Cytotoxic Drugs

Question 1

Cytotoxic drugs have both ______________ activity and the potential to damage normal tissue; most cytotoxic drugs are ______________

Answer 1

anti-cancer

teratogenic

• All cytotoxic drugs cause side-effects and a balance has to be struck between likely benefit and acceptable toxicity

Question 2

Chemotherapy (cytotoxic drugs) may be given with a _____________ intent or it may aim to _______________ or to _____________

Answer 2

curative

prolong life

palliate symptoms

Question 3

What is neoadjuvant therapy?

Answer 3

initial chemotherapy aimed at shrinking the primary tumour, thereby rendering local therapy less destructive or more effective

Question 4

What is adjuvant treatment?

Answer 4

follows definitive treatment of the primary disease when the risk of subclinical metastatic disease is known to be high

Question 5

Cytotoxic drugs fall into a number of classes, each with characteristic _______________ activity, _______________, and ______________. A knowledge of sites of metabolism and excretion is important because impaired drug handling as a result of disease is not uncommon and may result in enhanced toxicity

Answer 5

antitumour

sites of action

toxicity

Question 6

Many side-effects of cytotoxic drugs often do not occur at the time of administration, but _____________ later

Answer 6

days or weeks

• It is therefore important that patients and healthcare professionals can identify symptoms that cause concern and can contact an expert for advice

Question 7

A number of cytotoxic drugs will cause severe local tissue necrosis if ____________________ occurs

Answer 7

leakage into the extravascular compartment

*To reduce the risk of extravasation injury it is recommended that cytotoxic drugs are administered by appropriately trained staff

Question 8

A sore ________________ is a common complication of cancer chemotherapy; it is most often associated with fluorouracil, methotrexate, and the anthracyclines

Answer 8

mouth (oral mucositis)

Question 9

Oral mucositis is most often associated with which cytotoxic drugs? (3)

Answer 9

1. Fluorouracil
2. MTX
3. Anthracyclines

Question 10

What measures can be taken to minimize oral mucositis during chemotherapy? (2)

Answer 10

1. Rinsing mouth frequently and effective brushing of teeth with a soft brush 2-3 times daily
2. For fluorouracil, sucking ice chips during short infusions of the drug is also helpful
   * Once a sore mouth has developed, treatment is much less effective

Question 11

In general, mucositis is self-limiting but with poor oral hygiene it can be a focus for ________________.

Answer 11

blood-borne infection

Question 12

What is the cause of tumor lysis syndrome?

Answer 12

Spontaneous or treatment-related rapid destruction of malignant cells; pre-existing hyperuricemia, dehydration, and renal impairment are also predisposing factors

Question 13

Which patients are at risk of tumor lysis syndrome? (5)

Answer 13

1. Non-Hodgkin’s lymphoma (especially if high grade and bulky disease)
2. Burkitt’s lymphoma
3. ALL
4. AML (particularly if high white blood cell outs or bulky disease)
5. Occasionally those with solid tumors

Question 14

What are the features of tumor lysis syndrome? (6)

Answer 14

1. Hyperkalemia
2. Hyperuricemia
3. Hyperphosphatemia
4. Hypocalcemia
5. Renal damage
6. Arrhythmias

Question 15

Hyperuricaemia, which may be present in high-grade _____________ and _____________, can be markedly worsened by chemotherapy and is associated with _______________

Answer 15

lymphoma

leukaemia

acute renal failure

Question 16

How is hyperuricemia prevented in patients receiving chemotherapy for high grade lymphoma and leukemia? (2)

Answer 16

1. Allopurinol started 24 hours before treatment (or febuxostat started 2 days before cytotoxic therapy)
2. Adequate hydration

Question 17

______________, a recombinant urate oxidase, is licensed for hyperuricaemia in patients with haematological malignancy

Answer 17

Rasburicase; It rapidly reduces plasma-uric acid concentration and may be of particular value in preventing complications following treatment of leukaemias or bulky lymphomas.

Question 18

All cytotoxic drugs except _______________ and _______________ cause bone-marrow suppression

Answer 18

vincristine sulfate

bleomycin

Question 19

All cytotoxic drugs except vincristine sulfate and bleomycin cause _________________

Answer 19

bone-marrow suppression

Question 20

_________________ commonly occurs 7 to 10 days after administration, but is delayed for certain drugs, such as carmustine, lomustine, and melphalan.

Answer 20

Bone-marrow suppression

Question 21

Bone-marrow suppression commonly occurs ________________ after administration, but is delayed for certain drugs, such as carmustine, lomustine, and melphalan.

Answer 21

7 to 10 days

Question 22

________________ must be checked before each treatment with cytotoxic drugs, and doses should be reduced or therapy delayed if _______________ has not recovered.

Answer 22

Peripheral blood counts

bone-marrow

Question 23

Cytotoxic drugs may be contra-indicated in patients with acute ______________

Answer 23

Infection

*any infection should be treated before, or when starting, cytotoxic drugs.

Question 24

Fever in a neutropenic patient (neutrophil count less than 1.06×109/litre) requires __________________

Answer 24

immediate broad-spectrum antibacterial therapy;

Appropriate bacteriological investigations should be conducted as soon as possible

Question 25

Fever in a neutropenic patient (neutrophil count less than ______________) requires immediate broad-spectrum antibacterial therapy.

Answer 25

1.06×109/litre

Question 26

Patients taking cytotoxic drugs who have signs or symptoms of ______________ should be advised to seek prompt medical attention.

Answer 26

infection

Question 27

In selected patients, the duration and the severity of neutropenia can be reduced by the use of ____________________

Answer 27

recombinant human granulocyte-colony stimulating factors

Question 28

Symptomatic anaemia caused by cytotoxic drugs is usually treated with ____________________

Answer 28

red blood cell transfusions

Question 29

Reversible _______________ is a common complication of cytotoxic therapy, although it varies in degree between drugs and individual patients. No pharmacological methods of preventing this are available

Answer 29

hair loss

Question 30

Are there available mechanisms of preventing alopecia secondary to cytotoxic therapy?

Answer 30

No pharmacological methods available

Question 31

_________________ can be a complication of cancer itself, but chemotherapy increases the risk

Answer 31

Venous thromboembolism

Question 32

Venous thromboembolism can be a complication of cancer itself, but ______________ increases the risk

Answer 32

chemotherapy

Question 33

Most cytotoxic drugs are teratogenic and should not be administered during pregnancy, especially during the ________ trimester

Answer 33

first

Question 34

Are cytotoxic drugs safe to use during pregnancy?

Answer 34

No; teratogenic, especially during the first trimester * Considerable caution is necessary if a pregnant woman presents with cancer requiring chemotherapy, and specialist advice should always be sought

Question 35

Exclude ______________ before treatment with cytotoxic drugs

Answer 35

pregnancy

Question 36

_______________ advice should be given before cytotoxic therapy begins- women of childbearing age should use effective contraception during and after treatment

Answer 36

Contraceptive

Question 37

Regimens that do not contain an alkylating drug or procarbazine may have ____________ (more/less) effect on fertility

Answer 37

Less

Question 38

Regimens that do not contain an ____________ drug or _______________ may have less effect on fertility

Answer 38

alkylating procarbazine

Question 39

Cytotoxic therapies containing alkylating drugs or procarbazine carry the risk of causing permanent ________________

Answer 39

male sterility (there is no effect on potency); Pretreatment counselling and consideration of sperm storage may be appropriate

Question 40

Are women more or less affected by the sterilizing effects of alkylating drugs or procarbazine?

Answer 40

Compared to men, women are less severely affected, though the span of reproductive life may be shortened by the onset of premature menopause

Question 41

Is there an increase in fetal abnormalities or abortion rates recorded in patients who remain fertile after cytotoxic chemotherapy?

Answer 41

No

Question 42

Nausea and vomiting cause considerable distress to many patients who receive ________________ and to a lesser extent _______________, and may lead to refusal of further treatment

Answer 42

chemotherapy abdominal radiotherapy *prophylaxis of nausea and vomiting is therefore extremely important

Question 43

Nausea and vomiting associated with chemotherapy or abdominal radiotherapy may be ___________ (occurring within 24 hours of treatment), ___________ (first occurring more than 24 hours after treatment), or ____________ (occurring prior to subsequent doses)

Answer 43

acute delayed anticipatory

Question 44

Chemo-related nausea and vomiting: ______________ and ______________ symptoms are more difficult to control than ___________ symptoms and require different management

Answer 44

Delayed anticipatory acute

Question 45

Patients vary in their susceptibility to drug-induced nausea and vomiting; those affected more often include _____________, patients under ___________ years of age, ____________ patients, and those who experience ____________. Susceptibility also increases with repeated exposure to the cytotoxic drug.

Answer 45

women 50 anxious motion sickness

Question 46

Which cytotoxic therapies have MILD emetogenic potential? (5)

Answer 46

1. Fluorouracil 2. Etoposide 3. MTX (low dose) 4. Vinca alkaloids 5. Abdominal radiotherapy

Question 47

Which cytotoxic therapies have MODERATE emetogenic potential? (5)

Answer 47

1. Taxanes 2. Doxorubicin 3. Cyclophosphamide (intermediate and low dose) 4. Mitoxantrone 5. MTX (high dose)

Question 48

Which cytotoxic therapies have HIGH emetogenic potential? (3)

Answer 48

1. Cisplatin 2. Dacarbazine 3. Cyclophosphamide (high dose)

Question 49

____________ emetogenic treatment: fluorouracil, etoposide, methotrexate (less than 100 mg/m2, low dose in children), the vinca alkaloids, and abdominal radiotherapy.

Answer 49

Mildly

Question 50

______________ emetogenic treatment: the taxanes, doxorubicin hydrochloride, intermediate and low doses of cyclophosphamide, mitoxantrone, and high doses of methotrexate (0.1– 1.2 g/m2).

Answer 50

Moderately

Question 51

_______________ emetogenic treatment: cisplatin, dacarbazine, and high doses of cyclophosphamide.

Answer 51

Highly

Question 52

Prevention of acute symptoms: | For patients at low risk of emesis, pretreatment with ______________ or ______________ may be used.

Answer 52

dexamethasone lorazepam

Question 53

Prevention of acute symptoms: For patients at high risk of emesis, a _______________, usually given by mouth in combination with ______________ and the neurokinin receptor antagonist _____________ is effective.

Answer 53

5HT3-receptor antagonist dexamethasone aprepitant

Question 54

What is the first line drug regimen for prevention of chemo-related nausea in low risk patients?

Answer 54

Pretreatment with: - Dexamethasone OR - Lorazepam

Question 55

What is the first line drug regimen for prevention of chemo-related nausea in high risk patients?

Answer 55

5HT3-receptor antagonist (eg ondansetron) given orally + dexamethasone + aprepitant (nerokinin receptor antagonist)

Question 56

How are delayed symptoms of moderately emetogenic chemotherapy treated?

Answer 56

Dexamethasone + 5HT3-receptor antagonist

Question 57

How are delayed symptoms of highly emetogenic chemotherapy treated?

Answer 57

Dexamethasone + aprepitant | Rolapitant and metoclopramide are also licensed for delayed chemo-induced N/V

Question 58

Prevention of anticipatory symptoms related to chemotherapy: Good _____________ is the best way to prevent anticipatory symptoms. Lorazepam can be helpful for its amnesic, sedative, and anxiolytic effects.

Answer 58

symptom control

Question 59

Prevention of anticipatory symptoms of chemotherapy: Good symptom control is the best way to prevent anticipatory symptoms. _______________ can be helpful for its amnesic, sedative, and anxiolytic effects.

Answer 59

Lorazepam

Question 60

The _______________ cytotoxic drugs are associated with dose-related, cumulative, and potentially life-threatening cardiotoxic side-effects

Answer 60

anthracycline

Question 61

The anthracycline cytotoxic drugs are associated with dose-related, cumulative, and potentially life-threatening ____________ side-effects

Answer 61

cardiotoxic

Question 62

______________ is used to counteract the folate-antagonist action of methotrexate and thus speed recovery from methotrexate-induced mucositis or myelosuppression

Answer 62

Folinic acid (given as calcium folinate) * ‘folinic acid rescue’

Question 63

_______________ is also used in the management of methotrexate overdose, together with other measures to maintain fluid and electrolyte balance, and to manage possible renal failure

Answer 63

Folinic acid

Question 64

Does folinic acid counteract the antibacterial activity of folate antagonists such as trimethoprim?

Answer 64

Nope

Question 65

Folinic acid does not counteract the antibacterial activity of folate antagonists such as ______________

Answer 65

trimethoprim

Question 66

When folinic acid and fluorouracil are used together in metastatic colorectal cancer the _________________ improves compared to that with fluorouracil alone

Answer 66

response-rate

Question 67

When folinic acid and ________________ are used together in metastatic colorectal cancer the response-rate improves compared to that with ______________ alone

Answer 67

fluorouracil fluorouracil

Question 68

When ______________ and fluorouracil are used together in metastatic colorectal cancer the response-rate improves compared to that with fluorouracil alone

Answer 68

folinic acid

Question 69

The calcium salt of levofolinic acid, a single isomer of folinic acid, is also used for rescue therapy following methotrexate administration, for cases of methotrexate overdose, and for use with fluorouracil for colorectal cancer. The dose of calcium levofolinate is generally _____________ that of calcium folinate

Answer 69

half

Question 70

___________________ is a common manifestation of urothelial toxicity which occurs with the oxazaphosphorines, cyclophosphamide and ifosfamide

Answer 70

Haemorrhagic cystitis

Question 71

Haemorrhagic cystitis is a common manifestation of urothelial toxicity which occurs with the oxazaphosphorines, cyclophosphamide and ifosfamide; it is caused by the metabolite ___________

Answer 71

acrolein

Question 72

Which cytotoxic drugs are associated with the development of hemorrhagic cystitis? (3)

Answer 72

1. Oxazaphosphorines 2. Cyclophosphamide 3. Ifosfamide

Question 73

______________ reacts specifically with this acrolein in the urinary tract, preventing hemorrhagic cystitis

Answer 73

Mesna

Question 74

Mesna is used routinely (preferably by mouth) in patients receiving ____________, and in patients receiving ____________ by the intravenous route at a high dose (e.g. more than 2 g) or in those who experienced urothelial toxicity when given cyclophosphamide previously

Answer 74

ifosfamide cyclophosphamide

Question 75

Which drugs are considered cytotoxic antibiotics? (4)

Answer 75

1. Daunorubicin 2. Doxorubicin 3. Epirubicin 4. Idarubicin

Question 76

Many cytotoxic antibiotics (anthracyclines) act as ______________ and simultaneous use of radiotherapy should be avoided because it may markedly increased toxicity

Answer 76

radiomimetics

Question 77

Many cytotoxic antibiotics (anthracyclines) act as radiomimetics and simultaneous use of _______________ should be avoided because it may markedly increased toxicity

Answer 77

radiotherapy

Question 78

Doxorubicin hydrochloride is available as both ____________ and ____________ formulations

Answer 78

conventional liposomal * The different formulations vary in their licensed indications, pharmacokinetics, dosage and administration, and are NOT interchangeable

Question 79

What are the indications of conventional doxorubicin? (5)

Answer 79

1. Acute leukemias 2. Hodgkin’s lymphoma 3. Non-Hodgkin’s lymphoma 4. Pediatric malignancies 5. Some solid tumors including breast cancer

Question 80

Epirubicin hydrochloride is structurally related to doxorubicin hydrochloride and can be used to treat ____________ cancer

Answer 80

breast

Question 81

Epirubicin hydrochloride is structurally related to _______________ and can be used to treat breast cancer

Answer 81

doxorubicin hydrochloride

Question 82

Idarubicin hydrochloride has general properties similar to those of _______________; it is mostly used in the treatment of haematological malignancies

Answer 82

doxorubicin hydrochloride

Question 83

Idarubicin hydrochloride has general properties similar to those of doxorubicin hydrochloride; it is mostly used in the treatment of _______________

Answer 83

haematological malignancies

Question 84

Daunorubicin also has general properties similar to those of ______________

Answer 84

doxorubicin hydrochloride

Question 85

Bleomycin is given ____________ or ___________ to treat metastatic germ cell cancer and, in some regimens, non-Hodgkin’s lymphoma

Answer 85

intravenously intramuscularly

Question 86

Bleomycin is given intravenously or intramuscularly to treat ______________ cancer and, in some regimens, ______________

Answer 86

metastatic germ cell non-Hodgkin’s lymphoma

Question 87

Dactinomycin is principally used to treat ____________ cancers. Its side-effects are similar to those of doxorubicin, except that cardiac toxicity is not a problem

Answer 87

paediatric

Question 88

Dactinomycin is principally used to treat paediatric cancers. Its side-effects are similar to those of doxorubicin, except that _______________ toxicity is not a problem

Answer 88

cardiac

Question 89

What are the indications for mitomycin? (5)

Answer 89

1. Gastrointestinal cancer 2. Breast cancer 3. Non-small cell lung cancer 4. Metastatic pancreatic cancers 5. Bladder tumors (superficial) (All IV except bladder tumors which are administered via bladder instillation_

Question 90

Mitomycin causes delayed _______________ toxicity

Answer 90

Bone marrow

Question 91

Which drugs are in the class of vinca alkaloids? (4)

Answer 91

1. Vinblastine 2. Vincristine 3. Vindesine 4. Vinorelbine (semi-synthetic)

Question 92

Vinca alkaloids are used to treat which cancers? (4)

Answer 92

1. Leukemias 2. Lymphomas 3. Some solid tumors 4. Vinorelbine also used to treat breast cancer

Question 93

What is the mechanism of action of anti metabolites?

Answer 93

Antimetabolites are incorporated into new nuclear material or combine irreversibly with cellular enzymes, preventing normal cellular division

Question 94

Which drugs fall in the class of alkylating drugs? (7)

Answer 94

1. Cyclophosphamide 2. Ifosfamide 3. Melphalan 4. Lomustine 5. Carmustine 6. Estramustine 7. Mitobrornitol

Question 95

What is the mechanism of action of alkylating drugs?

Answer 95

Damage DNA, thus interfering with cell replication

Question 96

Cyclophosphamide is used mainly in combination with other agents for treating a wide range of malignancies, including some ______________, ____________, and _____________

Answer 96

leukaemias lymphomas solid tumours

Question 97

Cyclophosphamide is given ___________ or ____________; it is inactive until metabolized by the ____________

Answer 97

Orally Intravenously Liver

Question 98

____________ is licensed for the treatment of multiple myeloma, polycythaemia vera, childhood neuroblastoma, advanced ovarian adenocarcinoma, and advanced breast cancer

Answer 98

Melphalan * However, in practice, melphalan is rarely used for ovarian adenocarcinoma; it is no longer used for advanced breast cancer

Question 99

What are the indications of melphalan? (5)

Answer 99

1. MM 2. PCV 3. Childhood neuroblastoma 4. Advanced ovarian adenocarcinoma (rarely used) 5. Advanced breast cancer (no longer used)

Question 100

_______________ implants are licensed for intralesional use in adults for the treatment of recurrent glioblastoma multiforme as an adjunct to surgery

Answer 100

Carmustine

Question 101

Carmustine implants are also licensed for high-grade ______________ as adjunctive treatment to surgery and radiotherapy

Answer 101

malignant glioma

Question 102

Estramustine phosphate is a combination of an _______________ and _____________ used predominantly in prostate cancer

Answer 102

oestrogen chlormethine

Question 103

Estramustine phosphate is a combination of an oestrogen and chlormethine used predominantly in ______________ cancer

Answer 103

prostate

Question 104

_______________ is a combination of an oestrogen and chlormethine used predominantly in prostate cancer

Answer 104

Estramustine phosphate