Chapter 61-62: Oncology Flashcards

Question 1

Q

Define These General Terms

Carcinoma
Leukemia
Lymphoma
Multiple Myeloma
Sarcoma
Skin Cancer: Basal Cell & Squamous
Cell Carcinomas and Melanoma

Answer

A

1. Carcinoma: Cancer that starts in skin or in the tissues that line or cover internal organs.
2. Leukemia: Cancer of the leukocytes (WBCs); leukemia is referred to as blood cancer.
3. Lymphoma: Cancer of the lymphatic system
4. Multiple Myeloma: type of bone marrow cancer
5. Sarcoma: Cancer in connective tissue; Osteosarcoma is bone cancer
6. Skin Cancer: Basal Cell & Squamous Cell Carcinomas: Common. Unlikely to metastasize, rather simple to remove surgically/ topical; Melanoma: skin cancer that forms in the melanocytes - most deadly

Question 2

Q

WARNING SIGNS OF CANCER

The American Cancer Society (ACS) lists seven warning signs of cancer in an adult. Any of the CAUTION warning signs warrant referral to a physician. What does CAUTION stand for?

Answer

A

Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness

Question 3

Q

CANCER SCREENING GUIDELINES FOR AVERAGE RISK PATIENTS

Breast (for female only): for 40-44 y/o, 45-54 y/o; and +55 y/o

Answer

A

40-44 years: Annual mammograms are optional
45-54 years: Begin yearly mammograms
+55 years: Mammograms every 2 years or continue yearly

Question 4

Q

CANCER SCREENING GUIDELINES FOR AVERAGE RISK PATIENTS

Cervical (Female only): for 25-65 y/o

Answer

A

Pap smear every 3 years; HPV DNA test every 5 years; Pap smear + HPV DNA test every 5 years

Question 5

Q

CANCER SCREENING GUIDELINES FOR AVERAGE RISK PATIENTS

Colorectal (M/F) for +45 y/o

Question 6

Q

CANCER SCREENING GUIDELINES FOR AVERAGE RISK PATIENTS

Lung (M/F) for +50 y/o

Answer

A

Annual CT scan of chest if all of the following:
- Have at least a 20 pack year smoking hx
- still smoking or quit within 15 years

Question 7

Q

CANCER SCREENING GUIDELINES FOR AVERAGE RISK PATIENTS

Prostate (male)

Answer

A

If a patient opts to be tested, it involves:
■ Prostate specific antigen (PSA) test (blood test)
■ +/- a digital rectal exam (DRE)

Question 8

Q

DOSING CONSIDERATIONS FOR SELECT HIGHLY TOXIC CHEMO DRUGS: Bleomycin, doxorubicin, cisplatin, vincristine

Answer

A

Note: Dexrazoxane prevent cardiotox from doxorubicin

Question 9

Q

Common Toxicities of Select Chemotherapeutic Agents

Myelosuppression: List drug, monitoring, and management

Answer

A

- List drug: All chemo drugs except, Asparasinase, bleomycin, vincristine, -Mabs, and TKI
- Monitoring: CBC, bleeding
- Management: Neutropenia: colony-stimulating factors (CSFs); Anemia: RBC transfusions , and (in palliation only) or erythropoiesis-stimulating agents (ESA); Thrombocytopenia: platelet transfusions

Question 10

Q

Common Toxicities of Select Chemotherapeutic Agents

N/V: List drug, monitoring, and management

Answer

A

- List drug: Cisplatin, cyclophosphamide, ifosfamide, doxorubicin
- Monitoring: symp
- Management: Neurokinin-1 receptor antagonist (NK1 -RA); Serotonin-3 receptor antagonist (5HT3 -RA); dexamethasone; IV/ PO fluid hydration

Question 11

Q

Common Toxicities of Select Chemotherapeutic Agents

Mucositis: List drug, monitoring, and management

Answer

A

- List drug:Fluorouracil, methotrexate; capecitabine , irinotecan and many TKls
- Monitoring: S/sx of superinfection of oral ulcers
- Management: Symptomatic treatment mucosal coating agents; local analgesia

Question 12

Q

Common Toxicities of Select Chemotherapeutic Agents

Diarrhea: List drug, monitoring, and management

Answer

A

- List drug: lrinotecan, capecitabine, fluorouracil, methotrexate
- Monitoring: Frequency of bowel movement/ hydration
- Management: IV/PO fluid hydration antimotiliy medications (ie. loperimide)

Question 13

Q

Common Toxicities of Select Chemotherapeutic Agents

Cardiotoxicity (Cardiomyopathy): List drug, monitoring, and management

Answer

A

- List drug: Anthracyclines, HER2 inhibitors
- Monitoring:Left ventricular ejection fraction, cumulative lifetime dose
- Management: Do not exceed recommended lifetime cumulative dose; of 450-550 mg/m2 for doxorubicin; give dexrazoxane ppx in select patients receiving doxorubicin

Question 14

Q

Common Toxicities of Select Chemotherapeutic Agents

Cardiotoxicity (QT Prolong): List drug, monitoring, and management

Answer

A

- List drug: Arsenic trioxide , many TKls
- Monitoring: ECG
- Management: Keep K+, Mg, Ca within normal limits

Question 15

Q

Common Toxicities of Select Chemotherapeutic Agents

Pulmonary Toxicity: List drug, monitoring, and management

Answer

A

- List drug:Pulmonary fibrosis - Bleomycin; Busulfan; Carmustine; Lomustine. Pneumonitis: Methotrexate
- Monitoring: O2, symp of SOB
- Management: symp mang, stop tx, Steroids

Question 16

Q

Common Toxicities of Select Chemotherapeutic Agents

Hepatotoxicity: List drug, monitoring, and management

Answer

A

- List drug: Many..but focus on Antiandrogens (bicalutamide, flutamide, nilutamide); MTX
- Monitoring: LFT, jaudice
- Management: symp mang, stop tx, Steroids

Question 17

Q

Common Toxicities of Select Chemotherapeutic Agents

Nephrotoxicity: List drug, monitoring, and management

Answer

A

- List drug: Cisplatin, HD MTX
- Monitoring: BUN, SCr, urinalysis
- Management: Amifostine (Ethyol) can be given ppx with cisplatin..ensure adequate hydration. Do not exceed maximum dose of 100 mg/m2/ cycle for cisplatin. Leucovorin with MTX!

Question 18

Q

Common Toxicities of Select Chemotherapeutic Agents

Hemorrhagic Cystitis: List drug, monitoring, and management

Answer

A

- List drug:lfosfamide (all doses), cyclophosphamide (higher dose +1g)
- Monitoring:Urinalysis for blood
- Management: Mesna (Mesnex) is always given ppx with ifosfamide (and sometimes with cyclophosphamide). Ensure adaquate hydration

Question 19

Q

Common Toxicities of Select Chemotherapeutic Agents

Neuropathy: List drug, monitoring, and management

Answer

A

- List drug: Vinca alkaloids (vincristine, vinblastin); Platinums (cisplatin, oxaliplatin); Taxanes (paclitaxel, docetaxel); Proteasome inhibitors (bortezomib),
- Monitoring:S/sx of paresthesias (tingling, pain, numb)
- Management: See pic

Question 20

Q

Common Toxicities of Select Chemotherapeutic Agents

Thromboembolic Event: List drug, monitoring, and management

Answer

A

- List drug:Aromatase inhibitors (e.g., anastrozole); SERMs (e.g., tamoxifen); immunomodulators!!!
- Monitoring :S/sx of DVT /PE, stroke, MI
- Management:Consider thromboprophylaxis based on the patient’s risk

Question 21

Q

CHEMOMAN AND MAJOR TOXICITIES OF COMMON CHEMOTHERAPY DRUGS

Question 22

Q

CHEMOTHERAPY ADJUNCTIVE MEDICATION

List the Specific Chemotherpy That Needs Adj Medicaiton and what is the purpose of that adj medication?

Question 23

Q

Mang of SEs

Myelosuppression Recovery: general info

Answer

A

The lowest point for white blood cells (WBCs) and platelets, known as the nadir, typically occurs 7-14 days after treatment. Red blood cell (RBC) nadir happens later, usually after several months, due to their longer lifespan (~120 days).
WBCs and platelets usually recover within 3-4 weeks post-treatment before the next chemotherapy dose. The next cycle of chemotherapy might be delayed for recovery.
Drugs to speed up recovery may be necessary, and severe cases may require transfusions, such as packed RBCs for severe anemia.

Question 24

Q

NEUTROPENIA

Neutropenia, a type of leukopenia is low neutrophil counts assessed by ANC… Neutropenia Definitions

Question 25

Q

NEUTROPENIA

What are colony stimulating factors (CSFs) and how are they utilized in cancer treatment, particularly after chemotherapy?

Answer

A

Growth Colony stimulating factors (G-CSFs), boost white blood cell production in the bone marrow. They’re administered ppx after chemotherapy to reduce the risk of infection/ reduce mortality from neutropenia. CSFs, such as G-CSF (filgrastim) or pegylated G-CSF (pegfilgrastim), are recommended for patients with over a 20% chance of developing chemotherapy-induced febrile neutropenia.

Question 26

Q

NEUTROPENIA

Colony Stimulating Factors (CSF): Drugs names, SEs, Notes

Answer

A

- Drugs: G-CSF - Filgrastim (Neupogen); Pegylated G-CSF - Pegfilgrastim (Neulasta)
- SEs: bone pain, fever, rash
- Notes: Store in fridge; patient should report any sign of enlarged spleen (pain in left upper ab)

Question 27

Q

NEUTROPENIA

Febrile Neutropenia: general

Answer

A

Patients undergoing cytotoxic chemotherapy face infection risks from their own normal flora due to GI mucosa alterations caused by the drugs. Central venous access devices are common for chemotherapy administration to avoid vesicant-related damage, though they can also pose infection risks. Neutropenia increases susceptibility to infections, with fever often the sole indicator. Immediate empiric antibiotic treatment is crucial upon fever onset.

Question 28

Q

NEUTROPENIA

What is the criteria for Febrile Neutropenia DX Requirement

Question 29

Q

NEUTROPENIA

Medication Regimen For Low Risk Febrile Neutropenia (no comorbid)

Question 30

Q

NEUTROPENIA

Medication Regimen For High Risk Febrile Neutropenia (w/ comorbid)

Question 31

Q

ANEMIA

What treatment options are available for managing Anemia in Cancer patients? What are the cavets?

Answer

A

Hemoglobin (Hgb) levels guide the assessment of anemia, with standard ranges of 12-16 g/dL for females and 13.5-18 g/dL for males. Anemia management encompasses natural recovery, RBC transfusions, or, in rare cases, erythropoiesis-stimulating agents (ESAs) like erythropoietin (epoetin alfa, darbepoetin alfa). Notably, ESAs can exacerbate cancer progression/ increase progession and shorten survival, so not recommended during curative chemotherapy. ESAs are restricted to non-myeloid malignancies with chemotherapy-induced anemia, initiated only if Hgb is <10 g/dL, and with at least two months of planned chemotherapy remaining. Adequate iron levels are crucial for ESA effectiveness, necessitating assessment of serum ferritin, transferrin saturation (TSAT), and total iron-binding capacity (TIBC). Additionally, folate and vitamin B12 levels may require evaluation, especially if ESA response is poor.

Question 32

Q

CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING (CINV): what patient factors increase this risk of CINV? Additionally, what strategies are recommended for managing CINV, and what are the three subtypes of CINV?

Answer

A

Chemotherapy commonly causes n/v. Patient factors increasing this risk include female gender, age under 50, anxiety, depression, dehydration, motion sickness history, and prior n/v with treatment. To manage chemotherapy-induced nausea and vomiting (CINV), administer antiemetics 30 mins before treatment and provide take-home medication like ondansetron, prochlorperazine, or metoclopramide for breakthrough symptoms. CINV has three subtypes: acute, delayed, and anticipatory.

Question 33

Q

CINV has three subtypes: acute, delayed, and anticipatory… Talk about them

Question 34

Q

Antiemetic Regimens for Acute/Delayed Nausea & Vomiting: The goal is to prevent n/v, so antiemetic regimens are started before chemotherapy!…list the general drugs/ classes

Question 35

Q

General Antiemetic Regimen Based on Emetic Risk of chemo Regimen (minimal, low, mod, high risk)

Question 36

Q

What are the common medications used to manage breakthrough chemotherapy-induced nausea and vomiting (CINV), and what are the key considerations regarding their efficacy and side effects?

Answer

A

Despite antiemetic prophylaxis for acute and/or delayed chemotherapy-induced nausea and vomiting (CINV), breakthrough symptoms may occur. Various medications may be beneficial, including 5HT3 receptor antagonists, dopamine receptor antagonists, cannabinoids, olanzapine, lorazepam, dexamethasone, and scopolamine.

5HT3 receptor antagonists are generally well-tolerated, with common side effects such as migraine-like headaches and constipation. They also cause minimal sedation compared to dopamine receptor antagonists and cannabinoids.

Dopamine receptor antagonists, such as prochlorperazine, promethazine, and metoclopramide, are commonly prescribed, although some patients may experience unpleasant side effects. These drugs commonly cause sedation and some anticholinergic side effects. Extrapyramidal symptoms (EPS) such as acute dystonic reactions can occur, especially in younger patients. Acute dystonic reactions should be treated with anticholinergics like benztropine and diphenhydramine.

Droperidol, an antiemetic in the same class as haloperidol, has restricted use or has been entirely removed from most hospitals due to QT prolongation and the risk of Torsades de Pointes. Droperidol was commonly used for postoperative nausea and vomiting but not for CINV.

Cannabinoids, such as dronabinol and nabilone, can be used as second-line agents. These are synthetic analogs of delta-9-tetrahydrocannabinol, a naturally occurring component of Cannabis sativa (marijuana). Although these agents may be legally prescribed, they may cause side effects similar to cannabis, such as increased appetite, sedation, dysphoria, or euphoria. Despite its Schedule I classification, medical marijuana is available for both medical and nonmedical use in some states, and in some jurisdictions, it can be purchased for medical use only.

Question 37

Q

Anemetic Agents

Substance P/Neurokinin-1 receptor antagonists: MOA

Answer

A

Enhance the antiemetic effects of 5HT3 receptor antagonists and corticosteroids by blocking the substance P/neurokinin-1 receptor. This helps inhibit both the acute and delayed phases of chemotherapy-induced emesis.

Question 38

Q

Anemetic Agents

Substance P/Neurokinin-1 receptor antagonists: Drug, C/I, Note

Answer

A

Drugs: Aprepitant (Emend) - Oral; Fosaprepitant (Emend -IV)
C/I: Do not use with pimozide or cisapride
Notes: Aprepitant/fosaprepitant/netupitant are CYP3A4 inhibitors; dose of dexamethasone should be decreased

Question 39

Q

Anemetic Agents

5HT-3 Receptor Antagonists: Drug, C/I, Warning, SEs, Note

Answer

A

Drugs: Ondansetron (Zofran, Zuplenz film); Granisetron (Sancuso); Palonosetron (Aloxi)
C/I: Do not use 5HT3 antagonists with apomorphine (d/t hypotension)
Warning: Serotonin syndrome when used in combination with other serotonergic agents, QT prolong (dose dependent)
SEs: HA, consitpation

Question 40

Q

Anemetic Agents

Dopamine Receptor Antagonist (blocks dopamine in chemo trigger zone): Drug, BWs, warning, SEs

Answer

A

Drugs: Prochlorperazine (Compazine); Promethazine (Phenergan); Metoclopramide (Reglan); Olanzapine (Zyprexa); Haloperidol (Haldol)
BWs: For Promethazine: dont use in children under 2, do not give via SC, and IV can cause serious tissue injury via extravasation; Metoclopramide can cause tardive dyskinesia; Haldol can cause QT prolong
Warning: Parkinson’s disease may be exacerbated
SEs: Sedation, lethargy, EPS, decreased SZ threshold

Question 41

Q

Anemetic Agents

Cannabinoids: Drug, SEs

Answer

A

Drugs: Dronabinol (Marinol); Nabilone (Cesamet)
SEs: Somnolence, euphoria, increase appetite

Question 42

Q

Other GI SEs of Chemo

Chemotherapy-Induced Diarrhea: What are the common treatments for chemotherapy-induced diarrhea, and which chemotherapy drugs are often associated with this condition?

Answer

A

Chemotherapy-induced diarrhea (CID) can cause severe dehydration and electrolyte imbalances. Loperamide and diphenoxylate + atropine are prescribed to treat CID. The usual maximum dose of loperamide is 16 mg/day under medical supervision for CID. Fluorouracil, capecitabine, and irinotecan often lead to CID, with irinotecan causing early-onset diarrhea during infusion, treated with atropine for cholinergic excess symptoms. Tyrosine kinase inhibitors (TKIs) like sorafenib and sunitinib also commonly induce diarrhea.

Question 43

Q

Other GI SEs of Chemo

Oral Mucositis:

Answer

A

Chemotherapy-induced oral mucositis results in painful mouth ulcers appearing about a week after treatment (ie. 5FU, MTX). While it resolves on its own, it can be severe and needs treatment. Good oral hygiene is crucial despite the discomfort. Treatments like viscous lidocaine 2%, magic mouthwash, and systemic analgesics alleviate pain, facilitating eating and drinking. Rinsing with salt water helps retain moisture, and antifungal medications like nystatin or clotrimazole are used to prevent oral Candida infections.

Question 44

Q

Other SEs to Chemo

Hand-Foot Syndrome: How is hand-foot syndrome, aka palmar-plantar erythrodysesthesia (PPE), managed in patients undergoing chemotherapy with drugs?

Answer

A

Hand-foot syndrome, also known as palmar-plantar erythrodysesthesia (PPE), often occurs after treatment with certain chemotherapy drugs like capecitabine and fluorouracil, as well as tyrosine kinase inhibitors such as sorafenib and sunitinib. It happens when these drugs leak from capillaries into the hands and feet, causing tenderness, pain, and inflammation. Managing PPE involves using emollients to retain moisture and medications like steroids and pain relievers to reduce inflammation and discomfort. Dose adjustments may be necessary if symptoms persist.

Question 45

Q

Other SEs to Chemo

Tumor Lysis Syndrome: What is it? what are the treatment/ managment?

Answer

A

Chemotherapy can cause tumor cells to break down and release their contents into the bloodstream, leading to a condition called tumor lysis syndrome (TLS). TLS is most commonly seen in leukemia and non-Hodgkin lymphoma.

When tumor cells are lysed, substances such as potassium, phosphate, purines, and pyrimidines are released into the bloodstream.

TLS can result in high levels of potassium (which can cause abnormal heart rhythms), high levels of phosphate, low levels of calcium, and high levels of uric acid. Uric acid can crystallize and damage the kidneys, potentially leading to acute renal failure.

To prevent TLS, medications like allopurinol or febuxostat may be used. These drugs inhibit the enzyme that converts purines into uric acid. Allopurinol (xanthine oxidase inhibitor) is typically given at a lower dose for gout (~100 mg daily), but higher doses (400-800 mg/day) are used for TLS prevention. Febuxostat can be an alternative if allopurinol is not suitable.

For patients at high risk of TLS, such as those with a high white blood cell count or Burkitt lymphoma, rasburicase may be used. Rasburicase converts uric acid into a more easily excreted form. However, it is contraindicated in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Question 46

Q

Other SEs to Chemo

Hypercalcemia of Malig: What are the treatment options for hypercalcemia caused by certain cancers, and what are the considerations for each level of severity?

Answer

A

Certain cancers can cause calcium to be released from the bones into the bloodstream, leading to a condition called hypercalcemia. Mild hypercalcemia (corrected calcium < 12 mg/dL) usually does not require immediate treatment, but hydration may be considered. Moderate to severe hypercalcemia (corrected calcium > 12 mg/dL) can cause symptoms such as nausea, vomiting, fatigue, dehydration, and confusion.

Treatment for hypercalcemia involves intravenous hydration with normal saline and medications to lower calcium levels. The first-line treatment is usually an intravenous bisphosphonate such as pamidronate or zoledronic acid (Zometa). In severe cases, calcitonin (Miacalcin) may be added for a short duration (up to 48 hours) along with the bisphosphonate. However, calcitonin’s treatment duration is short d/t risk of tachyphylaxis

If hypercalcemia does not respond to intravenous bisphosphonates, denosumab (Xgeva) may be used as an alternative.

Question 47

Q

Other SEs to Chemo

Treatment of Immunologic Reactions (Cytokine Release Syndrome): To prevent immunologic reactions, most monoclonal
antibodies require the following premedications (with or without steroid)…

Answer

A

■ Acetaminophen (usually 650 mg PO)
■ Diphenhydramine (IV or PO) or another antihistamine

Question 48

Q

Other SEs to Chemo

IV ADMINISTRATION AND EXTRAVASATION: How to prevent and manage extravasation events?

Answer

A

Chemotherapy agents are hazardous drugs due to their carcinogenic, mutagenic, or teratogenic properties. Vesicant chemotherapy drugs like anthracyclines and vinca alkaloids can cause tissue necrosis if they leak from the vein (extravasation). In case of extravasation, apply cold compresses (except for vinca alkaloids and etoposide, where warm compresses are used) and use antidotes such as:
- Dexrazoxane or dimethyl sulfoxide for anthracyclines
- hyaluronidase for vinca alkaloids and etoposide
.
Some chemotherapy agents like cytarabine and methotrexate can be given intrathecally, but accidental intrathecal administration of vincristine is fatal.
.
Random note…Vaccination should precede chemo by + 2 weeks

Question 49

Q

Cancer Treatment Type: How does the sequence of neoadjuvant and adjuvant therapies complement surgical treatment in managing resectable cancers?

Answer

A

Surgery is the primary treatment for resectable cancers, aiming to remove the bulk of the tumor. Neoadjuvant therapy, like radiation or chemotherapy, may precede (given BEFORE) surgery to shrink the tumor for better resection. Adjuvant therapy, such as radiation or chemotherapy, is given AFTER surgery to eradicate any remaining disease and reduce the risk of recurrence.

Question 50

Q

Lung Cancer: What are the main types of lung cancer, their prevalence, and the leading cause of the disease?

Answer

A

Lung cancer, the most common worldwide, accounts for around 230,000 new cases annually in the United States. Its main types are non-small cell (about 85%), small cell (10-15%), and carcinoid (less than 5%). Smoking is responsible for roughly 80% of lung cancers, with the remaining cases linked to factors like radon, asbestos, and exposure to pollutants. Symptoms such as chronic cough and dyspnea warrant medical attention. Treatment typically involves surgery followed by radiation and/or chemotherapy. Despite improved survival rates upon smoking cessation, around 10% of cancer patients continue to smoke

Question 51

Q

Skin Cancer: What are the primary risk factors for skin cancer, and how does the “ABCDE” mnemonic aid in identifying suspicious skin spots? Additionally, what distinguishes the three main types of skin cancer in terms of prevalence and invasiveness?

Answer

A

Skin cancer, the most prevalent in the United States, is primarily associated with factors like UV light exposure, light skin, and a history of skin cancer or immunosuppression. Three main types include basal cell, squamous cell, and melanoma. Basal and squamous cell cancers, while common, are highly treatable if detected early. Melanoma, though less common, can be invasive. The “ABCDE” mnemonic helps identify suspicious skin spots for examination.

Question 52

Q

Breast Cancer: What are the primary risk factors for breast cancer? Additionally, how do screening methods such as mammograms and ultrasounds contribute to early detection, and what role do modifiable factors like weight and physical activity play in breast cancer risk?

Answer

A

Breast cancer is the second most common cancer in the United States, with being female being the top risk factor. Estrogen, which is more abundant in females, fuels most breast tumors. Female breast cells are more active and prone to mutation compared to male breast cells. Risk factors can include genetic mutations and lifestyle factors like obesity, low physical activity, poor nutrition, and tobacco use. Conditions like Klinefelter syndrome in males can also increase estrogen production and breast cancer risk.
.
While Breast Self Exams (BSE) are not screening tools, they can help identify changes in breast or nipple appearance or discharge that require further evaluation. Breast imaging is recommended every one to two years starting around age 40 or 45. Mammograms, using low-dose x-rays, are the main screening method. Additional images may be taken in a diagnostic mammogram if needed. Biopsies follow abnormal results, involving the removal of tissue samples for pathology examination.
.
Overweight postmenopausal women have a higher breast cancer risk due to increased estrogen production from fat cells. After menopause, estrogen decline leads to abdominal fat accumulation, contributing to weight gain.

Question 53

Q

What role do the BRCA1 and BRCA2 genes play regarding breast cancer

Answer

A

The BRCA1 and BRCA2 genes play a crucial role in suppressing tumor growth by repairing damaged DNA. Inherited mutations in these genes increase the risk of breast, ovarian, and prostate cancers. Women with BRCA mutations have a significantly higher likelihood of developing breast cancer, with estimates around 70%, compared to about 12% for those without these mutations. Fortunately, the prevalence of these mutations in the general population is low.

Question 54

Q

How does Klinefelter syndrome impact the risk of male breast cancer?

Answer

A

Male breast cancer is rare, accounting for less than 1% of cases, but the risk increases in those with a BRCA mutation or conditions that elevate estrogen levels, such as Klinefelter syndrome - condition in which males have 1 Y chromosome and 2 or more x chromosomes!! = higher estrogen production = heighten breast cancer risk

Question 55

Q

BREAST CANCER TREATMENT

Hormone-Sensitive Cancer Treatment: Breast tumors commonly express estrogen and progesterone receptors/ what is it categorized as…

Answer

A

Tumors with a high percentage of these receptors are termed hormone-sensitive and categorized as estrogen receptor positive (ER+), progesterone receptor positive (PR+), or both (ER+/PR+).

Question 56

Q

BREAST CANCER TREATMENT

Selective Estrogen Receptor Modulators (SERMs)
and Aromatase Inhibitors (Als)

Answer

A

Premenopausal women with hormone-sensitive cancer are typically treated with tamoxifen, a selective estrogen receptor modulator (SERM) that acts as an estrogen antagonist in breast cells. Tamoxifen blocks estrogen receptors, inhibiting tumor growth.
.
Aromatase inhibitors, which block estrogen production by inhibiting the aromatase enzyme, are used in postmenopausal women who produce estrogen mainly through androgen conversion. However, they are not effective in premenopausal women as they do not affect ovarian estradiol production/ should not be used as monotherapy in premeno women!
.
Raloxifene, another SERM, is used for breast cancer prevention and osteoporosis treatment (increase bone density) in postmenopausal women, but it is not first-line due to side effects like hot flashes and increased clotting risk.
.
In certain cases, premenopausal women may undergo medical menopause using gonadotropin-releasing hormone (GnRH) agonists like goserelin or leuprolide. These medications reduce LH and FSH levels, suppressing ovarian estradiol production, and making aromatase inhibitor (AI) treatment reasonable

Question 57

Q

BREAST CANCER TREATMENT

HER2 Overexpression: How does the HER2 oncogene contribute to breast tumor growth, and what treatment options are available for tumors that overexpress HER2?

Answer

A

The HER2 oncogene plays a significant role in promoting breast tumor growth, with approximately 20% of breast tumors overexpressing HER2 on the cell surface, leading to aggressive malignancy. However, drugs like trastuzumab (Herceptin) effectively treat tumors that overexpress HER2. These drugs bind to the HER2 receptor, preventing dimerization and halting the acceleration of cell division, thereby impeding tumor growth. Note: No dimerization = no growth! yay.

Question 58

Q

Breast Cancer Hormonal Treatment and CDK4/6 Inhibitors

Selective Estrogen Receptor Modulators (SERMs): Drug Names, BWs, SEs

Answer

A

Drugs: Tamoxifen, Raloxifene
.
BWs: increase risk of uterine or endometrial cancer (tamoxifen) and increase risk of
thromboembolic events (both drugs)
.
SEs:Hot flashes/night sweats, vaginal bleeding/spotting, vaginal discharge/ dryness/pruritus. decrease libido.. Tamoxifen also decrease bone density/ need vit d/ calcium supplement! Tamoxifen is also teratogenic!!!

Question 59

Q

Breast Cancer Hormonal Treatment and CDK4/6 Inhibitors

Selective Estrogen Receptor Degrader (SERD): Drug Name, SEs

Answer

A

Drug: Fulvestrant (IM)
.
SEs: increase LFT, inj site pain, hot flashes

Question 60

Q

Breast Cancer Hormonal Treatment and CDK4/6 Inhibitors

Aromatase Inhibitors : Drug Name, SEs

Answer

A

Drug: Anastrozole (Arimidex)
.
SEs: Hot flashes/night sweats, arthralgia/ myalgia (muscle damage), Higher risk of osteoporosis, Higher risk of CVD (compared to SERMs)

Question 61

Q

Breast Cancer Hormonal Treatment and CDK4/6 Inhibitors

Cyclin-Dept Kinase (CDK4/6) Inhibitor: Drug Names, SEs

Answer

A

Drugs: Palbociclib, Abemaciclib, Ribociclib (all oral)
SEs: Interstitial lung disease, Neutropenia , anemia, nausea, diarrhea, fatigue, thrombotic event

Question 62

Q

PROSTATE CANCER

Identifying Prostate Cancer: What diagnostic methods are used to detect prostate cancer?

Answer

A

The digital rectal exam (DRE) involves a physician inserting a gloved, lubricated finger into the rectum to feel for abnormalities in the prostate, which can indicate prostate cancer. If lumps or masses are detected, tissue is **biopsied **for pathology analysis.
.
Prostate-specific antigen (PSA) is a blood marker produced by normal and cancerous prostate cells. Elevated PSA levels, typically above 4 ng/mL, may indicate prostate cancer, although levels can also be increased in benign prostatic hyperplasia (BPH). PSA levels between 4 and 10 ng/mL can overlap between the two conditions, while levels above 10 ng/mL are more indicative of prostate cancer.

Question 63

Q

Hormonal Therapies for Prostate Cancer: What are the primary hormones targeted in prostate cancer treatment, and how is androgen deprivation therapy (ADT) used to suppress these hormones? Additionally, what are the adverse effects associated with ADT?

Answer

A

Similar to blocking estrogen in breast cancer, the primary hormones targeted in prostate cancer treatment are testosterone and dihydrotestosterone (DHT). This therapy, known as androgen deprivation therapy (ADT) or chemical castration, suppresses androgens, including testosterone and DHT. ADT can lead to adverse effects such as impotence, weakness, hot flashes, and bone density loss. It is achieved through gonadotropin-releasing hormone (GnRH) antagonists or agonists + often in combination with antiandrogens initially. Metastatic prostate cancer that does not respond to ADT is termed “castration-resistant” and may require chemotherapy.

Question 64

Q

Hormonal Therpies for Prostate Cancer

Gonadotropin-Releasing Hormone (GnRH) Agonists: MOA

Answer

A

Gonadotropin-releasing hormone (GnRH) agonists…. AKA Luteinizing hormone-releasing hormone (LHRH) agonists- suppress testosterone levels through a negative feedback mechanism. Initially, they cause a surge in testosterone followed by a gradual reduction.

Answer 55

A

Drugs: Leuprolide (Lupron Depot - IM); Goserelin (Zoladex - SC)
.
Unique Concerns: Decrease bone density (supplement with vti D/ calcium); Tumor flares (prevent with antiandrogens)
.
SEs: Hot flashes, impotence, gynecomastia, bone pain, QT prolongation

Answer 56

A

MOA: no initial surge in testosterone concentrations! so antiandrogen is not needed. It blocks GnHR receptors directly causing a decrease in testosteron
.
Drugs: Degarelix (SC); Relugolix (oral)
.
Unique Concerns: osteoporosis (supplement with vti D/ calcium); NO tumor flares :)

Answer 57

A

Class/ drugs:
- Antiandrogens (first gen): Bicalutamide;
Flutamide; Nilutamide
- Antiandrogens (2nd gen - added SEs of QT prolong): Apalutamide; Darolutamide; Enzalutamide
- Androgen Biosynthesis Inhibitor: Abiraterone

Answer 58

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Alkylating agents work by cross-linking DNA strands and inhibiting protein synthesis and DNA synthesis. These agents can cause DNA mutations that lead to “secondary malignancies” (e.g., leukemias and lymphomas)
.
Important Note: Cyclophosphamide and ifosfamide produce a metabolite, acrolein, that concentrates in the bladder and can cause hemorrhagic cystitis. The chemoprotectant mesna inactivates this toxic metabolite in the bladder.

Answer 59

A

Drugs & Unique Concerns
1. Cyclophosphamide and lfosfamide: Hemorrhagic cystitis..ensure adequate hydration + give mesna (ppx for ifosfamide and with HD cyclophos)
2. Carmustine
3. Busulfan: can cause pulmonary toxicity
.
General Warning: Severe skin reactions, including SJS/TEN

Answer 60

A

Platinum-based chemotherapeutic agents, similar to alkylating agents, disrupt DNA synthesis and cell replication by cross-linking DNA. They can induce toxicities resembling heavy metal poisoning (d/t the platinum), including peripheral sensory neuropathy, ototoxicity, and nephrotoxicity.
.
Cisplatin, particularly, has a high risk of nephrotoxicity and CINV. Because platinum compounds are excreted through the kidneys, dose adjustments are necessary for patients with renal impairment.

Answer 61

A

BW: Due to Renal toxicity/ototoxicity…doses >100 mg/m2/cycle must be confirmed with prescriber

Answer 62

A

BW: Anaphylactic like reactions - risk increases with repeated exeosure; caution when > 6 cycles of carboplatin are used!!!

Answer 63

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Anthracyclines (-rubicin) work by interfering with DNA, inhibiting topoisomerase II, and creating oxygen-free radicals that damage cells. However, they are associated with cardiotoxicity, which can lead to cardiomyopathy and heart failure. The risk of cardiotoxicity is related to the total cumulative dose of the drug. Dexrazoxane (Totect, Zinecard) is a chemoprotectant used to prevent doxorubicin-induced cardiotoxicity. Anthracyclines are also strong vesicants, and dexrazoxane can be used as an antidote for accidental doxorubicin extravasation. During administration, it is important to protect these medications from light.

Answer 64

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MOA: Topoisomerase I inhibitors disrupt DNA coiling and uncoiling during the S phase, causing breaks in both single and double DNA strands and preventing their repair.
lrinotecan (Camptosar)
Unique concerns/ SEs: Acute cholinergic symptoms: flushing, sweating, abdominal cramps, diarrhea(treat with atropine); Acute and Delayed diarrhea: treat with loperamide; can also cause myelosuppression

Answer 65

A

MOA: Topoisomerase II inhibitors function similarly to topoisomerase I inhibitors but act during the G2 phase, disrupting DNA coiling and causing breaks in both single and double strands, thereby preventing their repair.
1. Etoposide (IV/ Capsule): For IV it can cause infusion rate hypotension and use non-PCV bag/ tubings; Capsules should be refridgerated. SEs: myelosuppression, secondary malig
2. Bleomycin: not myelosuppresive! But can cause pulmonary tox..max lifetime dose is 400 units d/t pulm tox

Answer 66

A

MOA: Topoisomerase II inhibitors function similarly to topoisomerase I inhibitors but act during the G2 phase, disrupting DNA coiling and causing breaks in both single and double strands, thereby preventing their repair.
1. Etoposide (IV/ Capsule): For IV it can cause infusion rate hypotension and use non-PCV bag/ tubings; Capsules should be refridgerated. SEs: myelosuppression, secondary malig
2. Bleomycin: not myelosuppresive! But can cause pulmonary tox..max lifetime dose is 400 units d/t pulm tox

Answer 67

A

MOA: Vinca alkaloids inhibit the function of microtubules during M phase.
- Peripheral sensory and autonomic neuropathies (constipation) are common because MT play an important part in axonal transport in neuron; VinCristine is associated with more CNS toxicity (neuropathy) - vincristin is often capped at 2mg/dose and it’s in a small iv bag rather than syringe to prevent intrathecal admin!!!
- VinBlastine and vincorelBine are associated with more Bone marrow suppression (myelosuppression) than vincristine (not really myelosuppresive).
- Vinca alkaloids are potent vesicants. Use warm compresses and hyaluronidase if extravasation occurs.
- IV USE ONLY!!!! Accidental intrathecal admin will cause paralysis and death

Answer 68

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MOA: Taxanes inhibit the function of microtubules during the M phase. Peripheral sensory neuropathies are common with taxanes due to their impact on microtubules, crucial for axonal transport. Taxanes can lead to severe infusion-related hypersensitivity (BW) reactions, including fatal anaphylaxis, requiring varied premedication regimens. Liver metabolism necessitates dose adjustment for hepatic impairment. Taxanes should be administered before platinum-based compounds to avoid reduced elimination when given afterward.
.
1. Paclitaxel: Premed regimen - diphenhydramine, steroid, H2RA
2. Docetaxel: premedicate with steroids for 3 day; Causes severe fluid retention (ie. pleural effusion, cardiac tamponade, edema)

Answer 69

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MOA: These agents inhibit pyrimidine synthesis during S phase; an active metabolite (F-UMP) is incorporated into RNA to replace uracil and inhibits cell growth, while another active metabolite (5-dUMP) inhibits thymidylate synthetase.
.
1. Fluorouracll, 5-FU: Leucovorin: given with fluorouracil to increase efficacy
2. Capecitabine (Xeloda): Oral prodrug of fluorouracil; Dihydropyrimidine dehydrogenase (DPD) deficiency increase risk of toxicity; Take with food or 1 hr after meal
.
BW: increase INR
Warning/ SEs: Hand-foot syndrome, diarrhea, mucositis

Answer 70

A

These drugs disrupt enzymes in the folic acid cycle, inhibiting purine and pyrimidine biosynthesis during the S phase of the cell cycle. To mitigate toxicity such as myelosuppression, mucositis, and diarrhea, supplementation with folic acid or its analogs +/- vitamin B12 may be necessary
.
High doses of methotrexate require “rescue” with leucovorin (or levoleucovorin which is 1/2 the dose), the active form of folic acid that can bypass the enzyme block caused by methotrexate. It’s important to note that folic acid is ineffective for “rescue” with high-dose methotrexate.
.
All folate antimetabolites are assoiated with nephrotox..but HD MTX (>500mg/m2) is the most frequent cause!
.
MTX is also teratogenic!

Answer 71

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HD MTX (>500) requires leucovorin rescue
Hydration with IV sodium bicarb must be given to alkalinize urine to decrease risk of nephrotoxicity
Glucarpidase is antidote for MTX!
DDI (these decrease clearance of MTX!): NSAID, saliylates, beta lactam, PPI

Answer 72

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Bevacizumab (Avastin): Impairs wound healing, do not administer 28 days before/after surgery. Can ause severe bleeding, GI perforation

Answer 73

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Trastuzumab (Herceptin): Pharmacogenomics - test for HER2..needs to be overexpressed!, Monitor for LVEF (ECG or MUGA scan)

Answer 74

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Cetuximab (Erbitux): Pharmacogenomics - test for EGFR gene expression and KRAS mutation (must be KAS WT to use!)…SEs: acneiform rash..but rash = patient will have better response…avoid sunlight + use SPF and can use topial steroid/ abx for acne

Answer 75

A

Rituximab (Rituxan): Premedicate with diphenhydramine, acetaminophen, steroid; slowly titrate. BW - Hep B reactivation! check hep B before administering!!!

Answer 76

A

Pembrolizumab; Nivolumab: Immune-mediated toxicities - colitis, hepatotoxicity, pulmonary
toxicity, nephrotoxicity, many others. . .

Answer 77

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Tyrosine kinase inhibitors (TKIs) target various tyrosine kinase proteins involved in cell signaling pathways controlling cell growth and differentiation. They are administered orally and can be either “targeted,” aimed at specific abnormal tyrosine kinases linked to certain cancers, or “multi-targeted,” inhibiting multiple tyrosine kinases. Pharmacogenomic testing is necessary to identify patients likely to respond to targeted TKIs. TKIs have limited distribution through specialty pharmacies and may have altered oral bioavailability when taken with food, emphasizing the importance of following dosing instructions.

Answer 78

A

Used in chronic myelogenous leukemia (CML)
lmatinib (Gleevec) - take with food or within 1 hr after meal!
BCR-ABL gene translocation (Philadelphia Chromosome)!; Pharmacogenomics -must be
Philadelphia chromosome (BCR-ABL) positive in order to use
SEs: Fluid retention, QT prolongation

Answer 79

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Used in Melanoma
Vemurafenib, Dabrafenib
Must be BRAF V600E or V600K mutation positive in order to use
SEs: New malig, QT prolongation

Answer 80

A

Used in NSCLC
Afatinib, Erlotinib
Pharmacogenomics: must be EGFR mutation positive (exon 19 or 21) to use
SEs: Acneiform rash from an EGFR inhibitor indicates that a patient is expected to have a better response to the drug. Advise patients to avoid sunlight.
use sunscreen. Topical emollients, including topical steroids and antibiotics

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Chapter 61-62: Oncology Flashcards

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