Oncology SE Management

Question 1

Breast Cancer Screening

Answer 1

• Begin yearly mammograms from 45-54 yo

- >= 55 yo, continue yearly or increase to Q2y

Question 2

Cervical Cancer Screening

Answer 2

• 21-29 yo: Pap smear Q3y

- 30-65 yo: Pap smear + HPV DNA test Q5y

Question 3

Colon Cancer Screening

Answer 3

• 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

Question 4

Lung Cancer Screening

Answer 4

• 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

Question 5

Prostate Cancer Screening

Answer 5

IF patient chooses to be tests, involves:

• PSA test
• +/- DRE

Question 6

Bleomycin Dose Limit

Answer 6

Lifetime Cumulative Dose of 400u

-Reason: pulmonary toxicity

Question 7

Doxorubicin Dose Limit

Answer 7

Lifetime Cumulative Dose of 450-550 mg/m^2

-Reason: Cardiotoxicity

Question 8

Cisplatin Dose Limit

Answer 8

Dose per cycle shouldn’t exceed 100 mg/m^2

-Reason: Nephrotoxicity

Question 9

Vincristine Dose Limit

Answer 9

Single dose capped at 2 mg

-Reason: Neurotoxicity

Question 10

Myelosuppression Agents/Tx

Answer 10

• All chemo EXCEPT Asparaginase, bleomycin, vincristine
• Neutropenia => CSF
• Anemia => RBC transfusions, ESAs in palliative ONLY
• Thrombocytopenia => platelet transfusions

Question 11

N/V Agents/Tx

Answer 11

• Cisplatin, cyclophosphamide, ifosfamide

- Tx: Neurokinin-1 receptor antagonist (NK1-RA), 5HT3 antagonist, dexamethasone, IV/PO fluid hydration

Question 12

Mucositis Agents/Tx

Answer 12

• Fluorouracil, MTX
• Tx: symptomatic; mucosal coating agents, topical anesthetics (2% viscous lidocaine), antifungals/virals (Nystatin susp. or clotrimazole troches)

Question 13

Diarrhea Agents/Tx

Answer 13

• 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)

Question 14

Constipation Agents/Tx

Answer 14

• Vincristine

- Tx: Stimulant laxatives, PEG 3350

Question 15

Xerostomia Agents/Tx

Answer 15

• Radiation to head/neck

- Tx: Artificial saliva substitutes, pilocarpine

Question 16

Cardiotoxicity Agents/Tx

Answer 16

• 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

Question 17

Pulmonary Toxicity Agents/Tx

Answer 17

• Fibrosis: Bleomycin, busulfan, carmustine, lomustine
• Pneumonitis: Immune therapy MAbs
• Don’t exceed lifetime cumulative dose of bleomycin
• Give steroids if autoimmune mechanism is suspected

Question 18

Hepatotoxicity Agents/Tx

Answer 18

• Antiandrogens: bicalutamide, eflutamide, nilutamide

- Give steroids if autoimmune mechanism is suspected (immune therapy MAbs)

Question 19

Nephrotoxicity Agents/Tx

Answer 19

• Cisplatin, MTX (high doses)
• Cisplatin specific: Amifostine (Ethyol) given prophylactically, don’t exceed dose limitation
• Ensure adequate hydration

Question 20

Hemorrhagic Cystitis Agents/Tx

Answer 20

• Ifosfamide, cyclophosphamide (high doses)
• Mesna (Mesnex) - always given prophylactically with ifosfamide and sometimes with cyclophosphamide
• Ensure adequate hydration

Question 21

Neuropathy Agents/Tx

Answer 21

• Peripheral: Vinca alkaloids, platinums, taxanes
• Vincristine limited to 2 mg/dose
• Avoid cold temperatures and beverages with oxiplatin

Question 22

Thromboembolism Agents/Tx

Answer 22

• Aromatase inhibitors, SERMs
• Can cause stroke, DVT/PE, MI
• Consider thromboprophylaxis based on risk factors

Question 23

Leucovorin

Answer 23

• Given with fluorouracil to enhance efficacy
• Given prophylactically after MTX to decrease myelosuppression and mucositis (high-dose therapy)
• Can also use levoleucovorin (Fusilev)

Question 24

Vistogard

Answer 24

• Uridine Triacetate
• Antidote to Fluorouracil or capecitabine
• Use within 96 hours for an overdose to treat severe/life-threatening early-onset toxicity

Question 25

Voraxaze

Answer 25

- Glucarpidase | - Antidote to decrease excessive MTX due to acute renal failure

Question 26

Levels of Neutropenia

Answer 26

- Neutropenia: <1000 - Severe Neutropenia: <500 - Profound Neutropenia: <100

Question 27

Neutropenia Abx Requirements

Answer 27

- 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

Question 28

Low-Risk Empiric Abx Regimen

Answer 28

When ANC =< 500 for =<7 days | -Oral: Cipro OR Levofloxacin PLUS Augmentin OR Clindamycin

Question 29

High-Risk Empiric Abx Regimen

Answer 29

When ANC =<100 for >7 days, comorbidities, renal/hepatic impairment, IV!: - Cefepime OR - Ceftazadime OR - Meropenem OR - Imipenem/cilastatin OR - Zosyn

Question 30

ESA Use Requirements

Answer 30

- 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

Question 31

Platelet Transfusion Use Criteria

Answer 31

- Plt < 10,000 | - Plt <30,000 AND active bleeding is occuring

Question 32

CINV Risk Factors

Answer 32

- Female - <50 yo - Anxiety - Depression - Dehydration - Hx of motion sickness - Hx of N/V with other regimens

Question 33

Acute N/V Definition/Tx

Answer 33

- Within 24 hours of chemo | - 5HT3 antagonists are preferred (Zofran)

Question 34

Delayed N/V Definition/Tx

Answer 34

- >24 hours after chemo - NK1-RA, corticosteroids, or palonosetron - PLUS olanzapine

Question 35

Anticipatory N/V Definition/Tx

Answer 35

- Before chemo | - BZD started the evening prior to chemo

Question 36

High Emetic Risk Regimen Options

Answer 36

1. NK1-RA + 5HT3-RA + Olanzapine + Dexamethasone (preferred) 2. Palonosetron + Olanzapine + Dexamethasone 3. NK1-RA + 5HT3-RA + Dexamethasone * *Example of High-Emetic Risk: Cisplatin**

Question 37

Hand-Foot Syndrome

Answer 37

- 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

Question 38

Tumor Lysis Syndrome

Answer 38

- 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)

Question 39

Hypercalcemia of Malignancy

Answer 39

- 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)

Question 40

Extravasation with Anthracyclines

Answer 40

- Use cold compresses | - Dexrazoxane (Totect) or dimethyl sulfoxide as antidote

Question 41

Extravasation with Vinca Alkaloids/Etoposide

Answer 41

- Use warm compress | - Hyaluronidase as antidote