Pearls Flashcards
1
Q
G-CSF timing
A
Short acting: don’t give 24h before or after chemo
Long acting: don’t give within 12 days before or 24h after chemo
2
Q
G-CSF + bleomycin
A
G-CSF enhances bleomycin pulmonary toxicity- avoid use within 24 hours
-okay to use in testicular ca regimens
-g-CSF not recommended in initial Hodgkin’s regimens except BEACOPP (escalated)
3
Q
Which body weight is used for crcl in carbo AUC calculation?
A
Under/normal weight (BMI <25%): actual body wt
Overwt/ obese (BMI 25%+): adjusted body wt
Round scr to 0.7 or 0.8 usually
Use 24 hr urine collection gfr if available
4
Q
Which solid tumors are intermediate risk for TLS?
A
Neuroblastoma, germ cell tumors, small cell lung cancer
5
Q
How often is PCV dosed?
A
Q6 weeks- prolonged nadir
6
Q
ANC equation
A
10 x WBC x (%PMNs + % Bands)
7
Q
Which g-CSF can be used for tx of fn?
A
Filgrastim.
Pegfilgrastim is for ppx NOT tx
8
Q
When can you add vanc for Neutropenic fever?
A
-line infxn
-hx MRSA or drug resistant strep pneumo
-PNA
-sepsis or HD instability
-blood Cxs growing g+
-SSTI
*do not add for fever alone or for persistent fever- takes 2-7 days to resolve
9
Q
When do we consider ABX ppx for febrile neutropenia ?
A
If we expect pt to be neutropenic for > 1 wk
10
Q
When is pjp ppx needed ?
A
> 20 pred equivalents x >30 days
11
Q
Where does osteosarcoma usually spread to and recur?
A
Lungs
12
Q
Can Carboplatin replace cisplatin in testicular cancer?
A
No
13
Q
Vinca alkaloids and myelosuppression
A
-not for vincristine
-yes for Vinblastine and Vinorelbine
*B for BMS
14
Q
Which brain lesions are more likely to bleed spontaneously?
A
Brain Mets from RCC and melanoma.
Should still use AC
15
Q
How is acute bleomycin pulmonary toxicity tx?
A
Drug discontinuation and corticosteroids
16
Q
Which drug increases risk of cisplatin ototoxicity?
A
Vinblastine
17
Q
Goal serum testosterone with ADT
A
<50 after 1 month
18
Q
What is another name for IDH wild type grade 4 astrocytoma?
A
Molecular glioblastoma
19
Q
Adjuvant Nivolumab vs avelumab I’m bladder CA
A
Nivolumab: MIBC
Avelumab: metastatic
20
Q
Hypersensitivity to taxanes management
A
-give premeds (h1, h2, steroid)
-if you can control the situation CAN resume at a slower rate
-mild rxn give h1, severe give h1, h2, and steroid (like premeds)
21
Q
Hypersensitivity to platinums management
A
-Do NOT just decrease rate
-can consider desensitization protocol
-could rechallenge mild Oxaliplatin rxn
-could rechallenge if mild rxn on FIRST EXPOSURE, but do NOT rechallenge if rxn is on second or later exposure even if mild!
IgE type 1
22
Q
General management of hypersensitivity RXNs
A
Mild:
-stop infusion
-give h1 blocker or steroid if delayed rxn (platinums)
-if still not resolving give epi
Severe (changes to vitals or O2:
-stop infusion
-give oxygen
-nebulized bronchodilators
-give both h1 and h2 blockers
-give corticosteroids
-if not resolving give epi
Life-threatening:
-stop infusion
-put pt in recumbent position
-give epi
-O2 8-10L
-1-2 L NS IVB for hypotension
-give both h1 and h2 blocker
-give steroid
-additional support if in cardiopulmonary arrest
Can rechallenge grade 1-2
23
Q
When to stop filgrastim?
A
Stop when ANC above 1500 for 3 days or 5000 for 1 day- AFTER THE NADIR
fyi 1 day of pegfilgrastim is worth ~10days of filgrastim
24
Q
Define castrate resistant
A
Progression despite testosterone levels <50 ng/dL
25
When to add antifungal for FN?
Consider mold coverage after 4-7d of ABX (unless receiving mold ppx)
-ampho B, caspofungin, or voriconazole
-if azole ppx was given- azole resistant mold or candida may be the issue
-if no azole ppx- likely candida
26
Pediatric CV screening
No screening:
-no anthracycline , <15gy RT dose
Every 2y
-no anthra, >35gy RT
***-<250 mg/m2 dox, 15+guy RT***
->250 mg/m2 dox, any/no RT
Every 5y
-no anthracycline, 15-35gy RT
***-<250 mg/m2 dox, +<15 gy RT***
Note: RT is to chest, abdomen, spine (thoracic, whole), TBI
27
Informed consent in pediatrics (research)
***below is for research- in clinical setting child assent is NOT required if benefit outweighs risk***
No greater than minimal risk
-1 parent and child*
Greater than minimal risk with prospect of direct benefit
-1 parent and child*
Greater than minimal risk and no direct benefit
-both parents and child
All other research
-both parents and child
*child assent not required if expected significant benefit and not available outside research
***Generally assent required in children 7+***
28
Lovenox and doac adjustment for plt
Lovenox:
Plt>50k: full dose
Plt 25-50k: half dose
Plt<25k: hold
*do not use doacs in plt<50k
29
Preferred long term AC agents for VTE tx
LMWH (***dalteparin is cat 1***) edoxaban, xarelto- x6 months
*apixaban ok but BID dosing
*DONT USE DABIGATRAN
***edoxaban needs 5 days parental AC first***
30
Doacs v lmwh
Doac preferred;
-intact GIT
-don’t use if ***urinary*** or GI lesion
Lmwh preferred:
-luminal GI or gyn lesion
-if DDI
-when surgery is planned
-if in DAPT
*doacs appear to work better but more bleeding -esp GIB
31
When to stop ABX for FN?
And for kids?
***Below is for fever of unknown etiology!! For known infxn you tx for appropriate duration of that infxn***
A febrile x 48h and ANC>500
For kids
-afebrile for ***>24h***
-bone marrow recovery
-blood cx neg x 48h
-consider at 72h even if no narrow recovery
32
Gem-cis vs ddMVAC
ddMVAC preferred neoadjuvant but in metastatic setting they are equivalent
33
Which type of testicular cancer is sensitive to RT?
Seminoma
34
What type of endometrial cancers do and don’t benefit from HT?
Endometrioid adenocarcinoma benefit from HT
Serous and clear cell do not
35
Which novel antiandrogen is take with food?
Darolutamide
36
Which novel antiandrogen can be given for m1CRPC?
Enzalutamide
37
Bioavailability leucovorin and Mesna
Mesna: 50%
Leucovorin: 100% at doses<35
38
Alkylating agents: cell cycle specific or non-specific
Non-specific
39
Antitumor abx- cell cycle specific or non-specific
Generally non-specific; but may have specific component with topo-I component
40
Proteosome inhibitor- cell cycle specific or non-specific
Non-specific
41
Which cancers do we most commonly see hypercalcemia?
Multiple myeloma and breast
-note: prostate metastasizes to the bone but rarely causes hypercalcemia
-lymphomas can cause increased calcitriol- tx with steroids
42
Define de novo metastatic dx
When diagnosed they were already metastatic
43
Define metachronus metastatic dx
44
Platinum + taxane sequencing
Taxane—>platinum
45
Tamoxifen and raloxifene in hx of VTE
NO!
46
How do we know when to add Pertuzumab in early stage BC HER-2+ BC?
If LN positive
47
Leuprolide vs fulvestrant
Leuprolide - LHRH agonist
Fulvestrant - SERD
48
Vinca alkaloids cell cycle specific or non-specific?
Cell cycle specific
49
Taxanes cell cycle specific or non-specific?
Cell cycle specific
50
When are platinums preferred over taxanes in metastatic BC?
TNBC+ BRCA mutation
-double check TNBC part
51
ICANS
Immune effector cell associated neurotoxicity
*give keppra for seizure ppx with CAR-T cell therapy- usually happens a few weeks after CAR-T (start keppra day of therapy and ***continue x30 days after***)
*treat with steroids
52
Filgrastim in AML
Generally only used with:
-CLAG
-GCLAC
-FLAG
-FLAG-ida
-don’t use as primary ppx after ***induction***
-may use as primary if secondary ppx after ***consolidation***
-use for “priming” is controversial
-stop at least 7 days before obtaining remission bone marrow
-Caution in AML induction- theoretical risk of causing proliferation of leukemic blasts and/or increasing myelosuppression
-may consider in severe, life threatening infection during severe neutropenia or after interim bone marrow bx demonstrates aplasia w/o evidence of dx
***note: this is NOT a concern for ALL (lymphoid line are not granulocytes)***
53
Which antidepressants should be used with tamoxifen?
Venlafaxine, citalopram, escitalopram
***NOT SERTRALINE***
54
Bisphosphonate pearls
-dose reduce zolendronate for ***crcl <60*** for bone Mets (***don’t use if crcl<30)***
-don’t dose reduce for hypercalcemia unless scr >4.5
-causes myalgias and arthralgias
-modest decrease in bone pain
-hypocalcemia
-flu-like malaise, fevers, arthralgias, nephrotoxicity, ONJ
-give 500 ca2+ and 400-500 vit d per day
-onset for hypercalcemia is 2-4 days (same with denosumab)
-bisphosphonates are IV and denosumab is SQ
-denosumab has worse hypocalcemia
55
Denosumab pearls
-subQ
-preferred if renal impairment
-more expensive
-***usually used in hypercalcemia if refractory to bisphosphonates***
56
What effect does oral contraceptives have on breast and ovarian and endometrial cancer risk?
Breast: increased risk
Endometrial/ Ovarian: decreased risk
*progesterone increases BC risk and decreases endometrial cancer risk
*estrogen increases risk of endometrial cancer (so we give it with progesterone to counteract this) and breast cancer
57
When can you rechallenge a taxane after infusion rxn?
For mild rxns: rash, pruritis, flushing
Don’t rechallenge for severe rxns
58
Why doesn’t leucovorin rescue cancer cells?
Because cancer cells polyglutamate the heck out of MTX which keeps in the cell!
Note: leucovorin does NOT increase elimination of MTX so it’s ok to increase the dose for 24h, 48h, and 72h levels of > 10, 1, and 0.1 respectively
59
When should docetaxel be given with/without prednisone in postate cancer?
Castrate sensitive: without pred
Castrate resistant: with pred
60
TP53 and BRCAs and HER-2
Tumor suppressor:
-TP53
-BRCAs
-RB1
-ATM
-PTEN
Oncogenes:
-Her-2
-BRAF
-EGFR
-KRAS
-MET
-PIK3CA
61
Nivolumab and pembro in bladder and kidney
Bladder:
-MIBC: nivolumab for adjuvant
-Metastatic: pembro for second line (cat 1) and can also use nivo for second line
-pembro can also be an alternative 1st line in platinum ineligible
Kidney
-stage II: pembro x1y for adjuvant if grade IV +/-sarcomatoid fxs
-stageIII and IV adjuvant
-stage iv met: nivo can be used second line
62
Most common type of RCC
Clear cell
63
Which are and are not sensitive to RT: osteosarcoma, ewings, seminoma, non-seminoma
Sensitive: ewings (but RT not used much), seminoma
Not sensitive: osteosarcoma, non-seminoma
64
What is another name for her-2?
EGFR-2, ERBB2
65
At what stage do you differentiate b/w good risk and int/poor risk for seminomas and non-seminoma
Seminoma: stage IIC and up must differentiate b/w good and int risk (could be either)
Non-seminoma: stage IIIB and IIIC are both int/poor risk (everything below is good risk!)
66
Which acute leukemia requires CNS ppx?
ALL
67
G-CSF ADRs
Splenic rupture, bone pain, capillary leak syndrome (rare)
Note: don’t use within 14 days if car-T
68
BCR-ABL TKIs with or without food comparison
Imatinib: with food AND water
Dasatinib: with or without
Nilotinib: without food
Bosutinib: with food AND water
Asciminib: without food
Ponatinib: with or without
Note: all second gen should avoid acid suppressive therapy (all but imatinib)
69
When can TKI be stopped in chronic CML
-Stable ***DEEP molecular*** response ***(MR4)*** for at least ***2 years*** (4 separate tests 3 months apart)
-frequent and reliable monitoring (monthly x6 mo, bi-monthly x6 mo, then quarterly)
-patient consent
Note: not studied in bosutinib or Ponatinib
Other:
->18y/o
-no hx of accelerated or blast phase
-on first line therapy (unless switch d/t ADR)
-consult CML speciality center
-motivated pt w/ good communication
-on TKI x3-5 y
-prior evidence of detectable dx
Note: may experience TKI withdrawal phenomenon: ***MSK pain and pruritus*** for a few months: NSAIDs, APAP, maybe oral steroid
Resume within 4 weeks of loss of MMR
70
CML accelerated phase
***basically tx like second or third line chronic phase***
-second gen TKI or alternate second gen TKI
-Ponatinib if no other tki indicated
-omacetaxine if resistant to 2+ tki
-allo HCT
71
CML blast phase
***BCR-ABL TKI*** + induction tx of respective type of acute leukemia (could be ALL or AML)
-if second chronic phase is achieved- allogenic HCT
72
MTX level: 0.1 mM other units
***100 nmol***
1x10^-7M
73
Does leucovorin enter the cell
Yes! Glucarpidase does not I don’t think - that’s why we still need leucovorin when glucarpidase is given
74
Tamoxifen vs raloxifen BC prevention
-more VTE , cataracts, and uterine cancer with tamoxifen
-tamoxifen more effective
-both are indicated
75
When is BC risk reduction indicated?
***->35 y/o*** and 10+ year life expectancy (70+ y/o (asco)) ***AND*** any of the below:
-LCIS
-atypical hyperplasia (AH)
-BC risk >20% with model based on family hx
-pedigree suggestive of family hx
-know genetic predisposition
-prior thoracic RT <30 y/o
-Gail score 3%+
-10Y IBIS/tyrer cuzick ***5%+***
Consider when:
-Gail score 1.7%+
-BCRAT 3%+ (ASCO rec)
Options:
-mastectomy
-BSO
-tamoxifen or AI
76
Which Parps are used in BC? Ovarian? Prostate?
Breast: Olaparib or talazaparib
Prostate: Olaparib, Rucaparib, talazaparib, Niraparib
Ovarian: Olaparib, Niraparib, Rucaparib
77
Trick to preventing neuropathy with taxanes
Cryotherapy of hands and feet
78
Rolapitent pearls
-only one that’s not a 3A4 inhibitor
- don’t give more than q2 weeks
79
HPV vaccine and screening
Vaccine
-start age 11-12 for boys and girls (indicated ages 9-45)
-9-14: 2 dose series (0, 6-12 months
-15+: 3 dose series (0, 1-2, 6-12 months)
-also give 3 dose series of second dose given before 5 months
Note: strains 16 and 18 responsible for cervical cancer
80
Holding BTK-I around surgery
Minor: 3 days before and after
Major: 7 days before and after
81
Prostate: what does active surveillance entail?
Observation
***Active surveillance***
PSA q6 months, DRE q12 months, MRI no more than q12 months
This is different from screening which is less frequent (q2+ years) if at all
***Observation***
-PSA q6 months
-history and physical
-***NO BIOPSY***
82
Prostate: observation vs AS
Observation: life exp <10 y
AS: life exp >20y very low risk, and >10y for low risk
83
General tx recs for non-metastatic prostate
Low risk: observation for <10 yr LE and AS for >10y LE
Intermediate: observation <5 LE, 5-10 observation or tx, >10 tx
High risk: observation <5 yr LE,
>5 yr LE: EBRT + ADT , +/- abiraterone (very high risk) OR
EBRT + brachy + ADT
Regional:
-<5 y: observation or ADT
->5y: EBRT + ADT + abiraterone
*note: ADT usually starts before RT and is continued for 2-3 years
84
When to use LHRH antagonist over agonist
Concerns with tumor flare (bone pain, urinary symptoms, spinal cord injury/compression
85
BMA dosing
***zolendronate***
-SRE: 4 mg q3-4 or q12 weeks- double check
-Adjuvant BC tx: 4 mg q6 mo x3-5 yr
-Hyper ca2+: 4 mg, repeat in 7d
***Pamidronate***
SRE: ***90 mg*** (over 2h) q3-4 wk
Hyper ca2+: 90 (>13.5), 60 (12-13.5), 30 (<12)- repeat in 7 days
***denosumab***
-SRE: 120 mg q4wk
-hyper ca2+: 120 mg q7d if needed
-note: Preffered over zometa for bone Mets in ***CRPC***
-Duration 2 years in multiple
Myeloma for bone Mets- restart if patient relapses!!
-***May be indefinite for other cancers***
-In breast and prostate there two indications:
1) SRE ppx in pts w/ bone Mets
2) osteoporosis from AI/tamoxifen/LHRH/ADT with FRAX 10 yr risk hip fx 3%+ or major fx 20% (breast/prostate) or T score <-2 (breast) and these use ***osteoporosis dosing NOT oncology***
Note: prevention of SRE and bone Mets is the same thing
Myeloma pretty much always using BMA with ***oncology*** dosing- however not indicated for MGUS or smoldering or solitary plasmacytoma
Multiple myeloma: zolendronate or denosumab monthly for at least 12 months (may change zolendronate to q3 or q6 months after a year if VGPR achieved)
86
Ara-C syndrome
Fever, myalgia, bone pain, rash, chest pain, weakness
87
Which type of bilirubin indicated hepatic impairment
Conjugated
88
TP53 mutation and RT
Avoid RT- increased risk of secondary cancer
89
Normal ionized calcium
4.4-5.4
90
What does leucovorin not prevent ?
Renal tubular necrosis
91
What does adrenal deficiency cause?
Hypokalemia, HTN, edema
***This is abiraterone, which decreases glucocorticoid and increased mineralcorticoid production***
92
CINV In children
HEC: dex + 5HT3 + ***aprepitant (if >6 mo)***
MEC: 5HT3 + dex (if no CI, otherwise ***aprepitant)*** if can’t take dex (brain tumor/leukemia) and <6 mo old do palonosetron monotherapy
LEC: 5HT3
Min: no routine ppx
***This is for ACUTE CINV only, no data for delayed***
Note:
-dose reduce dex by 50% if given with aprepitant
-fosaprepitant is also approved
-omit dex if brain tumor (decreases chemo across BBB) or leukemia (increases risk fungal infections)
-if not using dex, palonosetron is the preferred 5HT3
93
Principles of informed consent
Beneficence, justice, respect for autonomy
94
VTE in malignancy tx duration
At least 3 months or as long as pt has active cancer
If catheter-as long as pt has catheter
***INDEFINITELY IN PATIENTS WITH ACTIVE CANCER, ON CHEMO, OR PERSISTENT RISK FACTORS***
95
Which 5HT3 inhibitor doesn’t prolong QTc?
Which helps with delayed CINV?
Max dose zofran?
When to apply granisetron patch?
QTc: ***palonosetron, transdermal and SubQ ER granisetron (PO and IV do!)***
Delayed CINV: Palonosetron (if given in day 1 no further 5HT3 needed)
Zofran max: 24 mg po, 16 mg IV/day
Granisetron: 24-48h before chemo
Dolasetron is discontinued
Other pearls
-don’t give 5HT3 beyond 24h
-granisetron ER injection given 30 mins before on day 1 and lasts 7 days; patch placed 24-48h prior
-aprepitant: inhibitor of 3A4 but inducer of 3A4 and 2c9 if given for >14 days
-aprepitant increases: oral contraceptives ***(use backup)***, warfarin ***(check INR in 7-10d)***, dex/MP (decrease dose)- NOTE THAT IT DOES NOT INTERACT WITH CHEMO AGENTS!!
-netupitant is a 3A4 inhibitor
-rolapitant: single dose (very long half life) minimum 2 week intervals, no effect on 3A4; inhibits BCRP caution with gefitinib, MTX, lapatinib, mitoxantrone, imatinib, topotecan, irinotecan, cycslosporin, statins; PO only (hypersensitivity with IV-removed)
***Steroids***
-unknown exact MOA
-avoid 3-5 days before and 90 days after CAR-T
-no data saying we can’t give dex before regimen that contains an ICI
-olz is a good alternative to dex
***Reglan and trimethobenzamide***
-reglan: blocks D2, blocks peripheral 5HT3 (high dose), increases motility
***phenothiazine***
-promethazine, compazine, chlorpromazine
-more hypotension than butyphenones
***butyrophenones***
-haldol, droperidol
-suitable alternative is phenothiazine fails
***Dex:***
-can cause hiccups
-can cause dyspepsia
-avoid 3-5d prior to and 90 d after CAR-T
***cannabinoids***
-breakthrough CINV, effective for low-moderate emetogenic agents
***Olanazapine***
-consider 2.5 mg if sedation from 5
-QTc shouldn’t be clinically meaningful
-don’t give with IV BZD (PO only)
HEC: 5Ht3, dex, NK-1, OLZ (dex 8 mg and olz should be continued on ***DAYS 2-4***to prevent delayed CINV). Note olz dose ***5 mg OR 10***
MEC: 5HT3 + dex (continue one or the other for ***days 2-3),*** could also chose a 3 drug regimen
LEC: single drug 5HT3 or dex, or reglan or compazine
Minimal: none
***oral***
Moderate-high: 5HT3 daily + breakthrough
Minimal-low: breakthrough only
***Multi-day***
-Tricky- evaluate emetogenic potential for each day
Note: social drinking does not decrease risk (daily drinking does)
96
When to consider EP over BEP in testicular cancer
>50 y/o, reduced GFR, or pulmonary comorbidities
97
Rasburicase pearls
After administration blood samples must be ***chilled*** and collected in tube containing ***heparin*** and assayed within ***4 hours*** or UA will be falsely low
Avoid in G6PD deficiency
0.2 mg/kg/day x 5 days or 1-2 fixed doses of 3-7.5 mg
98
TLS prevention
***Low risk:*** oral hydration and monitor
***intermediate-high risk:***
-BL G6PD
-IV ***Normal Saline*** +/- loop diuretics
-allopurinol 300-400 mg/m2/d (***don’t renally dose for this indication***)
-maybe rasburicase for high risk
Fun facts:
-phosphate binders only decrease dietary phos, not what’s released with TLS- fluids and HD is really all we can do- ***use if phos increase >25%***
-don’t tx asymptomatic hypocalcemia (risk of precipitation with phos). Give ca gluconate if needed
-loop diuretics can be important for fluid overloaded patients- great trick to have up your sleeve
***Dialysis is always last resort for treatment***
99
CNS ppx parenchyma vs leptomeningeal dx
Parenchymal: HD-MTX (not intrathecal)
Leptomeningeal: HD-MTX, IT MTX, IT Cytarabine (could give IT MTX + Cyt + dex)
***in other words- IT does not cover parenchyma dx- so IT only can be risk in some diseases like Burkitts***
100
Early vs late relapse times (ok to repeat initial therapy for late relapse)
***notecard is work in progress***
DLBCL: 12 months
FL: 2 years
Hairy cell: 2 years
AML: 12 months
Adult ALL: 36 months (3 years)
Peds ALL: 36 months (3 years)
Bladder: 12 months
SCLC: 3-6 months (***minus ICI***)!
Melanoma: 3 months
Multiple myeloma: 6 months
101
CAR-T and BiTE indications
***notecard is work in progress***
***DLBCL***
CAR-T:
axicabtagene, lisocabtagene, tisagenlecleucel
BiTE:
-Glofitamab
-epcoritamab
***MCL***
CAR-T:
-brexucabtagene
***multiple myeloma***
CAR-T:
-idelcabtagene vicleucel
-ciltacabtagene autoleucel
BiTE:
-talquetemab
-teclistamab
***ALL***
CAR-T
-tisagenlecleucel
-brexucabtagene
BiTE:
-blinatumomab
***Follicular lymphoma***
BiTE:
-mosunetuzumab
-epcoritamab
***Uveal melanoma***
BiTE:
-tabentafusp
102
Immunoglobulin heavy-chain variable region gene
IGHV
Un-mutated (
103
CLL duration of therapy for BTK-Is, venetoclax, FCR
-BTK: indefinitely
-Venetoclax: 1 year
-FCR: 6 months
104
Priming for CAR-T
5 days prior give lymphodepleting chemo (to allow CAR-T lymphocytes to work but depleting non-CAR-T lymphocytes)
Use FluCy (Fludarabine + Cytarabine)
105
CAR-T b- cell aplasia
May need IVIG for lvls IgG lvl< 400
(This is at least for DLBCB-idk about other diseases)
106
Sunscreen strength
SPF 15+
Reapply every 2 hours- one ounce
If no expiration date- sunscreen is good for 3 yrs (less if left in heat)
107
Hypercalcemia levels: unionized and ionized
Unionized
Mild: 10.5-12
Moderate: 12-14
Severe: >14
Ionized
Mild: 5.6-8
Moderate: 8-10
Severe: >10
108
Prophylactic AC drugs and doses
***Inpatient***
Dalt 5000 QD (5000 q12 or 7500 QD if bmi >40)
Lovenox 40 QD (bid if bmi >40)
UFH 5k q8-12h (7.5k if bmi>40)
Fonda 2.5 QD (avoid if <50k)
***Ambulatory***
***Dalt 200 u/kg x1 then 150 u/k x2 mo***
Lovenox 1 mg/kg x3 mo then 40 mg/d
Apix 2.5 bid
Xarelto 10 qd
Note: Dalt 200 u/kg then 150 u/kg daily is therapeutic dosing as well
Fonda therapeutic dose is:
<50kg: 5 mg QD
50-100 kg 7.5 mg qd
>100 kg: 10 mg QD
109
Which test is used to guide extended endocrine therapy in early stage breast cancer ?
BCI: 5.1-10
110
Why is BRAF used with MEK?
If used alone resistance develops and alternate MEK pathway will be used
111
Who should be screened for RCC?
VHL syndrome- CT or MRI yearly
112
False AFP and HCG elevation causes?
AFP: pregnancy, hepatocellular carcinoma. T1/2 7d
HCG: pregnancy, hypogonadism, marijuana T1/2 3d
113
When to avoid immunotherapy
-Strong hx of autoimmune disorders (e.g., ulcerative colitis)- ***if we’ll controlled you can get immunotherapy with closer monitoring!***
-organ or prior HCT transplant
114
Perioperative chemo
Chemo—>surgery—> chemo
115
Pseudo progression on ICI
Continued growth after 16 weeks can be considered true progression
116
PCR (molecular) vs IHC
IHC: testing for proteins
PCR (molecular): testing for genes
117
cfDNA vs ctDNA
Cell free DNA is cells in general (higher levels on cancer pts bc cells divide more)
Circulating tumor DNA is a subset of cell free DNA from tumor cells
118
Sensitivity v specificity
Sensitivity: low false negative rate (True positive rate)
Specificity: low false positive rate (True negative rate)
119
At what age can you start taking tamoxifen or other meds to decrease risk of BC?
Tamoxifen: 35y/o
Raloxifene: post-menopause (may be better for women with uterus)
AI: 35, (post-menopause)
Gail model 1.7%+
10yr IBIS tyrer cuzick 5%+
LCIS
***Note: duration is 5 years! Don’t confuse with HT therapy for tx of early stage BC which is often 10 years!***
Note: it will only reduce risk of ER+ BC
120
Can you give ESA for anemia ?
Not in myeloid malignancies
Except you can for MDS
121
Nsclc: what can happen when stopping ALK inhibitor
Tumor flare: indicated alk inhibitor is needed
Flare can also occur with ROS-1, RET, and MET
122
Anthracycline metabolism
Hepatic- )but not via cyps)- so don’t use in severe hepatic impairment
Should not need renal adjustment usually- maybe sometimes for daunorubicin
123
Fluoropyrimidine dose adjustments for DPD deficiency
Activity score 2: no change
Activity score 1 or 1.5: 50% decrease
Activity score 0 or 0.5: avoid use or significant dose reduction
124
NSCLC: who doesn’t get immunotherapy?
-EGFR or alk mutations
-autoimmune disorders
125
Cisplatin v Carboplatin in NSCLC
Carbo is often preferred. Cisplatin is curative, carbo better if stage 4 or poor pfs
126
Varenicline pearls
-nausea is bad!
-avoid if brain meds or seizure hx (same with bupropion)
-avoid with MAO-I, tamoxifen, or pts with closed angle glaucoma
127
Hyperviscosity and leukostasis
More with acute leukemias than chronic bc cells are smaller with chronic and less sticky etc.
Can happen with multiple myeloma
128
When are parps used for prostate and ovarian cancer?
Prostate: CRPC (not CSPC)
Ovarian:
-primary maintenance
-secondary maintenance only if ***platinum sensitive***
129
CAR-T and steroids
Generally avoid together. Only add steroids for emergent scenarios (like ICANS, CRS)
No steroid ***3-5 days before or 90 days after***
130
How to dose adjust R-EPOCH
ANC nadir >500: increase dox, cyclo, and etoposide 20%
ANC nadir <500 ***x1-2***: same dose
ANC nadir <500 ***x3+*** or plt nadir <25k: decrease 20%
Don’t adjust vincristine, pred, or rituxan
131
Which PARP-I can be used in early vs metastatic breast cancer?
Early: Olaparib
Metastatic: Olaparib or talazaparib
132
When is DD-AC->T preferred over TC? (Broad strokes)
LN 4+, grade 3, high recurrence score (oncotype) 30+
133
SCLC vs NSCLC immunotherapy
SCLC: atezolizumab or Durvalumab
NSCLC: atezolizumab, pembrolizumab, cemiplimab
134
SCLC vs NSCLC immunotherapy
SCLC: atezolizumab or Durvalumab
NSCLC: atezolizumab, pembrolizumab, cemiplimab
135
Time line to give leucovorin, glucarpidase, and uridine triacetate
-leucovorin: 24-42 hours
-glucarpidase: 48-60 hours
-uridine triacetate: 8-96 hours
136
When is pembro cps/TMB 10+ a thing?
Differentiated thyroid: TMB 10+ (second line)
Gastric/esophageal HER-2 (-): pembro cat 1 of cps 10+
Squamous esophageal subsequent: CPS>10
Metastatic TNBC: CPS 10+
Prostate: TMB 10+
Pancreatic second line: MSI-H/dMMR, tmb10+
137
What type of testicular cancer is usually left over after chemo?
Teratoma- not chemo sensitive
***Always do surgery for residual teratoma***
138
At which age is the total volume of intrathecal medication the same for a child and adult?
3 years (5-10 mL)
Use 5 mL if <3 years old
139
Anticoagulation with BTK-I?
Do NOT use warfarin!
140
What if you need BMA for hypercalcemia but there’s poor dentition?
Don’t wait for dental exam- this is an oncologist emergency
141
Anticoag in enteral feeding tube
Apix/xarelto/Edoxaban
Doacs are absorbed in stomach and proximal small bowel (except Apixaban which has some absorption in the colon)
142
BTK inhibitors: food?
Interactions?
All with or without
Ibrutinib with a large glass of water
Interactions: all are 3A4 substrates, Acalabrutinib capsule with acid suppressive (avoid, separate antacids by 2hr)
143
Spinal cord compression
-dex 4-10 iv qid
-surgery: LE >3 mo, paraplegia <24h, renal cell, melanoma, satcom
-RT: LE <3 mo, neurologic deficit >24h
Note: most commonly seen with lung, breast, and prostate cancer
Also multiple myeloma
144
Non standard premeds (notecard in progress)
-cetuximab- Benadryl
-mosunetuzumab-optional after cycle 2
-Cabazitaxel/paclitaxel- H1, H2, dex
-Glofitamab- drop steroid after cycle 3
-epcoritamab- only steroid after cycle 1, continue steroid x3 d after dose
-Loncastuximab- dex BID x3d starting day before
-amivantamab: : dex is only prior to wk 1 d1-2, then optional
-daratumumab: can omit for SQ starting w/ dose 4; also montelukast
-Amifostine: NS, 5HT3, and dex
-Idecabtagene: APAP/diphen NOT dex
-Dinutuximab: NS, APAP, Benadryl
-rituxan: h1, APAP
145
Rituximab hyaluronidase dosing (notecard in progress)
-DLBCL: 1400 R 23,400 H (5 mins)
-FL: 1400 R 23,400 H (5 mins)
146
Mucositis risk fxs
-tobacco/etoh
-poor oral hygiene
-young or old
-female
-low BMI
-head and neck ca
-prior hx RT and/or chemo
147
Smoking
-increases pulmonary complication
-increased surgical site infections
-poor wound healing
-decreased RT response
-increased RT complications
-effects erlotinib, irinotecan, and bendamustine
Start smoking cessation tx if ***ready to quit within 4 weeks*** or quit within ***past 30 days***
-NRT + SA NRT (gum, inh, spray etc) + behavior therapy x12 wks (cat 1)
-start with ***21 mg patch*** and inc to 35 or 42 mg
-varenicline + behavioral ***x12 weeks*** (cat 1) ***(VERY NAUSEATING)***, no brain Mets (seizures)
-***4+ sessions of at least 3 mins***
-take varenicline even if risk of NMDA contamination per fda
148
Purpose of albumin with ifosfamide
Neurotoxicity prevention
149
Exogenous pancreatic lipase
-500 u/kg/meal or 1000 u/kg/d or 25-75k/meal and half for snacks
-max 10,000 u/kg/d
-day **with or after*** meal, NOT before!
-NCCN recs half at start of meal and half in the middle
150
Peds genetics
-Wilms: LOH 1p and 16q (poor prognosis)
-Ewings: t(11;22), EWS-FLI1 gene fusion-diagnostic
-retinoblastoma: RB1 mutation at chromosome 13q15
151
Irinotecan vs 5FU myelosuppression
Irinotecan is worse
152
When to start mammogram for breast cancer screening after RT?
8 years after or age 25, whichever occurs ***LAST***
153
When to do lumbar puncture screening for CNS dx in AML
-CNS symptoms
-at first remission prior to consolidation in the following: monocytic differentiation, mixed phenotype acute leukemia, wbc >40K at diagnosis, high risk APL, flt-3, extramedullary dx
154
Testicular cancer induction
Sometimes give half a cycle or 50% reduced dose as induction when there’s is high dx burden and need urgent chemo
Can follow with full dose “cycle 1” 10-14 days later (as opposed to 21 days later)
155
Things where high risk/severe stands alone
-APL
-venetoclax TLS risk (LN >5 cm AND ALC >25, or LN >10 cm)
-radiation recall
156
3a4 inhibitor effect on AUC
Strong: 5 fold inc
Moderate: 2-5 fold inc
Weak: 1.25-2 fold inc
157
DIPG
Poor prognosis and spreads through ventricles
Diffuse intrinsic pontine glioma
158
Preferred HMA in ESRD
Decitabine
159
Germinal vs non-germinal B cell lymphoma
Germinal is easier to treat
160
ABC vs gbc lymphoma
Better outcomes with GBC
Note: Pola-R-CHP probably should only be used in ABC
ABC more associated with PCNSL
161
Who do we know CML treatment is or isn’t working ?
Should have hematologic remission in 3-6 months
162
Most likely cancer to have bone Mets
-breast
-prostate
-lung
-osteosarcoma
163
Predictive marker
Predicts a response or resistance Ti a treatment.
If it says “this mutation was not associated with a response” that’s not predictive
164
Types of bias
Selection: inclusion/exclusion criteria does not match real world population of interest
Misclassification: structured definitions
Allocation: randomization/stratification
Compliance: for oral medications
Attrition: reasons for discontinuation
Measurement: how were tests performed
Confounding: stratification
165
FOLFOXIRI vs folfirinox
FOLFIRINOX VS mFOLFIRINOX
***FOLFOXIRI HAS HIGHER CINV DOSE (3200 mg/m2)- idk if below points are even true***
Folfirinox has 5FU bolus and FOLFOXIRI doesn’t
Folfirinox has higher dose of irinotecan (180 mg/m2), compared to 165 mg/m2
***modified vs standard***
-mFOLFIRINOX has low irinotecan dose (150 mg/m2 rather than 180mg/m2)
-mFOLFIRINOX has no 5FU push
166
Goals of phase 1 study
Phase 1: max tolerated dose, dose limiting toxicity
-starting dose is 1/10th of LD10
167
Folic acid vs leucovorin (folinic acid)
Leucovorin restores the blockade of purine synthesis but folic acid does not (this is why we use it for HD-MTX but not folic acid)
Folic acid acid is used for non-oncology indications bc MOA is likely different but folic acid is still being depleted so we want to replace this
168
What is the role of the steroid is treating infusion reactions
It prevents delayed reaction, it does not provide immediate benefit (use h1 and h2 for immediate benefit)
169
When would you not give BMA in a patient with bone Mets?
CSPC
Note: can still do osteoporosis dosing as indicated for pts on ADT based on FRAX and DEXA
170
Which type of cervical cancer is more aggressive?
Adenocarcinoma or adenosquamous have much worse prognosis than squamous cell
171
When is HER-2 given or not given in early stage breast cancer?
Give if chemo is also given (don’t give without chemo)
Generally we will always do chemo + HER-2 for HER-2 positive unless small tumor and LN negative, then we may be less aggressive if we want
172
Deciding between Bispecific and car-T in R/R myeloma after 4 lines
If they have very short relapse we need something quicker so would pick Bispecific
173
BMA in multiple myeloma
All patients getting primary therapy for multiple myeloma should be given BMA x2 years
(So DONT need bone Mets!!)
174
Cut offs to check for nephro or hepatotoxicity of drugs if there are no dosing adjustments in labeling
Crcl<60
AST/ALT >75
175
VTE ppx for indwelling catheter
NO!
176
Health economic evaluation
Cost minimization: same result/benefit- which one is cheapest (different manufacturers of the same BP drug)
Cost effectiveness: evaluates the same outcome with different interventions and compares the cost to benefit ratio (wt loss program vs pill). Uses “natural units-“- eg blood glucose)
Cost utility: different health outcomes, looks at QALYS
Cost benefit: compared cost AND outcomes in monetary terms ($), (direct and indirect costs)
177
Which sarcomas spread through LN (as opposed to blood)?
SCARE
Synovial, clear cell, angio, rhabdo, epithelioid
178
Which CAR-T have increased risk of CRS?
-Axicabtagene
-Brexucabtagene
179
Why is bevacizumab not used in squamous cell lung cancer?
Increased risk of bleeding
180
A few random CINV drug reactions
-lorazepam + posaconazole
-Olz + IV BZD (use po instead)
181
APL management of bleeding complications
-PLT transfusion to goal of 30-50
-cryoprecipitate to goal fibrinogen of 100-150
182
When do PARP inhibitors come into play in prostate cancer?
Not until metastatic castration RESISTANT!
183
PSA false readings
Finasteride/dutasteride: false low
Saw palmetto: variable
Androgen blockers: false high
Ejaculation: false high
Prostatic manipulation: false high
184
mFOLFOX6 vs mFOLFOX7
6 has a 5FU push (not just CINV like 7)
185
ABVD effect on fertility
Doesn’t affect women’s fertility but may effect male fertility
186
Weird sign of Hodgkin’s lymphoma
-Itching/pruritis
-pain in LN after etoh consumption
187
Can you use prednisone with immunotherapy?
Doses less than 20 mg can be used (so probably just 10 mg)
188
Why is prednisone given with docetaxel in Prostate cancer?
Slows growth of prostate cancer cells by decreasing testosterone production in the adrenal gland
189
Which doac is pts needs to be in apalutamide or enzalutamide (daralutamide not covered maybe)
Use edoxaban or dabigatran
(Instead of Apixaban or rivaroxaban)
