Oncology Supportive Care Flashcards
1
Q
- A 50-year-old man is in the clinic to receive
his third cycle of R-CHOP (cyclophosphamide,
doxorubicin [hydroxydaunomycin], vincristine
[Oncovin], prednisone, and rituximab) for nonHodgkin lymphoma. He is very anxious, with nausea
and vomiting lasting for about 12 hours after his previous cycle of chemotherapy. The antiemetic regimen
he received for his previous cycle of chemotherapy
was granisetron 1 dose plus dexamethasone 1 dose
administered 30 minutes before chemotherapy. Which
regimen is most appropriate for the patient to receive
on day 1 of the next cycle of chemotherapy?
A. Granisetron 1 dose plus dexamethasone 1 dose
administered 30 minutes before chemotherapy.
B. Dolasetron 1 dose plus dexamethasone 1 dose
plus aprepitant 1 dose administered 30 minutes
before chemotherapy.
C. Netupitant/palonosetron 1 dose plus dexamethasone 1 dose plus lorazepam 1 dose administered
30 minutes before chemotherapy.
D. Metoclopramide 1 dose plus dexamethasone 1
dose plus aprepitant 1 dose administered 30 minutes before chemotherapy
A
- Answer: C
According to the NCCN guidelines, this regimen would
likely be considered highly emetogenic. According to
these guidelines, an NK1-based regimen with a serotonin-3 antagonist and dexamethasone combination would
be recommended (Answer C is correct). However, the
patient is likely having some anticipatory nausea/vomiting. Patients who have had poor control of nausea and
vomiting on previous cycles of chemotherapy are at an
elevated risk of anticipatory emesis. Anxious patients are
also at an elevated risk of CINV. Benzodiazepines help
decrease anxiety and, by causing anterograde amnesia,
may minimize anticipatory symptoms (Answer C is correct). Although it is unclear whether patients who do not
respond to one serotonin receptor antagonist will respond
to another, a change in regimen is needed (Answer A is not
correct). Substituting dolasetron for granisetron would be
acceptable, but adding lorazepam is essential (Answer B
is not correct). Metoclopramide is another option, but an
effective dose might be difficult to administer orally (especially as tablets), and again, adding lorazepam would be
preferred to adding aprepitant in this patient (Answer D is
not correct).
1
Q
- A 65-year-old man with metastatic non–small cell lung
cancer is brought to the clinic by his family because he
is lethargic and fatigued. Pertinent laboratory values
include serum calcium concentration 12 mg/dL and
albumin concentration 2 g/dL. Which therapy is best
for this patient’s lethargy and fatigue as the result of
hypercalcemia of malignancy?
A. Calcitonin 4 units/kg every 12 hours.
B. Furosemide 20 mg orally.
C. Dexamethasone 10 mg orally two times a day.
D. Zoledronic acid 4 mg intravenously.
A
- Answer: D
The corrected calcium is 13.6 mg/dL. Corrected calcium
concentrations greater than 12 g/dL should be treated with
a bisphosphonate (either pamidronate or zoledronic acid)
in addition to hydration with normal saline(Answer D is
correct). Furosemide may be needed during hydration, but
not before hydration because the patient is probably dehydrated (Answer B is not correct). This patient does not need
rapid reversal of hypercalcemia; therefore, calcitonin is not
needed (Answer A is not correct). Dexamethasone may be
used in patients with lymphoma or myeloma, but it has no
effect on metastatic non–small cell lung cancer (Answer C
is not correct)
2
Q
- A 20-year-old man was recently given a diagnosis of
acute myeloid leukemia. He has an elevated white
blood cell count (WBC), and he will receive chemotherapy tomorrow. Which is the best prevention
strategy for tumor lysis syndrome (TLS)?
A. Hydration with 5% dextrose (D5W), 1 L before
chemotherapy, plus allopurinol 300 mg/day.
B. Hydration with D5W, 100 mL/hour starting at
least 24 hours before chemotherapy, plus allopurinol 300 mg/day.
C. Hydration with normal saline 250 mL/hour starting at least 24 hours before chemotherapy plus
allopurinol 300 mg/day.
D. Hydration with normal saline 100 mL/hour starting at least 24 hours before chemotherapy plus
sodium bicarbonate 500 mg orally every 6 hours.
A
- Answer: C
The patient is at risk of TLS because he has a chemosensitive tumor and a high tumor burden (elevated WBC).
Prevention is key in TLS, which includes adequate saline
hydration and the use of allopurinol (Answer C is correct).
Dextrose 5% is an inappropriate parenteral fluid for hydration because it does not contain saline (Answer A and B
are not correct). The value of alkalinization with sodium
bicarbonate is somewhat controversial, but alkalinization is
not a replacement for allopurinol (Answer D is not correct).
3
Q
- An 18-year-old man is about to begin chemotherapy
with curative intent for acute lymphoblastic leukemia. On today’s complete blood cell count (CBC), his
hemoglobin (Hgb) is 7 g/dL, and he is experiencing
fatigue. Which is the best treatment recommendation?
A. Initiate epoetin.
B. Administer transfusion of packed red blood cells
(RBCs).
C. Delay chemotherapy treatment until Hgb recovers.
D. Reduce chemotherapy dosages to prevent further
decreases in Hgb
A
- Answer: B
This anemia is not attributable to treatment because chemotherapy has not yet begun. Epoetin and darbepoetin are
indicated only for noncurative chemotherapy-associated
anemia in non-myeloid tumors (answer A is not correct).
Chemotherapy should not be delayed, nor should chemotherapy dosages be reduced in the setting of a potentially
curable malignancy (Answer C and D are not correct).
Therefore, the patient should receive a transfusion of
packed RBCs because his hemoglobin is less than 8 g/dL
and he is fatigued (Answer B is correct)
4
Q
Questions 5–7 pertain to the following case.
A patient received her fourth cycle of chemotherapy with
paclitaxel/carboplatin for ovarian cancer 12 days ago.
She reports to the clinic this morning with a temperature
of 103°F. Her CBC is WBC 500 cells/mm3
, segmented
neutrophils 55%, band neutrophils 5%, basophils 15%,
eosinophils 5%, monocytes 15%, and platelet count 99,000
cells/mm3
. She denies any signs or symptoms of infection.
Her blood pressure is 115/60 mm Hg, heart rate is 80 beats/
minute, and respiratory rate is 15 breaths/minute.
- Which best represents the patient’s absolute neutrophil
count (ANC)?
A. 275 cells/mm3
B. 300 cells/mm3
C. 25 cells/mm3
D. 500 cells/mm3 - Which is the best course of action for this patient?
A. Admit her to the hospital for parenteral antibiotic
drugs.
B. Treat her as an outpatient with antibiotic drugs.
C. Initiate a colony-stimulating factor (CSF).
D. Discontinue chemotherapy. - Which statement about this patient is most accurate?
A. Given her monocyte count, her neutropenia is
expected to last for another week.
B. This is a nadir neutrophil count, and neutrophils
would be expected to start increasing soon.
C. The elevated absolute eosinophil count indicates
an allergic reaction to carboplatin.
D. It is unusual for the ANC to be this low in the setting of an elevated platelet count.
A
- Answer: B
(55% segmented neutrophils + 5% band neutrophils) ×
500 = 300 cells/mm3
(Answer B is correct). Other options
available will not produce the appropriate ANC count due
to miscalculation (Answer A, C and D are not correct - Answer: A
The patient is neutropenic (ANC 300 cells/mm3
). A temperature of 103°F places the febrile neutropenia outside
the definition of low-risk febrile neutropenia (Answer B is
not correct). Therefore, the patient should be hospitalized
for parenteral antibiotics and an infection workup (Answer
A is correct). She has none of the appropriate reasons to
administer CSFs (i.e., documented pneumonia, hypotension, sepsis syndrome, or fungal infection) (answer C is not
correct). Her chemotherapy may need to be delayed, but it
should be continued on count recovery (Answer D is not
correct). She should receive a CSF with the next cycle of
chemotherapy. - Answer: B
In this patient, febrile neutropenia developed at the time of
the expected neutrophil nadir, 12 days after chemotherapy
(Answer B is correct). Marrow recovery would be expected
to follow (Answer A is not correct). The percentage of
eosinophils may be slightly elevated, but the absolute
count is low (Answer C is not correct). The platelet count
is also low, not elevated. Neutrophils are often affected by
myelosuppressive chemotherapy to a greater degree than
are platelets (Answer D is not correct)
5
Q
- A 60-year-old man has head and neck cancer with
extensive involvement of facial nerves. His pain
medications include transdermal fentanyl 100 mcg/
hour every 72 hours and oral morphine solution 40
mg every 4 hours as needed. He is still having problems with neuropathic pain. Which treatment is best to
recommend?
A. Begin gabapentin and decrease the dosage of
fentanyl.
B. Increase the dosages of fentanyl and morphine.
C. Begin diazepam and increase the dosage of
fentanyl.
D. Begin gabapentin and continue fentanyl and morphine at the same dosage.
A
- Answer: D
Opioids may provide some relief from neuropathic pain,
but often, the response to opioids is less than optimal. In
general, higher opioid dosages provide greater pain relief;
therefore, increasing the dosage of fentanyl and morphine
is an option for this patient but will likely not be effective
because of the descriptions of neuropathic pain (Answer B
is not correct). Adjuvant analgesic drugs, including tricyclic antidepressants and anticonvulsants, are used to help
manage neuropathic pain. Gabapentin, with a good adverse
event profile, is a reasonable option. However, adjuvant
analgesic drugs should not be given to decrease the opioid
dosage or discontinue the use of opioid drugs (Answer A is
not correct). Adding gabapentin to the current medication
profile is the best choice (Answer D is correct). It may be
possible to decrease the dosages of opioids later if gabapentin provides adequate pain relief. Diazepam is more
effective for muscle spasms than for neuropathic pain, and
this option includes decreasing the fentanyl dosage at the
same time as the new drug is initiated (Answer C is not
correct)
6
Q
- A patient is receiving chemotherapy for limited-stage
small cell lung carcinoma. After the third cycle of
chemotherapy, she is hospitalized with febrile neutropenia. She recovers, and today she is scheduled to
receive the fourth cycle of chemotherapy. Which statement is the best treatment course for this patient?
A. The patient should receive filgrastim 250 mcg/m2
/
day subcutaneously for 10 days, given at least 24
hours after chemotherapy.
B. The patient should receive filgrastim 5 mcg/kg/
day subcutaneously, starting today.
C. The patient should receive pegfilgrastim 1 mg/
day subcutaneously for 6 days, given at least 24
hours after chemotherapy.
D. The patient should receive filgrastim 5 mcg/kg/
day subcutaneously for 7 days, given at least 24
hours after chemotherapy.
A
- Answer: D
Limited-stage small cell lung cancer is potentially curable; therefore, the patient should continue on the planned
chemotherapy dosages. The correct dosage of filgrastim
is 5 mcg/kg/day subcutaneously, not 250 mcg/m2
(this is
the dose for sargramostim) (Answer A is not correct). The
correct dosage for pegfilgrastim is a single 6-mg injection
(Answer C is not correct). Filgrastim should not be given
on the same day as chemotherapy (Answer B is not correct,
Answer D is correct)
7
Q
- A 60-year-old woman with breast cancer is to begin
chemotherapy with AC (doxorubicin and cyclophosphamide). Laboratory values today include sodium
140 mEq/L, potassium 3.8 mEq/L, glucose 100 mg/
dL, serum creatinine 1.1 mg/dL, aspartate aminotransferase 6 IU/L, alanine aminotransferase 35 IU/L,
and total bilirubin 2 mg/dL. Which statement is most
appropriate?
A. The dosage of doxorubicin should be decreased.
B. The dosage of cyclophosphamide should be
decreased.
C. Both chemotherapy drugs should be given at standard dosages.
D. Both chemotherapy drugs should be given at
decreased dosages.
A
- Answer: A
Doxorubicin undergoes hepatic clearance (by the biliary
tract), and there are recommendations for dosage reduction
based on bilirubin (Answer A is correct). There is no reason to reduce the cyclophosphamide dosage (Answer B is
not correct). Because only doxorubicin requires reduction,
both agents should not be adjusted based on the laboratory values given (Answer D is not correct). Both agents
shouldn’t be continued at the current dose as doxorubicin
must be adjusted in patients with elevated total bilirubin
(Answer D is not correct).
8
Q
- Large cell lymphoma is considered intermediate
(between indolent and highly aggressive) in tumor
growth and biology. Large cell lymphoma is sensitive
to chemotherapy and potentially curable. Metastatic
colorectal cancer is considered slow growing.
Although responses to chemotherapy commonly occur
and chemotherapy can prolong survival (by months),
metastatic colorectal cancer is not generally considered
curable with chemotherapy. Given these differences
between large cell lymphoma and metastatic colorectal
cancer, which statement is most accurate?
A. Patients with large cell lymphoma should receive
allopurinol before the first cycle of chemotherapy
because they are at an elevated risk of developing
TLS.
B. Patients with metastatic colorectal cancer should
receive allopurinol before the first cycle of chemotherapy because they are at an elevated risk of
developing TLS.
C. Patients with large cell lymphoma should receive
pamidronate before the first cycle of chemotherapy because they are at an elevated risk of
developing hypercalcemia.
D. Patients with metastatic colorectal cancer should
receive pamidronate before the first cycle of chemotherapy because they are at an elevated risk of
developing hypercalcemia
A
- Answer: A
Large cell lymphoma is faster growing and more chemosensitive than metastatic colorectal cancer (Answer B is
not correct). Therefore, patients with large cell lymphoma
are more likely to develop hyperuricemia or TLS from
rapid cell turnover, both before treatment and after chemotherapy (Answer A is correct). Hypercalcemia is not a
common complication of either of these diseases. Some
aggressive lymphomas may be associated with hypercalcemia, but pamidronate is used to treat, not prevent, this
complication (Answer C and D are not correct)
9
Q
- Consider the information provided earlier about large
cell lymphoma and metastatic colorectal cancer. Patient
1 with large cell lymphoma is receiving R-CHOP
(cyclophosphamide, doxorubicin [hydroxydaunomycin], vincristine [Oncovin], prednisone, and rituximab)
chemotherapy. Patient 2 with metastatic colorectal
cancer is receiving FOLFIRI (fluorouracil-leucovorin,
irinotecan) chemotherapy. On the day cycle 2 is due,
both patients have an ANC of 800 cells/mm3
. Which
statement is most appropriate, given the ANC values?
A. Patient 1 should receive chemotherapy to keep
him on schedule because he has a curable disease.
B. Patient 2 should receive chemotherapy to keep
him on schedule because he has a curable disease.
C. The chemotherapy for patient 1 should be held
for now, and he should receive filgrastim after the
next time he has chemotherapy.
D. The chemotherapy for patient 2 should be held
for now, and he should receive filgrastim after the
next time he has chemotherapy.
A
- Answer: C
Neither patient should undergo chemotherapy with an
ANC of 800 cells/mm3
(Answer A and B are not correct).
Both can be treated when neutropenia resolves (probably
within 1 week). It is important to keep patient 1 on schedule because his disease is potentially curable; therefore,
patient 1 should receive filgrastim after the next chemotherapy treatment to prevent another dose delay (answer
C is correct). When patient 2 resumes chemotherapy, his
dosages can be decreased to prevent a recurrence of neutropenia (Answer D is not correct).
10
Q
- Sometimes, extravasation is not immediately evident
when it occurs. Immediately after patient 1 receives
R-CHOP, an extravasation is suspected. Which is
the best treatment recommendation for the patient’s
extravasation?
A. Application of a warm pack for suspected extravasation of doxorubicin.
B. Application of a cold pack for suspected extravasation of vincristine.
C. Parenteral dexrazoxane for suspected extravasation of doxorubicin.
D. Application of sodium thiosulfate for suspected
extravasation of vincristine
A
- Answer: C
Injury after extravasation of an anthracycline is potentially
the most severe. Therefore, when the recommended antidotes for different vesicants conflict (e.g., heat vs. cold),
treatment should be directed at the anthracycline (Answer
B is not correct). Dexrazoxane is now indicated for doxorubicin extravasation (Answer C is correct). Cold, rather
than heat, would also be appropriate (Answer A is not correct). Although vincristine is considered a vesicant, sodium
thiosulfate is not the recommended antidote (Answer D is
not correct).
11
Q
- A 65-year-old man with metastatic melanoma is being
treated with nivolumab and ipilimumab. After treatment cycle 3, he presents to the emergency department
with concerns of fatigue and uncontrolled diarrhea. He
reports 8 loose stools per day for the past 4 days. On
examination, the patient appears dehydrated. Which is
the best course of management at this time?
A. Initiate intravenous fluid replacement and intravenous methylprednisolone 2 mg/kg/day. Patient
will need inpatient admission and monitoring
until improvement.
B. Initiate intravenous fluid replacement with 1 L of
normal saline. Discharge patient on loperamide 4
mg by mouth once, followed by 2 mg after each
loose stool until symptoms improve.
C. Initiate intravenous fluid replacement with 1 L of
normal saline. Discharge patient and discontinue
immunotherapy.
D. Initiate intravenous fluid replacement with 1 L of
normal saline. Discharge patient with a prescription for a prednisone taper of 20 mg once daily
for 3 days, followed by 15 mg once daily for 3
days, then 10 mg once daily for 3 days, then 5 mg
once daily for 3 days, then 2.5 mg for 3 days; then
discontinue
A
- Answer: A
Immune-related toxicities can occur with immunotherapy
such as PD-1/PD-L1 and CTLA-4 inhibitors and are more
common with combination therapy such as nivolumab
and ipilimumab. This patient has grade 3 colitis related
to immune checkpoint inhibitor therapy. The patient has
reported 8 loose stools per day and is dehydrated. Because
this is a severe irAE, the patient should be admitted to the
hospital for fluid management and high-dose intravenous
corticosteroid treatment (Answer A is correct). Because
this toxicity is immune related and treatment with steroids
is necessary to suppress the immune system in order to
reverse the toxicity, loperamide treatment would be inappropriate (Answer B is incorrect). Although discontinuing
immunotherapy can be considered for a grade 3 colitis toxicity, it is not required, and the patient may be able to restart
therapy once he improves; however, immediate intervention
Oncology Supportive Care
ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
1332
is needed with corticosteroid treatment (Answer C is incorrect). The proper dose of steroid is 1–2 mg/kg/day either
orally or intravenously, depending on the severity of the
toxicity (Answer D is incorrect)
