Therapeutics Exam 2 (Weddle/Scott) Flashcards
(238 cards)
1
Q
Etiology of N/V: GI Disorders (like a bunch) CNS Disorders (\_\_\_\_\_\_,\_\_\_\_\_\_\_,\_\_\_\_\_\_) Pain (acute or chronic) Pregnancy GI intake (excessive intake of \_\_\_\_\_ or\_\_\_\_\_)
A
CNS: anxiety, tumors, Headaches/migraines
Intake: intake of food or alcohol
2
Q
Etiology of N/V: Pregnancy --- 80% of pregnant women begins \_\_\_\_th - \_\_\_\_th week after last menstrual period usually resolves by \_\_\_th week
A
4th - 7th;
20th week
3
Q
what is hyperemesis gravidarum
A
continue to have issues with N/V and so much that the mom starts to lose weight (baby is at risk)
4
Q
What are some treatment induced causes of nausea and vomiting \_\_\_\_\_ agents \_\_\_\_\_ therapy \_\_\_\_\_\_ \_\_\_\_\_\_ NV associated with \_\_\_\_\_\_\_
A
ANP agents (anti-neoplastic) Radiation therapy opioids anesthesia assoc. with procedures
5
Q
Complications of N/V
A
PATIENT DISCOMFORT
dehydration
malnutrition
aspiration pneumonia (puke in the lungs –> infection)
Anxiety (anticipatory NV)
Compromise therapy (decrease chemo bc NV so bad)
DECREASED QOL
6
Q
Ways to Assess N/V
A
of episodes
onset
duration
severity of nausea (like pain scale: 0 - 10)
7
Q
what are the 4 inputs/influences of the vomiting center
A
coretx
CTZ/dorsal vagal complex
GI
Vestibular (motion!)
8
Q
Diseases that can cause N/V? (5?)
A
Metabolic disease neurologic disease GI disease genitourinary related to pregnancy
9
Q
Pathophys of N/V
site of drug actions?
A
dopamine receptors histamine receptors muscarinic receptors serotonin receptors neurokinin receptors
10
Q
Non-PCOL management of N/V
A
determine cause and put the gut to rest (clear liquids and IV hydration) dietary physical
11
Q
what are the dietary PCOL therapy options for N/V
A
avoid fatty, spicy, fried, sweet foods
odors could wreck them
12
Q
what are some physical PCOL therapy options for N/V
A
fresh air avoid sudden movements dim lights acupressure 3 fingers above the wrist
13
Q
drug therapy for N/V
what drugs are antihistamines/anticholinergics
A
meclizine
dimenhydramine
scopolamine
14
Q
MOA of antihistamines/anticholinergics
A
blocking histamine and muscarinic receptors in CTZ and vomiting center
15
Q
drug therapy for N/V
what drugs are phenothiazines
A
prochlorperazine
promethazine
chlorpromazine
16
Q
drug therapy for N/V
what drugs are serotonin antagonists
A
"-setrons" ondansetron granisetron palonosetron dolasetron
17
Q
ADEs of meclizine, dimenhydramine, scopolamine
A
antihistamines/anticholinergics
cause drowsiness and sedation and dry mouth and constipation and blurred vision and confusion
18
Q
ADEs of ondansetron and other “-setrons”
A
are serotonin antagonists
mild HA, dizziness, fatigue, constipation, QT prolongation
19
Q
MOA of phenothiazines
A
dopamine inhibition at CTZ
20
Q
ADEs of promethazine, chlorpromazine, prochrorperazine
A
dizziness, sedation, dry mouth, hypotension, EPS!!!!
21
Q
what serotonin antagonist has a long ass half life (40 hours)
A
palonosetron
22
Q
what serotonin antagonists are super pricey vs which ones are cheap boys
A
cheap: ondansetron, granisteron
pricey: dolasteron, palonosetron
23
Q
which serotonin antagonist has NO oral dosage form
A
palonosetron
24
Q
biggest disadvantage with serotonin antagoinsts
A
no suppositories!!
25
what are the more odd types of serotonin antagonists dosage forms
sancuso (granisetron) - PATCH
Sustol (granisertron) ER injection
26
what drugs are butryophenones
haloperidol and droperidol
| not used for N/V a lot
27
biggest ADEs of haloperidol and droperidol
EPS and QT prolongation!!
| will also see sedation and hypotension
28
what is the MOA of olanzapine
blocks D2, 5-HT2C, and 5-HT3 receptors
29
main side effect of olanzapine
sedation
30
what drugs are neurokinin antagonists
"-pitants"
aprepitant
fosaprepitant
rolapitant
31
ADEs of aprepitant, fosaprepitant, rolapitant?
neurokinin 1 antagonists
fatigue, HICCUPS, constipation, decrease appetite
32
Neurokinin antagonists are indicated for what kind of nausea and is not indicated for?
indicated for BOTH acute and delayed
not indicated as monotherapy
*rolapitant is indicated only for delayed though
33
Sancuse (granisetron) patch:
apply when?
may be worn for how long?
avoid _____ to site for up to 10 days
apply 24 - 48 hours BEFORE chemo
wear for up to 7 days
avoid sun exposure to site!
34
dosing schedule for aprepitant
oral agent:
one dose on day 1; and
then doses on days 2 and 3
35
dosing schedule for fosaprepitant
one dose IV on day 1
36
dosing schedule for rolapitant
one dose 1 -2 hours prior to chemo
37
benzos are especially helpful for what kind of NV
anticipatory
38
MOA of metoclopramide?
dopamine inhibition and serotonin inhibition (at high doses!)
39
ADEs of metoclopramide
EPS!! drowsiness, sedation, diarrhea, restlessness, agitatin
40
how to prevent EPS?
benadryl
41
what s the hardest NV to treat?
delayed
42
Factors affecting CINV:
| Females or males are more susceptible?
Females
43
Factors affecting CINV:
| EtOH intake effect?
pts with chronic EtOH intake will have less N/V
44
Factors affecting CINV:
| prior chemo?
if NV was not controlled well before --- they will have increase NV risk
45
Factors affecting CINV:
| personality?
anxious personality
46
Factors affecting CINV:
| predisposed NV?
if previous motion sickness....
47
what chemo agent has high risk of single IV ANPs
cisplatin
48
For preventing acute CINV:
always treat when risk is _______
always use ____ therapy whenever possible
mod to high risk
| PO therapy --- it is cheaper
49
Dosing time if IV or oral in relation to ANP admin?
if IV - give 30 mins before
| if PO - give 60 mins before
50
if high emetic risk: use how many drugs and what classes (per Scott)
```
4 drugs....
5-ht3 antagonist
NK 1 receptor antag
Dexamethasone
olanzapine
```
51
if moderate emetic risk: use how many drugs and what classes (per Scott)
2 or 3 drugs
5-ht3 antagonist
NK 1 receptor antag
Dexamethasone
or
5-ht3 antagonist (on day 1)
Dexamethasone (on day 1)
52
Treating motion sickness:
| _______ is key
prevention
53
what are the three main options for treating motion sickness
Scopolamine
Dimenhydrinate
Meclizine
54
the scopolamine patch for motion sickness should be applied about _____ hours before and will last for _____ hours
24 hours before
last 72 hours
55
Take dimenhydrinate needs to be taken _____ before needed
30 - 60 mins
56
Take Meclizine needs to be taken _____ before needed
30 - 60 minutes
57
how long will meclizine last
4 hours
58
how to prevent low emetic risk CINV
single dose of
dexamethasone 8 mg PO
or
5-HT3 antag
59
how to prevent CINV with minimal emetic risk drugs
do not do a routine anti emetic therapy -- just do PRN
60
CINV:
| complications?
dehydration
electrolyte abnormalities (low K+)
fatigue
depression
61
CINV:
| Acute vs Delayed N/V? (time frame)
acute < 24 hours of getting chemo
delayed > 24 hrs after getting chemo
62
CINV - Pathophys:
| ______ cells lining the GI tract contain large stores of ______ and is released in massive quantities after chemo
enterochromaffin; stores of serotonin
63
CINV - Pathophys:
| when serotonin gets to the ______ it stimulates the ______ center
chemoreceptor trigger zone (CTZ);
| vomiting center
64
what are the main neurotransmitters implicated in CINV?
dopamine, histamine, acetylcholine, serotonin, substance P
65
what neurotransmitters are not MAJOR targets for CINV but reserved more for refractory or breakthrough
histamine and acetylcholine
66
Combo chemo and CINV:
| Levels ____ do not contribute to the emetogenicity of the combo
1 and 2 (minimal and low)
67
Combo chemo and CINV:
| adding levels ______increases the level of emetogenicity by ____ level
levels 3 and 4 (moderately)
| increase by 1 level
68
Common toxicities of CINV drugs:
| Serotonin antagonists
HA
asymptomatic/transient EKG changes - QT
constipation
increased transaminases
69
Common toxicities of CINV drugs:
| Corticosteroids
short term: anxiety, euphoria, insomnia, hyperglycemia, increased appetite
70
Common toxicities of CINV drugs:
| Substance P antagonists
hiccups
| DRUG INTERACTIONS
71
Common toxicities of CINV drugs:
| dopamine antagonists
EPS, diarrhea, sedation
72
Common toxicities of CINV drugs:
| phenothiazines
sedation
akathisia
dystonia
73
Common toxicities of CINV drugs:
| cannabinoids
```
drowsiness
dizziness
euphoria - mood changes
hallucinations
increased appetite
```
74
what drugs can be used for breakthrough N/V (weddle)
```
Lorazepam
Dronabinol/Nailone
serotonin antagonists (dolas,granis, ondans)
dexamethasone
scopolamine
haloperidol/metoclopramide
olanzapine
prochlorperazine/promethazine
```
75
drugs for delayed N/V (weddle)
```
Dexamethasone
Aprepitant
Metoclopramide
lorazepam
diphenhydramine
```
76
actions to do for anticipatory N/V
prevention
behavioral
alprazolam/lorazepam
77
what are some behavioral actions for anticipatory NV
relaxation
hypnosis/guided imagery
music therapy
acupuncture/acupressure
78
Mucositis:
| can affect what part of the body?
entire length of the GI tract from top to bottom
79
Mucositis course parallels the _______
neutrophil nadir
80
Mucositis begins ~ on days ______ after ____
5 - 7; after chemo (max at 10 - 14 days...)
81
Mucositis will improve as __________ increases
neutrophil count
82
Risk factors for Mucositis?
pre-existing oral lesions
poor dental hygiene/ill fitting dentures
pts getting chemo and radiation
83
Diet recommendations of Mucositis?
Avoid rough foods: salt, spicy, acidic
eat soft or liquids foods
AVOIDING smoking and alcohol
84
General Mouth Care Strategies?
salt/soda rinses BID - QID
soft bristled toothbrush
saliva substitute for radiation induced xerostomia
85
Main ways to manage the pain of Mucositis?
topical anesthetics (marys magic -lidocaine/antacids..)
Oral cyrotherapy (ice chips!)
Sucralfate (soothing and coating agent)
oral or parenteral opioid analgesics
86
Neutropenia?
low WBCs (<0.5 x 10^9)
87
if WBCs are low - pts are at risk of what?
infections
88
if pt has thrombocytopenia - they are at risk of?
have low platelets therefore risk of bleeding!
89
if pt has low RBCS - the patient is at risk for?
hypoxia and fatigue and anemiaaaa
90
normal ranges of WBCs/platelets/RBCs?
WBC: 4.8 - 10.8 x10^9/L
Platelets: 140 - 400 x10^9/L
RBCs: 4.6 - 6.2 x10^6/uL
91
definition of Nadir?
the lowest value of blood counts fall to during a cycle of chemotherapy
(lowest ANC = absolute neutrophil count)
92
ANC = ? (what eq'n)
WBC x % granulocytes (segs +bands)
93
To give a pt chemo their levels must be what?
WBC:
OR
ANC and Platelet?
WBC: > 3 x10^9/L (WBC > "3000(
| ANC > 1.5 x10^9/L AND Platelet > 100
ANC > 1500; Platelet > 100,000
94
Severe neutropenia defined as?
<0.5 x 10^9/L
95
Febrile Neutropenia defined as?
ANC < 0.5 x10^9/L
| AND a single oral temp > 101 F or >100.4 for at least an hour
96
CSFs (colony stimulating factors) used prophylactic following chemo has demonstrated what benefits?
decreased incidence of febrile neutropenia
decreased length of hospitalization
decreased confirmed infections
decreased duration of abx
97
who should be treated with CSFs because of primary prophylaxis of febrile neutropenia
high risk pts!
those pts would be preexisting neutropenia due to disease
extensive prior chemo
previous irradiation to the pelvis/areas containing large amounts of bone
98
should you treat febrile neutropenia with CSFs?
Nooooo.only do it if they are very sick
99
Other uses for CSFs:
support pts getting ______ chemo
after a ______ transplant to reduce duration of severe neutropenia
dose dense chemo!!!
use after stem cell transplant!
100
Other uses for CSFs:
| used alone or in combo, after chemo, with plerixafor to mobilize ____________
peripheral blood progenitor cells
101
what drugs are CSF
Filgrastim
Pegfilgrastim
Sargramostim
102
Filgrastimvs Pegfilgrasim:
| which one has a longer 1/2 life
pegfilgrastim
103
Filgrastimvs Pegfilgrasim:
| which one is 3 -5 days of doses and which one is 1 day
3-5 days: filgrastim
| pegfilgrastim: 1 dose
104
Pegfilgrastim PK?
non -linear PK;
| clearance increases w/ increasing neutrophil count
105
what is Neuplasta?
an on body injector that gives CSF's the day after chemo
106
dosing of Filgrastimvs Pegfilgrasim:
Filgrastim WT BASED!!! booo
| peg: 6 mg SQ x 1 dose
107
Filgrastim Dosing:
| dosing conundrum?
vials come in only 300 or 480 mcg single vials
| round to nearest vial size!!!
108
ADEs of filgrastim
flu-like sxs
bone and joint pain (give loratadine --- histamine release based pain)
DVT
rare: spleen enlargement
109
Thrombocytopenia:
| do not treat until the platelet count is below _____
<20 x10^9/L;
| <10 x 10^9/L`
110
how is thrombocytopenia treated?
typically transfusions
| but can also use oprelvekin (interleukin 11) --- not used tho
111
General causes of anemia?
decreased RBC production (cancer therapy/tumor infiltration into bone marrow)
decrease EPO production
Decrease body stores of vit. B12, iron, folic acid
blood loss
112
Chemotherapy and Anemia:
| pts with a Hgb < _____ or a drop > than ______ from baseline should undergo a work up
< 11
> 2
113
Chemotherapy and Anemia:
| if a pt is symptomatic -- do what?
transfuse as indicated
consider use of ESA
perform iron studies
114
Black box warnings of ESA?
short overall survival if the target Hgb is > 12
115
typically ESAs are not recommended but who would you consider it with?
if pt and CKD
if pt going under palliative chemo (aka like metastatic??)
pt w/out other identifiable causes
116
Chemotherapy and Anemia:
ESA vs transfusion
which one has faster onset
transfusion
117
what drugs are ESAs
Epoetin
| darbepoetin
118
Epoetin vs darbepoetin:
| which one has a longer half life
darbepoetin
119
Epoetin: typically given every ______
Darbepoetin: typically given every ______
E: every week (once a week)
D: every 3 weeks
120
to give an ESA: must do an _____ study
iron
| ESAs won't do shit if there is no iron present
121
iron absorption will DECREASE if food is eaten ____ hours before or _____ hours after ingestion
2 hours before
1 hour after ingestion
122
which IV iron has a required test dose
iron dextran
123
Classic Chemo Toxicities:
| if they get myalgias/arthralgias - what to treat it with?
NSAIDs
| Pts may require opioids
124
Classic Chemo Toxicities:
| if they get hemorrhagic cystitis- what to treat it with?
MESNA!! (used to prevent)
| Hydration (prevention)
125
Classic Chemo Toxicities:
| if they get heart failure - what to treat it with?
monitor for cumulative dose
assess for risk factors
DEXRAZOXANE (chemoprotectant -- more for anthracyclines)
126
Classic Chemo Toxicities:
| if they get peripheral neuropathy - what to treat it with?
change infusion rates
| adjunctive pain medications
127
Classic Chemo Toxicities:
| if they get pulmonary toxicites- what to treat it with?
corticoidsteroids (no good tx once it happens :( )
128
```
Type I Chemo Related CARDIAC Dysfunction:
ACUTE
is seen with the ______ drug class
is like a ______
not common
occurs _______after a dose
rarely is _______ observed
```
seen w/ anthracyclines
like a MI
occurs immediately after a dose
rarely is pericarditis/CHF seen
129
```
Type I Chemo Related CARDIAC Dysfunction:
CHRONIC
onset usually seen when?
IS common
related to _____ dose
(reversible or irreversible?)
```
with a year of getting anthracycline therapy
cumulative
IRREVERSIBLE
130
Type I Chemo Related CARDIAC Dysfunction:
LATE ONSET
occurs more often in who?
seen more in childhood/adolescence cancer survivors who received anthracyclines
131
Type II Chemo Related CARDIAC Dysfunction:
| is seen with that drug class?
HER 2 targeted therapies
| ex: trastuzumab
132
Type II Chemo Related CARDIAC Dysfunction:
| reversible or irreversible
reversible
133
Type II Chemo Related CARDIAC Dysfunction:
| how to treat?
stop the HER2 target drug -- give CHF drugs --- restart HER2 drug and keep on CHF drugs!!
134
Classic Chemo Toxicities:
| what drugs would cause myalgia/arthralgias (weddle - from table)
paclitaxel/docetaxel
anastrozole/eltrozole
exemestane
135
Classic Chemo Toxicities:
what drugs would cause hemorrhagic cystitis
(weddle - from table)
high dose cyclophosphamide
| ifosfamide
136
Classic Chemo Toxicities:
what drugs can cause heart failure
(weddle - from table)
antracycylines
high dose corticosteroids
trastuzumab
137
Classic Chemo Toxicities:
what drugs can cause peripheral neuropathy
(weddle - from table)
taxanes
vinca alkaloids
(microtubule boys)
138
Classic Chemo Toxicities:
what drugs can cause pulmonary toxicity
(weddle - from table)
bleomycin
139
Breast Cancer Epidemiology:
| Risk of breast cancer ______ with age
increases
140
Breast Cancer Epidemiology:
| decreased in _______ therapy has contributed to the decrease in mortality based on results from the WHI
decrease HRT (hormonal replacement therapy)
141
Breast Cancer Risk Factors:
| more than ____% of pts will NOT have any risk factors
60%
142
Breast Cancer Risk Factors:
| family history?
of 1st and 2nd degree relatives with disease has increased risk
143
Breast Cancer Risk Factors:
| estrogen?
endogenous exposure (aka early menstrual cycle start or late menopause)
or exogenous estrogen (oral contraceptives/HRT)
144
Breast Cancer Risk Factors:
Personal history of cancer or radiation are risk factors
usually what are the causes for radiation exposure?
prior tx for lymphoma w/ mediastinal?? or environmental radiation exposure
145
Breast Cancer Risk Factors:
| _____ because mechanism thought to be due to decreased hepatic metab of estrogen
alcohol
146
Breast Cancer Risk Factors:
| prior breast biopsies w/ __________
proliferative histology
| atypical hyperplasia, fibroadenomas, previous breast cancer
147
Breast Cancer Risk Factors:
| risk factor related to children?
if nulliparity (no kids) or if first childbirth is after 30 yrs = increased risk
148
Breast Cancer Risk Factors:
| related to height and weight?
if increased height and weight
149
Breast Cancer Risk Factors:
| diet?
asian based diet = less risk
150
Breast Cancer Genetics:
only a small part (5-10%) of breast cancers are familial but when the _____ gene has a mutation then there is a laaarge increased risk
BRCA1 or 2 gene (a tumor suppressor gene)
151
the _____ risk model is a risk assessment tool to determine ______ in % of developing breast cancer compared to an age matched control
GAIL risk;
| RR (relative risk)
152
Breast cancer screening:
______ exams have been removed from the screening guidelines
*but _____ is exam is considered an important discussion w/ women starting age 20
breast self exams and clinical breast exams
| women should know what is normal and what is not
153
Breast cancer screening: ACS recommendations for a mammogram
40 - 44 y.o: opportunity for annual exams
45 - 54 y.o: annual mammograms
> 55: every other year mammograms or the opportunity for annual exams (if good health and > 10 years life expectancy)
154
Breast Cancer Prvention:
High risk patients (ex: with ______ mutations) may get risk reduction surgeries
what are these risk reduction surgeries
BRCA mutations
prophylactic mastectomy; bilateral oophorectomy
155
The breast cancer risk reduction surgeries --- are they 100% effective??
hell nah,
| buut mastectomy can reduce risk by like 90% and oophorectomy can decrease risk by like 50%
156
what 3 drugs have been studied for prevention of breast cancer
tamoxifen (P1 trial)
raloxifene (MORE trial/P2 (aka STARtrial))
exemestane
157
The trial (P1) finding out if tamoxifen was effective in reducing breast cancer risk showed what positive or negative events
positive: decreased risk in invasive/noninvasive breast cancer!! AND decreased skeletal events
negative: increased endometrial cancer; increased stroke/PE/DVT
158
STAR trial P2 trial demonstrated that _______ was as effective in ______ in decreasing breast cancer reduction
raloxifene is as effective as tamoxifen in breast cancer reduction
159
Pros and Cons of raloxifene (compared to tamoxifen)
Pros: fewer uterine cancers and fewer blood clots
cons: there was an increased risk of non-invasive cancers compared to tamoxifen????
160
AIs (aromatase inhibitors) are they effective in reduction and are they reasonable options for breast cancer prevention in post menopausal
yes -- seen to be effective
but not currently FDA approved for PREVENTION
may be used in high risk pts
161
breast is composed of what things?
ducts, lobules, fatty tissue, connective tissue, and lymph nodes!
(lots of lymph nodes aka lots of opportunities of where it can spread)
162
two main kinds of breast cancer
Invasive and non invasive (in situ) carcinoma
163
Invasive breast cancer has invaded beyond the _______ of the ____ or _____
beyond basement membrane
of duct or lobule
164
subtypes of invasive breast cancer
IDC and ILC
IDC = invasive ductal carcinoma
ILC = invasive lobular carcinoma
165
subtypes of non-invasive breast cancer
DCIS and LCIS
DCIS: ductal carcinoma in situ
LCIS: lobular carcinoma in situ
166
most common two types of breast cancer?
IDC and ILC!!
IDC ~ 750%
ILC ~ 15%
167
DCIS: seen as _______ in a mammogram
microcalcifications
168
there is invasive and non-invasive breast cancer -- what is the 3rd type?
inflammatory
169
inflammatory breast cancer:
| ______ form of breast cancer with ____onset and _____ prognosis
aggressive;
rapid onset;
poor prognosis
170
what would the pts breast look like/present like?
"orange peel"/peau d'orange
edema/redness
warmth/inflammation
171
why usually a delayed in diagnosis in inflammatory breast cancer?
ppl think it is cellulitis
172
```
Typical Presentation of breast cancer pts
most patients (90%) present with a ________ lump in the breast
```
(most women detect lesion by themselves with self exam)
a painLESS lump (less than 10% will have pain as 1st symptom)
173
Typical Presentation of breast cancer pts
what are some other presentations of breast cancer?
(other than a painless lump)
nipple discharge/rertaction/ or dimpling
174
diagnosis of breast cancer?
Clinical breast exam/mammogram (maybe ultrasound)
Hx and PE (physical exam)
Core biopsy!!! (gold standard)
surgical biopsy
fine needle aspiration
175
what are the qualities/results/pathyology do you see from a biopsy
```
tumor size
invasiveness
tissue type
differentiation
nodal involvement
ER/PR+ (hormonal receptor status)
HER2 Neu status
```
176
two ways to test for HER2?
FISH!! (fluor in situ hybridization)
| immunohistochemistry (detects protein expression)
177
ways to stage a tumor?
TNM shiiit
178
Oncotype DX :
| if high risk, medium risk, or low risk --- what kind of therapy??
high risk: chemo + endocrine
medium: NO CHEMO! - just endocrine (decided after a trial )
low: hormonal therapy only
179
Adjuvant vs neoadjuvant
adjuvant: after surgery
neoadjuvant: before surgery
180
If pt has stage 0 breast cancer and it is LCIS what are the general treatment strategy options
1 - observe
or
2 - use tamoxifen or aromatase inhibitors
or
3 - consider bilateral masectomies (reconstruction?)
(not considered risk factor invasive disease)
181
If pt has stage 0 breast cancer and it is DCIS what are the general treatment strategy options
1 - lumpectomy followed by radiation therapy
or
2 - total mastectomy +/- reconstruction
or
3 - lumpectomy alone
4 - consider endocrine therapy if pt has ER/PR + disease
182
what is a lumpectomy ?
"breast conserving surgery" -- just taking out the lump/tumor
183
the goal for all stages of breast cancer is to ______
except for the stage of _____ the goal is ________
goal is to cure! stages 0 - 3
stage 4 = stabilize the disease
184
If pt has stage I, II, or IIIA breast cancer - what are the general treatment strategy options
breast conserving surgery(aka lumpectomy) + radiation therapy
or MRM (modified radical mastectomy) +/- radiation therapy
*some stage II or IIIA may get NEOadjuvant (before surgery to shrink tumor)
MOST women get adjuvant therapy (after surgery) either chemo, hormonal +/- biologic therapy
185
If pt has stage IIIB and IIIC breast cancer - what are the general treatment strategy options
most women have neoadjuvant chemo follow by MRM or lumpectomy
adjuvant therapy as appropriate
186
morphine: renal or liver function need to be considered before use?
yes- both!!
187
hydromorphone: renal or liver function need to be considered before use?
yes! both!!
188
what pain med does not have an IV formulation
oxycodone
189
what pain med is good because there are no renal or liver issues
fentanyl
190
what drug should not be used in a opioid naive person
fentanyl!! (potent as hell)
191
```
Methadone should be avoided in pts because of what 4 reasons?
Numerous ________
Risk for __________
History of ________
Poor ________
```
numerous drug interactions (QTc prolongation!!)
risks of syncope or arrhythmias
hx of unpredictable adherence
poor cognition
192
for methadone pts need a baseline ______
EKG because of QT prolongation
193
the half life of methadone is ______
unpredictable!!
194
Methadone:
typically ok in ______ dysfunction
but should be avoided in severe ______ dysfunction
ok in renal
avoid in liver
195
Toxicities and management of Opioids:
| if constipation - what to do?
add a bowel regimen! (always do this!!)
| mild stimulant laxative and stool softener!!
196
Toxicities and management of Opioids:
| if sedation - what to do?
tolerance will develop within a few days
hold sedatives or anxiolytics
consider dose reduction
197
Toxicities and management of Opioids:
| if N/V - what to do?
change opioid
consider adding scheduled anti-emetic therapy
(metoclopramide or prochlorperazine)
(this side effect can go away usually around 7 - 10 days)
198
T or F: patients will develop a tolerance for constipation when on pain meds
FALSE!! add a bowel regimen!
199
Pruritus is seen most with _______
| what pain med
morphine
200
Toxicities and management of Opioids:
| if pruritis - what to do?
seen most with morphine..
change opioid or decrease dose
consider adding an antihistamine (benadryl)
201
Toxicities and management of Opioids:
| if hallucinations/confusion/ or delirium - what to do?
decrease dose or change opioid
| consider adding a neruoleptic med
202
Toxicities and management of Opioids:
| if myoclonic jerking - what to do?
may be a sign of toxicity
| consider changing opioid or treating underlying cause
203
Toxicities and management of Opioids:
| if respiratory depression - what to do?
hold the opioid!!!
(sedation will precede resp. depression)
give LOW DOSE naloxone!!!!!! (if on opioids for chronic pain)
(do not give large rescue amounts --- do not want to take away all the pain)
204
what is the celiac plexus
group of nerves that supply organs in the abdomen
205
celiac plexus block is usually helpful in patients that have______ cancer
pancreatic
206
Intrathecal pain pumps are good for pts who??
pts who are refractory to other opioid therapy or increased toxicites
or pts that gave more toxicities than benefit from traditional opioid therapy
207
On-Q pump?
LOCAL pain relief
208
adjuvant pain therapy alternatives?
dexamethasone/NSAIDs
| remember neuropathic pain!
209
T or F: it is ok for pts on opioids to use their opioids for anxiety and depression/for sleep
Falseeee
210
if patients has stage IV breast cancer
the goal is _________
therapy will primarily consist of _____ and _______
______ typically only used for symptomatic relief
Radiation is used sometimes for palliation
goal = stabilize the disease
therapy = chemo and hormonal therapy
surgery for symptom relief...
211
T or F: radical mastectomies are not really used anymore
TRUE!
| surgery has increased morbidity assoc. with it
212
different between radical mastectomy and MRM (modified radical mastectomy)
radical: major and minor pectoralis
| MRM: jus minor pect.
both will do nodes and breast
213
Lumpectomy is usually done with _____ therapy
| *may not do that therapy in pts who are ______
radiation
over 70 y.o
214
breast cancer patients typically get neoadjuvant therapy have a _____
large tumor (> 1 cm)
215
Breast cancer pts will get chemo if they have what 2 characteristics?
```
large tumor (> 1 cm)
or lymph node positive
```
216
adjuvant hormonal therapy options for breast cancer
Surgical ablation (oopherectomy)
SERMs
LHRH analogs
AI's (aromatase inhibitors)
217
LHRH analogs will decrease the hormone levels in about _______ (how long)
2 - 4 weeks
218
AI's or LHRH analogs are used only in postmenopausal women
AI's!!!
| i think you can give LHRH analogs in premenopausal women and "make" them post menopausual???
219
If a women with breast cancer is postmenopausal what is the first line/best option for hormonal adjuvant therapy
AI's for 5 YEARS then another 5 years...
(best ADE profile!)
*dont forget the cancer must be ER+!!
220
If a women with breast cancer is premenopausal what is the first line/best options for hormonal adjuvant therapy
Tamoxifen for 5 years then another 5 year or
????
AI x5 then more Ai x5 or T x5 ???
221
adjuvant therapy of trastuzumab for adjuvant therapy in breast cancer is typically done for _______ (how long)
```
1 year
(no benefit seen to do it longer)
```
222
Adjuvant chemo in breast cancer:
| durations longer than ________ do not appear to improve survival
3 - 6 months
223
Breast cancer patients may get neoadjuvant therapy if ________
tumor is big > 1 cm
224
if giving dose dense anthracyclines (can be done in breast cancer pts) --- you must give ________
CSFs!! (bc neutropenia risk is high af)
225
most common adjuvant chemo for breast cancer
doxorubicin (CARDIOTOX!!) and cyclophosphamide
| aka the "AC" chemo
226
was seen that giving _____ after doxorubicin and cyclophosphomide has improved outcomes in pts with LN + disease (in breast cancer lecture)
paclitaxel
| can give this dose dense! weekly but lower dose!
227
```
For treating metastatic breast cancer:
if ER/PR +
Bone Metastasis
Asymptomatic
Visceral
```
what to do?
Hormone therapy!!
since bone disease - do bisphosphonate or denosumab
(bone metastasis tend to have better prognosis - do not bed to be aggressive with chemo)
OR send them to a clinical trial
228
pre-treat pts getting paclitaxel with what?
reduce SENSITIVITY RXNS with:
bendaryl
dexamethasone
famotidine (H2 blocker)
229
doxorubicin or cyclophosphamide is a vesicant and can cause extreme damage when it gets extravasted
doxorubicin!!
| anything to do about that?? no clue
230
```
For treating metastatic breast cancer:
if ER/PR -
Symptomatic
Visceral
or hormone refractory
what to do?
```
if HER2+: anti- HER2 therapy and CHEMO
if HER2-: CHEMO
231
for metastatic breast cancer:
if pt is to get chemo:
single agent or combo therapy is best?
single
| combo = more toxicities with not enough extra benefits
232
what is the first line option for HER2+ disease?
| with doses!! (she said know these :( )
Trastuzumab:
8 mg/kg IV day 1 followed by 6 mg/kg IV
pertuzumab
840mg IV day 1 followed by 420 mg IV
docetaxel
75 mg/m^2 IV
233
CDKs have are activated in _____ breast cancer
ER+ !!!
234
using CDK 4/6 inhibitors in ER+ breast cancer can be beneficial how?
can actually reverse some acquired resistance to previous hormone therapy
235
which CDK 4/6 inhibitor is the "best" and why do the other ones stink
Palbociclib = "good one"
Ribociclib: hella monitoring (LFTs and QT prolongation/EKG)
Abemaciclib = BID (booooo)
236
what monitoring should be done with palbociclib
neutropenia: monitor CBC before therapy, and beginning of each cycle and day 14 of the first 2 cycles
then monthly
Pulmonary embolism: monitor for signs and sxs
237
Breast Cancer:
| give pts radiation when?
if tumor > 5 cm
or 4 + positive lymph nodes
if pt has had lumpectomy
if positive margins after surgery
238
Breast cancer:
| when would pts get neoadjuvant therapy
when the tumor is greater than 1 cm?
