Oncology- Supportive Care Flashcards
What are the different treatment options for cancer?
- surgery
- radiation
- systemic therapy
What is the general regimens of chemotherapy?
- multiple agents (different mechanisms, effects different points of the cell cycle, avoid toxicity)
- given in cycles to recover from toxicities (absolute neutrophil count (ANC) > 1.5, platelet count > 10,000, non-hematologic toxicities resolved)
What is Tumor Agnostic Therapies?
the same drug is used to treat all canccer types that have the genetic mutation or biomarker that is targeted by the drug
What are the general adverse effects of chemotherapy?
- nausea/vomiting
- myelosuppression
- mucositis
- alopecia
- diarrhea/constipation
- neuropathy
- long term effects= cardiomyopathy, infertility, secondary maligancies
How many patients experience chemotherapy induced nausea/vomiting (CINV)?
70-80%
Why is it important to treat chemotherapy induced nausea/vomiting (CINV)?
- impairs QOL
- increases healthcare resources
- may compromise adhearance
- may necessiate chemotherapy dose reduction
What neurotransmitters involved in chemotherapy induced nausea/vomiting (CINV)?
- serotonin
- dopamine
- substance P
Define: Acute CINV
< 24 hours, peaks hour 5-6
What are the risk factors for acute CINV?
- younger age (<50)
- female
- low alcohol intake
- chemotherapy dose or emetogenicity (risk of inducing N/V)
- history of motion sickness/morning sickness
Define: Delayed CINV
> 24 hours, peaks hour 48-72 hours, duration 6-7 days
What are the risk factors for delayed CINV?
poor control of acute CINV
What drugs are serotonin (5-HT3) receptor antagonists?
- dolasteron
- granisteron
- ondansetron
- palonosteron
What is the place in therapy for serotonin receptor antagonists?
prophylatic for acute CINV
What are the adverse effects of serotonin receptor antagonists?
- headache
- increased LFTs
- constipation
- QT prolongation
What drugs are Neurokinin (NK) 1 Receptor Antagonists?
- aprepitant (PO and injectable emulsion)
- fosaprepitant
- rolapitant
- netupitant/palonosteron (IV x 1 dose)
- fosnetupitant/palonosetron (IV x 1 dose)
What is the dosing of Aprepitant PO for CINV?
125 mg PO day 1, then 80 mg PO daily on day 2 and 3
What is the place in therapy for Neurokinin (NK) 1 Receptor Antagonist?
acute and delayed emesis, recommended for highly emetogenic chemotherapy
What are the adverse effects of Neurokinin (NK) 1 Receptor Antagonist?
- fatigue/asthenia
- hiccups
- dyspepsia
What is the place in therapy for corticosteroids?
acute and delayed emesis
What is the dosing of corticosteroids for CINV?
dexamethasone 8-12 mg (IV or PO)
What are the adverse effects of corticosteroids?
- hyperglycemia
- insomnia
- dyspepsia
- fluid retention
- mood changes
- weight gain
What is “standard prophylaxis” for CINV?
- 5-HT3 antagnonist day 1
- dexamthasone 12 mg day 1, then 8 mg days 2-4
- NK1 antagonist day 1
What is the use of olanzapine?
acute or delayed, dosed 10 mg PO daily days 1-4
What are the adverse effects of olanzapine?
- headache
- agitation
- somnolence
- insomnia
- tardive dyskinesia
- hypotension
- tachycardia
What are the non-pharmqacological recommendations for CINV?
- encourage small, frequent bland meals (avoid spicy/greasy foods)
- encourage patient to keep mind busy
What is the treatment for low emetic risk for parenteral antineoplastic therapies?
pick one of the following:
- dexamethasone 8-12mg PO/IV once on the day of chemo
- prochlorperazine 10 mg IV/PO once on the day of chemo
- serotonin antagonist PO once on the day of chemo
- +/- lorazepam 0.5-2mg PO/IV (for anticipatory N/V)
What is the preferred treatment for high emetic risk for parenteral antineoplastic therapies?
- Day 1: Olanzapine 5-10mg PO, serotonin antagonist PO/IV, dexamethasone 12mg PO/IV, NK1 antagonist
- Day 2-4: Olanzapine 5-10mg PO daily, dexamethasone 8mg daily
regimens with olanzapine is preferred!
What is the recommendation for antiemetic for multiple day parenteral chemotherapy treatment?
- serotonin antagonist with chemotherapy based on N/V risk (palonosetron prior to chemo: may repeat x 1 after 3 days)
- dexamethasone daily and up to 3 days following chemotherapy
- aprepitant PO can be given daily up to 5-7 days
- olanzapine may be given daily and for 2 days following chemotherapy
What is the preferred treatment for high-moderate emetic risk for oral antineoplastic therapies?
- prophylaxis= 5-HT3 antagonist daily
- PRN= metoclopramide, prochlorperazine, 5-HT3 antagonist preferred
What is the preferred treatment for low emetic risk for oral antineoplastic therapies?
metoclopramide, prochlorperazine, 5-HT antagonist PRN
What may be used for breakthrough emesis?
treat with a medication in a different class, considering scheduling antiemetics, upgrade prophylaxis regimen for next cycle
When does neutropenia effect chemotherapy patients?
10-14 days after chemotherapy, recovery is seen in3-4 weeks
What are the risk factors for neutropenia?
- chemotherapy agent
- chemotherapy regimen
- age > 65
- organ dysfunction
- prior treatments
What is neutropenia?
absolute neutrophil count (ANC) < 500/ mm3
What are the consequences of neutropenia?
- increased risk of infection (potentially life threatening)= prolonged hospitalization, broad spectrum/high dose antibiotics needed
- delayed chemotherapy
- dose reduction
What can be used to prevent chemotherapy-induced neutropenia?
granulocyte colony stimulating factors (G-CSF)
- filgrastim
- pegfligrastim
- eflapegrastim
- sargramostim (granulocyte-macrophage colony stimulating factors (GM-CSF))
What is the dosing of filgrastim?
5 mcg/kg/d
What are the adverse effects of granulocyte-colony stimulating factors (G-CSF)?
- bone pain
- allergic reactions
- pulmonary toxicity in patients receiving bleomycin
- spenic rupture (rare)
What is the dosing of pegfilgrastim?
6mg x 1 dose
long acting agent and requires at least 2 weeks between chemotherapy cycles
When would prophylaxis therapy be recommended for febrile neutropenia?
high risk (>20%)
When would decreased dose of colony stimulating factor (CSF) be indicated?
febrile neutropenia experienced with prior cycle and prior colony stimulating factor (CSF)
When should colony stimulating factor (CSF) be given to chemotherapy patients?
24-72 hours after chemotherapy
How does pegfilgrastim on body injector work?
placed on the body the same day as chemotherapy and injects pegfilgrastim ~27 hours after application
Neulasta OnPro and Udenyca OnBody
What is Triliciclib?
CDK 4/6 inhibitor that protects RBC, neutrophils, platelets, lymphoctes- only indicated for small cell lung cancer
given prior to chemotherapy
When would erthropoiesis stimulating agents (ESA) be indicated chemotherapy induced anemia?
- when other causes of anemia are ruled out (bleeding, hemolysis, deficiencies)
- hemoglobin < 10 g/dL or Hgb 10-12 g/dL based on clinical judgement
What are the treatment options for chemotherapy induced anemia?
- packed RBC transfusion
- erythropoietin stimulating agents (darbepoetin alfa, epoetin alfa)
What is the black box warning of Eeythropoiesis Stimulating Agents (ESA)?
increased risk of death, MI, stroke, venous thromboembolism, thrombosis of vascular access, and tumor progression/recurrance
CANCER:
- shortened survival and/or increased risk of tumor progression or recurrance
- to avoid risks, use lowest dose possible to decrease transfusion need
- use only for anemia from myelosuppressive chemotherapy
- do not use when chemotherapy as the anticipated outcome of cure
- discontinue following chemotherapy
What may be used to manage thrombocytopenia?
- platelet transfusion
- chemotherapy dose reduction
- regimen change
- thrombopoietin receptor agonist= romiplostim (limited data to support use)
- triliciclib?
What is mucositis?
inflammatory lesions of the oral and/or GI tract leading to pain, infection, NPO, dose reduction or delays
How can mucositis be prevented?
- good oral care: brushing, flossing, bland rinses, moisturizers
- PO cryotherapy (extreme cold therapy)
- recombinant human fibroblast growth factor (KGF1), taken for 3 days prior to chemotherapy
What are the treatment options for mucositis?
- topical anesthetics
- opioids for pain
- bioadherent gel?
supersaturated calcium/phosphate products?
What are common cutaneous reactions?
- palmar- plantar erythodysesthesia
- acneiform rash
- alopecia
- nail changes/onycholysis
What is the main cause of Acneiform rash?
EGFR inhibitors
What is the prevention of Acneiform rash?
tetracyclines (reduce severity)
What is the treatment for Acneiform rash?
topical or oral antibiotics (clindamycin)
What is tumor lysis syndrome?
breakdown of tumor cells causing hyperuricemia (= crystallization in kidney, AKI), hyperkalemia (= cardiac arrhythmias, muscle weakness, paralysis), hyperphosphatemia (=binds calcium, hypocalcemia, AKI), hypocalcemia (muscle cramps, confusion, memory loss, delirium, depression, hallucinations)
emergency!!!
What are the risk factors for tumor lysis syndrome?
- larger tumor burden
- sensitive to treatment
- pre-existing/spontaneous tumor lysis
- leukemia
- high grade & low grade lymphoma
- solid tumors
What is the prevention of tumor lysis syndrome?
- hydration as tolerated
- allopurinol (300 mg/d)
- rasburicase (if uric acid is increased prior to chemotherapy initiation)
What is the treatment for tumor lysis syndrome?
- hyperuricemia (hydration, allopurinol, rasburicase)
- hyperkalemia (sodium zirconium cyclosilicate, patiromer, rapid acting insulin + dextrose, abormal ECG = calcium gluconate)
- hyperphosphatemia (aluminum hydroxide, sevelamer)
- hypocalcemia (no treatment, unless symptomatic, then minimal calcium supplementation)
- dialysis in severe or refractory cases
What is hypercalcemia of malignancy?
direct induction of osteolysis by tumor cells by cytokines
common in breast, multiple myeloma, lymphoma
What is humoral hypercalcemia of malignancy?
common in non-metastatic solid tumors, tumor production of vit D analouges and secretion of PTHrP
poor prognosis
What are the clinical signs/symptoms of hypercalcemia?
- weakness, lethargy, confusion, stupor, coma
- constipation, anorexia, nausea
-acute renal failure - QT shortening/arrhythmias
mild/moderate hypercalcema (<12 mg/dL) may be asymptomatic
What is the treatment of hypercalcemia?
- hydration with NS
- avoid diuretics (generally pt are dehydrated)
- calcitonin (4 units/kg subQ q12h for 48h)- generally stops working 48-72hours of use
- bisphosphonates (takes time to benefit)
- denosumab (refractory situations)
What is the dosing of bisphosphonates for hypercalcemia?
- pamidronate 60-90 mg IV over 4-24 hours
- zoledronic 4mg IV over 15 minutes
no clinical difference, wait 7 days between treatments
What is febrile neutropenia?
neutropenia + single PO temp > 101 OR 100.4+ for at least an hour
When would a patient be at low infection risk?
anticipated neutropenia less than 7 days
When would a patient be at high infection risk?
anticipated neutropenia > 10 days
