscreen, at least SPF _______, and reapplying every _______ reduces the risk of developing skin cancer.

15-30; 2 hours

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Lifetime cumulative dose: 400 units
Toxicity: ?

bleomycin; pulmonary toxicity

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Lifetime cumulative dose: 450-550 mg/m2
Toxicity: ?

doxorubicin; cardiotoxicity

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Dose per cycle shouldn’t exceed 100 mg/m2
Toxicity: ?

cisplatin; nephrotoxicity

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Single dose capped at 2 mg
Toxicity: ?

vincristine; neuropathy

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Medication that prevents cardiac damage from doxorubicin

dexrazoxane

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Almost all chemo drugs cause myelosuppression, except:

asparaginase, bleomycin, vincristine

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Match the management to their related toxicity:

Neutropenia: __
Anemia: __
Thrombocytopenia: __

a. Platelet transfusions
b. Colony-stimulating factors (CSFs)
c. RBC transfusions, and (in palliation only) erythropoiesis-stimulating agents (ESAs)

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Cisplatin, cyclosphosphamide, and ifosfamide commonly cause which chemo-related toxicity?

nausea and vomiting

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What medications are used to manage chemo-induced nausea and vomiting (CINV)?

neurokinin-1 receptor antagonist (NK1-RA), serotonin-3 receptor antagonist (5HT3-RA), dexamethasone, olanzapine, metoclopramide, prochlorperazine

IV/PO fluid hydration

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Which chemo drugs most commonly cause mucositis?

fluorouracil and methotrexate

Chemo drugs that commonly cause diarrhea

irinotecan, capecitabine, fluorouracil, methotrexate

Therapeutic treatment of chemo-induced diarrhea

IV/PO fluid hydration, antimotility meds (loperamide) Irinotecan: Atropine for early-onset diarrhea

Chemo drugs that commonly cause constipation and its management

vincristine Management: Stimulant laxatives, PEG 3350 (Miralax)

Management of xerostomia (dry mouth)

artificial saliva substitutes, pilocarpine, amifostine

Chemo drugs that commonly cause: Pulmonary fibrosis Pneumonitis

Pulmonary fibrosis: Bleomycin, busulfan, carmustine, lomustine Pneumonitis: Methotrexate (with chronic use) and MAbs targeting CTLA-4 or PD-1

Management of pulmonary toxicity caused by chemo

- Symptomatic management - Stop therapy - Steroids (if an autoimmune mechanism is suspected) for immunotherapy agents - Do not exceed recommended lifetime cumulative dose of 400 units for bleomycin

Drugs that commonly cause hepatotoxicity

- Antiandrogens (bicalutamide, flutamide, nilutamide) - Folate antimetabolites (methotrexate) - Pyrimidine analog antimetabolites (cytarabine) - Some MAbs

Drugs that commonly cause nephrotoxicity and its management

Cisplatin and methotrexate (high doses) Management: - Amifostine (Ethyol) can be given prophylactically with cisplatin to reduce the risk of nephrotoxicity - Adequate hydration - Max dose of cisplatin

Which chemo drugs causes hemorrhagic cystitis?

ifosfamide (all doses) cyclophosphamide (higher doses > 1 g/m2)

Which drug is always given prophylacticallt with ifosfamide (and sometimes with cyclophosphamide) to reduce the risk of hemorrhagic cystitis?

Mesna (Mesnex)

Chemo drugs that cause peripheral neuropathy and autonomic neuropathy

Peripheral: Vinca alkaloids (vincristine, vinblastine, vinorelbine), platinums (cisplatin, oxaliplatin), and taxanes (paclitaxel, docetaxel, cabazitaxel) Autonomic: Vinca alkaloids

Oxaliplatin causes an acute ______________; instruct patients to avoid _________ and avoid drinking _________.

Cold-mediated sensory neuropathy; cold temperatures; cold beverages

Aromatase inhibitors (e.g., anastrozole, letrozole), SERMs (e.g., tamoxifen, raloxifene), and immunomodulators commonly cause what chemo-induced toxicity?

thromboembolism

Adjunctive treatment used as prophylaxis to prevent ________ from cisplatin.

Amifostine (Ethyol) and hydration; nephrotoxicity

Given with fluorouracil to enhance efficacy (as a cofactor)

leucovorin or levoleucovorin

Fluorouracil or capecitabine antidote: Use within __ hours for an overdose or to treat severe, life-threatening or early-onset toxicity.

Uridine triacetate; 96

Adjunctive treatment used as prophylaxis to prevent ________________ from ifosfamide.

Mesna (Mesnex) and hydration

Used to prevent or treat acute diarrhea from irinotecan

atropine

Used to treat delayed diarrhea from irinotecan

loperamide

Given prophylactically after high-dose methotrexate to decrease ___________ and ____________.

Leucovorin or levoleucovorin; myelosuppression; mucositis

Antidote to decrease excessive methotrexate levels d/t acute _______________.

glucarpidase; renal failure

The lowest point that WBCs and platelets reach is called the _______, which occurs (with most drugs) about ________ days after chemo.

nadir; 7-14

The RBC nadir generally occurs after several months of treatment, d/t the long life-span of RBCs, which around _______ days.

120

How long does it take WBCs and platelets to recover post-treatment?

3-4 weeks

Neutropenia is defined as an ANC of less than ________ cells/mm3.

1,000

Severe neutropenia is defined as an ANC of less than _____ cells/mm3.

500

How do growth colony stimulating factors (G-CSFs or CSFs) work? How and why are they given?

- Stimulate the production of WBCs in the bone marrow - Given prophylactically after chemo - Shorten the time that a pt is at risk for infection d/t neutropenia - Reduce mortality from infections

T/F: G-CSFs are used for acute treatment of neutropenia.

False; only used to prevent (or reduce) neutropenia

Example of a G-CSF

filgastrim

Example of a pegylated G-CSF

pegfilgastrim

Filgastrim is given ______, and pegfilgastrim is given __________.

daily; once per chemo cycle

What is the advantage of pegfilgastrim over filgastrim?

Pegfilgastrim is pegylated, which extends its half-life.

CSF that's used only for stem cell transplants.

sargramostim

Side effects of filgastrim and pegfilgastrim

Bone pain Also fever, glomerulonephritis, generalized rash, injection-site reactions

Side effects of sargramostim

Fever, bone pain, arthralgias, myalgias, rash Also dyspnea, peripheral edema, pericardial effusion, HTN, chest pain

Where should G-CSFs be stored?

in the fridge

The first dose of CSFs should be administered no sooner than ______ hours after chemo, but can be given up to ____ hours after.

24; 96

When receiving CSF therapy, patients should report any signs of __________, which can be described as ________________________.

enlarged spleen; pain in the left upper abdomen

Which CSF must be documented when given?

pegfilgastrim

_____ may be the only sign of infection in a neutropenic patient.

Fever

Neutropenia diagnosis requirements

1. PO temp > 38.3 C (101 F) x 1 reading or PO temp > 38 C (100.4 F) sustained for 1 hour 2. ANC < 500 cells/mm3 or ANC that's expected to decrease to < 500 cells/mm3 during the next 48 hours

G+ and G- bacteria cause infections in febrile neutropenia, but Gram _______ bacteria have the highest risk for causing sepsis.

negative

Low risk for neutropenia is defined as: - Expected ANC < 500 for

7; no comorbidities

High risk for neutropenia is defined as: - Expected ANC 7 days - Presence of ________________ - Evidence of renal or hepatic impairment (CrCl < ____ or LFTs > ______)

100; comorbidities; 30; 5x ULN

Initial empiric antibiotics used for patients at low risk for neutropenia

ORAL anti-pseudomonal antibiotics: - Ciprofloxacin or levofloxacin PLUS - Augmentin (for adequate G+ coverage) or clindamycin (if allergic to penicillin)

Initial empiric antibiotics used for patients at high risk for neutropenia

INTRAVENOUS anti-pseudomonal antibiotics: - Cefepime or - Ceftazidime or - Meropenem or - Imipenem/cilastatin or - Piperacillin/tazobactam (Zosyn)

T/F: Erythropoiesis-stimulating agents (ESAs) are for palliation only and are not recommended in patients receiving chemotherapy with curative intent.

true

Why are ESAs only used in palliation?

They can shorten survival and increase tumor progression (I.e., they can contribute to cancer growth).

ESAs should only be initiated when the Hgb is < _____ g/dL.

ESAs don't work well to correct the anemia if ______ levels are inadequate, so _______________, _________________ ,and _______________ must be assessed.

- iron - serum ferritin - transferrin saturation (TSAT) - total iron-binding capacity (TIBC)

Thrombocytopenia (low platelets) can result in spontaneous, ______________________.

uncontrolled bleeding

For chemo-induced nausea and vomiting (CINV), administer antiemetics at least ____________ prior to chemo and provide ____________ for breakthrough N/V.

30 minutes; take-home antiemetics

This type of CINV occurs within 24 hours after chemo.

acute

This type of CINV occurs before chemo.

anticipatory

This type of CINV occurs > 24 hours after chemo.

delayed

Match the type of CINV with its correct drug treatment: 1. 5-HT3 receptor antagonists __ 2. NK1 receptor antagonists, corticosteroids, palonsetron, olanzapine __ 3. Benzodiazepines __ a. Delayed b. Anticipatory c. Acute

1. c 2. a 3. b

For anticipatory CINV, benzodiazepinezs should be started the _____________ chemo to alleviate anxiety and N/V.

evening before

5HT3-RA drugs used for CINV

ondansetron, granisetron, palonosetron

NK1-RA drugs used for CINV

aprepitant PO, fosaprepitant IV, rolapitant

Combination drugs used for CINV

- netupitant/palonosetron PO (Akynzeo) - fosnetupitant/palonosetron IV (Akynzeo)

Steroid used for CINV

dexamethasone

Antiemetic regimen used for high emetic risk patients

- NK1-RA + 5HT3-RA + olanzapine + dexamethasone (preferred) - Palonsetron + olanzapine + dexamethasone - NK1-RA + 5HT3-RA + dexamethasone

Antiemetics beneficial for breakthrough CINV

- 5HT3-RAs - dopamine receptor antagonists - cannabinoids - olanzapine -Others: dexamethasone, lorazepam, scopolamine

- Usually well-tolerated by most patients - Common side effects: Migraine-like headaches and constipation - Cause minimal sedation compared to dopamine receptor antagonists and cannabinoids

Serotonin receptor antagonists (5HT-3 RAs)

- Commonly cause sedation and some anticholinergic side effects -Extrapyramidal symptoms (EPS), such as acute dystonic reactions can also occur, especially in younger patients - Drugs: Prochlorperazine, promethazine, and metoclopramide

dopamine receptor antagonists

Acute dystonic reactions caused by dopamine receptor antagonists should be treated with what?

anticholinergics (benztropine, diphenhydramine)

- Used to be commonly used for post-op N/V (not CINV) - Has restricted use (or has been removed entirely) in most hospitals d/t QT prolongation and the risk of Torsades de Pointes

droperidol

Examples of cannabinoids

dronabinol and nabilone

Used as 2nd line agents for CINV

cannabinoids

Cannabinoids are synthetic analogs of what?

delta-9-tetrahydrocannabiol

Side effects of cannabinoids

increased appetite, sedation, dysphoria or euphoria

Match the drug class with its correct MOA: 1. Augment the antiemetic activity of 5HT-3 receptor antagonists and corticosteroids to inhibit acute and delayed phases of chemo-induced emesis ___ 2. Work both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone 3. Enhance GABA to decrease neuronal excitability 4. Block specific receptors in the CNS, including the chemoreceptor trigger zone 5. Activate specific receptors within the CNS and/or inhibit the vomiting control mechanism in the medulla oblongata a. Cannabinoids b. 5HT-3 receptor antagonists c. Dopamine receptor antagonists d. Substance P/Neurokinin-1 receptor antagonists e. Benzodiazepines

1. d 2. b 3. e 4. c 5. a

Aprepitant and fosaprepitant fall under which drug class?

Substance P/Neurokinin-1 receptor antagonists

5HT-3 receptor antagonists examples

ondansetron, granisetron, palonosetron

Which 5HT-3 receptor antagonist comes in a patch that's applied 24-48 hours before chemo and can be left in place for up to 7 days?

granisetron (Sancuso)

5HT-3 RECEPTOR ANTAGONISTS CI: Don't use with _______ d/t severe hypotension and loss of consciousness Warnings: - Dose-dependent ________________________ (more common with IV) - Serotonin syndrome when used in combo with other serotonergic agents Side effects: Headache, _________________

apomorphine (Apokyn); QT prolongation; constipation

Which 2 5HT-3 receptor antagonists are FDA-approved for delayed CINV?

palonosetron and Sustol (granisetron)

DEXAMETHASONE (DECADRON) CI: Systemic fungal infections, cerebral malaria Side effects: - Short-term AEs include _____ appetite, fluid ________, emotional instability, _______, GI upset - _______ doses increase BP and blood glucose (especially in patients with diabetes)

increased; retention; insomnia; higher

List drugs that fall are dopamine receptor antagonists

prochlorperazine, promethazine, metoclopramide, olanzapine, droperidol

Promethazine BBW: - Don't use in kids < _____ years - Don't give via intra-arterial or __ administration - IV route can cause serious ______ injury if _______________ occurs - Deep __ injection is preferred

- 2 - SC - tissue; extravasation - IM

Metoclopramide BBW: - _______ __________ that can be irreversible; risk is increased by _________ ________ and _____ __________ ____ - Avoid tx with metoclopramide for > __ weeks - Decrease dose in _____ impairment

- Tardive dyskinesia; increased duration; total cumulative dose - 12 - renal

Droperidol BBW: - __ ____________ and serious ___________ - All patients should have a 12-lead ECG prior to receiving and continue for ___ hours after completing tx

- QT prolongation; arrhythmias - 2 to 3

Prochlorperazine BBW: - Increased _________ in _______ patients with ________-related _________

mortality; elderly; dementia-related psychosis

DOPAMINE RECEPTOR ANTAGONISTS Warnings: Symptoms of _________ _______ may be exacerbated. Avoid use in patients with this disease. Side effects: Sedation, lethargy, acute ___ (common in children), can ________ seizure threshold - Strong anticholinergic side effects (e.g., constipation), except with ______________ (diarrhea) __________ is not used for CINV

- Parkinson disease - EPS; decrease - Metoclopramide - Dronabinol

Cannabinoids are schedule _ controlled substances.

T/F: Nabilone needs to be refrigerated.

False; nabilone doesn't need to be stored in the fridge, but dronabinol does.

Painful oral ulcerations resulting from damage to oral mucosal epithelial cells

mucositis

Damage to the salivary glands usually caused by radiation therapy to the head or neck regions

xerostomia

A cholinergic drug that causes salivation and lacrimation; used for xerostomia caused by some cancer drugs and for dry eyes

pilocarpine

Antimotility agents used for chemo-induced diarrhea

loperamide and diphenoxylate/atropine

Max dose of loperamide

16 mg/day

Fluorouracil, capecitabine, and irinotecan commonly cause diarrhea that occurs several ____ after chemo.

days

Irinotecan can cause early-onset diarrhea that occurs during the infusion of the drug and is often accompanied by symptoms of ___________ excess, such as ....

cholinergic excess: abdominal cramping, rhinitis, lacrimation, and salivation

What can be used to help relieve symptoms of mucositis?

viscous lidocaine 2%, magic mouthwash, and systemic analgesics

Oral mucositis increases the risk of what, and what medications are used to treat this complication?

- Candida infection (oral thrush) - Nystatin PO suspension or clotrimazole troches

Which chemo drugs can cause hand-foot syndrome?

- capecitabine - fluorouracil - Others: cytarabine, liposomal doxorubicin, and the tyrosine kinase inhibitors (sorafenib and sunitinib)

Match the therapies used for symptoms of hand-foot syndrome with its intended use: 1. Provides temporary relief of pain and tenderness __ 2. Retains moisture in the hands and feet __ 3. Lessen inflammation and pain __ a. Emollients b. Cooling hands and feet with cold compresses c. Steroids and pain medications

1. b 2. a 3. c

Tumor lysis syndrome (TLS) most commonly occurs with which cancers?

leukemia and non-Hodgkins lymphoma

TLS causes acute _____kalemia (which can cause ___________), ____calcemia (which can cause ________), and ______uricemia (which can damage the _______).

- hyperkalemia (arrhythmias) - hypocalcemia (seizures) - hyperuricemia (kidneys)

Medications used for TLS

allopurinol and rasburicase

Allopurinol doses in TLS are ______ than when used for tx of gout. It's continued for _____ days after chemo.

higher; 10-14

Rasburicase is added to allopurinol when allopurinol and hydration fail to control the uric acid level or isn't a reasonable option (e.g., with the risk of ______________________).

allopurinol-induced rash/severe skin reactions

Mild hypercalcemia of malignancy is typically asymptomatic and can be treated with _________ and ____ ________.

hydration; loop diuretics

What are treatment options for moderate-to-severe hypercalcemia of malignancy (calcium > 12 mg/dL)?

- IV hydration with normal saline - calcitonin - IV bisphosphonates - denosumab

Calcitonin is sometimes used initially for up to __ hours; treatment duration is short because _____________________ develops quickly.

48; tachyphylaxis (tolerance)

Considered 1st line for hypercalcemia of malignancy and may be given with calcitonin in severe cases

IV bisphosphonates: Pamidronate and zoledronic acid

Alternative to IV bisphosphonates

denosumab

Denosumab and IV bisphosphonates have the added benefits of what?

building bone density and reducing fractures

Match the treatment options for hypercalcemia of malignancy with its correct description: 1. Increases renal calcium excretion in minutes to hours; can be used in mild, moderate, and severe cases __ 2. Inhibits bone resorption and increases renal calcium excretion in 2-6 hours; used in moderate and severe cases __ 3. Inhibits bone resorption by stopping osteoclast function; works in 24-72 hours; used in mild, moderate, and severe cases __ 4. Blocks the interaction between RANKL and RANK, preventing osteoclast formation; works in 24-72 hours; used in moderate and severe cases __ a. Denosumab (Xgeva) b. Calcitonin (Miacalcin) c. IV bisphosphonates d. Hydration with normal saline and loop diuretics

1. d 2. b 3. c 4. a

Zometa and Reclast are the brand names of what drug?

zoledronic acid

The dose of Zometa is ________ The dose of Reclast is _________

Zometa: 4 mg IV once Reclast: 5 mg IV yearly for osteoporosis

Xgeva and Prolia are the brand names of what drug?

denosumab

What is difference between Xgeva and Prolia dosing?

Xgeva: 120 mg SC on days 1, 8, and 15 of the first month, then monthly Prolia: 60 mg SC every 6 months for osteoporosis

Immunologic reactions commonly occur with virtually every _____________________.

monoclonal antibody

To prevent immunologic reactions, monoclonal antibodies require premedication with which drugs?

1. Acetaminophen (usually 650 mg PO) 2. Diphenhydramine (IV or PO) or another antihistamine

All chemotherapy drugs are vesicants; however, which chemo drugs are MAJOR vesicants?

anthracyclines and vinca alkaloids

If extravasation occurs, apply ____ compresses (except with _______________ and ______________, use ____ compresses).

cold; vinca alkaloids; etoposide; warm

Which chemo drugs can be administered intrathecally, and what is the requirement to do so?

- Cytarabine, methotrexate, hydrocortisone, and thiotepa - They must be preservative-free

Accidental intrathecal administration of this chemo agent can be fatal.

vincristine

Vaccination during chemo should be avoided. When chemo is planned, vaccination should precede chemo by how long?

>/= 2 weeks