Oncology SE Management Flashcards
Breast Cancer Screening
- Begin yearly mammograms from 45-54 yo
- >= 55 yo, continue yearly or increase to Q2y
Cervical Cancer Screening
- 21-29 yo: Pap smear Q3y
- 30-65 yo: Pap smear + HPV DNA test Q5y
Colon Cancer Screening
- Stool-based tests - fecal occult blood test (gFOBT, Qy >= 45yo) or stool DNA test (Q3y)
- Visual exams of colon and rectum - colonoscopy Q10y and sigmoidoscopy Q5y
Lung Cancer Screening
- CT scan annually at 55-74 yo IF:
- In good health
- Have 30 pack-year smoking history
- Still smokes or quit within the past 15 years
Prostate Cancer Screening
IF patient chooses to be tests, involves:
- PSA test
- +/- DRE
Bleomycin Dose Limit
Lifetime Cumulative Dose of 400u
-Reason: pulmonary toxicity
Doxorubicin Dose Limit
Lifetime Cumulative Dose of 450-550 mg/m^2
-Reason: Cardiotoxicity
Cisplatin Dose Limit
Dose per cycle shouldn’t exceed 100 mg/m^2
-Reason: Nephrotoxicity
Vincristine Dose Limit
Single dose capped at 2 mg
-Reason: Neurotoxicity
Myelosuppression Agents/Tx
- All chemo EXCEPT Asparaginase, bleomycin, vincristine
- Neutropenia => CSF
- Anemia => RBC transfusions, ESAs in palliative ONLY
- Thrombocytopenia => platelet transfusions
N/V Agents/Tx
- Cisplatin, cyclophosphamide, ifosfamide
- Tx: Neurokinin-1 receptor antagonist (NK1-RA), 5HT3 antagonist, dexamethasone, IV/PO fluid hydration
Mucositis Agents/Tx
- Fluorouracil, MTX
- Tx: symptomatic; mucosal coating agents, topical anesthetics (2% viscous lidocaine), antifungals/virals (Nystatin susp. or clotrimazole troches)
Diarrhea Agents/Tx
- Irinotecan, capecitabine, fluorouracil, MTX
- Tx: IV/PO fluid hydration, antimotility meds (loperamide, max 16 mg/d)
- Irinotecan specific: atropine for early-onset (prevent or tx)
Constipation Agents/Tx
- Vincristine
- Tx: Stimulant laxatives, PEG 3350
Xerostomia Agents/Tx
- Radiation to head/neck
- Tx: Artificial saliva substitutes, pilocarpine
Cardiotoxicity Agents/Tx
- Cardiomyopathy: Anthracyclines
- QT Prolongation: Arsenic trioxide and many TKIs (ECG monitoring)
- Be sure not to exceed lifetime cumulative doses
- Give dexrazoxane prophylactically in doxorubicin pts
Pulmonary Toxicity Agents/Tx
- Fibrosis: Bleomycin, busulfan, carmustine, lomustine
- Pneumonitis: Immune therapy MAbs
- Don’t exceed lifetime cumulative dose of bleomycin
- Give steroids if autoimmune mechanism is suspected
Hepatotoxicity Agents/Tx
- Antiandrogens: bicalutamide, eflutamide, nilutamide
- Give steroids if autoimmune mechanism is suspected (immune therapy MAbs)
Nephrotoxicity Agents/Tx
- Cisplatin, MTX (high doses)
- Cisplatin specific: Amifostine (Ethyol) given prophylactically, don’t exceed dose limitation
- Ensure adequate hydration
Hemorrhagic Cystitis Agents/Tx
- Ifosfamide, cyclophosphamide (high doses)
- Mesna (Mesnex) - always given prophylactically with ifosfamide and sometimes with cyclophosphamide
- Ensure adequate hydration
Neuropathy Agents/Tx
- Peripheral: Vinca alkaloids, platinums, taxanes
- Vincristine limited to 2 mg/dose
- Avoid cold temperatures and beverages with oxiplatin
Thromboembolism Agents/Tx
- Aromatase inhibitors, SERMs
- Can cause stroke, DVT/PE, MI
- Consider thromboprophylaxis based on risk factors
Leucovorin
- Given with fluorouracil to enhance efficacy
- Given prophylactically after MTX to decrease myelosuppression and mucositis (high-dose therapy)
- Can also use levoleucovorin (Fusilev)
Vistogard
- Uridine Triacetate
- Antidote to Fluorouracil or capecitabine
- Use within 96 hours for an overdose to treat severe/life-threatening early-onset toxicity
Voraxaze
- Glucarpidase
- Antidote to decrease excessive MTX due to acute renal failure
Levels of Neutropenia
- Neutropenia: <1000
- Severe Neutropenia: <500
- Profound Neutropenia: <100
Neutropenia Abx Requirements
- If fever occurs (>38.3 C, 101 F), start empiric abx immediately
- Treated with neutrophil <500 or anticipated to drop under 500 within 48 hours
- MUST have Gram”-“ coverage to avoid sepsis, including P. aeruginosa coverage
Low-Risk Empiric Abx Regimen
When ANC =< 500 for =<7 days
-Oral: Cipro OR Levofloxacin PLUS Augmentin OR Clindamycin
High-Risk Empiric Abx Regimen
When ANC =<100 for >7 days, comorbidities, renal/hepatic impairment, IV!:
- Cefepime OR
- Ceftazadime OR
- Meropenem OR
- Imipenem/cilastatin OR
- Zosyn
ESA Use Requirements
- Cancer must not have curative intent
- Hgb must < 10
- Use lowest dose possible
- TSAT, TIBC, and ferritin must be assessed first, ESAs will not work well if iron levels are inadequate
Platelet Transfusion Use Criteria
- Plt < 10,000
- Plt <30,000 AND active bleeding is occuring
CINV Risk Factors
- Female
- <50 yo
- Anxiety
- Depression
- Dehydration
- Hx of motion sickness
- Hx of N/V with other regimens
Acute N/V Definition/Tx
- Within 24 hours of chemo
- 5HT3 antagonists are preferred (Zofran)
Delayed N/V Definition/Tx
- > 24 hours after chemo
- NK1-RA, corticosteroids, or palonosetron
- PLUS olanzapine
Anticipatory N/V Definition/Tx
- Before chemo
- BZD started the evening prior to chemo
High Emetic Risk Regimen Options
- NK1-RA + 5HT3-RA + Olanzapine + Dexamethasone (preferred)
- Palonosetron + Olanzapine + Dexamethasone
- NK1-RA + 5HT3-RA + Dexamethasone
* *Example of High-Emetic Risk: Cisplatin**
Hand-Foot Syndrome
- Palmar-Plantar erythrodysesthesia
- Occurs frequently with fluorouracil and capecitabine
- Cool hands/feet for temporary relief
- Steroids and analgesics can also be used to lessen pain/inflammation
- Emollients for retaining moisture in hands/feet
Tumor Lysis Syndrome
- Can cause HYPER K/Phos, and HYPOcalcemia
- Also hyperuricemia which crystallizes and causes kidney damage
- First: Allopurinol and hydration to control uric acid levels
- Second: Add rasburicase (expensive) if first-line doesn’t control UA or isn’t an option (SE/allergy/etc)
Hypercalcemia of Malignancy
- Cancers leaching Ca from bones; causes them to be weak and prone to fracture
- Mild: hydration and loop diuretics
- Mod-Severe (symptomatic): IV hydration (NS), Calcitonin sometimes initially (only 48 hours duration; tachyphylaxis), IV bisphosphonates (zoledronic acid, pamidronate) are usually first line (alt: denosumab)
Extravasation with Anthracyclines
- Use cold compresses
- Dexrazoxane (Totect) or dimethyl sulfoxide as antidote
Extravasation with Vinca Alkaloids/Etoposide
- Use warm compress
- Hyaluronidase as antidote
