Treatment Modalities and Monitoring Flashcards
Treatment decisions for Cancer are based on:
● Extent of disease
● Prognosis and staging
● Patients wishes
● Determine curative or palliative care
● Treat comorbidities
Cancer Therapies are ____
Toxic
Cancer therapies have a _____
Narrow therapeutic index (TI)
May have to treat to the point of toxicity
Local Treatment
● Surgery
● Radiation
● Ablation
Systemic Treatment
● Chemotherapy
○ Hormone therapy
○ Molecular targeted therapy
● Biological Therapy
○ Immunotherapy
____ – chemo and/or radiation prior to surgical resection
Neoadjunctive Therapy
______ – chemo and/or radiation at the time or just after surgery
Adjunctive Therapy
Most effective means of treating cancer
Surgery
Why is surgery helpful with specific metastasis?
○ Limit lung metastasis from osteosarcoma
○ Colon cancer metastasis to the liver (fewer than 5 mets to 1 lobe)
Additional benefits to surgery
○ Decrease mass effect (debulking)
○ Preserve organ function
○ Make the cancer more treatable by other means
Why is it important to Avoid disturbance of tumor as much as possible in surgery?
Prevent vascular and lymphatic spread
_____ is the first draining node from the tumor
Sentinel node
Surgery Also used for _____
palliative or supportive measures
Radiation Therapy
● Ionizing radiation
○ Hydroxyl radicals from tissue/cell water
○ Breaks in DNA and generation of free radicals
● Free radicals aggressively search for and steal electrons from other molecules damaging the cell wall, proteins and organelles
● Uses X-rays and Gamma rays
○ Eject orbital electron and produce ions
Radiation dose is based on ____
the amount of energy absorbed by the
tumor
Goal of radiation dosing
Idea is to catch more cells in their mitotic phase, which makes them more susceptible to radiation damage
Radiation Therapy – Delivery types
● Teletherapy – focused beams of radiation generated at a distance and aimed at the tumor
○ External beam radiation, Gamma Knife
● Brachytherapy – encapsulated sources of radiation implanted directly into or adjacent to tumor tissues
○ Radioactive seed implant for prostate cancer
● Systemic Therapy – radionuclides administered
○ IV or PO but targeted to the tumor site
Urgent radiation
○ Malignant spinal cord compression
○ SVC Syndrome
○ Hemoptysis
■ Disruption of vessels and/or friable tumor
○ Airway obstruction
Goal of Urgent Radiation
● Urgent consult to Radiation Oncology
● Decrease the size of the tumor and/or reduce pain
Radiation damage can occur to healthy cells by
○ Acute toxicity
○ Chronic toxicity
Goal of Radiation Therapy
Maximize effect on tumor cells, while sparing healthy tissue
Injured tissues release ____ that cause systemic effects
cytokines
Tissues with ____ cell turnover are more susceptible to radiation damage
high
Chronic Radiation Toxicity
○ Thyroid failure
○ Cataracts and retinal damage → Blindness
○ Disrupts salivary glands → Dental caries
○ Anosmia
○ Myocardial infarction, pericarditis
○ Lung injury and/or fibrosis
○ Radiation enteritis or cystitis
○ Risk of second solid tumor ~1% each year after second decade of treatment
Ablative Therapy
Radio Frequency: Focused microwave (non-ionizing radiation) to induce thermal injury to the tissue
Cryosurgical: Using extreme cold to destroy the lesion
Thermal (not widely available): Usually done in conjunction with other Tx
3 Types of Chemotherapy
○ Conventional “Cytotoxic” Agents
○ Targeted Agents
■ Hormonal Therapies
○ Biologic Therapies
Conventional “Cytotoxic” Agents
● Main target is DNA
○ Not specific to cancer, can harm normal tissues
■ Narrow therapeutic indices
● Used in conjunction with surgery
○ Eliminate smaller disseminated tumors
Conventional “Cytotoxic” Agent groups
○ Alkylating Agents
○ Antitumor Antibiotics and Topoisomerase Poisons
○ Antimetabolites
○ Antimitotic Agents (Mitotic Spindle Inhibitors)
Alkylating Agents – Cyclophosphamide are used for
non-hodgkin’s lymphoma, breast cancer
Side effects of Alkylating Agents
Cystitis, pulmonary fibrosis, cardiac dysfunction
Contraindication: Liver disease impairs metabolism
Antitumor Antibiotics and Topoisomerase Poisons – Doxorubicin
○ Generate free radicals causing single stranded breaks DNA
○ Unwinds DNA (“S-phase”)
Used for many, many types of cancer
Alkylating Agents – Cyclophosphamide
○ Cross-links DNA, giving the appearance of “breaks” in the DNA
○ Cannot complete normal cell division
○ Promotes apoptosis
Side effects Doxorubicin
Myelosuppression, alopecia, nausea, and
mucositis, cardiotoxic
Antimetabolites – Methotrexate
○ Interfere with purine or pyrimidine synthesis
○ Most toxic to cells in the “S phase”
Antimetabolites – Methotrexate uses
Used for acute Lymphoblastic Leukemia (ALL), non Hodgkin lymphoma
Side effects of Antimetabolites – Methotrexate
Myelosuppression, stromitis, diarrhea
Antimitotic Agents – Vincristine
○ Disaggregation of microtubules
○ Block cell growth in the “M-Phase”
○ Strong promoter of apoptosis
Antimitotic Agents – Vincristine uses
Used for hodgkin’s and non Hodgkin lymphoma, neuroblastoma
Side effects of Antimitotic Agents (Mitotic Spindle Inhibitors) – Vincristine
Neurotoxicity – “glove and stocking” neuropathy, jaw pain,
paralytic ileus, urinary retention
Systemic Treatment – Targeted Agents
Use of antibodies or cytokines directed at specific molecular targets (oncogenes products)expressed in the malignant tumor
● Ultimately leads to tumor cell death
Targeted Agents example
Imatinib (non-receptor tyrosine kinase antagonist)
Imatinib MOA
○ Targets ATP binding site of the p210 protein kinase
○ Which targets the Philadelphia chromosome of Chronic
Myelogenous Leukemia (CML)
Targeted Agents - Hormonal Agents
● Alter gene transcription in hormone-responsive tissues
Hormonal agent uses
○ Estrogen, androgen and glucocorticoid
○ Breast, prostate and lymph cancers
Hormonal agents example
Tamoxifen
Tamoxifen MOA
● Estrogen receptor antagonist, blocking biologic effect of the hormone
● Works best if the tumor manifests the estrogen receptor
Systemic Treatment – Biologic (Immunologic)
● Help induce host immune response to the tumor cells
● Manipulate host tumor interaction
Biologic (Immunologic) example
Rituximab
Rituzimab MOA
● Targets CD20 molecule on B-cell lymphomas
● Effects both tumor signaling and activated immune response to B-cell
neoplasm
Biologic treatment side effects
● Infusion hypersensitivity reactions – usually limited to the first infusion
● Hives, fever, fatigue, myelosuppression
● S/E can be managed with prophylactic glucocorticoids and antihistamines
Stem Cell Transplant
● Used for leukemias
● Autologous or from a donor
● Higher dose of
chemotherapy can be used
● Stem cells used to “rescue”
the patient
Precision Medicine
“Genomic medicine” – via DNA sequencing, target specific genetic
alterations associated with a tumor
Precision medicine examples
○ BRAF – Vemurafenib (Inhibits BRAF enzyme, used in Melanoma)
○ RET – Sunitinib and sorafenib (Antineoplastic, tyrosine kinase inhibitors)
Symptom Management in cancer is about
Maintaining and improving quality of life
When we are talking about pain from cancer we need to determine whether ___
it is Pain from the tumor itself or from the treatment
Determine the cause of the pain in Cancer includes deciphering whether it is ___
○ Nociceptive (somatic or visceral – structure involvement)
○ Neuropathic (CNS or nerve involvement)
Pain treatment in cancer
○ Pain medications
○ Therapy aimed at the tumor
○ Neurostimulator
○ Regional analgesia
Nausea management treatment
● Prochlorperazine (Compazine)
● Dexamethasone IV
● Ondansetron (Zofran)
● Metoclopramide (Reglan)
Symptom management - Effusions
Fluid accumulation
○ “Malignant Pleural Effusion” (lung, breast, lymphoma)
○ Pericardial effusion → Cardiac Tamponade
○ Peritoneum
drainage techniques for effusions
○ Thoracentesis or chest tube
○ U/S guided pericardiocentesis,
Surgery – “Pericardial window”
○ Paracentesis
Symptom Management – Nutrition
Decreased appetite or changes in metabolism → Weight Loss
○ Cachexia
What to Monitor for nutrition in Cancer symptoms
● Weight
● Albumin
● Transferrin
Nutrition treatment in cancer
● Enteral nutrition supplementation (oral or feeding tube)
● Parenteral supplementation (IV)
Symptom Management – Anemia
● Fatigue, exertional fatigue
● Tachycardia
● Dizziness
● Depression
● Anorexia
Anemia treatment in cancer
Iron, EPO, transfusion with “packed RBC” (if criteria met)
Myelosuppression
Radiation and/or Chemotherapy suppresses bone marrow production
of WBC
Febrile Neutropenia
(Neutrophil < 1500; range 2,500-7000)
Single oral temperature > 101 F, or > 100.4 F for at least an hour, with
neutrophil count < 1500 cells/microliter
Febrile Neutropenia Presentation
Fever, chills, rash, diarrhea, mouth ulcers, or any sign of infection
Treatment of myelosuppression
● Neupogen – WBC growth factor
● Strict infection precaution
○ Lower threshold for antibiotics
○ Oncology consult (if not already established)
Myelosuppression - Thrombocytopenia
○ Common in hematologic malignancy
○ Severe bleeding risk with platelets < 20,000/uL
Myelosuppression - Thrombocytopenia treatment
Platelet Transfusion
○ Risk of transfusion reactions/sensitization
○ Rapid platelet clearance
Stomatitis
● Common in chemo patients
● Ulcerations in the mouth and esophagus
Stomatitis Treatment
● Good oral care
● Avoid irritative foods
Response to treatment
○ Complete response – evidence that the cancer disappears
○ Partial response – decreased size of the cancer
○ Stable Disease – no change, remains stable
○ Progressive disease – new lesions or increase in size
Monitoring criteria for Cancer
■ Labs
■ Imaging
■ Tumor markers
● Track progression or regression of tumor burden
● Not used for diagnosis (not specific enough)
