Oncology Part 2 Flashcards
anticipatory nausea/vomiting
learned response conditioned by severity and duration of previous emetic reactions from prior cycles of chemotherapy
acute nausea/vomiting
emetic response correlating with the administration of chemotherapy; usually within 24 hours of receiving chemotherapy
delayed nausea/vomiting
related to chemotherapy; usually occurs > 24 hours following completion of chemotherapy
breakthrough nausea/vomiting
occurs even if on scheduled anti-emetics prior to chemotherapy
refractory nausea/vomiting
persistent nausea/vomiting despite appropriate anti-emetics
pathophysiology of chemotherapy induced nausea/vomiting (CINV)
-begins in GI tract with cytotoxic chemotherapy inducing damage to epithelial cells lining GI tract
-enterochromaffin cells contain large stores of serotonin, which are released in massive quantities after exposure to chemotherapy
-serotonin activates chemoreceptor trigger zone (CTZ) which stimulates the vomiting center (located in nucleus tractus solitarii in medulla)
nausea
inclination to vomit or a feeling in the throat or epigastric region alerting an individual that vomiting is imminent
wretching
labored movement of abdominal and thoracic muscles before vomiting
vomiting
ejection or forced expulsion of gastric contents through the mouth
neurotransmitters involved in CINV
-dopamine
-histamine
-acetylcholine
-serotonin
-substance P
levels of emetogenic risk
-highly emetogenic (>90% frequency of emesis; level 5)
-moderately emetogenic (>30-90% frequency of emesis; level 3-4)
-low emetic risk (10-30% frequency of emesis; level 2)
-minimal emetic risk (<10% frequency of emesis; level 1)
What levels of emetogenic risk contribute to the emetogenicity of the chemotherapy regimen?
≥ level 3
risk factors for CINV
-female
-children
-prior history of motion sickness, morning sickness, and/or CINV
-anxiety/high pre-treatment anticipation of nausea
What can be a protective factor for CINV?
chronic alcohol use
How is the medication regimen for prophylaxis of acute nausea/vomiting determined?
emetogenic potential of chemotherapy
What drug class can be substituted for each other for prophylaxis of acute nausea/vomiting?
5-HT3 receptor antagonists
What are the four drug classes that can be included in a highly emetogenic CINV regimen?
-NK-1 antagonist
-steroid
-5-HT3 antagonist
-atypical antipsychotic
What two drug classes are always included in a CINV medication regimen?
-steroid
-5-HT3 antagonist
What is the suffix of NK-1 antagonists?
-pitant
What steroid is used for CINV?
dexamethasone
What is the suffix of 5-HT3 antagonists?
-setron
What atypical antipsychotic is used for CINV?
olanzapine
What two drug classes can be added to a CINV medication regimen for toxicities?
-benzodiazepine
-H2 blocker/proton pump inhibitor
What benzodiazepine can be added to a CINV medication regimen for toxicities?
lorazepam
How many medications are in a low emetogenic CINV regimen?
one
What drug classes are used to treat breakthrough nausea/vomiting?
-dopamine receptor antagonists
-phenothiazines
-antipsychotic
-benzodiazepine
-cannabinoids
-serotonin antagonists
-steroid
-anticholinergic
What dopamine receptor antagonists are used to treat breakthrough nausea/vomiting?
-haloperidol
-metoclopramide
What phenothiazines are used to treat breakthrough nausea/vomiting?
-prochlorperazine
-promethazine
What cannabinoids are used to treat breakthrough nausea/vomiting?
-dronabinol
-nabilone
What anticholinergic is used to treat breakthrough nausea/vomiting?
scopolamine
What drug classes are typically used to treat delayed nausea/vomiting?
-steroid
-NK-1 antagonist
-atypical antipsychotic
What are the treatment options for anticipatory nausea/vomiting?
-prophylaxis
-behavioral therapy
-acupuncture/acupressure
-benzodiazepine
What are the treatment guidelines for radiation induced emesis?
-start pre-treatment for each day of radiation therapy
-5-HT3 antagonist (PO) +/- dexamethasone
common toxicities for 5-HT3 antagonists
-headache
-asymptomatic and transient ECG changes
-constipation
-increased transaminases
How can headaches due to 5-HT3 antagonists be addressed?
switch to another 5-HT3 antagonist
common toxicities for corticosteroids
-anxiety
-euphoria
-insomnia
-hyperglycemia
-increased appetite (weight gain)
common toxicities for NK-1 antagonists
-hiccups
-drug interactions
common toxicities for dopamine antagonists
-extrapyramidal side effects
-diarrhea
-sedation
common toxicities for atypical antipsychotics
-dystonic reactions
-sedation
common toxicities for phenothiazines
-sedation
-akathisia
-dystonia
-tissue damage (IV promethazine)
common toxicities for cannibanoids
-drowsiness
-dizziness
-euphoria
-mood changes
-hallucinations
-increased appetite
common toxicities for benzodiazepines
-sedation
-hypotension
-urinary incontinence
-hallucinations
common toxicities for anticholinergics
-vision problems
-inability to urinate
-xerostomia
-constipation
When are anti-emetics most effective?
at least 5-30 minutes before chemotherapy as prophylaxis
What should always be provided to patients after chemotherapy?
PRN anti-emetics for at home use
When does the onset of mucositis usually occur?
5-7 days after chemotherapy
When does mucositis improve?
increase of neutrophil count
What type of chemotherapy is most likely to cause mucositis?
continuous infusions
What drugs are most likely to cause mucositis?
-anthracyclines
-5-fluorouracil (5-FU)
risk factors for mucositis
-pre-existing oral lesions
-poor dental hygiene or ill-fitting dentures
-combined modality treatment (i.e., chemotherapy and radiation)
diet recommendations for mucositis
-avoid rough food, spices, salt, and acidic fruit
-eat soft or liquid foods, non-acidic fruit, soft cheeses, and eggs
-avoid smoking, alcohol, and OTC mouthwash
What patients should receive pre-treatment dental screening?
-radiation therapy to oral mucosa
-high-dose chemotherapy with bone marrow transplant
What are general mouth care strategies to prevent mucositis?
-baking soda rinses 2-4 times daily
-soft-bristled toothbrush to minimize gingival irritation
-saliva substitute for radiation-induced xerostomia
What are the treatment options for pain management of mucositis?
-topical anesthetics
-oral cryotherapy
-sucralfate
-oral and parenteral opioid analgesics
clinical pearls of topical anesthetics for pain management of mucositis
-short-term effects
-various combinations of lidocaine, diphenhydramine, and antacids (magic mouthwash)
-swish and spit (or swallow) every few hours PRN
clinical pearls of oral cryotherapy for pain management of mucositis
-vasoconstriction may decrease chemotherapy delivery to oropharyngeal mucosa
-use ice chips 30 minutes before chemotherapy
clinical pearls of sucralfate for pain management of mucositis
-forms protective barrier
-swish and swallow
-taste and texture may be nauseating
clinical pearls of oral and parenteral opioid analgesics for pain management of mucositis
-moderate to severe mucositis
-oral solutions may contain high concentrations of alcohol, which burns
-use of patient-controlled analgesia (PCA) pump is common
decreased white blood cells (WBC)
-neutropenia
-leukopenia
-granulocytopenia
decreased platelets
thrombocytopenia
decreased red blood cells (RBC)
anemia
What is the most common dose-limiting toxicity of chemotherapy?
bone marrow suppression
nadir
lowest value blood counts fall to during cycle of chemotherapy
When does the onset of neutropenia usually occur?
10-14 days after chemotherapy administration
When does neutropenia usually recover by?
3-4 weeks after chemotherapy
What are the lab values necessary in order for chemotherapy to be administered?
-WBC > 3x10^3/uL OR
-absolute neutrophil count (ANC) > 1.5x10^3/uL AND
-platelet count ≥ 100x10^3/uL
severe neutropenia lab value
ANC < 0.5x10^3/uL
febrile neutropenia
severe neutropenia with single oral temperature > 101ºF OR ≥ 100.4ºF for at least 1 hour
neutropenia presentation
fever with no other s/s of infection
primary prophylaxis of neutropenia guidelines
-if patient is to receive chemotherapy expected to cause ≥ 20% incidence of febrile neutropenia
-high risk patients
What patients are defined as high risk for primary prophylaxis of neutropenia?
-pre-existing neutropenia due to disease
-extensive prior chemotherapy
-previous radiation to pelvis or other areas containing large amounts of bone marrow
secondary prophylaxis of neutropenia guidelines
use colony stimulating factor (CSF) preventively with next cycle of chemotherapy
What are other uses for CSFs?
-dose-dense chemotherapy
-alone or with plerixafor after chemotherapy to mobilize peripheral blood progenitor cells
-stem cell transplant
CSF drugs
-filgrastim
-pegfilgrastim
route and frequency of administration for filgrastim
SQ QD
clinical pearls of pegfilgrastim
-pegylated molecule
-longer half-life than filgrastim
-more expensive
-non-linear PK
-self-injector available
What drug is not a biosimilar to filgrastim but works through a similar mechanism of action?
tbo-filgrastim (Granix)
What drugs are biosimilars to filgrastim?
-filgrastim-sndz (Zarxio)
-filgrastim-aafi (Nivestym)
-filgrastim-ayow (Releuko)
dosing recommendations for filgrastim
-start up to 3-4 days after chemotherapy
-continue until post-nadir ANC recovers to at least near normal levels
dosing recommendations for pegfilgrastim
-start at least 24 hours after chemotherapy
-can be administered up to 3-4 days after chemotherapy
-leave at least 14 days between dose and next cycle of chemotherapy
CSF adverse effects
-flu-like symptoms
-bone, joint, and/or musculoskeletal pain
-deep vein thrombosis (DVT)
-splenic enlargement (long-term use)
What medications can be used to treat bone, joint, and/or musculoskeletal pain due to CSF use?
-acetaminophen
-non-opioid analgesics
-loratidine
When are platelet transfusions indicated for thrombocytopenia?
-≤ 10x10^3/uL (varies by institution)
-active bleeding
-before surgical procedures
causes of anemia
-decreased RBC production
-decreased erythropoietin production
-decreased vitamin B12, iron, or folic acid
-blood loss
When should patients undergo a work-up for chemotherapy induced anemia?
-hemoglobin (Hgb) ≤ 11 g/dL OR
-≥ 2 g/dL drop from baseline
chemotherapy induced anemia symptomatic patient treatment guidelines
-transfuse as indicated
-consider use of erythropoietic stimulating agents (ESAs)
-perform iron studies
What drug class has a black box warning for use in cancer patients?
ESAs
When should ESAs not be used in patients with chemotherapy induced anemia?
-myelosuppressive chemotherapy with curative intent
-not receiving chemotherapy
-non-myelosuppressive chemotherapy
When should ESAs be considered for use in patients with chemotherapy induced anemia?
-cancer and chronic kidney disease (CKD)
-palliative chemotherapy
-no other identifiable causes
What is the frequency of administration of epoetin alfa?
weekly
What is the benefit of darbepoetin vs. epoetin alfa?
prolonged half-life
darbepoetin indication for cancer
chemotherapy induced anemia due to chemotherapy of non-myeloid malignancies
Which cancer patients on ESA therapy should have baseline iron studies performed?
all
What chemotherapies cause myalgias/arthralgias?
-taxanes
-aromatase inhibitors
What is the recommended treatment of myalgias/arthralgias due to chemotherapy?
-NSAIDs
-opioids (if necessary)
What chemotherapies cause hemorrhagic cystitis?
-high dose cyclophosphamide
-ifosfamide
What is the recommended treatment of hemorrhagic cystitis due to chemotherapy?
-hydration
-mesna
What chemotherapies cause heart failure?
-anthracyclines
-high-dose cyclophosphamide
-HER2 targeted therapies (i.e., trastuzumab)
What is the recommended treatment of heart failure due to chemotherapy?
-monitor cumulative dose
-assess for risk factors
-dexrazoxane
What chemotherapies cause peripheral neuropathy?
-taxanes
-vinca alkaloids
-platinums
What is the recommended treatment of peripheral neuropathy due to chemotherapy?
-change infusion rates
-adjunctive pain medications (i.e., gabapentin, amitriptyline)
What chemotherapy causes pulmonary toxicities?
bleomycin
What is the recommended treatment of pulmonary toxicities due to chemotherapy?
corticosteroids
acute type I chemotherapy related cardiac dysfunction
-occurs immediately after single dose or course of therapy with anthracycline
-uncommon
-not related to cumulative dose
chronic type I chemotherapy related cardiac dysfunction
-onset usually within 1 year of anthracycline therapy
-need to discontinue anthracycline
-common and life-threatening
-related to cumulative dose
What are symptoms of chronic type I chemotherapy related cardiac dysfunction?
-tachycardia
-tachypnea
-exercise intolerance
-pulmonary and venous congestion
-ventricular dilation
-poor perfusion
-pleural effusion
late onset type I chemotherapy related cardiac dysfunction
-develops several years after therapy
-manifests as ventricular dysfunction, congestive heart failure (CHF), conduction disturbances, and arrhythmias
-more common in pediatric cancer patients who received anthyracyclines
What does the risk of cardiotoxicity depend on when administering chemotherapy?
cycles of chemotherapy
What drug causes type II chemotherapy related cardiac dysfunction?
trastuzumab
type II chemotherapy related cardiac dysfunction
-not dose-related
-ranges widely in severity
-not associated with cardiac damage
-REVERSIBLE (can restart therapy)
OPQRSTU
-Onset
-Provoking factors
-Quality
-Radiation
-Severity
-Time
-Understanding
assessment of pain questions
-What other symptoms do you have associated with pain?
-What are your bowel movements?
-What medications have you used in the past?
-What medication allergies do you have?
What medications are used for stage 1 of pain?
non-opioid +/- adjuvant agent
What medications are used for stage 2 of pain?
opioid for mild to moderate pain +/- non-opioid +/- adjuvant agent
What medications are used for stage 3 of pain?
opioid for moderate to severe pain +/- non-opioid +/- adjuvant agent
What levels of pain should non-opioids be used for?
1-3
What levels of pain should combination products/mild opioids be used for?
4-6
What levels of pain should opioids be used for?
7-10
What are non-opioid medication options?
-acetaminophen
-ibuprofen
-aspirin
What are combination product/mild opioid medication options?
-hydrocodone/acetaminophen
-hydrocodone/ibuprofen
-tramadol
-oxycodone/acetaminophen
-oxycodone/aspirin
-oxycodone/ibuprofen
-codeine/acetaminophen
What are opioid medication options?
-morphine
-hydromorphone
-oxycodone
-fentanyl
-methadone
What medication class does not have maximum doses?
opioids
morphine clinical pearls
-toxicity in patients with renal insufficiency
-use with caution in liver dysfunction
What dosage forms is morphine available in?
-short-acting tablets
-long-acting tablets
-solutions (regular and concentrated)
-IV
-parenteral
hydromorphone clinical pearls
-use lower doses or longer dosing intervals in patients with renal insufficiency
-use with caution in liver dysfunction
-more potent than morphine
What dosage forms is hydromorphone available in?
-short-acting tablets
-long-acting tablets
-solution
-IV
-parenteral
oxycodone clinical pearls
-metabolized by CYP2D6
-sedation and CNS toxicity (patients with renal failure)
-use with caution in liver dysfunction
What dosage forms is oxycodone available in?
-short-acting tablets
-long-acting tablets
-solution
fentanyl clinical pearls
-very potent
-do not start for opioid naive patients
What dosage forms is fentanyl available in?
-patch
-IV
-buccal
-nasal spray
-lozenges
What patients is fentanyl ideal for?
-refractory nausea/vomiting
-head/neck/esophageal cancer patients who cannot maintain adequate oral intake
What dosage forms does fentanyl have REMS for?
transmucosal and nasal
What patients should be considered for methadone use?
-true morphine allergy
-opioid-induced adverse drug reactions (ADRs)
-pain refractory to high-dose opioids
-neuropathic pain
-need long-acting oral dosage form at low cost
What patients should methadone be avoided in?
-numerous drug interactions
-risks for syncope or arrhythmias
-history of unpredictable adherence
-poor cognition
methadone clinical pearls
-avoid in severe liver dysfunction
-half-life very unpredictable
-risk of QT prolongation (need baseline ECG)
What percentage can a dose be reduced by when switching opioid agents?
25%
What is the preferred route of administration for opioids?
oral
How can constipation due to opioids be managed?
mild stimulant laxative +/- stool softener upon initiation of opioids
How can sedation due to opioids be managed?
-hold sedatives and/or anxiolytics
-consider dose reduction
How can nausea/vomiting due to opioids be managed?
-change opioid
-consider adding scheduled anti-emetic therapy (should resolve in 7-10 days)
How can pruritus due to opioids be managed?
-decrease dose or change opioid
-consider adding scheduled anti-histamine therapy (i.e., diphenhydramine)
What opioid is pruritus most commonly seen with?
morphine
What common toxicity of opioids do patients not develop a tolerance to?
constipation
How can hallucinations due to opioids be managed?
-decrease dose or change opioid
-consider adding neuroleptic medication
How can confusion/delirium due to opioids be managed?
-decrease dose or change opioid
-consider adding neuroleptic medication
How can myoclonic jerking due to opioids be managed?
consider changing opioid or treating underlying causes
How can respiratory depression due to opioids be managed?
-hold opioid
-give low dose naloxone (chronic pain)
What are other therapeutic options for pain due to cancer?
-patient controlled analgesia (PCA)
-celiac plexus block
-intrathecal pain pump
-radiation therapy
-bisphosphonate therapy
What patients should a PCA be used with caution?
patients with sleep apnea
What patients are at highest risk of oversedation and respiratory depression with opioid use?
patients during first 24 hours after surgery
How should PCAs be adjusted?
-decrease or stop basal rate when patient no longer needs it
-if receiving multiple bolus doses, then increase basal dose rate
How to change dose of controlled PCA?
-calculate 24-hour dose of current drug
-convert to equivalent 24-hour dose of new agent
-reduce dose by ~25%
-divide 24-hour dose into appropriate dose
-add breakthrough PRN dosing (~10-20% of 24-hour dose Q4H PRN)
When are celiac plexus blocks used?
patients with pancreatic cancer
When are intrathecal pain pumps used?
patients refractory to other opioid therapies or increased toxicities
How should oral doses be adjusted for intrathecal pain pumps?
decreased
What are commonly used opioid medications for intrathecal pain pumps?
-morphine
-hydromorphone
-fentanyl
-clonidine
-baclofen
-ziconotide
-bupivacaine
When is radiation therapy commonly used for pain?
-painful bony metastases
-brain metastases
-spinal cord compression
adjuvant pain therapy alternatives
-dexamethasone
-NSAIDs
complete response (CR)
disappearance of all target lesions
partial response (PR)
30% decrease in sum of longest diameter of target lesions
progressive disease (PD)
20% increase in sum of longest diameter of target lesions
stable disease (SD)
small changes that do not meet other criteria
invasive carcinoma in breast cancer
invasion beyond basement membrane of duct or lobule in breast
What is the most common type of breast cancer?
invasive ductal carcinoma
ductal carcinoma in situ (DCIS)
normal cells undergo pre-malignant gene transformation
lobular carcinoma in situ (LCIS)
tumor has not invaded beyond lobule basement membrane
inflammatory breast cancer
aggressive form of breast cancer with rapid onset and poor prognosis
presentation of inflammatory breast cancer
-edema
-redness
-warmth
-inflammation
-orange skin
If the recurrence score (RS) is < 26, what type of therapy is indicated for breast cancer?
hormonal therapy
If the RS is ≥ 26, what type of therapy is indicated for breast cancer?
chemotherapy and hormonal therapy
stages I, II, and IIIA breast cancer general treatment strategies
-lumpectomy and radiation
-modified radical mastectomy (MRM) +/- radiation
-neoadjuvant chemotherapy (stage II and IIIA)
-adjuvant therapy
stages IIIB and IIIC breast cancer general treatment strategies
-neoadjuvant chemotherapy
-MRM OR lumpectomy AND radiation
-adjuvant therapy
stage IV breast cancer general treatment strategies
-palliative treatment
-radiation (palliative)
-surgery (palliative)
What therapy is not indicated for neoadjuvant treatment of breast cancer?
radiation
What are the treatment guidelines if a patient has ER/PR+, LN-, and HER2- breast cancer with a tumor ≤ 0.5 cm?
adjuvant hormonal therapy
What are the treatment guidelines if a postmenopausal patient has ER/PR+, LN-, and HER2- breast cancer with a tumor > 0.5 cm OR 1-3 positive nodes and no 21 gene RT-PCR assay completed?
-adjuvant hormonal therapy OR
-adjuvant chemotherapy then hormonal therapy
What are the treatment guidelines if a postmenopausal patient has ER/PR+, LN-, and HER2- breast cancer with a tumor > 0.5 cm OR 1-3 positive nodes and RS < 26?
adjuvant hormonal therapy
What are the treatment guidelines if a postmenopausal patient has ER/PR+, LN-, and HER2- breast cancer with a tumor > 0.5 cm OR 1-3 positive nodes and RS ≥ 26?
adjuvant chemotherapy then hormonal therapy
What are the treatment guidelines if a premenopausal patient has ER/PR+, LN-, and HER2- breast cancer with an RS ≤ 15?
adjuvant hormonal therapy +/- ovarian suppression (OS)
What are the treatment guidelines if a premenopausal patient has ER/PR+, LN-, and HER2- breast cancer with an RS 16-25?
-adjuvant hormonal therapy +/- OS OR
-adjuvant chemotherapy then hormonal therapy
What are the treatment guidelines if a premenopausal patient has ER/PR+, LN-, and HER2- breast cancer with an RS ≥ 26?
adjuvant chemotherapy then hormonal therapy
What are the treatment guidelines if a patient has ER/PR+ and HER2+ breast cancer with a tumor size ≤ 0.5 cm?
adjuvant hormonal therapy +/- chemotherapy with HER2 targeted therapy
What are the treatment guidelines if a patient has ER/PR+ and HER2+ breast cancer with a tumor size > 0.5 cm?
adjuvant chemotherapy with HER2 targeted therapy then hormonal therapy
What does an oopherectomy do?
removes largest source of estrogen
tamoxifen clinical pearls
-estrogen agonist (bones, lipids) and antagonist (breast)
-reduces risk of developing contralateral breast cancer
What is the dose of tamoxifen?
20 mg QD
What is the major toxicity of tamoxifen?
hot flashes
What is the dosing frequency for LNRH analogs?
QM or Q3M
What are the third-generation aromatase inhibitors (AIs)?
-anastrozole
-letrozole
-exemestane
Which third-generation AI is non-steroidal?
exemestane
third-generation AI clinical pearls
-only for postmenopausal patients
-if used in premenopausal patients, need OS
-fewer adverse effects, but no bone protection
What hormone therapy guidelines are recommended for premenopausal patients diagnosed with breast cancer?
-tamoxifen for 5 years +/- OS
-AI for 5 years WITH OS
What is the preferred hormone therapy guideline for postmenopausal patients diagnosed with breast cancer?
AI for 5 years then consider AI for additional 5 years
What are the most common chemotherapy agents for breast cancer?
-doxorubicin
-epirubicin
-cyclophosphamide
-methotrexate
-fluorouracil
-carboplatin
-paclitaxel
-docetaxel
What is the schedule of a standard chemotherapy regimen for breast cancer?
4-6 cycles given Q3-4W
What are the medications in the dose dense anthracycline chemotherapy regimen preferred for HER2- breast cancer?
-doxorubicin
-cyclophosphamide
-paclitaxel
-growth factors
What are the medications in the TC chemotherapy regimen preferred for HER2- breast cancer?
-docetaxel
-cyclophosphamide
When should an anthracycline chemotherapy regimen be avoided in patients with breast cancer?
history of cardiac problems or cardiac risks
What are the medications in the APT chemotherapy regimen for HER2+ breast cancer?
-paclitaxel
-trastuzumab
What are the medications in the TCH chemotherapy regimen for HER2+ breast cancer?
-docetaxel
-carboplatin
-trastuzumab
What are the medications in the TCH and pertuzumab chemotherapy regimen for HER2+ breast cancer?
-docetaxel
-carboplatin
-trastuzumab
-pertuzumab
What is the standard of care for triple negative breast cancer?
pembrolizumab (for 1 year)
What is the preferred chemotherapy regimen for triple negative breast cancer?
-paclitaxel
-carboplatin
-doxorubicin
-cyclophosphamide
-pembrolizumab
What are the recommended treatment options for asymptomatic visceral ER/PR+ metastatic breast cancer with bone metastases?
-hormonal therapy +/- bisphosphonate or denosumab (for bone disease only)
-clinical trials
What is the recommended treatment option for symptomatic visceral or hormone refractory ER/PR- HER2+ metastatic breast cancer?
anti-HER2 therapy +/- chemotherapy
What is the recommended treatment option for symptomatic visceral or hormone refractory ER/PR- HER2- metastatic breast cancer?
chemotherapy
When should hormonal therapy be administered to breast cancer patients?
-ER and/or PR+
-long disease-free survival
-prior response to therapy
-bone only disease
When should chemotherapy be administered to breast cancer patients?
-ER/PR-
-short disease-free survival
-rapidly progressing disease
-disease refractive to hormonal therapy
What are the preferred chemotherapy single agents for breast cancer?
-doxorubicin
-liposomal doxorubicin
-paclitaxel
-capecitabine
-gemcitabine
-vinorelbine
-eribulin
-sacituzumab govitecan-hziy
What is the recommended first-line treatment for HER2+ metastatic disease?
-trastuzumab
-pertuzumab
-docetaxel or paclitaxel
What is the recommended second-line treatment for HER2+ metastatic disease?
fam-trastuzumab deruxtecan-nxki
What are the recommended first-line single agents for triple negative breast cancer (TNBC)?
carboplatin and cisplatin
When are pembrolizumab and chemotherapy preferred over platinums for TNBC?
combined positive score ≥ 10
What treatment is preferred for TNBC if there is no positive score?
platinum-based chemotherapy
What is the preferred first-line hormonal therapy for metastatic breast cancer?
AI and CDK 4/6 inhibitor
What CDK 4/6 inhibitors are preferred for breast cancer?
-abemaciclib
-palbociclib
-ribociclib
What are the preferred second-line hormonal therapies for metastatic breast cancer?
-fulvestrant and CDK 4/6 inhibitor (if not used before)
-everolimus and hormonal therapy
What endocrine therapies are preferred for breast cancer?
-exemestane
-fulvestrant
-tamoxifen
What hormonal therapies are useful in certain circumstances for breast cancer?
-megestrol acetate
-ethinyl estradiol
-abemaciclib
What are the monitoring parameters for abemaciclib?
-complete blood count
-diarrhea
What is the monitoring parameter for palbociclib?
complete blood count
What are the monitoring parameters for ribociclib?
-complete blood count
-QTc prolongation
How often should a complete blood count be completed for CDK 4/6 inhibitors?
monthly
What are the screening guidelines for breast self exams?
-age ≥ 20 years old
-discuss benefits and limitations
What are the screening guidelines for clinical breast exams?
not recommended
What are the screening guidelines for mammograms?
-age 40-44: opportunity for annual exams
-age 45-54: annual mammograms
-age ≥ 55: biennial mammograms or opportunity for annual exams
signs and symptoms of early prostate cancer
asymptomatic
signs and symptoms of advanced prostate cancer
-alterations in urinary habits
-impotence
-lower extremity edema
-weight loss
-anemia
What grading scale is used to measure severity of disease for prostate cancer?
Gleason score
What does a 2-4 on the Gleason scale mean?
slow-growing, well-differentiated prostate cancer
What does an 8-10 on the Gleason scale mean?
aggressive, poorly differentiated prostate cancer
normal range of prostate specific antigen (PSA)
0-4 ng/mL
What does a PSA of > 4 ng/mL indicate?
further evaluation
What does a PSA of > 10 ng/mL and/or > 0.75 ng/mL/year indicate?
highly suspicious of malignancy
What does treatment choice for prostate cancer depend on?
-stage
-grade of disease
-age of patient
-health status
-personal preference
How often should PSA levels be measured?
every 6 months
What does localized treatment of prostate cancer include?
-active surveillance
-radiation therapy
-surgery
What are complications of radiation for prostate cancer?
-bladder and/or rectal symptoms
-erectile dysfunction
-radiation proctitis
How long is radiation therapy for prostate cancer?
8-9 weeks
When should androgen deprivation therapy (ADT) be added on in prostate cancer treatment?
patients at intermediate to high risk
What is the timeline for adjuvant ADT?
-start before radiation therapy
-continue during radiation therapy
-continue 1-3 years after radiation therapy
What is the definitive curative therapy for prostate cancer?
radical prostatectomy and pelvic lymph node dissection (PLND)
What is the goal level of testosterone after 1 month of therapy for prostate cancer?
< 50 ng/dL
What anti-androgens are used for prostate cancer treatment?
-bicalutamide
-nilutamide
-flutamide
-abiraterone
-enzalutamide
What LHRH agonists are used for ADT in prostate cancer?
-leuprolide
-goserelin
-triptorelin
-histerelin
What is the frequency of LHRH agonists?
every 3 months/12 weeks
What are acute toxicities of LHRH agonists?
-tumor flare
-gynecomastia
-hot flashes
-erectile dysfunction
-edema
-injection site reaction
What are long-term toxicities of LHRH agonists?
-osteoporosis
-fracture
-obesity
-insulin resistance
-changes in lipids
-increased risk of diabetes and CV events
What drug has less CV events compared to LHRH agonists?
relugolix
Which anti-androgen has the most toxicities?
nilutamide
When are LHRH agonists and anti-androgens administered in combination?
metastatic prostate cancer
What anti-androgen is most commonly administered for prostate cancer?
bicalutamide
What are the general principles of first-line therapy for metastatic prostate cancer?
-goal: palliative therapy
-need to determine PSA recurrence or overt metastatic disease
-determine PSA doubling time
When can ADT be delayed for prostate cancer?
PSA recurrence
When should ADT be considered for prostate cancer?
rapid PSA velocity OR short PSA doubling time AND long life expectancy
When should ADT be administered for prostate cancer?
if PSA doubling time < 6 months
What is a treatment option for m0 hormone sensitive prostate cancer (HSPC)?
orchiectomy
What are symptoms of disease flare due to LHRH agonists in prostate cancer?
-bone pain
-increased urinary symptoms
What patient population should be considered for intermittent ADT?
patients with biochemical failure
m0 castrate resistant prostate cancer (CRPC)
increasing PSA with no response to ADT, but no distant metastasis found on scans
What are the recommended treatment guidelines for m0CRPC?
-continue ADT (LHRH agonist)
-add enzalutamide, apalutamide, or darolutamide
What drugs should be avoided with enzalutamide?
CYP2C8 inhibitors
What drug does enzalutamide decrease serum concentrations of?
warfarin
What patient population should enzalutamide be used with caution in?
patients with history of seizures
What patient population should apalutamide be used with caution in?
history of:
-seizures
-QTc prolongation
-falls
-thyroid dysfunction
What anti-androgen for prostate cancer has less toxicities?
darolutamide
Out of enzalutamide, apalutamide, and darolutamide, which drug has the most toxicities?
enzalutamide
What are the recommended treatment guidelines for low volume m1HSPC?
-ADT
-continue ADT and add abiraterone AND prednisone, enzalutamide, or apalutamide
What drug must abiraterone acetate be co-administered with to prevent adrenal insufficiency?
prednisone
What is a counseling point for abiraterone acetate?
take on an empty stomach
What are treatment options for high volume m1HSPC?
-ADT
-ADT + abiraterone + prednisone
-ADT + enzalutamide
-ADT + apalutamide
-chemotherapy
What are the NCCN guideline recommended chemotherapy regimens for high volume m1HSPC?
-ADT + docetaxel + abiraterone
-ADT + docetaxel + darolutamide
What are the recommended treatment guidelines for metastatic CRPC?
continue ADT and maintain castrate testosterone concentrations
What is the recommended first-line chemotherapy treatment for metastatic prostate cancer?
docetaxel and prednisone
What is the consistency of a normal prostate similar to?
tip of nose
What is the consistency of a prostate with cancer similar to?
chin
What exam is indicated after an abnormal PSA or digital rectal exam (DRE)?
transrectal ultrasonography
At what age should men start getting scheduled prostate cancer screenings?
≥ 50 years old
What is an optional screening test for prostate cancer?
DRE
At what PSA level are annual prostate cancer screenings recommended?
≥ 2.5 ng/mL
At what PSA level are biennial prostate cancer screenings recommended?
< 2.5 ng/mL
