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Pharm oncology Flashcards

1
Q

4 Pillars of cancer tx

SRCI

A
  1. Surgery
  2. Radiation
  3. Chemotherapy
  4. Immunotherapy
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2
Q

Cancer treatment timeline

broad

A

Surgery
* galen-> breast cancer
* Mastectomies 1800s
* Exploratory surgeries 1900s
* Now robotics

Radiation
* Roentgen->new kind of ray
* Early docs gave themselves Radiation to determine dose
* now= CRT- Conformal Radiation therapy

Chemo
* ww2 nitrogen mustard gas exposure
* Aminopterin- MTX precursor- ALL tx
* Devita and Cannellos for MOPP- 1st combo chemo cured Hodgkins
* Now-> targeted therapies

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3
Q

Chemo basics

rarely singel

A
  1. Cycles and days are numbered (cycle 3 day 8)
  2. Setting and intent matter
  3. No side effect free regimens-> management of AEs have drastically improved
    * N/V most feared
    * Myelosuppression most common
    * alopecia= not all chemo
    * oral therapies are not necessarily less than IV chemo
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4
Q

types of settings and intent for chemo

A
  1. Neoadjuvant vs Adjuvant (before or after surgery)
  2. curative vs palliative
  3. first line vs second or third
  4. Dose dense (more often) vs Dose intense (give more)
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5
Q

Antineoplastic man

A

https://s3.amazonaws.com/brainscape-prod/system/cm/401/570/643/a_image_card.?1666118097

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6
Q

CTCAE

common terminology criteria for adverse events

A

standards for description and safety info for oncology practice and research: Very Bad, Significant, or profound anemia means different things

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7
Q

Chemo Induced Nausea/Vomiting (CINV)

A

antiemetic guidelines

how likely a chemo drug is to cause N/V

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8
Q

Causes CINV

Cisplatin

Class Ankylating agents/Platinums

A

MOA: inhibits DNA synth by the formation of DNA cross-liks (NONSPECIFIC)
Uses: Many- lung, head, neck, pancreatic, ovarian
AE: CINV, peripheral neuropathy, myelosuppresion, NEPHROTOXIC, OTOTOXIC
Monitoring: CBC, CMP, audiometric @ baseline, neuro exam

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9
Q

Types of Emesis and Prevention of CINV

A
  1. Acute emesis- 1-2 hours after for 4-6 hours
  2. Delayed emesis- after 24 hours
  3. Anticipatory emesis- prior to tx due to conditioned response

Receive Pre-Medications for CINV + rescue meds

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10
Q

Classes of antiemetics for CINV

1 of each is given

A
  1. 5-HT3 Receptor antagonists (ondansetron)- QTc prolongation
  2. Neurokinin-1 receptor antagonists (best for delayed N/V)- CYP3A4 inhibitor
  3. Additional options- Glucocorticosteroids, Lorazepam
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11
Q

Chemo Induced Diarrhea- Mech, ddx, tx

A

Mechanism:
* secretory: high secretion of electrolytes due to low absorp (epithelial damage)
* Osmotic: increased intraluminal osmotic substance
* Altered GI motility

DDX: Infectious causes-e. coli, fat malabsorption-pancreatic ca, Neutropenic enterocolitis- guts infection

TX:
mild: loperamide/imodium
Severe: Octreotide
All: bland diet, hydration

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12
Q

Irinotecan/Camptosar, CPT-11

class: plant alkaloid

A

MOA: Topoisomerase 1 Inhibitor (S&G2 phase)
Uses: Colon and pancreatic
AE: Diarrhea imm and delayed, CINV, Neutropenia, Fatigue
Monitoring: CBC, CMP, Mag, Phos

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13
Q

Chemo induced myelosuppression (most common se)

A

Most common dose limiting AE-> 1 or more cell lines can be effected-> dose reductions and delays= management

General Management:
Prevent: growth factors-> for neutropenia, Prophylactic antibiotics for prolonged neutropenia
TX: platelet and RBC transfusion

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14
Q

Dose dense AC (ddAC+T) for HER2- Breast cancer

Doxorubicin (adriamycin): Anthracycline
Cyclophosphamide: Alklating agen

A

MOA:
* Doxorubicin: Intercalation btwn DNA base pairs by inhibition of topoisomerase 2 and steric obstruction (multiple phases of the cell cycle)
* cross linking DNA strands and decreasing DNA synth (cell cycle non specific)

Uses:
Neoadjuvant chemo for Stage 3 Her 2= shrink tumors for surgeon

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15
Q

AC(ddAC)= Cycle length, AE, Monitoring

A

Cycle:
on Day 1 of each 14 day cycle-> for 4 cycles
+ weekly Taxol for 12 cycles
AE: Neutropenia, CINV, infusion site rxn (doxorubicin is vesicant= skin eating), cardiotoxicity low LF
Monitoring: CBC, CMP, Echo before at completion and 6 months post bc doxo-> cardio

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16
Q

AC(ddAC)= Cycle length, AE, Monitoring

A

Cycle:
on Day 1 of each 14 day cycle-> for 4 cycles
+ weekly Taxol for 12 cycles
AE: Neutropenia, CINV, infusion site rxn (doxorubicin is vesicant= skin eating), cardiotoxicity low LF
Monitoring: CBC, CMP, Echo before at completion and 6 months post bc doxo-> cardio

17
Q

Chemo induced neutropenia- meaning, tx, risk of neut fever

A

Neutropenia= ANC<1500
Severe= ANC<500
Control measures: Hand hygiene, no flowers, no rectal thermometer
G-CSF Prophylaxis for those in risk of fever or neutropenia is greater than 20 percent
Chemo regimen + patient factors= risk of neut fever
* 65 yr old and older
* previous chemo
* open wounds or surgery
* multiple comorbid conditions
* HIV

18
Q

G-CSF->Granulocyte colony stimulating factors: EX, MOA, dosage, AE, Monitoring

prevent neutropenia

A

Ex: Filgrastim, Pegfilgrastim
MOA: binds to hematopoietic cell receptors and stim production, maturation, and activation of neutrophils
Dosage: IV or on body injector
AE: BONE PAIN = LORATADINE b4 and after to prevent, NSAIDS for pain. Leukocytosis
Monitoring: CBC, fever curves

19
Q

Febrile Neutropenia definition and groups

A

Def: single oral temperature of 101 F or 100.4 for more than 1 hour
Cause: 20-30% of cases = translocation of endogenous bacteria- Gram+
what to KNOW: when chemo, what regimen, ANC-> blood culture 1st+ IV Abx w/in 60 min then imaging, UA, lactic acid, Procalcitonin

Groups:
High risk: 95%
* Severe Neutropenia for more than 7 days
* severe comorbidities
* renal or hepatic dysfunciton
ADMIT AND IV ANTIBIOTICS
Low risk: 5%
* receiving OP (outpatient) chemo
* no comorbidities
* good performance status
* expected to recover counts quickly
* youth

OP tx w/ oral fluoroquinolone plus amoxicillin

20
Q

Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) classes

A

Rituximab/Rituxan: Monoclonal anti-CD20
Cyclophosphamide: Alkylating agent
Doxorubicin/Adriamycin: Athracycline
Vincristine/Oncovin: Vinca alkaloid
Prednisone: Glucocorticoid

21
Q

R-CHOP, uses, cycle, AE

A

Uses: Aggressive Non Hodgkins lymphomas
Cycle: 21 days except prednisone on day 1-4
AE: Myelosuppression-> severe nuetropenia >20%, infusion rxn (rituxan), neuropathy(vincristine), cardiotoxicity

22
Q

Cardiotoxicity of chemodrugs basics+common agents

A

Complications:
* Arrhythmias
* heart failure
* myocardial necrosis->dilated cardiomyopathy
* Vasospasm or vasoocclusion-> angina or MI
* pericardial disease
* arterial occlusive events

common agents:
* anthracyclines
* Fluoropyrimidines
* HER2 targeted therapies

23
Q

Cardiotoxic drug classes

A
  1. Anthracyclines
    * doxorubican, heme malignancies, ROS mediated decreased LVEF, LIFETIME DOSE LIMIT
  2. Fluoropyrimidines
    * Fluorouracil, GI cancers, CORONARY SPASM, access risk factors
  3. HER2-targeted therapies
    * Trastuzumab, HER2+ breast/colon/gastric, Asympt decrease LVEF, Echo q3 plus q6 for 2 years after
24
Q

Chemo induced Peripheral Neuropathy (CIPN) common

A

PROFOUND IMPACT ON QUALITY OF LIFE
Colon (Oxaliplatin)
Breast (Taxanes)
* one of the mc reasons chemo dose is reduced
other cures, cyrotherapy, compression, exercise, duloxetine-> may treat…..but lack data

25
Q

Paclitaxel/Taxol

class: Taxanes

A

MOA: Microtubule dysregulation-G2 mitotic phase- spindle poisons
Uses: MANY
AE: CIPN, muscle aches, infusion reactions, alopecia
Monitoring: CBC, CMP, neuro exam

26
Q

Brain mass presentation

A

Presentation: new onset seizures, focal neurologic symptoms, Headache, vision changes, dizziness, refractory N/V
Metastatic disease is 5x more common than primary brain tumors
MC primary brain tumor: Meningioma- benign
MC malignant brain tumor: Glioblastoma

Management: Steroids for cerebral edema or surgical resection, bc most chemo dont cross BBB

27
Q

Imatinib/Gleevex

Class: Tyrosine kinase inhibitor TKI

A

MOA: inhibits Bcr-Abl tyrosine kinase-> philadelphia chromosome
Uses: CML, Ph chromosome positive ALL
AE: Edema, MSK pain, N/V/D, myelosuppression
Monitoring: CBC, CMP, Bcr-Able transcript levels

28
Q

Breast Cancer biomarkers

A
  1. HR Positive-70-80%
    neoadjuvant/adjuvant tx with AROMATASE INHIBITOR OR TAMOXIFEN- estrogen blocker
  2. HER2+
    “triple positive”- more favorable-directed therapies
  3. Triple Negative
    most aggressive-> AA-> white with premenopausal->post meno
29
Q

Trastuzumab/Herceptin

Class: Monoclonal AB

A

MOA: blocks transmem HER2 receptos whose downstream signals promote cell proliferation-> may also have ab dependent cellular cytotoxicity
Uses: HER2+-> breast, colon, gastric, endometrial
AE: cardiotoxicity, infusion rxn, pulmonary toxicity, nvd
monitoring: CBC, CMP, q3 month echos

30
Q

NSCLC targeted therapies

lung cancer

A

9 currently targetable mutations w/ 1st or 2nd line drug approvals
1. Epidermal growth factor receptor EGFR-> mc targetable mutation
2. Osimertinib/Tagrisso- CNS penetration

31
Q

EGFR TKI toxicities

lung cancer

Lizzo

A

Rash-MC
Diarrhea-MC
QTC prolongation
Decreased EF
Ocular

32
Q

Immunotherapy history

Busch+

A
  1. Busch+Fehleisen-> intentionally infected cancer patients
  2. Dr. William Coley- “father of cancer imunotherapy”-> Coley’s toxins=inactivated S pyogenes and S marcescens-> regression or cure in over 1000 patients
  3. Rosenberg used IL-2 for renal cell cancer
  4. Allison-> CTLA-4
  5. Honjo-> programmed cell death ligand
33
Q

Immunotherapy in current practice

A

Widely used:
1. Melanoma
2. RCC
3. NSCLC
4. Heavily pretreated cHL-> hodgkins lymphoma

Less than stellar successes:
1. Breast
2. CRC
3. SCLC
4. Primary CNS tumors
5. Pancreatic

34
Q

IO biomarkers

A

PDL1
TMB
MMR status

35
Q

IO toxicities

A

dermatologic= MC
endocrinopathies
diarrhea/colitits
constitutional
pneumonitis
hepatitis

36
Q

Immune related AE management

by grade

A

Grade 1: supportive measure, monitor
Grade 2: PO steroids, consider daily dose
Grade 3: PO steroids, alternate immunosuppression, hold IO
Grade 4: hospitalize, IV steroids, discontinue IO

endocrine replacement doesnt necessitate discontinuation

37
Q

Immune related AE management

by grade

A

Grade 1: supportive measure, monitor
Grade 2: PO steroids, consider daily dose
Grade 3: PO steroids, alternate immunosuppression, hold IO
Grade 4: hospitalize, IV steroids, discontinue IO

endocrine replacement doesnt necessitate discontinuation

38
Q

CAR-T cell therapy

A

Chimeric antigen receptor T-cells
FDA approved for ALL, lymphoma and MM-> target CD19
AE: Cytokine release syndrome

Pharm (9 decks)

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