Lung Cancer Flashcards by Sara Baldwin

What is the MOST likely cause of lung cancer? What other risk factors are there?

TOBACCO SMOKE
Environmental respiratory carcinogens (asbestos, arsenic, air pollution)
Radiation
Genetics

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What are some differences between small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC)?

SCLC: much shorter survival (1-3 MONTHS), rapid tumor growth, rarely surgical interventions but very chemo/RT-sensitive, no target agents

NSCLC: longer survival (1 year), slower tumor growth, surgery routine but not very RT/chemo sensitive, large role for target agents

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What are common symptoms of lung cancer?

Pulmonary = dyspnea, cough, chest pain
Red flag = repeat scripts for pneumonia/bronchitis
Fatigue, weight loss/anorexia, hypercalcemia
Metastasis can cause neurologic sx
Superior Vena Cava (SVC) syndrome

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Lifetime smoke history is quantified by _____________ how do you calculate this?

“Pack years”
= (years smoking) x (# packs/day)

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Who should be screened for lung cancer?

Adults 50-80 yo
Current or former smokers who quit ≤ 15 yrs + ≥ 20 pack-year hx

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What is the screening test for lung cancer?

Low Dose CT (LDCT) annually

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What are the two steps that need to be taken to diagnose lung cancer?

CT scan of chest
Lung tissue biopsy (confirm tumor presence and type)

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Define Early Stage, Locally Advanced Stage and Advanced Stage lung cancer

Early: Stage 1 or 2 w/ negative nodes
Locally Advanced: Stage 2 or 3 w/ positive nodes
Advanced: Stage 4

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What is the difference between limited stage and extensive stage lung cancer?

Limited: confined to one lung +/- lymph node involvement confined to same side

Extensive: involves both lungs +/- lymph node involvement on both sides +/- extrapulmonary metastases

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For EARLY stage NSCLC STAGE 1 what are the steps for resectable vs unresectable cancer?

Resectable: just resection
Unresectable: RT alone

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For EARLY stage NSCLC STAGE 2 what are the steps for resectable vs unresectable cancer?

Resectable: +/- neoadjuvant & adjuvant therapy
Unresectable: Concurrent chemo & RT

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For EARLY stage NSCLC STAGE 3 what are the steps for resectable vs unresectable cancer?

Resectable: Neoadjuvant therapy, adjuvant therapy, +/- RT
Unresectable: Concurrent chemo+RT, Durvalumab maintenance

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What are some neoadjuvant regimens for early stage NSCLC?

Nivolumab + platinum based chemo x 3 cycles
Pembrolizumab + cisplatin chemo x 4 cycles
Platinum based chemo x 4 cycles

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What are some adjuvant regimens for early stage NSCLC?

Osimertinib daily ≤ 3 years
Atezolizumab ≤ 1 year
Pembrolizumab ≤ 1 year
Platinum based chemo x 4 cycles

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What are the platinum-based chemotherapy regimens? Which are preferred for squamous, nonsquamous and cisplatin-intolerant patients?

Non-squamous:
Cisplatin/pemetrexed

Squamous:
Cisplatin/docetaxel
Cisplatin/gemcitabine

Cisplatin-intolerant:
Carboplatin/pemetrexed
Carboplatin/paclitaxel
Carboplatin/gemcitabine

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What are some AEs that CISPLATIN has?

N/V
Diarrhea/constipation
Nephrotoxicity (hypokalemia, Hypomagnesemia)
Ototoxicity
Peripheral neuropathy

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What are some AEs that CARBOPLATIN has?

Myelosuppression (thrombocytopenia)
Diarrhea/constipation
(Fewer AEs = better tolerated than cisplatin

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What is the weight that should be used for dosing carboplatin?

IBW - standard
Adjusted BW - if actual body weight is 1.2 x IBW
Actual BW - if IBW is less than ABW

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What is the equation for IBW?

Male = 50 + (2.3 x inches over 5 foot)
Female 45.5 + (2.3 x inches over 5 foot)

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What is the adjusted body weight equation?

IBW + 0.4 x (ABW - IBW)

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What is the Cockcroft-Gault equation

(140 - age) x weight kg
——————————- x 0.85 if female
72 x SCr

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What is the equation for carboplatin dosing? What is the max CrCl used?

Target AUC x (CrCl + 25)
CrCl ≤ 125 mL/min

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What are some major AEs of the taxanes (paclitaxel/docetaxel)?

Study These Flashcards

Alopecia
Peripheral neuropathy
Hypersensitivity reaction (premeditate, from the solvent)
Peripheral edema (docetaxel only)

How is Pemetrexed eliminated? What level should it be avoided in?

Study These Flashcards

Renal elimination
Avoid use if CrCl < 45

What are some AEs of Pemetrexed? What should it be supplemented with??

Red/pruritic skin rash Diarrhea Fatigue **Supplement with: Folic acid + Vitamin B12 - use dexamethasone BID the days around chemo to decrease rash incidence**

For advanced NSCLC, we primarily use targetable genetic mutation therapy. Which mutations do we target?

EGFR (epidermal growth factor receptor) ALK KRAS (ROS-I, BRAF, NTRK, MET, RET, HER-2)

EGFR mutations are most prevalent in _______ and ________ in lung cancer. They target exon ____ deletions and exon ____ mutations

Most prevalent in adenocarcinomas and non-smokers Target exon 19 deletion and exon 21 point mutations

What are some EGFR drugs used in advanced NSCLC? Which is first line?

1st gen: erlotinib, gefitinib, afatinib 2nd gen: dacomitinib 3rd gen: **Osimertinib (1st line)** -improved CNS activity and tolerability

What are some AEs of of EGFR inhibitor Osimertinib?

**Skin rash** Dry skin Conjunctivitis Diarrhea Fatigue Nail Toxicity Stomatitis **Myelosuppression** **QTc prolongation**

What are some nonpharmacologic PREVENTION strategies for EGFR inhibitor-related rash? What are some TREATMENTS?

Prevention = sun screen, gentle skin care (loose clothes, avoid hot showers, avoid OTC acne products, use hydrophilic creams) Rx = topical or systemic corticosteroids/antibiotics

ALK inhibitor drugs for advanced NSCLC are all _____ drugs

Oral

Of the ALK inhibitor drugs for advanced NSCLC, why are Alectinib and Lorlatinib preferred?

Alectinib = only ALK inhibitor with significant improvement in survival Lorlatinib = 3rd gen, improved potency and BBB penetration

Only 2nd and 3rd gen ALK inhibitors are used in practice for NSCLC. Name these drugs!

2nd gen = Alectinib, brigatinib 3rd gen = Lorlatinib

What are some AEs of ALK inhibitor brigatinib?

**Interstitial lung disease** HTN Diarrhea Myalgia

What are some AEs of ALK inhibitor Alectinib?

**LFT abnormalities** Anemia Constipation Myalgia

What are some AEs of ALK inhibitor Lorlatinib?

Higher BBB penetration = more CNS AEs **Mood disorders Neuropathy Cognitive effects Dyslipidemia & weight increase**

KRAS inhibitors used for advanced NSCLC is most common in ________ patients and confer a _____ prognosis

Common in SMOKERS Has POOR prognosis

Name the two KRAS inhibitors used in NSCLC.

Sotorasib Adagrasib “-rasib”

What is a special consideration with KRAS inhibitor sotorasib?

Requires an acidic environment for proper oral bioavailability **Avoid PPIs or H2RAs**

Classifying treatments for advanced NSCLC is dependent on PD-LI positive (PD-LI 1-49%, >50%) or negative (PD-LI <1%) status. What is the regimen for pts w PD-LI 1-49%? >50%? What is the regimen for negative pts?

POSITIVE: PD-LI > 50% = PD-I/PD-LI inhibitor only PD-LI 1-49% = PD-I/PD-LI inhibitor + chemo NEGATIVE: PD-I/PD-LI inhibitor + chemo

What are some immunotherapy agents that can be used to treat PD-LI in advanced NSCLC?

Pembrolizumab, Cemiplimab (can be be used with chemo) Atezolizumab

If a lung cancer patient has disease progression even with therapy (NON-CHECKPOINT) what should they try?

Pembrolizumab Nivolumab Atezolizumab

If a lung cancer patient has disease progression even with therapy (PRIOR CHECKPOINT) what should they try?

**Docetaxel + Ramucirumab (preferred over single agent)** Docetaxel Gemcitabine Albumin-Bound Paclitaxel Pemetrexed (if nonsquamous)

What is the MOA of PD-L1? Aka why are PD-L1 inhibitors effective?

PD-L1 makes T-cells recognize the cancer cells as normal/prevents it from attacking. PD-L1 inhibitors cover the site from recognition and allow the T cell to attack and recruit the immune system.

What are the grades of immunotherapy-related AEs? (Similar to exam 1) describe what actions should be taken for each grade

Caution in autoimmune disorder pts! Grade 1 = continue immunotherapy Grade 2 = hold therapy and consider corticosteroid Grade 3+ = 0.5-2 mg/kg/day **x 1 month** prednisone until grade 1

What is VEGF MOA and why is it crucial to inhibit?

VEGF is an angiogenic factor that is secreted by cancer cells to create new vessels. By inhibiting VEGF, we cut off nutrition to the cancer

What are the two VEGF inhibitors used in NSCLC?

Bevacizumab Ramucirumab

What are acute AEs of VEGF inhibitors? What are some delayed AEs?

Acute: HTN Delayed: [deals w bleeding] thrombosis, epistaxis, major bleeding, GI tears, proteinuria, diarrhea (ramcirumab)

In what type of pts should we avoid use of VEGF inhibitors?

Squamous histology (bevacizumab) Recent hemoptysis [blood from mouth] On anticoag therapy for VTE Recent surgery (Aka any recent risk for bleeding)

In SCLC, how quick is relapse after complete drug response? What kind of radiation is offered after partial/complete drug response?

Relapse usually 6-8 months after complete response **Prophylactic cranial radiation 🧠** is offered post-response

What chemo/RT is offered FIRST LINE in limited stage SCLC?

Cisplatin + Etoposide + RT Carboplatin + Etoposide + RT

What chemo/RT is offered FIRST LINE in extensive stage SCLC?

Carboplatin + Etoposide + Atezolizumab (immunotherapy) Carboplatin + Etoposide + Durvalumab Cisplatin + Etoposide + Durvalumab

What chemo/RT is offered SECOND LINE in SCLC?

Topotecan Lurbinectedin

What is the MOA of Etoposide (SCLC)? What is a notable AE?

MOA - topoisomerase II inhibitor, DNA double strand breaks AE - myelosuppression

What is the MOA of topotecan (SCLC)? What are some notable AEs?

Topoisomerase I inhibitor, leads to DNA single strand breaks AEs - Myelosuppression, neutropenia

What is the MOA of Lurbinectedin (SCLC)? What are some notable AEs? What should be used for pretreatment?

MOA - alkylates DNA residues and results in DNA damage AEs - Fatigue, hepatic enzyme elevation, nausea, extravasation (leakage of blood) Pretreat w dexamethasone (decrease hepatic elevations) and 5-HT3 antagonists for antiemetic

Lung Cancer Flashcards

(56 cards)