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Fall 2018/P3 Year' > Therapeutics Exam 2 (Weddle/Scott) > Flashcards

Therapeutics Exam 2 (Weddle/Scott) Flashcards

1
Q 
Etiology of N/V:
GI Disorders (like a bunch)
CNS Disorders (\_\_\_\_\_\_,\_\_\_\_\_\_\_,\_\_\_\_\_\_)
Pain (acute or chronic)
Pregnancy
GI intake (excessive intake of \_\_\_\_\_ or\_\_\_\_\_)
A

CNS: anxiety, tumors, Headaches/migraines

Intake: intake of food or alcohol

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2
Q 
Etiology of N/V:
Pregnancy ---
80% of pregnant women 
begins \_\_\_\_th - \_\_\_\_th week after last menstrual period
usually resolves by \_\_\_th week
A

4th - 7th;

20th week

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3
Q

what is hyperemesis gravidarum

A

continue to have issues with N/V and so much that the mom starts to lose weight (baby is at risk)

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4
Q 
What are some treatment induced causes of nausea and vomiting
\_\_\_\_\_ agents
\_\_\_\_\_ therapy
\_\_\_\_\_\_
\_\_\_\_\_\_
NV associated with \_\_\_\_\_\_\_
A 
ANP agents (anti-neoplastic)
Radiation therapy
opioids
anesthesia
assoc. with procedures
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5
Q

Complications of N/V

A

PATIENT DISCOMFORT
dehydration
malnutrition
aspiration pneumonia (puke in the lungs –> infection)
Anxiety (anticipatory NV)
Compromise therapy (decrease chemo bc NV so bad)
DECREASED QOL

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6
Q

Ways to Assess N/V

A

of episodes
onset
duration
severity of nausea (like pain scale: 0 - 10)

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7
Q

what are the 4 inputs/influences of the vomiting center

A

coretx
CTZ/dorsal vagal complex
GI
Vestibular (motion!)

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8
Q

Diseases that can cause N/V? (5?)

A 
Metabolic disease
neurologic disease
GI disease
genitourinary
related to pregnancy
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9
Q

Pathophys of N/V

site of drug actions?

A 
dopamine receptors
histamine receptors
muscarinic receptors
serotonin receptors
neurokinin receptors
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10
Q

Non-PCOL management of N/V

A 
determine cause 
and
put the gut to rest (clear liquids and IV hydration)
dietary 
physical
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11
Q

what are the dietary PCOL therapy options for N/V

A

avoid fatty, spicy, fried, sweet foods

odors could wreck them

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12
Q

what are some physical PCOL therapy options for N/V

A 
fresh air
avoid sudden movements
dim lights
acupressure
3 fingers above the wrist
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13
Q

drug therapy for N/V

what drugs are antihistamines/anticholinergics

A

meclizine
dimenhydramine
scopolamine

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14
Q

MOA of antihistamines/anticholinergics

A

blocking histamine and muscarinic receptors in CTZ and vomiting center

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15
Q

drug therapy for N/V

what drugs are phenothiazines

A

prochlorperazine
promethazine
chlorpromazine

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16
Q

drug therapy for N/V

what drugs are serotonin antagonists

A 
"-setrons"
ondansetron
granisetron
palonosetron
dolasetron
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17
Q

ADEs of meclizine, dimenhydramine, scopolamine

A

antihistamines/anticholinergics

cause drowsiness and sedation and dry mouth and constipation and blurred vision and confusion

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18
Q

ADEs of ondansetron and other “-setrons”

A

are serotonin antagonists

mild HA, dizziness, fatigue, constipation, QT prolongation

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19
Q

MOA of phenothiazines

A

dopamine inhibition at CTZ

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20
Q

ADEs of promethazine, chlorpromazine, prochrorperazine

A

dizziness, sedation, dry mouth, hypotension, EPS!!!!

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21
Q

what serotonin antagonist has a long ass half life (40 hours)

A

palonosetron

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22
Q

what serotonin antagonists are super pricey vs which ones are cheap boys

A

cheap: ondansetron, granisteron
pricey: dolasteron, palonosetron

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23
Q

which serotonin antagonist has NO oral dosage form

A

palonosetron

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24
Q

biggest disadvantage with serotonin antagoinsts

A

no suppositories!!

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25
Q

what are the more odd types of serotonin antagonists dosage forms

A

sancuso (granisetron) - PATCH

Sustol (granisertron) ER injection

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26
Q

what drugs are butryophenones

A

haloperidol and droperidol

not used for N/V a lot

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27
Q

biggest ADEs of haloperidol and droperidol

A

EPS and QT prolongation!!

will also see sedation and hypotension

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28
Q

what is the MOA of olanzapine

A

blocks D2, 5-HT2C, and 5-HT3 receptors

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29
Q

main side effect of olanzapine

A

sedation

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30
Q

what drugs are neurokinin antagonists

A

“-pitants”
aprepitant
fosaprepitant
rolapitant

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31
Q

ADEs of aprepitant, fosaprepitant, rolapitant?

A

neurokinin 1 antagonists

fatigue, HICCUPS, constipation, decrease appetite

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32
Q

Neurokinin antagonists are indicated for what kind of nausea and is not indicated for?

A

indicated for BOTH acute and delayed

not indicated as monotherapy

*rolapitant is indicated only for delayed though

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33
Q

Sancuse (granisetron) patch:
apply when?
may be worn for how long?
avoid _____ to site for up to 10 days

A

apply 24 - 48 hours BEFORE chemo

wear for up to 7 days

avoid sun exposure to site!

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34
Q

dosing schedule for aprepitant

A

oral agent:
one dose on day 1; and
then doses on days 2 and 3

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35
Q

dosing schedule for fosaprepitant

A

one dose IV on day 1

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36
Q

dosing schedule for rolapitant

A

one dose 1 -2 hours prior to chemo

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37
Q

benzos are especially helpful for what kind of NV

A

anticipatory

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38
Q

MOA of metoclopramide?

A

dopamine inhibition and serotonin inhibition (at high doses!)

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39
Q

ADEs of metoclopramide

A

EPS!! drowsiness, sedation, diarrhea, restlessness, agitatin

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40
Q

how to prevent EPS?

A

benadryl

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41
Q

what s the hardest NV to treat?

A

delayed

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42
Q

Factors affecting CINV:

Females or males are more susceptible?

A

Females

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43
Q

Factors affecting CINV:

EtOH intake effect?

A

pts with chronic EtOH intake will have less N/V

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44
Q

Factors affecting CINV:

prior chemo?

A

if NV was not controlled well before — they will have increase NV risk

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45
Q

Factors affecting CINV:

personality?

A

anxious personality

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46
Q

Factors affecting CINV:

predisposed NV?

A

if previous motion sickness….

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47
Q

what chemo agent has high risk of single IV ANPs

A

cisplatin

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48
Q

For preventing acute CINV:
always treat when risk is _______
always use ____ therapy whenever possible

A

mod to high risk

PO therapy — it is cheaper

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49
Q

Dosing time if IV or oral in relation to ANP admin?

A

if IV - give 30 mins before

if PO - give 60 mins before

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50
Q

if high emetic risk: use how many drugs and what classes (per Scott)

A 
4 drugs....
5-ht3 antagonist
NK 1 receptor antag
Dexamethasone
olanzapine
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51
Q

if moderate emetic risk: use how many drugs and what classes (per Scott)

A

2 or 3 drugs
5-ht3 antagonist
NK 1 receptor antag
Dexamethasone

or
5-ht3 antagonist (on day 1)
Dexamethasone (on day 1)

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52
Q

Treating motion sickness:

_______ is key

A

prevention

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53
Q

what are the three main options for treating motion sickness

A

Scopolamine
Dimenhydrinate
Meclizine

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54
Q

the scopolamine patch for motion sickness should be applied about _____ hours before and will last for _____ hours

A

24 hours before

last 72 hours

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55
Q

Take dimenhydrinate needs to be taken _____ before needed

A

30 - 60 mins

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56
Q

Take Meclizine needs to be taken _____ before needed

A

30 - 60 minutes

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57
Q

how long will meclizine last

A

4 hours

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58
Q

how to prevent low emetic risk CINV

A

single dose of
dexamethasone 8 mg PO
or
5-HT3 antag

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59
Q

how to prevent CINV with minimal emetic risk drugs

A

do not do a routine anti emetic therapy – just do PRN

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60
Q

CINV:

complications?

A

dehydration
electrolyte abnormalities (low K+)
fatigue
depression

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61
Q

CINV:

Acute vs Delayed N/V? (time frame)

A

acute < 24 hours of getting chemo

delayed > 24 hrs after getting chemo

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62
Q

CINV - Pathophys:

______ cells lining the GI tract contain large stores of ______ and is released in massive quantities after chemo

A

enterochromaffin; stores of serotonin

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63
Q

CINV - Pathophys:

when serotonin gets to the ______ it stimulates the ______ center

A

chemoreceptor trigger zone (CTZ);

vomiting center

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64
Q

what are the main neurotransmitters implicated in CINV?

A

dopamine, histamine, acetylcholine, serotonin, substance P

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65
Q

what neurotransmitters are not MAJOR targets for CINV but reserved more for refractory or breakthrough

A

histamine and acetylcholine

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66
Q

Combo chemo and CINV:

Levels ____ do not contribute to the emetogenicity of the combo

A

1 and 2 (minimal and low)

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67
Q

Combo chemo and CINV:

adding levels ______increases the level of emetogenicity by ____ level

A

levels 3 and 4 (moderately)

increase by 1 level

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68
Q

Common toxicities of CINV drugs:

Serotonin antagonists

A

HA
asymptomatic/transient EKG changes - QT
constipation
increased transaminases

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69
Q

Common toxicities of CINV drugs:

Corticosteroids

A

short term: anxiety, euphoria, insomnia, hyperglycemia, increased appetite

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70
Q

Common toxicities of CINV drugs:

Substance P antagonists

A

hiccups

DRUG INTERACTIONS

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71
Q

Common toxicities of CINV drugs:

dopamine antagonists

A

EPS, diarrhea, sedation

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72
Q

Common toxicities of CINV drugs:

phenothiazines

A

sedation
akathisia
dystonia

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73
Q

Common toxicities of CINV drugs:

cannabinoids

A 
drowsiness
dizziness
euphoria - mood changes
hallucinations
increased appetite
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74
Q

what drugs can be used for breakthrough N/V (weddle)

A 
Lorazepam
Dronabinol/Nailone
serotonin antagonists (dolas,granis, ondans)
dexamethasone
scopolamine
haloperidol/metoclopramide
olanzapine
prochlorperazine/promethazine
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75
Q

drugs for delayed N/V (weddle)

A 
Dexamethasone
Aprepitant
Metoclopramide
lorazepam
diphenhydramine
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76
Q

actions to do for anticipatory N/V

A

prevention
behavioral
alprazolam/lorazepam

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77
Q

what are some behavioral actions for anticipatory NV

A

relaxation
hypnosis/guided imagery
music therapy
acupuncture/acupressure

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78
Q

Mucositis:

can affect what part of the body?

A

entire length of the GI tract from top to bottom

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79
Q

Mucositis course parallels the _______

A

neutrophil nadir

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80
Q

Mucositis begins ~ on days ______ after ____

A

5 - 7; after chemo (max at 10 - 14 days…)

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81
Q

Mucositis will improve as __________ increases

A

neutrophil count

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82
Q

Risk factors for Mucositis?

A

pre-existing oral lesions
poor dental hygiene/ill fitting dentures
pts getting chemo and radiation

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83
Q

Diet recommendations of Mucositis?

A

Avoid rough foods: salt, spicy, acidic
eat soft or liquids foods
AVOIDING smoking and alcohol

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84
Q

General Mouth Care Strategies?

A

salt/soda rinses BID - QID
soft bristled toothbrush
saliva substitute for radiation induced xerostomia

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85
Q

Main ways to manage the pain of Mucositis?

A

topical anesthetics (marys magic -lidocaine/antacids..)
Oral cyrotherapy (ice chips!)
Sucralfate (soothing and coating agent)
oral or parenteral opioid analgesics

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86
Q

Neutropenia?

A

low WBCs (<0.5 x 10^9)

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87
Q

if WBCs are low - pts are at risk of what?

A

infections

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88
Q

if pt has thrombocytopenia - they are at risk of?

A

have low platelets therefore risk of bleeding!

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89
Q

if pt has low RBCS - the patient is at risk for?

A

hypoxia and fatigue and anemiaaaa

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90
Q

normal ranges of WBCs/platelets/RBCs?

A

WBC: 4.8 - 10.8 x10^9/L
Platelets: 140 - 400 x10^9/L
RBCs: 4.6 - 6.2 x10^6/uL

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91
Q

definition of Nadir?

A

the lowest value of blood counts fall to during a cycle of chemotherapy
(lowest ANC = absolute neutrophil count)

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92
Q

ANC = ? (what eq’n)

A

WBC x % granulocytes (segs +bands)

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93
Q

To give a pt chemo their levels must be what?
WBC:
OR
ANC and Platelet?

A

WBC: > 3 x10^9/L (WBC > “3000(

ANC > 1.5 x10^9/L AND Platelet > 100
ANC > 1500; Platelet > 100,000

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94
Q

Severe neutropenia defined as?

A

<0.5 x 10^9/L

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95
Q

Febrile Neutropenia defined as?

A

ANC < 0.5 x10^9/L

AND a single oral temp > 101 F or >100.4 for at least an hour

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96
Q

CSFs (colony stimulating factors) used prophylactic following chemo has demonstrated what benefits?

A

decreased incidence of febrile neutropenia
decreased length of hospitalization
decreased confirmed infections
decreased duration of abx

97
Q

who should be treated with CSFs because of primary prophylaxis of febrile neutropenia

A

high risk pts!
those pts would be preexisting neutropenia due to disease
extensive prior chemo
previous irradiation to the pelvis/areas containing large amounts of bone

98
Q

should you treat febrile neutropenia with CSFs?

A

Nooooo.only do it if they are very sick

99
Q

Other uses for CSFs:
support pts getting ______ chemo
after a ______ transplant to reduce duration of severe neutropenia

A

dose dense chemo!!!

use after stem cell transplant!

100
Q

Other uses for CSFs:

used alone or in combo, after chemo, with plerixafor to mobilize ____________

A

peripheral blood progenitor cells

101
Q

what drugs are CSF

A

Filgrastim
Pegfilgrastim
Sargramostim

102
Q

Filgrastimvs Pegfilgrasim:

which one has a longer 1/2 life

A

pegfilgrastim

103
Q

Filgrastimvs Pegfilgrasim:

which one is 3 -5 days of doses and which one is 1 day

A

3-5 days: filgrastim

pegfilgrastim: 1 dose

104
Q

Pegfilgrastim PK?

A

non -linear PK;

clearance increases w/ increasing neutrophil count

105
Q

what is Neuplasta?

A

an on body injector that gives CSF’s the day after chemo

106
Q

dosing of Filgrastimvs Pegfilgrasim:

A

Filgrastim WT BASED!!! booo

peg: 6 mg SQ x 1 dose

107
Q

Filgrastim Dosing:

dosing conundrum?

A

vials come in only 300 or 480 mcg single vials

round to nearest vial size!!!

108
Q

ADEs of filgrastim

A

flu-like sxs
bone and joint pain (give loratadine — histamine release based pain)
DVT

rare: spleen enlargement

109
Q

Thrombocytopenia:

do not treat until the platelet count is below _____

A

<20 x10^9/L;

<10 x 10^9/L`

110
Q

how is thrombocytopenia treated?

A

typically transfusions

but can also use oprelvekin (interleukin 11) — not used tho

111
Q

General causes of anemia?

A

decreased RBC production (cancer therapy/tumor infiltration into bone marrow)
decrease EPO production
Decrease body stores of vit. B12, iron, folic acid
blood loss

112
Q

Chemotherapy and Anemia:

pts with a Hgb < _____ or a drop > than ______ from baseline should undergo a work up

A

< 11

> 2

113
Q

Chemotherapy and Anemia:

if a pt is symptomatic – do what?

A

transfuse as indicated
consider use of ESA
perform iron studies

114
Q

Black box warnings of ESA?

A

short overall survival if the target Hgb is > 12

115
Q

typically ESAs are not recommended but who would you consider it with?

A

if pt and CKD
if pt going under palliative chemo (aka like metastatic??)
pt w/out other identifiable causes

116
Q

Chemotherapy and Anemia:
ESA vs transfusion

which one has faster onset

A

transfusion

117
Q

what drugs are ESAs

A

Epoetin

darbepoetin

118
Q

Epoetin vs darbepoetin:

which one has a longer half life

A

darbepoetin

119
Q

Epoetin: typically given every ______

Darbepoetin: typically given every ______

A

E: every week (once a week)

D: every 3 weeks

120
Q

to give an ESA: must do an _____ study

A

iron

ESAs won’t do shit if there is no iron present

121
Q

iron absorption will DECREASE if food is eaten ____ hours before or _____ hours after ingestion

A

2 hours before

1 hour after ingestion

122
Q

which IV iron has a required test dose

A

iron dextran

123
Q

Classic Chemo Toxicities:

if they get myalgias/arthralgias - what to treat it with?

A

NSAIDs

Pts may require opioids

124
Q

Classic Chemo Toxicities:

if they get hemorrhagic cystitis- what to treat it with?

A

MESNA!! (used to prevent)

Hydration (prevention)

125
Q

Classic Chemo Toxicities:

if they get heart failure - what to treat it with?

A

monitor for cumulative dose
assess for risk factors
DEXRAZOXANE (chemoprotectant – more for anthracyclines)

126
Q

Classic Chemo Toxicities:

if they get peripheral neuropathy - what to treat it with?

A

change infusion rates

adjunctive pain medications

127
Q

Classic Chemo Toxicities:

if they get pulmonary toxicites- what to treat it with?

A

corticoidsteroids (no good tx once it happens :( )

128
Q 
Type I Chemo Related CARDIAC Dysfunction:
ACUTE
is seen with the \_\_\_\_\_\_ drug class
is like a \_\_\_\_\_\_
not common
occurs \_\_\_\_\_\_\_after a dose 
rarely is \_\_\_\_\_\_\_ observed
A

seen w/ anthracyclines

like a MI

occurs immediately after a dose

rarely is pericarditis/CHF seen

129
Q 
Type I Chemo Related CARDIAC Dysfunction:
CHRONIC
onset usually seen when?
IS common
related to \_\_\_\_\_ dose 
(reversible or irreversible?)
A

with a year of getting anthracycline therapy
cumulative

IRREVERSIBLE

130
Q

Type I Chemo Related CARDIAC Dysfunction:
LATE ONSET

occurs more often in who?

A

seen more in childhood/adolescence cancer survivors who received anthracyclines

131
Q

Type II Chemo Related CARDIAC Dysfunction:

is seen with that drug class?

A

HER 2 targeted therapies

ex: trastuzumab

132
Q

Type II Chemo Related CARDIAC Dysfunction:

reversible or irreversible

A

reversible

133
Q

Type II Chemo Related CARDIAC Dysfunction:

how to treat?

A

stop the HER2 target drug – give CHF drugs — restart HER2 drug and keep on CHF drugs!!

134
Q

Classic Chemo Toxicities:

what drugs would cause myalgia/arthralgias (weddle - from table)

A

paclitaxel/docetaxel

anastrozole/eltrozole
exemestane

135
Q

Classic Chemo Toxicities:
what drugs would cause hemorrhagic cystitis
(weddle - from table)

A

high dose cyclophosphamide

ifosfamide

136
Q

Classic Chemo Toxicities:
what drugs can cause heart failure
(weddle - from table)

A

antracycylines
high dose corticosteroids
trastuzumab

137
Q

Classic Chemo Toxicities:
what drugs can cause peripheral neuropathy
(weddle - from table)

A

taxanes
vinca alkaloids

(microtubule boys)

138
Q

Classic Chemo Toxicities:
what drugs can cause pulmonary toxicity
(weddle - from table)

A

bleomycin

139
Q

Breast Cancer Epidemiology:

Risk of breast cancer ______ with age

A

increases

140
Q

Breast Cancer Epidemiology:

decreased in _______ therapy has contributed to the decrease in mortality based on results from the WHI

A

decrease HRT (hormonal replacement therapy)

141
Q

Breast Cancer Risk Factors:

more than ____% of pts will NOT have any risk factors

A

60%

142
Q

Breast Cancer Risk Factors:

family history?

A

of 1st and 2nd degree relatives with disease has increased risk

143
Q

Breast Cancer Risk Factors:

estrogen?

A

endogenous exposure (aka early menstrual cycle start or late menopause)

or exogenous estrogen (oral contraceptives/HRT)

144
Q

Breast Cancer Risk Factors:
Personal history of cancer or radiation are risk factors

usually what are the causes for radiation exposure?

A

prior tx for lymphoma w/ mediastinal?? or environmental radiation exposure

145
Q

Breast Cancer Risk Factors:

_____ because mechanism thought to be due to decreased hepatic metab of estrogen

A

alcohol

146
Q

Breast Cancer Risk Factors:

prior breast biopsies w/ __________

A

proliferative histology

atypical hyperplasia, fibroadenomas, previous breast cancer

147
Q

Breast Cancer Risk Factors:

risk factor related to children?

A

if nulliparity (no kids) or if first childbirth is after 30 yrs = increased risk

148
Q

Breast Cancer Risk Factors:

related to height and weight?

A

if increased height and weight

149
Q

Breast Cancer Risk Factors:

diet?

A

asian based diet = less risk

150
Q

Breast Cancer Genetics:
only a small part (5-10%) of breast cancers are familial but when the _____ gene has a mutation then there is a laaarge increased risk

A

BRCA1 or 2 gene (a tumor suppressor gene)

151
Q

the _____ risk model is a risk assessment tool to determine ______ in % of developing breast cancer compared to an age matched control

A

GAIL risk;

RR (relative risk)

152
Q

Breast cancer screening:
______ exams have been removed from the screening guidelines

*but _____ is exam is considered an important discussion w/ women starting age 20

A

breast self exams and clinical breast exams

women should know what is normal and what is not

153
Q

Breast cancer screening: ACS recommendations for a mammogram

A

40 - 44 y.o: opportunity for annual exams
45 - 54 y.o: annual mammograms
> 55: every other year mammograms or the opportunity for annual exams (if good health and > 10 years life expectancy)

154
Q

Breast Cancer Prvention:
High risk patients (ex: with ______ mutations) may get risk reduction surgeries

what are these risk reduction surgeries

A

BRCA mutations

prophylactic mastectomy; bilateral oophorectomy

155
Q

The breast cancer risk reduction surgeries — are they 100% effective??

A

hell nah,

buut mastectomy can reduce risk by like 90% and oophorectomy can decrease risk by like 50%

156
Q

what 3 drugs have been studied for prevention of breast cancer

A

tamoxifen (P1 trial)
raloxifene (MORE trial/P2 (aka STARtrial))
exemestane

157
Q

The trial (P1) finding out if tamoxifen was effective in reducing breast cancer risk showed what positive or negative events

A

positive: decreased risk in invasive/noninvasive breast cancer!! AND decreased skeletal events
negative: increased endometrial cancer; increased stroke/PE/DVT

158
Q

STAR trial P2 trial demonstrated that _______ was as effective in ______ in decreasing breast cancer reduction

A

raloxifene is as effective as tamoxifen in breast cancer reduction

159
Q

Pros and Cons of raloxifene (compared to tamoxifen)

A

Pros: fewer uterine cancers and fewer blood clots

cons: there was an increased risk of non-invasive cancers compared to tamoxifen????

160
Q

AIs (aromatase inhibitors) are they effective in reduction and are they reasonable options for breast cancer prevention in post menopausal

A

yes – seen to be effective
but not currently FDA approved for PREVENTION
may be used in high risk pts

161
Q

breast is composed of what things?

A

ducts, lobules, fatty tissue, connective tissue, and lymph nodes!

(lots of lymph nodes aka lots of opportunities of where it can spread)

162
Q

two main kinds of breast cancer

A

Invasive and non invasive (in situ) carcinoma

163
Q

Invasive breast cancer has invaded beyond the _______ of the ____ or _____

A

beyond basement membrane

of duct or lobule

164
Q

subtypes of invasive breast cancer

A

IDC and ILC

IDC = invasive ductal carcinoma

ILC = invasive lobular carcinoma

165
Q

subtypes of non-invasive breast cancer

A

DCIS and LCIS

DCIS: ductal carcinoma in situ
LCIS: lobular carcinoma in situ

166
Q

most common two types of breast cancer?

A

IDC and ILC!!

IDC ~ 750%
ILC ~ 15%

167
Q

DCIS: seen as _______ in a mammogram

A

microcalcifications

168
Q

there is invasive and non-invasive breast cancer – what is the 3rd type?

A

inflammatory

169
Q

inflammatory breast cancer:

______ form of breast cancer with ____onset and _____ prognosis

A

aggressive;
rapid onset;
poor prognosis

170
Q

what would the pts breast look like/present like?

A

“orange peel”/peau d’orange
edema/redness
warmth/inflammation

171
Q

why usually a delayed in diagnosis in inflammatory breast cancer?

A

ppl think it is cellulitis

172
Q 
Typical Presentation of breast cancer pts
most patients (90%) present with a \_\_\_\_\_\_\_\_ lump in the breast

(most women detect lesion by themselves with self exam)

A

a painLESS lump (less than 10% will have pain as 1st symptom)

173
Q

Typical Presentation of breast cancer pts
what are some other presentations of breast cancer?

(other than a painless lump)

A

nipple discharge/rertaction/ or dimpling

174
Q

diagnosis of breast cancer?

A

Clinical breast exam/mammogram (maybe ultrasound)
Hx and PE (physical exam)
Core biopsy!!! (gold standard)

surgical biopsy
fine needle aspiration

175
Q

what are the qualities/results/pathyology do you see from a biopsy

A 
tumor size
invasiveness
tissue type
differentiation
nodal involvement
ER/PR+ (hormonal receptor status)
HER2 Neu status
176
Q

two ways to test for HER2?

A

FISH!! (fluor in situ hybridization)

immunohistochemistry (detects protein expression)

177
Q

ways to stage a tumor?

A

TNM shiiit

178
Q

Oncotype DX :

if high risk, medium risk, or low risk — what kind of therapy??

A

high risk: chemo + endocrine

medium: NO CHEMO! - just endocrine (decided after a trial )
low: hormonal therapy only

179
Q

Adjuvant vs neoadjuvant

A

adjuvant: after surgery
neoadjuvant: before surgery

180
Q

If pt has stage 0 breast cancer and it is LCIS what are the general treatment strategy options

A

1 - observe
or
2 - use tamoxifen or aromatase inhibitors
or
3 - consider bilateral masectomies (reconstruction?)
(not considered risk factor invasive disease)

181
Q

If pt has stage 0 breast cancer and it is DCIS what are the general treatment strategy options

A

1 - lumpectomy followed by radiation therapy
or
2 - total mastectomy +/- reconstruction
or
3 - lumpectomy alone
4 - consider endocrine therapy if pt has ER/PR + disease

182
Q

what is a lumpectomy ?

A

“breast conserving surgery” – just taking out the lump/tumor

183
Q

the goal for all stages of breast cancer is to ______

except for the stage of _____ the goal is ________

A

goal is to cure! stages 0 - 3

stage 4 = stabilize the disease

184
Q

If pt has stage I, II, or IIIA breast cancer - what are the general treatment strategy options

A

breast conserving surgery(aka lumpectomy) + radiation therapy

or MRM (modified radical mastectomy) +/- radiation therapy

*some stage II or IIIA may get NEOadjuvant (before surgery to shrink tumor)

MOST women get adjuvant therapy (after surgery) either chemo, hormonal +/- biologic therapy

185
Q

If pt has stage IIIB and IIIC breast cancer - what are the general treatment strategy options

A

most women have neoadjuvant chemo follow by MRM or lumpectomy
adjuvant therapy as appropriate

186
Q

morphine: renal or liver function need to be considered before use?

A

yes- both!!

187
Q

hydromorphone: renal or liver function need to be considered before use?

A

yes! both!!

188
Q

what pain med does not have an IV formulation

A

oxycodone

189
Q

what pain med is good because there are no renal or liver issues

A

fentanyl

190
Q

what drug should not be used in a opioid naive person

A

fentanyl!! (potent as hell)

191
Q 
Methadone should be avoided in pts because of what 4 reasons?
Numerous \_\_\_\_\_\_\_\_
Risk for \_\_\_\_\_\_\_\_\_\_
History of \_\_\_\_\_\_\_\_
Poor \_\_\_\_\_\_\_\_
A

numerous drug interactions (QTc prolongation!!)
risks of syncope or arrhythmias
hx of unpredictable adherence
poor cognition

192
Q

for methadone pts need a baseline ______

A

EKG because of QT prolongation

193
Q

the half life of methadone is ______

A

unpredictable!!

194
Q

Methadone:
typically ok in ______ dysfunction
but should be avoided in severe ______ dysfunction

A

ok in renal

avoid in liver

195
Q

Toxicities and management of Opioids:

if constipation - what to do?

A

add a bowel regimen! (always do this!!)

mild stimulant laxative and stool softener!!

196
Q

Toxicities and management of Opioids:

if sedation - what to do?

A

tolerance will develop within a few days
hold sedatives or anxiolytics
consider dose reduction

197
Q

Toxicities and management of Opioids:

if N/V - what to do?

A

change opioid
consider adding scheduled anti-emetic therapy
(metoclopramide or prochlorperazine)
(this side effect can go away usually around 7 - 10 days)

198
Q

T or F: patients will develop a tolerance for constipation when on pain meds

A

FALSE!! add a bowel regimen!

199
Q

Pruritus is seen most with _______

what pain med

A

morphine

200
Q

Toxicities and management of Opioids:

if pruritis - what to do?

A

seen most with morphine..
change opioid or decrease dose
consider adding an antihistamine (benadryl)

201
Q

Toxicities and management of Opioids:

if hallucinations/confusion/ or delirium - what to do?

A

decrease dose or change opioid

consider adding a neruoleptic med

202
Q

Toxicities and management of Opioids:

if myoclonic jerking - what to do?

A

may be a sign of toxicity

consider changing opioid or treating underlying cause

203
Q

Toxicities and management of Opioids:

if respiratory depression - what to do?

A

hold the opioid!!!
(sedation will precede resp. depression)
give LOW DOSE naloxone!!!!!! (if on opioids for chronic pain)
(do not give large rescue amounts — do not want to take away all the pain)

204
Q

what is the celiac plexus

A

group of nerves that supply organs in the abdomen

205
Q

celiac plexus block is usually helpful in patients that have______ cancer

A

pancreatic

206
Q

Intrathecal pain pumps are good for pts who??

A

pts who are refractory to other opioid therapy or increased toxicites
or pts that gave more toxicities than benefit from traditional opioid therapy

207
Q

On-Q pump?

A

LOCAL pain relief

208
Q

adjuvant pain therapy alternatives?

A

dexamethasone/NSAIDs

remember neuropathic pain!

209
Q

T or F: it is ok for pts on opioids to use their opioids for anxiety and depression/for sleep

A

Falseeee

210
Q

if patients has stage IV breast cancer
the goal is _________
therapy will primarily consist of _____ and _______
______ typically only used for symptomatic relief
Radiation is used sometimes for palliation

A

goal = stabilize the disease
therapy = chemo and hormonal therapy
surgery for symptom relief…

211
Q

T or F: radical mastectomies are not really used anymore

A

TRUE!

surgery has increased morbidity assoc. with it

212
Q

different between radical mastectomy and MRM (modified radical mastectomy)

A

radical: major and minor pectoralis

MRM: jus minor pect.
both will do nodes and breast

213
Q

Lumpectomy is usually done with _____ therapy

*may not do that therapy in pts who are ______

A

radiation

over 70 y.o

214
Q

breast cancer patients typically get neoadjuvant therapy have a _____

A

large tumor (> 1 cm)

215
Q

Breast cancer pts will get chemo if they have what 2 characteristics?

A 
large tumor (> 1 cm)
 or lymph node positive
216
Q

adjuvant hormonal therapy options for breast cancer

A

Surgical ablation (oopherectomy)
SERMs
LHRH analogs
AI’s (aromatase inhibitors)

217
Q

LHRH analogs will decrease the hormone levels in about _______ (how long)

A

2 - 4 weeks

218
Q

AI’s or LHRH analogs are used only in postmenopausal women

A

AI’s!!!

i think you can give LHRH analogs in premenopausal women and “make” them post menopausual???

219
Q

If a women with breast cancer is postmenopausal what is the first line/best option for hormonal adjuvant therapy

A

AI’s for 5 YEARS then another 5 years…
(best ADE profile!)
*dont forget the cancer must be ER+!!

220
Q

If a women with breast cancer is premenopausal what is the first line/best options for hormonal adjuvant therapy

A

Tamoxifen for 5 years then another 5 year or
????
AI x5 then more Ai x5 or T x5 ???

221
Q

adjuvant therapy of trastuzumab for adjuvant therapy in breast cancer is typically done for _______ (how long)

A 
1 year
(no benefit seen to  do it longer)
222
Q

Adjuvant chemo in breast cancer:

durations longer than ________ do not appear to improve survival

A

3 - 6 months

223
Q

Breast cancer patients may get neoadjuvant therapy if ________

A

tumor is big > 1 cm

224
Q

if giving dose dense anthracyclines (can be done in breast cancer pts) — you must give ________

A

CSFs!! (bc neutropenia risk is high af)

225
Q

most common adjuvant chemo for breast cancer

A

doxorubicin (CARDIOTOX!!) and cyclophosphamide

aka the “AC” chemo

226
Q

was seen that giving _____ after doxorubicin and cyclophosphomide has improved outcomes in pts with LN + disease (in breast cancer lecture)

A

paclitaxel

can give this dose dense! weekly but lower dose!

227
Q 
For treating metastatic breast cancer:
if ER/PR +
Bone Metastasis
Asymptomatic
Visceral

what to do?

A

Hormone therapy!!
since bone disease - do bisphosphonate or denosumab

(bone metastasis tend to have better prognosis - do not bed to be aggressive with chemo)

OR send them to a clinical trial

228
Q

pre-treat pts getting paclitaxel with what?

A

reduce SENSITIVITY RXNS with:
bendaryl
dexamethasone
famotidine (H2 blocker)

229
Q

doxorubicin or cyclophosphamide is a vesicant and can cause extreme damage when it gets extravasted

A

doxorubicin!!

anything to do about that?? no clue

230
Q 
For treating metastatic breast cancer:
if ER/PR -
Symptomatic
Visceral
or hormone refractory
what to do?
A

if HER2+: anti- HER2 therapy and CHEMO

if HER2-: CHEMO

231
Q

for metastatic breast cancer:
if pt is to get chemo:
single agent or combo therapy is best?

A

single

combo = more toxicities with not enough extra benefits

232
Q

what is the first line option for HER2+ disease?

with doses!! (she said know these :( )

A

Trastuzumab:
8 mg/kg IV day 1 followed by 6 mg/kg IV

pertuzumab
840mg IV day 1 followed by 420 mg IV

docetaxel
75 mg/m^2 IV

233
Q

CDKs have are activated in _____ breast cancer

A

ER+ !!!

234
Q

using CDK 4/6 inhibitors in ER+ breast cancer can be beneficial how?

A

can actually reverse some acquired resistance to previous hormone therapy

235
Q

which CDK 4/6 inhibitor is the “best” and why do the other ones stink

A

Palbociclib = “good one”

Ribociclib: hella monitoring (LFTs and QT prolongation/EKG)

Abemaciclib = BID (booooo)

236
Q

what monitoring should be done with palbociclib

A

neutropenia: monitor CBC before therapy, and beginning of each cycle and day 14 of the first 2 cycles
then monthly

Pulmonary embolism: monitor for signs and sxs

237
Q

Breast Cancer:

give pts radiation when?

A

if tumor > 5 cm
or 4 + positive lymph nodes
if pt has had lumpectomy
if positive margins after surgery

238
Q

Breast cancer:

when would pts get neoadjuvant therapy

A

when the tumor is greater than 1 cm?

Fall 2018/P3 Year' (16 decks)

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