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BCOP- Joey > Pearls > Flashcards

Pearls Flashcards

1
Q

G-CSF timing

A

Short acting: don’t give 24h before or after chemo

Long acting: don’t give within 12 days before or 24h after chemo

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2
Q

G-CSF + bleomycin

A

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)

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3
Q

Which body weight is used for crcl in carbo AUC calculation?

A

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

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4
Q

Which solid tumors are intermediate risk for TLS?

A

Neuroblastoma, germ cell tumors, small cell lung cancer

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5
Q

How often is PCV dosed?

A

Q6 weeks- prolonged nadir

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6
Q

ANC equation

A

10 x WBC x (%PMNs + % Bands)

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7
Q

Which g-CSF can be used for tx of fn?

A

Filgrastim.

Pegfilgrastim is for ppx NOT tx

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8
Q

When can you add vanc for Neutropenic fever?

A

-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

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9
Q

When do we consider ABX ppx for febrile neutropenia ?

A

If we expect pt to be neutropenic for > 1 wk

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10
Q

When is pjp ppx needed ?

A

> 20 pred equivalents x >30 days

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11
Q

Where does osteosarcoma usually spread to and recur?

A

Lungs

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12
Q

Can Carboplatin replace cisplatin in testicular cancer?

A

No

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13
Q

Vinca alkaloids and myelosuppression

A

-not for vincristine

-yes for Vinblastine and Vinorelbine
*B for BMS

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14
Q

Which brain lesions are more likely to bleed spontaneously?

A

Brain Mets from RCC and melanoma.

Should still use AC

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15
Q

How is acute bleomycin pulmonary toxicity tx?

A

Drug discontinuation and corticosteroids

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16
Q

Which drug increases risk of cisplatin ototoxicity?

A

Vinblastine

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17
Q

Goal serum testosterone with ADT

A

<50 after 1 month

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18
Q

What is another name for IDH wild type grade 4 astrocytoma?

A

Molecular glioblastoma

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19
Q

Adjuvant Nivolumab vs avelumab I’m bladder CA

A

Nivolumab: MIBC

Avelumab: metastatic

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20
Q

Hypersensitivity to taxanes management

A

-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)

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21
Q

Hypersensitivity to platinums management

A

-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

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22
Q

General management of hypersensitivity RXNs

A

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

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23
Q

When to stop filgrastim?

A

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

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24
Q

Define castrate resistant

A

Progression despite testosterone levels <50 ng/dL

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25
Q

When to add antifungal for FN?

A

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

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26
Q

Pediatric CV screening

A

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

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27
Q

Informed consent in pediatrics (research)

A

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+

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28
Q

Lovenox and doac adjustment for plt

A

Lovenox:
Plt>50k: full dose
Plt 25-50k: half dose
Plt<25k: hold

*do not use doacs in plt<50k

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29
Q

Preferred long term AC agents for VTE tx

A

LMWH (dalteparin is cat 1) edoxaban, xarelto- x6 months

*apixaban ok but BID dosing
DONT USE DABIGATRAN
*edoxaban needs 5 days parental AC first

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30
Q

Doacs v lmwh

A

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

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31
Q

When to stop ABX for FN?

And for kids?

A

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

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32
Q

Gem-cis vs ddMVAC

A

ddMVAC preferred neoadjuvant but in metastatic setting they are equivalent

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33
Q

Which type of testicular cancer is sensitive to RT?

A

Seminoma

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34
Q

What type of endometrial cancers do and don’t benefit from HT?

A

Endometrioid adenocarcinoma benefit from HT

Serous and clear cell do not

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35
Q

Which novel antiandrogen is take with food?

A

Darolutamide

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36
Q

Which novel antiandrogen can be given for m1CRPC?

A

Enzalutamide

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37
Q

Bioavailability leucovorin and Mesna

A

Mesna: 50%
Leucovorin: 100% at doses<35

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38
Q

Alkylating agents: cell cycle specific or non-specific

A

Non-specific

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39
Q

Antitumor abx- cell cycle specific or non-specific

A

Generally non-specific; but may have specific component with topo-I component

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40
Q

Proteosome inhibitor- cell cycle specific or non-specific

A

Non-specific

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41
Q

Which cancers do we most commonly see hypercalcemia?

A

Multiple myeloma and breast

-note: prostate metastasizes to the bone but rarely causes hypercalcemia

-lymphomas can cause increased calcitriol- tx with steroids

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42
Q

Define de novo metastatic dx

A

When diagnosed they were already metastatic

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43
Q

Define metachronus metastatic dx

A
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44
Q

Platinum + taxane sequencing

A

Taxane—>platinum

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45
Q

Tamoxifen and raloxifene in hx of VTE

A

NO!

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46
Q

How do we know when to add Pertuzumab in early stage BC HER-2+ BC?

A

If LN positive

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47
Q

Leuprolide vs fulvestrant

A

Leuprolide - LHRH agonist

Fulvestrant - SERD

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48
Q

Vinca alkaloids cell cycle specific or non-specific?

A

Cell cycle specific

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49
Q

Taxanes cell cycle specific or non-specific?

A

Cell cycle specific

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50
Q

When are platinums preferred over taxanes in metastatic BC?

A

TNBC+ BRCA mutation

-double check TNBC part

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51
Q

ICANS

A

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

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52
Q

Filgrastim in AML

A

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)

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53
Q

Which antidepressants should be used with tamoxifen?

A

Venlafaxine, citalopram, escitalopram

NOT SERTRALINE

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54
Q

Bisphosphonate pearls

A

-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

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55
Q

Denosumab pearls

A

-subQ
-preferred if renal impairment
-more expensive
-usually used in hypercalcemia if refractory to bisphosphonates

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56
Q

What effect does oral contraceptives have on breast and ovarian and endometrial cancer risk?

A

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

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57
Q

When can you rechallenge a taxane after infusion rxn?

A

For mild rxns: rash, pruritis, flushing

Don’t rechallenge for severe rxns

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58
Q

Why doesn’t leucovorin rescue cancer cells?

A

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

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59
Q

When should docetaxel be given with/without prednisone in postate cancer?

A

Castrate sensitive: without pred

Castrate resistant: with pred

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60
Q

TP53 and BRCAs and HER-2

A

Tumor suppressor:
-TP53
-BRCAs
-RB1
-ATM
-PTEN

Oncogenes:
-Her-2
-BRAF
-EGFR
-KRAS
-MET
-PIK3CA

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61
Q

Nivolumab and pembro in bladder and kidney

A

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

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62
Q

Most common type of RCC

A

Clear cell

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63
Q

Which are and are not sensitive to RT: osteosarcoma, ewings, seminoma, non-seminoma

A

Sensitive: ewings (but RT not used much), seminoma

Not sensitive: osteosarcoma, non-seminoma

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64
Q

What is another name for her-2?

A

EGFR-2, ERBB2

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65
Q

At what stage do you differentiate b/w good risk and int/poor risk for seminomas and non-seminoma

A

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!)

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66
Q

Which acute leukemia requires CNS ppx?

A

ALL

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67
Q

G-CSF ADRs

A

Splenic rupture, bone pain, capillary leak syndrome (rare)

Note: don’t use within 14 days if car-T

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68
Q

BCR-ABL TKIs with or without food comparison

A

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)

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69
Q

When can TKI be stopped in chronic CML

A

-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

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70
Q

CML accelerated phase

A

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

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71
Q

CML blast phase

A

BCR-ABL TKI + induction tx of respective type of acute leukemia (could be ALL or AML)

-if second chronic phase is achieved- allogenic HCT

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72
Q

MTX level: 0.1 mM other units

A

100 nmol

1x10^-7M

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73
Q

Does leucovorin enter the cell

A

Yes! Glucarpidase does not I don’t think - that’s why we still need leucovorin when glucarpidase is given

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74
Q

Tamoxifen vs raloxifen BC prevention

A

-more VTE , cataracts, and uterine cancer with tamoxifen
-tamoxifen more effective
-both are indicated

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75
Q

When is BC risk reduction indicated?

A

->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

76
Q

Which Parps are used in BC? Ovarian? Prostate?

A

Breast: Olaparib or talazaparib

Prostate: Olaparib, Rucaparib, talazaparib, Niraparib

Ovarian: Olaparib, Niraparib, Rucaparib

77
Q

Trick to preventing neuropathy with taxanes

A

Cryotherapy of hands and feet

78
Q

Rolapitent pearls

A

-only one that’s not a 3A4 inhibitor
- don’t give more than q2 weeks

79
Q

HPV vaccine and screening

A

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

80
Q

Holding BTK-I around surgery

A

Minor: 3 days before and after
Major: 7 days before and after

81
Q

Prostate: what does active surveillance entail?

Observation

A

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

82
Q

Prostate: observation vs AS

A

Observation: life exp <10 y

AS: life exp >20y very low risk, and >10y for low risk

83
Q

General tx recs for non-metastatic prostate

A

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

84
Q

When to use LHRH antagonist over agonist

A

Concerns with tumor flare (bone pain, urinary symptoms, spinal cord injury/compression

85
Q

BMA dosing

A

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)

86
Q

Ara-C syndrome

A

Fever, myalgia, bone pain, rash, chest pain, weakness

87
Q

Which type of bilirubin indicated hepatic impairment

A

Conjugated

88
Q

TP53 mutation and RT

A

Avoid RT- increased risk of secondary cancer

89
Q

Normal ionized calcium

A

4.4-5.4

90
Q

What does leucovorin not prevent ?

A

Renal tubular necrosis

91
Q

What does adrenal deficiency cause?

A

Hypokalemia, HTN, edema

This is abiraterone, which decreases glucocorticoid and increased mineralcorticoid production

92
Q

CINV In children

A

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

93
Q

Principles of informed consent

A

Beneficence, justice, respect for autonomy

94
Q

VTE in malignancy tx duration

A

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

95
Q

Which 5HT3 inhibitor doesn’t prolong QTc?

Which helps with delayed CINV?

Max dose zofran?

When to apply granisetron patch?

A

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)

96
Q

When to consider EP over BEP in testicular cancer

A

> 50 y/o, reduced GFR, or pulmonary comorbidities

97
Q

Rasburicase pearls

A

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

98
Q

TLS prevention

A

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

99
Q

CNS ppx parenchyma vs leptomeningeal dx

A

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

100
Q

Early vs late relapse times (ok to repeat initial therapy for late relapse)

notecard is work in progress

A

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

101
Q

CAR-T and BiTE indications

notecard is work in progress

A

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

102
Q

Immunoglobulin heavy-chain variable region gene

A

IGHV

Un-mutated (</=2% mutated): poor prognosis CLL

103
Q

CLL duration of therapy for BTK-Is, venetoclax, FCR

A

-BTK: indefinitely
-Venetoclax: 1 year
-FCR: 6 months

104
Q

Priming for CAR-T

A

5 days prior give lymphodepleting chemo (to allow CAR-T lymphocytes to work but depleting non-CAR-T lymphocytes)

Use FluCy (Fludarabine + Cytarabine)

105
Q

CAR-T b- cell aplasia

A

May need IVIG for lvls IgG lvl< 400

(This is at least for DLBCB-idk about other diseases)

106
Q

Sunscreen strength

A

SPF 15+

Reapply every 2 hours- one ounce

If no expiration date- sunscreen is good for 3 yrs (less if left in heat)

107
Q

Hypercalcemia levels: unionized and ionized

A

Unionized
Mild: 10.5-12
Moderate: 12-14
Severe: >14

Ionized
Mild: 5.6-8
Moderate: 8-10
Severe: >10

108
Q

Prophylactic AC drugs and doses

A

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

109
Q

Which test is used to guide extended endocrine therapy in early stage breast cancer ?

A

BCI: 5.1-10

110
Q

Why is BRAF used with MEK?

A

If used alone resistance develops and alternate MEK pathway will be used

111
Q

Who should be screened for RCC?

A

VHL syndrome- CT or MRI yearly

112
Q

False AFP and HCG elevation causes?

A

AFP: pregnancy, hepatocellular carcinoma. T1/2 7d

HCG: pregnancy, hypogonadism, marijuana T1/2 3d

113
Q

When to avoid immunotherapy

A

-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

114
Q

Perioperative chemo

A

Chemo—>surgery—> chemo

115
Q

Pseudo progression on ICI

A

Continued growth after 16 weeks can be considered true progression

116
Q

PCR (molecular) vs IHC

A

IHC: testing for proteins
PCR (molecular): testing for genes

117
Q

cfDNA vs ctDNA

A

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

118
Q

Sensitivity v specificity

A

Sensitivity: low false negative rate (True positive rate)

Specificity: low false positive rate (True negative rate)

119
Q

At what age can you start taking tamoxifen or other meds to decrease risk of BC?

A

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

120
Q

Can you give ESA for anemia ?

A

Not in myeloid malignancies

Except you can for MDS

121
Q

Nsclc: what can happen when stopping ALK inhibitor

A

Tumor flare: indicated alk inhibitor is needed

Flare can also occur with ROS-1, RET, and MET

122
Q

Anthracycline metabolism

A

Hepatic- )but not via cyps)- so don’t use in severe hepatic impairment

Should not need renal adjustment usually- maybe sometimes for daunorubicin

123
Q

Fluoropyrimidine dose adjustments for DPD deficiency

A

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

124
Q

NSCLC: who doesn’t get immunotherapy?

A

-EGFR or alk mutations
-autoimmune disorders

125
Q

Cisplatin v Carboplatin in NSCLC

A

Carbo is often preferred. Cisplatin is curative, carbo better if stage 4 or poor pfs

126
Q

Varenicline pearls

A

-nausea is bad!
-avoid if brain meds or seizure hx (same with bupropion)
-avoid with MAO-I, tamoxifen, or pts with closed angle glaucoma

127
Q

Hyperviscosity and leukostasis

A

More with acute leukemias than chronic bc cells are smaller with chronic and less sticky etc.

Can happen with multiple myeloma

128
Q

When are parps used for prostate and ovarian cancer?

A

Prostate: CRPC (not CSPC)

Ovarian:
-primary maintenance
-secondary maintenance only if platinum sensitive

129
Q

CAR-T and steroids

A

Generally avoid together. Only add steroids for emergent scenarios (like ICANS, CRS)

No steroid 3-5 days before or 90 days after

130
Q

How to dose adjust R-EPOCH

A

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

131
Q

Which PARP-I can be used in early vs metastatic breast cancer?

A

Early: Olaparib

Metastatic: Olaparib or talazaparib

132
Q

When is DD-AC->T preferred over TC? (Broad strokes)

A

LN 4+, grade 3, high recurrence score (oncotype) 30+

133
Q

SCLC vs NSCLC immunotherapy

A

SCLC: atezolizumab or Durvalumab

NSCLC: atezolizumab, pembrolizumab, cemiplimab

134
Q

SCLC vs NSCLC immunotherapy

A

SCLC: atezolizumab or Durvalumab

NSCLC: atezolizumab, pembrolizumab, cemiplimab

135
Q

Time line to give leucovorin, glucarpidase, and uridine triacetate

A

-leucovorin: 24-42 hours
-glucarpidase: 48-60 hours
-uridine triacetate: 8-96 hours

136
Q

When is pembro cps/TMB 10+ a thing?

A

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+

137
Q

What type of testicular cancer is usually left over after chemo?

A

Teratoma- not chemo sensitive

Always do surgery for residual teratoma

138
Q

At which age is the total volume of intrathecal medication the same for a child and adult?

A

3 years (5-10 mL)

Use 5 mL if <3 years old

139
Q

Anticoagulation with BTK-I?

A

Do NOT use warfarin!

140
Q

What if you need BMA for hypercalcemia but there’s poor dentition?

A

Don’t wait for dental exam- this is an oncologist emergency

141
Q

Anticoag in enteral feeding tube

A

Apix/xarelto/Edoxaban

Doacs are absorbed in stomach and proximal small bowel (except Apixaban which has some absorption in the colon)

142
Q

BTK inhibitors: food?

Interactions?

A

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)

143
Q

Spinal cord compression

A

-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

144
Q

Non standard premeds (notecard in progress)

A

-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

145
Q

Rituximab hyaluronidase dosing (notecard in progress)

A

-DLBCL: 1400 R 23,400 H (5 mins)
-FL: 1400 R 23,400 H (5 mins)

146
Q

Mucositis risk fxs

A

-tobacco/etoh
-poor oral hygiene
-young or old
-female
-low BMI
-head and neck ca
-prior hx RT and/or chemo

147
Q

Smoking

A

-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

148
Q

Purpose of albumin with ifosfamide

A

Neurotoxicity prevention

149
Q

Exogenous pancreatic lipase

A

-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

150
Q

Peds genetics

A

-Wilms: LOH 1p and 16q (poor prognosis)
-Ewings: t(11;22), EWS-FLI1 gene fusion-diagnostic
-retinoblastoma: RB1 mutation at chromosome 13q15

151
Q

Irinotecan vs 5FU myelosuppression

A

Irinotecan is worse

152
Q

When to start mammogram for breast cancer screening after RT?

A

8 years after or age 25, whichever occurs LAST

153
Q

When to do lumbar puncture screening for CNS dx in AML

A

-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

154
Q

Testicular cancer induction

A

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)

155
Q

Things where high risk/severe stands alone

A

-APL
-venetoclax TLS risk (LN >5 cm AND ALC >25, or LN >10 cm)
-radiation recall

156
Q

3a4 inhibitor effect on AUC

A

Strong: 5 fold inc
Moderate: 2-5 fold inc
Weak: 1.25-2 fold inc

157
Q

DIPG

A

Poor prognosis and spreads through ventricles

Diffuse intrinsic pontine glioma

158
Q

Preferred HMA in ESRD

A

Decitabine

159
Q

Germinal vs non-germinal B cell lymphoma

A

Germinal is easier to treat

160
Q

ABC vs gbc lymphoma

A

Better outcomes with GBC

Note: Pola-R-CHP probably should only be used in ABC

ABC more associated with PCNSL

161
Q

Who do we know CML treatment is or isn’t working ?

A

Should have hematologic remission in 3-6 months

162
Q

Most likely cancer to have bone Mets

A

-breast
-prostate
-lung
-osteosarcoma

163
Q

Predictive marker

A

Predicts a response or resistance Ti a treatment.

If it says “this mutation was not associated with a response” that’s not predictive

164
Q

Types of bias

A

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

165
Q

FOLFOXIRI vs folfirinox

FOLFIRINOX VS mFOLFIRINOX

A

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

166
Q

Goals of phase 1 study

A

Phase 1: max tolerated dose, dose limiting toxicity
-starting dose is 1/10th of LD10

167
Q

Folic acid vs leucovorin (folinic acid)

A

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

168
Q

What is the role of the steroid is treating infusion reactions

A

It prevents delayed reaction, it does not provide immediate benefit (use h1 and h2 for immediate benefit)

169
Q

When would you not give BMA in a patient with bone Mets?

A

CSPC

Note: can still do osteoporosis dosing as indicated for pts on ADT based on FRAX and DEXA

170
Q

Which type of cervical cancer is more aggressive?

A

Adenocarcinoma or adenosquamous have much worse prognosis than squamous cell

171
Q

When is HER-2 given or not given in early stage breast cancer?

A

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

172
Q

Deciding between Bispecific and car-T in R/R myeloma after 4 lines

A

If they have very short relapse we need something quicker so would pick Bispecific

173
Q

BMA in multiple myeloma

A

All patients getting primary therapy for multiple myeloma should be given BMA x2 years

(So DONT need bone Mets!!)

174
Q

Cut offs to check for nephro or hepatotoxicity of drugs if there are no dosing adjustments in labeling

A

Crcl<60

AST/ALT >75

175
Q

VTE ppx for indwelling catheter

A

NO!

176
Q

Health economic evaluation

A

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)

177
Q

Which sarcomas spread through LN (as opposed to blood)?

A

SCARE

Synovial, clear cell, angio, rhabdo, epithelioid

178
Q

Which CAR-T have increased risk of CRS?

A

-Axicabtagene
-Brexucabtagene

179
Q

Why is bevacizumab not used in squamous cell lung cancer?

A

Increased risk of bleeding

180
Q

A few random CINV drug reactions

A

-lorazepam + posaconazole

-Olz + IV BZD (use po instead)

181
Q

APL management of bleeding complications

A

-PLT transfusion to goal of 30-50
-cryoprecipitate to goal fibrinogen of 100-150

182
Q

When do PARP inhibitors come into play in prostate cancer?

A

Not until metastatic castration RESISTANT!

183
Q

PSA false readings

A

Finasteride/dutasteride: false low
Saw palmetto: variable
Androgen blockers: false high
Ejaculation: false high
Prostatic manipulation: false high

184
Q

mFOLFOX6 vs mFOLFOX7

A

6 has a 5FU push (not just CINV like 7)

185
Q

ABVD effect on fertility

A

Doesn’t affect women’s fertility but may effect male fertility

186
Q

Weird sign of Hodgkin’s lymphoma

A

-Itching/pruritis
-pain in LN after etoh consumption

BCOP- Joey (11 decks)

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