Pearls Flashcards
G-CSF timing
Short acting: don’t give 24h before or after chemo
Long acting: don’t give within 12 days before or 24h after chemo
G-CSF + bleomycin
G-CSF enhances bleomycin pulmonary toxicity- avoid use within 24 hours
-okay to use in testicular ca regimens
-g-CSF not recommended in initial Hodgkin’s regimens except BEACOPP (escalated)
Which body weight is used for crcl in carbo AUC calculation?
Under/normal weight (BMI <25%): actual body wt
Overwt/ obese (BMI 25%+): adjusted body wt
Round scr to 0.7 or 0.8 usually
Use 24 hr urine collection gfr if available
Which solid tumors are intermediate risk for TLS?
Neuroblastoma, germ cell tumors, small cell lung cancer
How often is PCV dosed?
Q6 weeks- prolonged nadir
ANC equation
10 x WBC x (%PMNs + % Bands)
Which g-CSF can be used for tx of fn?
Filgrastim.
Pegfilgrastim is for ppx NOT tx
When can you add vanc for Neutropenic fever?
-line infxn
-hx MRSA or drug resistant strep pneumo
-PNA
-sepsis or HD instability
-blood Cxs growing g+
-SSTI
*do not add for fever alone or for persistent fever- takes 2-7 days to resolve
When do we consider ABX ppx for febrile neutropenia ?
If we expect pt to be neutropenic for > 1 wk
When is pjp ppx needed ?
> 20 pred equivalents x >30 days
Where does osteosarcoma usually spread to and recur?
Lungs
Can Carboplatin replace cisplatin in testicular cancer?
No
Vinca alkaloids and myelosuppression
-not for vincristine
-yes for Vinblastine and Vinorelbine
*B for BMS
Which brain lesions are more likely to bleed spontaneously?
Brain Mets from RCC and melanoma.
Should still use AC
How is acute bleomycin pulmonary toxicity tx?
Drug discontinuation and corticosteroids
Which drug increases risk of cisplatin ototoxicity?
Vinblastine
Goal serum testosterone with ADT
<50 after 1 month
What is another name for IDH wild type grade 4 astrocytoma?
Molecular glioblastoma
Adjuvant Nivolumab vs avelumab I’m bladder CA
Nivolumab: MIBC
Avelumab: metastatic
Hypersensitivity to taxanes management
-give premeds (h1, h2, steroid)
-if you can control the situation CAN resume at a slower rate
-mild rxn give h1, severe give h1, h2, and steroid (like premeds)
Hypersensitivity to platinums management
-Do NOT just decrease rate
-can consider desensitization protocol
-could rechallenge mild Oxaliplatin rxn
-could rechallenge if mild rxn on FIRST EXPOSURE, but do NOT rechallenge if rxn is on second or later exposure even if mild!
IgE type 1
General management of hypersensitivity RXNs
Mild:
-stop infusion
-give h1 blocker or steroid if delayed rxn (platinums)
-if still not resolving give epi
Severe (changes to vitals or O2:
-stop infusion
-give oxygen
-nebulized bronchodilators
-give both h1 and h2 blockers
-give corticosteroids
-if not resolving give epi
Life-threatening:
-stop infusion
-put pt in recumbent position
-give epi
-O2 8-10L
-1-2 L NS IVB for hypotension
-give both h1 and h2 blocker
-give steroid
-additional support if in cardiopulmonary arrest
Can rechallenge grade 1-2
When to stop filgrastim?
Stop when ANC above 1500 for 3 days or 5000 for 1 day- AFTER THE NADIR
fyi 1 day of pegfilgrastim is worth ~10days of filgrastim
Define castrate resistant
Progression despite testosterone levels <50 ng/dL
When to add antifungal for FN?
Consider mold coverage after 4-7d of ABX (unless receiving mold ppx)
-ampho B, caspofungin, or voriconazole
-if azole ppx was given- azole resistant mold or candida may be the issue
-if no azole ppx- likely candida
Pediatric CV screening
No screening:
-no anthracycline , <15gy RT dose
Every 2y
-no anthra, >35gy RT
-<250 mg/m2 dox, 15+guy RT
->250 mg/m2 dox, any/no RT
Every 5y
-no anthracycline, 15-35gy RT
-<250 mg/m2 dox, +<15 gy RT
Note: RT is to chest, abdomen, spine (thoracic, whole), TBI
Informed consent in pediatrics (research)
below is for research- in clinical setting child assent is NOT required if benefit outweighs risk
No greater than minimal risk
-1 parent and child*
Greater than minimal risk with prospect of direct benefit
-1 parent and child*
Greater than minimal risk and no direct benefit
-both parents and child
All other research
-both parents and child
*child assent not required if expected significant benefit and not available outside research
Generally assent required in children 7+
Lovenox and doac adjustment for plt
Lovenox:
Plt>50k: full dose
Plt 25-50k: half dose
Plt<25k: hold
*do not use doacs in plt<50k
Preferred long term AC agents for VTE tx
LMWH (dalteparin is cat 1) edoxaban, xarelto- x6 months
*apixaban ok but BID dosing
DONT USE DABIGATRAN
*edoxaban needs 5 days parental AC first
Doacs v lmwh
Doac preferred;
-intact GIT
-don’t use if urinary or GI lesion
Lmwh preferred:
-luminal GI or gyn lesion
-if DDI
-when surgery is planned
-if in DAPT
*doacs appear to work better but more bleeding -esp GIB
When to stop ABX for FN?
And for kids?
Below is for fever of unknown etiology!! For known infxn you tx for appropriate duration of that infxn
A febrile x 48h and ANC>500
For kids
-afebrile for >24h
-bone marrow recovery
-blood cx neg x 48h
-consider at 72h even if no narrow recovery
Gem-cis vs ddMVAC
ddMVAC preferred neoadjuvant but in metastatic setting they are equivalent
Which type of testicular cancer is sensitive to RT?
Seminoma
What type of endometrial cancers do and don’t benefit from HT?
Endometrioid adenocarcinoma benefit from HT
Serous and clear cell do not
Which novel antiandrogen is take with food?
Darolutamide
Which novel antiandrogen can be given for m1CRPC?
Enzalutamide
Bioavailability leucovorin and Mesna
Mesna: 50%
Leucovorin: 100% at doses<35
Alkylating agents: cell cycle specific or non-specific
Non-specific
Antitumor abx- cell cycle specific or non-specific
Generally non-specific; but may have specific component with topo-I component
Proteosome inhibitor- cell cycle specific or non-specific
Non-specific
Which cancers do we most commonly see hypercalcemia?
Multiple myeloma and breast
-note: prostate metastasizes to the bone but rarely causes hypercalcemia
-lymphomas can cause increased calcitriol- tx with steroids
Define de novo metastatic dx
When diagnosed they were already metastatic
Define metachronus metastatic dx
Platinum + taxane sequencing
Taxane—>platinum
Tamoxifen and raloxifene in hx of VTE
NO!
How do we know when to add Pertuzumab in early stage BC HER-2+ BC?
If LN positive
Leuprolide vs fulvestrant
Leuprolide - LHRH agonist
Fulvestrant - SERD
Vinca alkaloids cell cycle specific or non-specific?
Cell cycle specific
Taxanes cell cycle specific or non-specific?
Cell cycle specific
When are platinums preferred over taxanes in metastatic BC?
TNBC+ BRCA mutation
-double check TNBC part
ICANS
Immune effector cell associated neurotoxicity
give keppra for seizure ppx with CAR-T cell therapy- usually happens a few weeks after CAR-T (start keppra day of therapy and *continue x30 days after)
*treat with steroids
Filgrastim in AML
Generally only used with:
-CLAG
-GCLAC
-FLAG
-FLAG-ida
-don’t use as primary ppx after induction
-may use as primary if secondary ppx after consolidation
-use for “priming” is controversial
-stop at least 7 days before obtaining remission bone marrow
-Caution in AML induction- theoretical risk of causing proliferation of leukemic blasts and/or increasing myelosuppression
-may consider in severe, life threatening infection during severe neutropenia or after interim bone marrow bx demonstrates aplasia w/o evidence of dx
note: this is NOT a concern for ALL (lymphoid line are not granulocytes)
Which antidepressants should be used with tamoxifen?
Venlafaxine, citalopram, escitalopram
NOT SERTRALINE
Bisphosphonate pearls
-dose reduce zolendronate for crcl <60 for bone Mets (don’t use if crcl<30)
-don’t dose reduce for hypercalcemia unless scr >4.5
-causes myalgias and arthralgias
-modest decrease in bone pain
-hypocalcemia
-flu-like malaise, fevers, arthralgias, nephrotoxicity, ONJ
-give 500 ca2+ and 400-500 vit d per day
-onset for hypercalcemia is 2-4 days (same with denosumab)
-bisphosphonates are IV and denosumab is SQ
-denosumab has worse hypocalcemia
Denosumab pearls
-subQ
-preferred if renal impairment
-more expensive
-usually used in hypercalcemia if refractory to bisphosphonates
What effect does oral contraceptives have on breast and ovarian and endometrial cancer risk?
Breast: increased risk
Endometrial/ Ovarian: decreased risk
*progesterone increases BC risk and decreases endometrial cancer risk
*estrogen increases risk of endometrial cancer (so we give it with progesterone to counteract this) and breast cancer
When can you rechallenge a taxane after infusion rxn?
For mild rxns: rash, pruritis, flushing
Don’t rechallenge for severe rxns
Why doesn’t leucovorin rescue cancer cells?
Because cancer cells polyglutamate the heck out of MTX which keeps in the cell!
Note: leucovorin does NOT increase elimination of MTX so it’s ok to increase the dose for 24h, 48h, and 72h levels of > 10, 1, and 0.1 respectively
When should docetaxel be given with/without prednisone in postate cancer?
Castrate sensitive: without pred
Castrate resistant: with pred
TP53 and BRCAs and HER-2
Tumor suppressor:
-TP53
-BRCAs
-RB1
-ATM
-PTEN
Oncogenes:
-Her-2
-BRAF
-EGFR
-KRAS
-MET
-PIK3CA
Nivolumab and pembro in bladder and kidney
Bladder:
-MIBC: nivolumab for adjuvant
-Metastatic: pembro for second line (cat 1) and can also use nivo for second line
-pembro can also be an alternative 1st line in platinum ineligible
Kidney
-stage II: pembro x1y for adjuvant if grade IV +/-sarcomatoid fxs
-stageIII and IV adjuvant
-stage iv met: nivo can be used second line
Most common type of RCC
Clear cell
Which are and are not sensitive to RT: osteosarcoma, ewings, seminoma, non-seminoma
Sensitive: ewings (but RT not used much), seminoma
Not sensitive: osteosarcoma, non-seminoma
What is another name for her-2?
EGFR-2, ERBB2
At what stage do you differentiate b/w good risk and int/poor risk for seminomas and non-seminoma
Seminoma: stage IIC and up must differentiate b/w good and int risk (could be either)
Non-seminoma: stage IIIB and IIIC are both int/poor risk (everything below is good risk!)
Which acute leukemia requires CNS ppx?
ALL
G-CSF ADRs
Splenic rupture, bone pain, capillary leak syndrome (rare)
Note: don’t use within 14 days if car-T
BCR-ABL TKIs with or without food comparison
Imatinib: with food AND water
Dasatinib: with or without
Nilotinib: without food
Bosutinib: with food AND water
Asciminib: without food
Ponatinib: with or without
Note: all second gen should avoid acid suppressive therapy (all but imatinib)
When can TKI be stopped in chronic CML
-Stable DEEP molecular response (MR4) for at least 2 years (4 separate tests 3 months apart)
-frequent and reliable monitoring (monthly x6 mo, bi-monthly x6 mo, then quarterly)
-patient consent
Note: not studied in bosutinib or Ponatinib
Other:
->18y/o
-no hx of accelerated or blast phase
-on first line therapy (unless switch d/t ADR)
-consult CML speciality center
-motivated pt w/ good communication
-on TKI x3-5 y
-prior evidence of detectable dx
Note: may experience TKI withdrawal phenomenon: MSK pain and pruritus for a few months: NSAIDs, APAP, maybe oral steroid
Resume within 4 weeks of loss of MMR
CML accelerated phase
basically tx like second or third line chronic phase
-second gen TKI or alternate second gen TKI
-Ponatinib if no other tki indicated
-omacetaxine if resistant to 2+ tki
-allo HCT
CML blast phase
BCR-ABL TKI + induction tx of respective type of acute leukemia (could be ALL or AML)
-if second chronic phase is achieved- allogenic HCT
MTX level: 0.1 mM other units
100 nmol
1x10^-7M
Does leucovorin enter the cell
Yes! Glucarpidase does not I don’t think - that’s why we still need leucovorin when glucarpidase is given
Tamoxifen vs raloxifen BC prevention
-more VTE , cataracts, and uterine cancer with tamoxifen
-tamoxifen more effective
-both are indicated
When is BC risk reduction indicated?
->35 y/o and 10+ year life expectancy (70+ y/o (asco)) AND any of the below:
-LCIS
-atypical hyperplasia (AH)
-BC risk >20% with model based on family hx
-pedigree suggestive of family hx
-know genetic predisposition
-prior thoracic RT <30 y/o
-Gail score 3%+
-10Y IBIS/tyrer cuzick 5%+
Consider when:
-Gail score 1.7%+
-BCRAT 3%+ (ASCO rec)
Options:
-mastectomy
-BSO
-tamoxifen or AI
Which Parps are used in BC? Ovarian? Prostate?
Breast: Olaparib or talazaparib
Prostate: Olaparib, Rucaparib, talazaparib, Niraparib
Ovarian: Olaparib, Niraparib, Rucaparib
Trick to preventing neuropathy with taxanes
Cryotherapy of hands and feet
Rolapitent pearls
-only one that’s not a 3A4 inhibitor
- don’t give more than q2 weeks
HPV vaccine and screening
Vaccine
-start age 11-12 for boys and girls (indicated ages 9-45)
-9-14: 2 dose series (0, 6-12 months
-15+: 3 dose series (0, 1-2, 6-12 months)
-also give 3 dose series of second dose given before 5 months
Note: strains 16 and 18 responsible for cervical cancer
Holding BTK-I around surgery
Minor: 3 days before and after
Major: 7 days before and after
Prostate: what does active surveillance entail?
Observation
Active surveillance
PSA q6 months, DRE q12 months, MRI no more than q12 months
This is different from screening which is less frequent (q2+ years) if at all
Observation
-PSA q6 months
-history and physical
-NO BIOPSY
Prostate: observation vs AS
Observation: life exp <10 y
AS: life exp >20y very low risk, and >10y for low risk
General tx recs for non-metastatic prostate
Low risk: observation for <10 yr LE and AS for >10y LE
Intermediate: observation <5 LE, 5-10 observation or tx, >10 tx
High risk: observation <5 yr LE,
>5 yr LE: EBRT + ADT , +/- abiraterone (very high risk) OR
EBRT + brachy + ADT
Regional:
-<5 y: observation or ADT
->5y: EBRT + ADT + abiraterone
*note: ADT usually starts before RT and is continued for 2-3 years
When to use LHRH antagonist over agonist
Concerns with tumor flare (bone pain, urinary symptoms, spinal cord injury/compression
BMA dosing
zolendronate
-SRE: 4 mg q3-4 or q12 weeks- double check
-Adjuvant BC tx: 4 mg q6 mo x3-5 yr
-Hyper ca2+: 4 mg, repeat in 7d
Pamidronate
SRE: 90 mg (over 2h) q3-4 wk
Hyper ca2+: 90 (>13.5), 60 (12-13.5), 30 (<12)- repeat in 7 days
denosumab
-SRE: 120 mg q4wk
-hyper ca2+: 120 mg q7d if needed
-note: Preffered over zometa for bone Mets in CRPC
-Duration 2 years in multiple
Myeloma for bone Mets- restart if patient relapses!!
-May be indefinite for other cancers
-In breast and prostate there two indications:
1) SRE ppx in pts w/ bone Mets
2) osteoporosis from AI/tamoxifen/LHRH/ADT with FRAX 10 yr risk hip fx 3%+ or major fx 20% (breast/prostate) or T score <-2 (breast) and these use osteoporosis dosing NOT oncology
Note: prevention of SRE and bone Mets is the same thing
Myeloma pretty much always using BMA with oncology dosing- however not indicated for MGUS or smoldering or solitary plasmacytoma
Multiple myeloma: zolendronate or denosumab monthly for at least 12 months (may change zolendronate to q3 or q6 months after a year if VGPR achieved)
Ara-C syndrome
Fever, myalgia, bone pain, rash, chest pain, weakness
Which type of bilirubin indicated hepatic impairment
Conjugated
TP53 mutation and RT
Avoid RT- increased risk of secondary cancer
Normal ionized calcium
4.4-5.4
What does leucovorin not prevent ?
Renal tubular necrosis
What does adrenal deficiency cause?
Hypokalemia, HTN, edema
This is abiraterone, which decreases glucocorticoid and increased mineralcorticoid production
CINV In children
HEC: dex + 5HT3 + aprepitant (if >6 mo)
MEC: 5HT3 + dex (if no CI, otherwise aprepitant) if can’t take dex (brain tumor/leukemia) and <6 mo old do palonosetron monotherapy
LEC: 5HT3
Min: no routine ppx
This is for ACUTE CINV only, no data for delayed
Note:
-dose reduce dex by 50% if given with aprepitant
-fosaprepitant is also approved
-omit dex if brain tumor (decreases chemo across BBB) or leukemia (increases risk fungal infections)
-if not using dex, palonosetron is the preferred 5HT3
Principles of informed consent
Beneficence, justice, respect for autonomy
VTE in malignancy tx duration
At least 3 months or as long as pt has active cancer
If catheter-as long as pt has catheter
INDEFINITELY IN PATIENTS WITH ACTIVE CANCER, ON CHEMO, OR PERSISTENT RISK FACTORS
Which 5HT3 inhibitor doesn’t prolong QTc?
Which helps with delayed CINV?
Max dose zofran?
When to apply granisetron patch?
QTc: palonosetron, transdermal and SubQ ER granisetron (PO and IV do!)
Delayed CINV: Palonosetron (if given in day 1 no further 5HT3 needed)
Zofran max: 24 mg po, 16 mg IV/day
Granisetron: 24-48h before chemo
Dolasetron is discontinued
Other pearls
-don’t give 5HT3 beyond 24h
-granisetron ER injection given 30 mins before on day 1 and lasts 7 days; patch placed 24-48h prior
-aprepitant: inhibitor of 3A4 but inducer of 3A4 and 2c9 if given for >14 days
-aprepitant increases: oral contraceptives (use backup), warfarin (check INR in 7-10d), dex/MP (decrease dose)- NOTE THAT IT DOES NOT INTERACT WITH CHEMO AGENTS!!
-netupitant is a 3A4 inhibitor
-rolapitant: single dose (very long half life) minimum 2 week intervals, no effect on 3A4; inhibits BCRP caution with gefitinib, MTX, lapatinib, mitoxantrone, imatinib, topotecan, irinotecan, cycslosporin, statins; PO only (hypersensitivity with IV-removed)
Steroids
-unknown exact MOA
-avoid 3-5 days before and 90 days after CAR-T
-no data saying we can’t give dex before regimen that contains an ICI
-olz is a good alternative to dex
Reglan and trimethobenzamide
-reglan: blocks D2, blocks peripheral 5HT3 (high dose), increases motility
phenothiazine
-promethazine, compazine, chlorpromazine
-more hypotension than butyphenones
butyrophenones
-haldol, droperidol
-suitable alternative is phenothiazine fails
Dex:
-can cause hiccups
-can cause dyspepsia
-avoid 3-5d prior to and 90 d after CAR-T
cannabinoids
-breakthrough CINV, effective for low-moderate emetogenic agents
Olanazapine
-consider 2.5 mg if sedation from 5
-QTc shouldn’t be clinically meaningful
-don’t give with IV BZD (PO only)
HEC: 5Ht3, dex, NK-1, OLZ (dex 8 mg and olz should be continued on DAYS 2-4to prevent delayed CINV). Note olz dose 5 mg OR 10
MEC: 5HT3 + dex (continue one or the other for days 2-3), could also chose a 3 drug regimen
LEC: single drug 5HT3 or dex, or reglan or compazine
Minimal: none
oral
Moderate-high: 5HT3 daily + breakthrough
Minimal-low: breakthrough only
Multi-day
-Tricky- evaluate emetogenic potential for each day
Note: social drinking does not decrease risk (daily drinking does)
When to consider EP over BEP in testicular cancer
> 50 y/o, reduced GFR, or pulmonary comorbidities
Rasburicase pearls
After administration blood samples must be chilled and collected in tube containing heparin and assayed within 4 hours or UA will be falsely low
Avoid in G6PD deficiency
0.2 mg/kg/day x 5 days or 1-2 fixed doses of 3-7.5 mg
TLS prevention
Low risk: oral hydration and monitor
intermediate-high risk:
-BL G6PD
-IV Normal Saline +/- loop diuretics
-allopurinol 300-400 mg/m2/d (don’t renally dose for this indication)
-maybe rasburicase for high risk
Fun facts:
-phosphate binders only decrease dietary phos, not what’s released with TLS- fluids and HD is really all we can do- use if phos increase >25%
-don’t tx asymptomatic hypocalcemia (risk of precipitation with phos). Give ca gluconate if needed
-loop diuretics can be important for fluid overloaded patients- great trick to have up your sleeve
Dialysis is always last resort for treatment
CNS ppx parenchyma vs leptomeningeal dx
Parenchymal: HD-MTX (not intrathecal)
Leptomeningeal: HD-MTX, IT MTX, IT Cytarabine (could give IT MTX + Cyt + dex)
in other words- IT does not cover parenchyma dx- so IT only can be risk in some diseases like Burkitts
Early vs late relapse times (ok to repeat initial therapy for late relapse)
notecard is work in progress
DLBCL: 12 months
FL: 2 years
Hairy cell: 2 years
AML: 12 months
Adult ALL: 36 months (3 years)
Peds ALL: 36 months (3 years)
Bladder: 12 months
SCLC: 3-6 months (minus ICI)!
Melanoma: 3 months
Multiple myeloma: 6 months
CAR-T and BiTE indications
notecard is work in progress
DLBCL
CAR-T:
axicabtagene, lisocabtagene, tisagenlecleucel
BiTE:
-Glofitamab
-epcoritamab
MCL
CAR-T:
-brexucabtagene
multiple myeloma
CAR-T:
-idelcabtagene vicleucel
-ciltacabtagene autoleucel
BiTE:
-talquetemab
-teclistamab
ALL
CAR-T
-tisagenlecleucel
-brexucabtagene
BiTE:
-blinatumomab
Follicular lymphoma
BiTE:
-mosunetuzumab
-epcoritamab
Uveal melanoma
BiTE:
-tabentafusp
Immunoglobulin heavy-chain variable region gene
IGHV
Un-mutated (</=2% mutated): poor prognosis CLL
CLL duration of therapy for BTK-Is, venetoclax, FCR
-BTK: indefinitely
-Venetoclax: 1 year
-FCR: 6 months
Priming for CAR-T
5 days prior give lymphodepleting chemo (to allow CAR-T lymphocytes to work but depleting non-CAR-T lymphocytes)
Use FluCy (Fludarabine + Cytarabine)
CAR-T b- cell aplasia
May need IVIG for lvls IgG lvl< 400
(This is at least for DLBCB-idk about other diseases)
Sunscreen strength
SPF 15+
Reapply every 2 hours- one ounce
If no expiration date- sunscreen is good for 3 yrs (less if left in heat)
Hypercalcemia levels: unionized and ionized
Unionized
Mild: 10.5-12
Moderate: 12-14
Severe: >14
Ionized
Mild: 5.6-8
Moderate: 8-10
Severe: >10
Prophylactic AC drugs and doses
Inpatient
Dalt 5000 QD (5000 q12 or 7500 QD if bmi >40)
Lovenox 40 QD (bid if bmi >40)
UFH 5k q8-12h (7.5k if bmi>40)
Fonda 2.5 QD (avoid if <50k)
Ambulatory
Dalt 200 u/kg x1 then 150 u/k x2 mo
Lovenox 1 mg/kg x3 mo then 40 mg/d
Apix 2.5 bid
Xarelto 10 qd
Note: Dalt 200 u/kg then 150 u/kg daily is therapeutic dosing as well
Fonda therapeutic dose is:
<50kg: 5 mg QD
50-100 kg 7.5 mg qd
>100 kg: 10 mg QD
Which test is used to guide extended endocrine therapy in early stage breast cancer ?
BCI: 5.1-10
Why is BRAF used with MEK?
If used alone resistance develops and alternate MEK pathway will be used
Who should be screened for RCC?
VHL syndrome- CT or MRI yearly
False AFP and HCG elevation causes?
AFP: pregnancy, hepatocellular carcinoma. T1/2 7d
HCG: pregnancy, hypogonadism, marijuana T1/2 3d
When to avoid immunotherapy
-Strong hx of autoimmune disorders (e.g., ulcerative colitis)- if we’ll controlled you can get immunotherapy with closer monitoring!
-organ or prior HCT transplant
Perioperative chemo
Chemo—>surgery—> chemo
Pseudo progression on ICI
Continued growth after 16 weeks can be considered true progression
PCR (molecular) vs IHC
IHC: testing for proteins
PCR (molecular): testing for genes
cfDNA vs ctDNA
Cell free DNA is cells in general (higher levels on cancer pts bc cells divide more)
Circulating tumor DNA is a subset of cell free DNA from tumor cells
Sensitivity v specificity
Sensitivity: low false negative rate (True positive rate)
Specificity: low false positive rate (True negative rate)
At what age can you start taking tamoxifen or other meds to decrease risk of BC?
Tamoxifen: 35y/o
Raloxifene: post-menopause (may be better for women with uterus)
AI: 35, (post-menopause)
Gail model 1.7%+
10yr IBIS tyrer cuzick 5%+
LCIS
Note: duration is 5 years! Don’t confuse with HT therapy for tx of early stage BC which is often 10 years!
Note: it will only reduce risk of ER+ BC
Can you give ESA for anemia ?
Not in myeloid malignancies
Except you can for MDS
Nsclc: what can happen when stopping ALK inhibitor
Tumor flare: indicated alk inhibitor is needed
Flare can also occur with ROS-1, RET, and MET
Anthracycline metabolism
Hepatic- )but not via cyps)- so don’t use in severe hepatic impairment
Should not need renal adjustment usually- maybe sometimes for daunorubicin
Fluoropyrimidine dose adjustments for DPD deficiency
Activity score 2: no change
Activity score 1 or 1.5: 50% decrease
Activity score 0 or 0.5: avoid use or significant dose reduction
NSCLC: who doesn’t get immunotherapy?
-EGFR or alk mutations
-autoimmune disorders
Cisplatin v Carboplatin in NSCLC
Carbo is often preferred. Cisplatin is curative, carbo better if stage 4 or poor pfs
Varenicline pearls
-nausea is bad!
-avoid if brain meds or seizure hx (same with bupropion)
-avoid with MAO-I, tamoxifen, or pts with closed angle glaucoma
Hyperviscosity and leukostasis
More with acute leukemias than chronic bc cells are smaller with chronic and less sticky etc.
Can happen with multiple myeloma
When are parps used for prostate and ovarian cancer?
Prostate: CRPC (not CSPC)
Ovarian:
-primary maintenance
-secondary maintenance only if platinum sensitive
CAR-T and steroids
Generally avoid together. Only add steroids for emergent scenarios (like ICANS, CRS)
No steroid 3-5 days before or 90 days after
How to dose adjust R-EPOCH
ANC nadir >500: increase dox, cyclo, and etoposide 20%
ANC nadir <500 x1-2: same dose
ANC nadir <500 x3+ or plt nadir <25k: decrease 20%
Don’t adjust vincristine, pred, or rituxan
Which PARP-I can be used in early vs metastatic breast cancer?
Early: Olaparib
Metastatic: Olaparib or talazaparib
When is DD-AC->T preferred over TC? (Broad strokes)
LN 4+, grade 3, high recurrence score (oncotype) 30+
SCLC vs NSCLC immunotherapy
SCLC: atezolizumab or Durvalumab
NSCLC: atezolizumab, pembrolizumab, cemiplimab
SCLC vs NSCLC immunotherapy
SCLC: atezolizumab or Durvalumab
NSCLC: atezolizumab, pembrolizumab, cemiplimab
Time line to give leucovorin, glucarpidase, and uridine triacetate
-leucovorin: 24-42 hours
-glucarpidase: 48-60 hours
-uridine triacetate: 8-96 hours
When is pembro cps/TMB 10+ a thing?
Differentiated thyroid: TMB 10+ (second line)
Gastric/esophageal HER-2 (-): pembro cat 1 of cps 10+
Squamous esophageal subsequent: CPS>10
Metastatic TNBC: CPS 10+
Prostate: TMB 10+
Pancreatic second line: MSI-H/dMMR, tmb10+
What type of testicular cancer is usually left over after chemo?
Teratoma- not chemo sensitive
Always do surgery for residual teratoma
At which age is the total volume of intrathecal medication the same for a child and adult?
3 years (5-10 mL)
Use 5 mL if <3 years old
Anticoagulation with BTK-I?
Do NOT use warfarin!
What if you need BMA for hypercalcemia but there’s poor dentition?
Don’t wait for dental exam- this is an oncologist emergency
Anticoag in enteral feeding tube
Apix/xarelto/Edoxaban
Doacs are absorbed in stomach and proximal small bowel (except Apixaban which has some absorption in the colon)
BTK inhibitors: food?
Interactions?
All with or without
Ibrutinib with a large glass of water
Interactions: all are 3A4 substrates, Acalabrutinib capsule with acid suppressive (avoid, separate antacids by 2hr)
Spinal cord compression
-dex 4-10 iv qid
-surgery: LE >3 mo, paraplegia <24h, renal cell, melanoma, satcom
-RT: LE <3 mo, neurologic deficit >24h
Note: most commonly seen with lung, breast, and prostate cancer
Also multiple myeloma
Non standard premeds (notecard in progress)
-cetuximab- Benadryl
-mosunetuzumab-optional after cycle 2
-Cabazitaxel/paclitaxel- H1, H2, dex
-Glofitamab- drop steroid after cycle 3
-epcoritamab- only steroid after cycle 1, continue steroid x3 d after dose
-Loncastuximab- dex BID x3d starting day before
-amivantamab: : dex is only prior to wk 1 d1-2, then optional
-daratumumab: can omit for SQ starting w/ dose 4; also montelukast
-Amifostine: NS, 5HT3, and dex
-Idecabtagene: APAP/diphen NOT dex
-Dinutuximab: NS, APAP, Benadryl
-rituxan: h1, APAP
Rituximab hyaluronidase dosing (notecard in progress)
-DLBCL: 1400 R 23,400 H (5 mins)
-FL: 1400 R 23,400 H (5 mins)
Mucositis risk fxs
-tobacco/etoh
-poor oral hygiene
-young or old
-female
-low BMI
-head and neck ca
-prior hx RT and/or chemo
Smoking
-increases pulmonary complication
-increased surgical site infections
-poor wound healing
-decreased RT response
-increased RT complications
-effects erlotinib, irinotecan, and bendamustine
Start smoking cessation tx if ready to quit within 4 weeks or quit within past 30 days
-NRT + SA NRT (gum, inh, spray etc) + behavior therapy x12 wks (cat 1)
-start with 21 mg patch and inc to 35 or 42 mg
-varenicline + behavioral x12 weeks (cat 1) (VERY NAUSEATING), no brain Mets (seizures)
-4+ sessions of at least 3 mins
-take varenicline even if risk of NMDA contamination per fda
Purpose of albumin with ifosfamide
Neurotoxicity prevention
Exogenous pancreatic lipase
-500 u/kg/meal or 1000 u/kg/d or 25-75k/meal and half for snacks
-max 10,000 u/kg/d
-day with or after* meal, NOT before!
-NCCN recs half at start of meal and half in the middle
Peds genetics
-Wilms: LOH 1p and 16q (poor prognosis)
-Ewings: t(11;22), EWS-FLI1 gene fusion-diagnostic
-retinoblastoma: RB1 mutation at chromosome 13q15
Irinotecan vs 5FU myelosuppression
Irinotecan is worse
When to start mammogram for breast cancer screening after RT?
8 years after or age 25, whichever occurs LAST
When to do lumbar puncture screening for CNS dx in AML
-CNS symptoms
-at first remission prior to consolidation in the following: monocytic differentiation, mixed phenotype acute leukemia, wbc >40K at diagnosis, high risk APL, flt-3, extramedullary dx
Testicular cancer induction
Sometimes give half a cycle or 50% reduced dose as induction when there’s is high dx burden and need urgent chemo
Can follow with full dose “cycle 1” 10-14 days later (as opposed to 21 days later)
Things where high risk/severe stands alone
-APL
-venetoclax TLS risk (LN >5 cm AND ALC >25, or LN >10 cm)
-radiation recall
3a4 inhibitor effect on AUC
Strong: 5 fold inc
Moderate: 2-5 fold inc
Weak: 1.25-2 fold inc
DIPG
Poor prognosis and spreads through ventricles
Diffuse intrinsic pontine glioma
Preferred HMA in ESRD
Decitabine
Germinal vs non-germinal B cell lymphoma
Germinal is easier to treat
ABC vs gbc lymphoma
Better outcomes with GBC
Note: Pola-R-CHP probably should only be used in ABC
ABC more associated with PCNSL
Who do we know CML treatment is or isn’t working ?
Should have hematologic remission in 3-6 months
Most likely cancer to have bone Mets
-breast
-prostate
-lung
-osteosarcoma
Predictive marker
Predicts a response or resistance Ti a treatment.
If it says “this mutation was not associated with a response” that’s not predictive
Types of bias
Selection: inclusion/exclusion criteria does not match real world population of interest
Misclassification: structured definitions
Allocation: randomization/stratification
Compliance: for oral medications
Attrition: reasons for discontinuation
Measurement: how were tests performed
Confounding: stratification
FOLFOXIRI vs folfirinox
FOLFIRINOX VS mFOLFIRINOX
FOLFOXIRI HAS HIGHER CINV DOSE (3200 mg/m2)- idk if below points are even true
Folfirinox has 5FU bolus and FOLFOXIRI doesn’t
Folfirinox has higher dose of irinotecan (180 mg/m2), compared to 165 mg/m2
modified vs standard
-mFOLFIRINOX has low irinotecan dose (150 mg/m2 rather than 180mg/m2)
-mFOLFIRINOX has no 5FU push
Goals of phase 1 study
Phase 1: max tolerated dose, dose limiting toxicity
-starting dose is 1/10th of LD10
Folic acid vs leucovorin (folinic acid)
Leucovorin restores the blockade of purine synthesis but folic acid does not (this is why we use it for HD-MTX but not folic acid)
Folic acid acid is used for non-oncology indications bc MOA is likely different but folic acid is still being depleted so we want to replace this
What is the role of the steroid is treating infusion reactions
It prevents delayed reaction, it does not provide immediate benefit (use h1 and h2 for immediate benefit)
When would you not give BMA in a patient with bone Mets?
CSPC
Note: can still do osteoporosis dosing as indicated for pts on ADT based on FRAX and DEXA
Which type of cervical cancer is more aggressive?
Adenocarcinoma or adenosquamous have much worse prognosis than squamous cell
When is HER-2 given or not given in early stage breast cancer?
Give if chemo is also given (don’t give without chemo)
Generally we will always do chemo + HER-2 for HER-2 positive unless small tumor and LN negative, then we may be less aggressive if we want
Deciding between Bispecific and car-T in R/R myeloma after 4 lines
If they have very short relapse we need something quicker so would pick Bispecific
BMA in multiple myeloma
All patients getting primary therapy for multiple myeloma should be given BMA x2 years
(So DONT need bone Mets!!)
Cut offs to check for nephro or hepatotoxicity of drugs if there are no dosing adjustments in labeling
Crcl<60
AST/ALT >75
VTE ppx for indwelling catheter
NO!
Health economic evaluation
Cost minimization: same result/benefit- which one is cheapest (different manufacturers of the same BP drug)
Cost effectiveness: evaluates the same outcome with different interventions and compares the cost to benefit ratio (wt loss program vs pill). Uses “natural units-“- eg blood glucose)
Cost utility: different health outcomes, looks at QALYS
Cost benefit: compared cost AND outcomes in monetary terms ($), (direct and indirect costs)
Which sarcomas spread through LN (as opposed to blood)?
SCARE
Synovial, clear cell, angio, rhabdo, epithelioid
Which CAR-T have increased risk of CRS?
-Axicabtagene
-Brexucabtagene
Why is bevacizumab not used in squamous cell lung cancer?
Increased risk of bleeding
A few random CINV drug reactions
-lorazepam + posaconazole
-Olz + IV BZD (use po instead)
APL management of bleeding complications
-PLT transfusion to goal of 30-50
-cryoprecipitate to goal fibrinogen of 100-150
When do PARP inhibitors come into play in prostate cancer?
Not until metastatic castration RESISTANT!
PSA false readings
Finasteride/dutasteride: false low
Saw palmetto: variable
Androgen blockers: false high
Ejaculation: false high
Prostatic manipulation: false high
mFOLFOX6 vs mFOLFOX7
6 has a 5FU push (not just CINV like 7)
ABVD effect on fertility
Doesn’t affect women’s fertility but may effect male fertility
Weird sign of Hodgkin’s lymphoma
-Itching/pruritis
-pain in LN after etoh consumption
Can you use prednisone with immunotherapy?
Doses less than 20 mg can be used (so probably just 10 mg)
Why is prednisone given with docetaxel in Prostate cancer?
Slows growth of prostate cancer cells by decreasing testosterone production in the adrenal gland
