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126 Cards in this Set

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whats median age at diagnosis of breast cancer
60
its most common cause of Cancer in chix
Gail Model dose what
determines chemoprevention eligibity with tamoifen

not validated for all ethnic groups
2 types of non-invasive breast cancer
LCIS- lobular carcinoma- not premalignant
observer, tx only in high risk

DCIS-ductal carincoma-premalignant
surgery, radiation
whats recommended age for mammography

who should get a breast MRI
40 y.o.

BRCA mutation carriers
1st degree relative of one
use staging of cancer for
prognosis and kind of tx to use
sentintel LN vs axillary LN
sentinel- if cancer is not in 1st LN, then its not in 2nd, or 3rd

axillary-removal of axillary LN-causes lymphedema
IF hormone receptor and progesterone receptor are negative..
tends to be more aggressive
If breast cancer is HER2 (+)
this is an oncogene-so promotes cell growth

ups tumor aggressivness

use trastuzumab theraphy
anthrocylclines S.E.
cardiotox thats irreversible
treatment for EBC
surgery->adjuvant chemo-> radiation-> hormonal therapy
treatment for LABC
neoadjuvant therapy**-> surgery-> adjuvant chemo-> radiation-> hormonaltheraphy
masectomy vs breast conservation surgery
masectomy-older way, skin and nipple sparing

BCS- lumpectomy, LN evaluation, and radiation= results like masectomy
ALLOWS FOLLOWED BY SURGERY**
candidates for BCS

C/I for BCS
stage 0-2 and ppl with T3N0M0

C/I- >=2 primary tumors in diff areas

radiation hx, pregnancy
radiation in breast cancer
reduces risk of reoccurance by

started when?
20%

start 4 wks AFTER CHEMO..chemo increases cardiotox or radiation recall

but hormone tx can be used same time as radiation
what is radiation recall

drugs that cause this
inflam of skin from radiation and then chemo -like bad sunburn

capecitabine, cyclophosphamide, docetaxel, doxorubicin, 5FU, methotrexate, paclitaxel
oncotype DX
what does it do
screens for expression of 21 genes

if low score- avoid chemo and do hormon tx

if high-do adjuvant chemo
adjuvant theraphy
tumors <.5cm and LN -
wont benefit from adjuvant theraphy (chemo, hormonal tx)
adjuvant theraphy
tumors .6-1 cm and LN -
low recurrence
may give chemo
adjuvant theraphy
tumors with LN+
give chemo (adjuvant therapy)
adjuvant theraphy
tumors >1cm
may require adjuvant tx
if HER2-benefit from Trastuzumab
adjuvant horomonal therapy
premenopausal pt's
-tamoxifen
-ovarian ablation (removal or irradiation)
-LH-RH agonist -ovarian suppresion
adjuvant horomonal therapy
postmenopausal pts
tamoxifen
armatase inhibitors
tamoxifen
what kinda drug is it
which HR is it in?
how long to tx with generally
SERM- antag-agonist
its in pre and postmenopausal HR

generally tx with 5 yrs
S.E. of tamoxifen
hotflashes, thromboembolism (cause its estrogen agonist)

prevents bone loss
Aromatase inhibitors
MOA
drugs
blocks conversion of androgens to estrogen
anastrazole
letrozole
exemastane
AI (Aromatase inhib)
used in...why
S.E.
for adjuvant in postmenopausal
increase chances of BCS surgery

bone loss- so get baseline
which 2 AIs have cross sensitivity

if fail one of those, which one cause u use
anastrazole + lerozole
if fail one, can't use other

use exemestane if fail 1 of others
premenopausal tx
use

after 5 yrs you get postmenopause- use what
tamoxifen x 5 yrs

after 5 yrs get menopause- stop tamox, do AI x 5 yrs
premenopause tx
but get postmenopause before 5 yrs-tx how?
complete tamoxifen x5 yrs, then switch to AI x 2-3 yrs to complete 5 yrs?
postmenopause tx
regimens
-AI x 5 yrs
-Tamoxifen x 5 yrs
-Tamox 2-3 yrs, then AI to complete 5 yrs
-Tamox 5-6 yrs, then AI x 5yrs
whats tx for
low risk, LN -
CMF
cyclophosphamide/MTX/5-FU
whats tx for
HIGH RISK, LN - (HER2+, HR-)

if LN+
anthracycline based regimen

if LN+ give taxane also
whats tx for
HER2+ AND TUMOR >1
trastuzumab regimen
chemo toxicities
for anthracyclines
BMS, mucositis
alopecia
hepatic dose, vesicant
IRREVS. CARDIOTOX!
chemo toxicities
for Taxanes
TOTAL BODY ALOPECIA
premedicate
chemo toxicities
trastuzumab
REVERSB. cardiotox
what do you premedicate with for trastuzumab

S.E.
APAP 650MG + BENADRYL 50mg

S.E.-CHF, fever,
metastatic therapy
goal
who has better prognosis
palliation NOT cure, inc QOL

bone and soft tissue metastatis
for metastatis
use hormonal therapy for who?
HR+
bone metastatis
for metastatis
use chemo for who?
HR-, symptomatic visceral metastatis(lung/liver)
which meds are targeted therapy for metastatic cancers
trastuzumab
lapatinib
horomonal therpy options in metatic breast cancer
premenopause-tamoxifen, ovarian ablation

postmeno-tamox, AI, fULVESTRANT
whats preferred tx for HR+ postmenopausal metastatic dx
AIs- anastrazole, letrezole

if dx progresses- use exemastene
whats alternative tx for HR+ postmenopausal metastatic dx
tamoxifen or toremifene
has cross resistance
whats second line tx for HR+ postmenopausal metastatic dx
fulvestrant-its pure estrogen receptor blocker- unlike tamox who has agonist action also
chemo drugs for metastatic breast cancer
single tx is preferred
doxorub
paclitaxel, docetaxel
capecitabine
vinorelbine
gemcitabine
eribulin
lapatinib MOA

requires?

SE
Inhib tyrosine kinase of HER2 and Epithel growth factor (EPGF)

use if failed anthracyline, taxane, trastuzumab

requires hepatic dose adjust
SE-hand + foot syndrome
Lung Cancer
R.F
tobacco promotes carcinogens
tks 5 yrs of quiting to impact risk

if smoke 15cigs/day,cut to half, risk decrease by 25%
Lung Cancer
more R.F.
environment-asbestos, benzene, radon

genetic-1st degree relative

hx of TB, pulm fibrosis, bronchitis, COPD, empys. asthma
genetic mutations
EGFR mutations-confirm sensitivty to what
K-Ras oncogene mutation-

ALK fusion oncogene
sensitivty to egfr kinase inhib( eriotonib + Gefitinib)

ALK-crizotonib
lung cancer normally advances to
bone pain, neurlogical pain, spinal cord compression
2 types of lung cancer
NSCLC-non small cell lung Cancer

SCLC-small cell lung cancer
NSCLC- subdivdes into
adenocarcinoma-common in nonsmokers (pheripheral llung)

squamous cell CA- central lung-due to smoking

Large cell CA- pheripheral lung
SCLC
rapidally growing
agressive
in NSCLC tx
when would you do surgery
stages 1-2, only curative stage 3

stages for palliation therapy
in NSCLC tx
when to do radiation
unresectable tumor
chemoradiation
in NSCLC TX
when to do chemo

what drug is notmally in this regimen
stages 2-4, ADJUVANT(surgery)

cisplantin based
in NSCLC TX
what stage would you use bevacizumab
stage IV
what is preferred tx for chemo in NSCLC

a stage IIIb is considered
DOUBLETS

IIIB- unresectable tumor= give chemoradiation
common tx in chemoradiation
(stage IIIB)
cisplatin +etoposide or vinblastine

always give taxenes first, then cisplatin=less BMS
NSCLC stage IV( nonsquamous) tx
ALK mutation

EGFR mutation

EGFR mutation - or unknown
ALK- criztonib (PO)

EGFR + erlotonib

EGFR unknown- cisplatin + pemetrexed + bevacuzimab
NSCLC Stage IV (squamous) tx
cisplatin based doublet
cisplatin + vinorebline + cetuximab
NSCLC Stage IV
PS 3-4
PS 3-4: give supportive care, no benefit from chemo
NSCLC tx for stage 4
Second line agent

Third line?
Use single agent
Docetaxel, pemetrexed or erlonib

3rd- erlotonib
Crizotinib
Used for?
MOA
SE
NSCLC locally advanced or metastatic ALK+ mutation

Inhibs ALK tyrosine kinase

Requires renal dose adjustment

QT prolong**
Erlotinib
MOA
SE
Inhibs EGFR tyrosine
Use in EGFR+ mutation

Need hepatic adjustment

SE- dermatological toxicity- acne rash, mild use top clinda or cortisone
Severe- oral minocycline
Bevacizumab
MOA
Use in? But not?
Angiogenesis inhib

Use in Stage 4 non squamous

NOT for squamous type- cause pulmonary hemorrhage

SE- wound healing complication, proteinuria**, thromboembolism
Pemetrexed
Inhibs folate metab(like 5-fu + methotrexate)

Need hepatic and renal adjust
SE-myleosuppression
What do you premed pt with if on pemetrexed
Give folic acid and b12 start wk before tx
Cisplatin dosing is based on?
What adjust needs to be done
BSA mg/m2

Renal impairment adjust
Carboplatin dosing is based on?

What's general auc wanted
Calvert formula
Dose= auc x ( CrCL + 25)

Untxed 6-8 usually 6
If using Cockcroft formula use which weight

If Salazar use
What's formula
Actual body weight

Sal- adjusted
Adjus(kg)= (actual- ideal) x .4 + ideal
Whats the minimum scr used in carboplatin dosing

What's max crcl used
0.6 mg/dl

Max 125 ml/min
SCLC
Limited stage
Extended stage
Dx confined to 1 hemithorax and regional LN

Ex-beyond 1 thorax
SCLC
Limited stage tx
Goal is cure
Tudors < 3cm do surgery + adju chemo

Chemoradiation= cisplatin + etoposide + concurrent radiation
SCLC
Extended stage tx
Goal is PALIATIVE
Chemo cisplatin + etoposide
Or ironotecan + etop
SCLC 2nd line tx
When to do it and what drug
If relapsedrugs elapse > 6 months after 1st tx rechallenge w/ topotecan
When to do prophylactic cranial radiation
Once receive CR with chemo this is recommended for limited and extended stages of SCLC
Nociceptive pain has 2 types
Somatic pain- from bone, joints
sharp, well localized, throbbing

Visceral pain- from internal organs
Aches, cramps
Transduction of pain
Injury releases bradykinin, serotonin K, histamine
Triggers PG's and subst P release
Transmission of pain
Type A- somAtic- myelinated

Type C- visCeral - unmyelinated(dull pains)
Endogenous opiate system
Release endorphins bind opiate receptors
Kappa, mu, and delta
Assesing pain
Use Pqrstu
Precip- what worsens it
Quality- how feel, visceral?
Region-where?
Severity-
Time- constant?
U- You how's it affecting you
WHO analgesic ladder
Mild pain- Tylenol (non opiate)
Mild-mod pain- hydrocodone
Mod-severe- IV opioids
Class of opioids
Phenanthrenes
Phenylheptylamines
Phenylpiperdines
Morphinans
Benzomorphans
NSAIDS indicated for?
Mild pain (1-3) and/or bone

Use NSAID that worked for pt in past
Which NSAIDs don't inhibit plt aggregation
Selective cox2 inhibit
Salsalate
Choline+ Mg salicylate
NSAID toxicities
Renal- RF if pt >60, really excreted chemo...D/C if scr/BUN doubles

GI- RF >60, hex of PUD
Tx w/ H2 blocker, PPI, misoprostol
Switch to COX2 selective
Cox2 selective meds
Meloxicam> Celebrex> etodolac> ibuprofen> naproxen
Pts with CV RF should not get Celebrex in what doses
Not more than >400 mg/D or Naproxen > 440mg/D

These Show dose related inc in MI
Ketorlac IV vs. PO dose
Max days? Why?
30mg IV but 10 mg PO max 120mg/d

Max 5 days cause GI effects
Ketorlax max for pts >65 yo and <50 kg
Max 60 mg/D
NSAIDS adv vs disadvantage
Adv- additive analgesia
Bone pain, no constipation, no tolerance

Disadvantage- ceiling doses(max)
Renal insuff bleeds, antipyretic(may mask fever)
Tylenol
Moa
Inhibs prostaglandin synthesis blocks pain impulse
NO anti-inflam action
Tylenol toxicity
How much?
Mech
Antidote
>4g for 1-2 days
Depletes glutathione, destroys hepatocytes

Give mucomyst- nasty dilute in juice
Use Rumack/Mathews nomogram to see if use or not
Whats are phases/presentations of Tylenol toxicity
Phase 1- (1-24H) N/V, anorexia, diaphoresis

Phase2- (24-72H) RUQ pain, inc in LFTs

Phase3- (72-96h) jaundice
Opioids formulation for mod pain
For severe pain
Mod(4-6) PO
Severe(7-10) IV
Mu receptor produces-

Kappa produces-

Delta-
Mu- analgesia, resp depress, euphoria, dependence, miosis

Kappa- analgesia, sedation (NO euphoria)

Delta- analgesia
Opioid allergy vs SE
Important card!!
True allergy- anaphylaxis, bronchospasm

SE- N/V, constipation, drowsiness, confusion
Phenanthrenes meds
Morphine, codeine, nalbuphine
Oxycodone
Phenylpiperidines meds
If allergic to opioids(rare) use this class

Meperidine, fentanyl, diphenoxylate
Phenylheptylamines meds
Methadone- not 1st line, use in tolerant pts
Morphinans
Levorphanol, butorphanol
Antag/ agonists
Comparison chart
Morphine
Iv- 10mg
PO -30mg
Standard everything is compared to
Comparison chart
Buprenorphine
Iv- 0.3
PO- 0.4 mg
Comparison chart
Codeine
IV- 100
PO- 200mg
Comparison chart
Fentanyl
IV- 0.1 mg
Takes 12 h to work, so use another med till kicks in
Comparison chart
Hydrocodone
PO 30mg
Comparison chart
Hydromorphone
IV- 1.5
PO- 7.5mg
Potent, preferred in renal insuff
Comparison chart
Meperidine
IV- 75 to 100mg
PO- 300mg
Toxic metab
Comparison chart
Oxycodone
PO 20mg
Comparison chart
Oxymorphone
IV- 1mg
PO- 10mg
Comparison chart
Tramadol
PO- 120mg
Pts with difficulty swallowing can use
Kadian or avinza- can open and put in applesauce,
Kadian-(long acting)can sprinkle in 10mls of water for GT

Don't crush, chew or let dissolve
Morphine dosing in renal insuff
Crcl 10-50 dec dose by25%

<10 dec dose by 50%
Hydro morphine/ hydrocodone in renal insuff
Crcl 10-50 dec dose by 50%

<10 dec dose by 75%
Oxycodone in renal insuff
10-50 dec by 50%
<10 don't use
If pt is renal insuff what's preferred opioids
Fentanyl or methadone for tolerant pts
Usual morphine ratio is 10:30 but what is ratio in renal insuff
10: 20 cause metab formed m6G is more active then morphine
Hepatic dosing for
Morphine
Hydrocodone
Oxycodone
Morp- incr dosing interval by doubling it (q2h-> q 4 h now)

Hydrocodone- dec dose by 50%

Oxycodone- dec dose by 25-50%

Basically use fentanyl
Uncommon opioid se

Common
Hallucinations
Dysphoria
Seizures

Common- no tolerant constipation
sedation! Pruritis
How to tx opioid constipation?

Tx opioid reps depress

Opioid pruritis
ATC constip= ATC laxative (softener+stim)
If fail 2 lax +on opi x2wks use methylnaltrexone sc once

Reps dep- naloxone in 9ml of NS

Pruritis- 1st Benadryl, if persists use nalbuphine
Opioid dosing steps
Calc dosage incr by total use in 24H (ATC +breakthrough)
Then calc dose for new drug

If pain is controlled then dec dose by 25-50% for cross tolerance

If pain NOT controlled- switch keep 100% or inc to 125%

Calc breakthrough dose-10or20% total 24H dose and give over 1H
Neuropathic pain describe
Tingling, stabbing, shooting
If nerve compression use glucocorticoids
Tx of neuropathic pain
TCA- nortriptyline, desipramine
Anticonv- gabapentin, pregabalin***

SSRIs- venlafax, duloxetine
Topic- lidocaine(12h on/ off or arrithymias) capsaicin
Meds for bone pain
NSAIDs and inc till analgesic effex

Local bone pain- local radiation or nerve block

Diffuse bone pain- bisphosph, hormonal/ chemotherapy

Consider physical therapy