Supportive Care in Oncology

Question 1

What are the disease risks factors of Mucositis?

Answer 1

• Head and neck cancer
• Treatment plan
  
  • Chemo vs radiation
• Duration of treatment
• Dose of therapy
• Frequency of therapy

Question 2

What are the patient risks factors of Mucositis?

Answer 2

• Smoking
• Baseline oral hygiene
• Younger age
• Female sex
• Pretreatment nutritional status

Question 3

Which old chemotherapy promotes mucositis?

Answer 3

• Antimetabolites (5-FU and Methotrexate)
• Platin-Derived (Cisplatin and Carboplatin)
• Taxanes (Docetaxel and Paclitaxel)
• Anthracyclines (Doxorubicin)
• Alkylating agents (Cyclophosphamide)
• Irinotecan

Question 4

Which new chemotherapy promotes mucositis?

Answer 4

• mTOR inhibitors (Everolimus)
• EGFR inhibitors (Cetuximab)
• Tyrosine kinase inhibitors (Afatinib)
• Multi kinase inhibitors (Sunitinib)
• CTLA-4 inhibitors (Ipilimumab)

Question 5

How do you prevent mucositis for chemotherapy?

Answer 5

• Prophylactic oral care
• Professional dental assessment – if high risk
• Cryotherapy
• Mucoadhesive hydrogel rinses (MuGard)
• Supersaturated calcium phosphate rinses (BioSal)

Question 6

How do you prevent mucositis for radiation?

Answer 6

• Prophylactic oral care
• Professional dental assessment
• Shielding and limiting of mucosal exposure
• Dietary modifications
• Mucoadhesive hydrogel rinses
• Supersaturated calcium phosphate rinses
• Low-level laser therapy

Question 7

How do you treat mucositis due to chemotherapy?

Answer 7

• Bland rinses (NS or baking soda)
• 2% viscous lidocaine swish and spit
• Diet modification
• 2% morphine mouthwash swish and spit
• Systemic opiates

Question 8

How do you treat mucositis due to radiation?

Answer 8

• Bland rinses (NS or baking soda)
• 2% viscous lidocaine swish and spit
• Gabapentin
• Low-level laser therapy
• 2% morphine mouthwash swish and spit
• Doxepin-containing mouthwashes
• Systemic opiates

Question 9

How do you treat mucositis due to targeted agents?

Answer 9

• Dexamethasone mouthwash (for everolimus)
• Systemic steroids (for refractory mTOR inhibitor mucositis)

Question 10

What drugs are irritants?

Answer 10

• Antimetabolite
• Liposomal
• Platin salts
• Alkylating agents
• Topoisomerase I inhibitors
• Arsenic
• Bleomycin
• Bortezomib
• Brentuximab
• Etoposide

Question 11

Which drugs are vesicants?

Answer 11

• Platinums
• Vinca alkaloids
• Anthracyclines
• Antitumor antiobitcs

Question 12

What are the symptoms of extravasation?

Answer 12

• Tingling
• Burning
• Discomfort
• Pain

Question 13

What are signs of extravasation?

Answer 13

• Swelling
• Redness or blanching
• Absence of blood return
• Resistance during IV bolus administration

Question 14

What are the patient risk factors of extravasation?

Answer 14

• Circulatory issues:
  
  • PVD, Raynaud’s
  • Small/fragile vein
• Obesity
• Multiple venipunctures
• Impaired communication:
  
  • Dementia, aphasia
  • Medication side effects

Question 15

What are the iatrogenic risk factors of extravasation?

Answer 15

• Inexperience
• Multiple cannulation attempts
• Unsuitable access site
• Infusion pump use
• Prolonged infusion

Question 16

How do you treat extravasation?

Answer 16

1. Stop & disconnect infusion and Leave needle in place
2. Identify extravasated drug
3. Attempt to gently aspirate as much extravasated drug as possible and Avoid manual pressure over area as needle is removed
4. Draw an outline around injury area
5. Notify prescriber and Start specific treatment measures ASAP
6. Elevate affected limb and administer analgesia if needed

Question 17

What are the contributing factors of hypercalcemia?

Answer 17

• Calcium supplements/TPN
• HCTZ/Chlorthalidone
• Lithium
• Vitamin D
• Sedatives/hypnotics
• Opioids
• Renal impairment

Question 18

What is the treatment of hypercalcemia?

Answer 18

• Discontinue contributing meds
• Stabilize the patient
  
  • Acutely lower serum calcium to safer level
• Treat the underlying cause
  
  • Chemotherapy and/or RT (if possible)

Question 19

IV Fluids

Hypercalcemia

Answer 19

• Aggressive hydration = 1st line treatment
  
  • Rationale: Dilute serum Ca2+ and increases its excretion
• Onset: within hours duration: short-lived

Question 20

Antiresorptive Therapy

Hypercalcemia

Answer 20

• Bisphosphonates
  
  • Pamidronate (Aredia)
  • Zoledronic Acid (Zometa)
• RANKL (Receptor Activator of Nuclear Factor k-beta Ligand) Inhibitor
  
  • Denosumab (Prolia)
• Goal: Prevent further Ca2+ release from bone

Question 21

Bisphosphate

Answer 21

• Guideline-recommended for moderate or severe HCM
• Dose may be repeated 7 days later if poor response
• Monitoring: Scr (can cause ATN); Ca level

Question 22

Which Bisphosphonate to choose?

Hypercalcemia

Answer 22

• Zoledronic acid preferred over Pamidronate for HCM
• Note: Pamidronate contraindicated if Scr > 3 mg/dL or ClCr < 30 mL/min
• Zoledronic acid contraindicated when Scr ≥ 4.5 mg/dL

Question 23

Denosumab

Hypercalcemia

Answer 23

• Guidelines suggest instead of bisphosphonate for moderate or severe HCM (low LOE)
  
  • Less recurrent HCM; fewer skeletal-related events
• Monitoring: Ca** [new boxed warning]
  o **NEED Calcium + Vit D supplementation

Question 24

Calcitonin

Answer 24

• Guideline-recommended for severe HCM - Rationale: Inhibits osteoclasts & prevents Ca2+ reabsorption

Question 25

What is the severe HCM treatment plan?

Answer 25

• IV fluids
• Calcitonin
• Zoledronic Acid