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112 Cards in this Set

  • Front
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Top 3 most common cancers by incidence and deaths per year
Incidence- prostate (men) breast (women), lung, colon
Death- lung CA both, prostate (men) breast (woman), then colon both
Carcinogenesis steps
initiation,
promotion,
transformation,
progression
Oncogenes
exs
EGFR, HER-2/neu

- overexpressed in CA
Tumor suppressor genes
ex
p53, BRCA 1 and 2

- mutations increase likiness
Metastasis- Common sites for lung, colon and breast cancer
- all bone and liver

Lung- brain, adrenal

colon- lungs

breast- lung, brain
Angiogenesis
vascularization of tumor- leads metastasis
Screening
Breast
self exam 20 and over monthly

clinical 20-39 q3 years,
or over 40 every year

mammography- over 40 q yr
Screening
Colon
fecal occult q 1

flexible sigmiodscopy or FIT- q 5 years

colonoscopy- q 10 years
Staging
letters...
T-size
N-lymph involvement (next worse)
M- metastasis (worst)
Staging
numbers...
Stage 1- local
Stage 2-3 local/regioonal extension
stage 4- metastasis
chemo works best when
tumor small
Cell cycle agents dose scedule
continuous infusions
Mitosis agents
vinca alkaloids(never intrathecally),

taxanes (both hepatic dose adjust)

(both vesicans)
G1 agents
nitrosureas, asparaginase
G2 agents
epidopophyllotoxins, bleomycin
S phase agents
Antimetabolites- Antifolate(trex), antipyrimidines, antipurines (purine/ guanine)
Multiphase acvitiy agents
-alkylating agent, anthracycline antibiotics....others cisplatin, mycins
Monoclonal antibodies
-target?
-target CD markers(allow body to recognize) or target growth factor receptors (block cell growth)
Next few tell me the target....
iilii
Bevacizumab
VEGF
Brentuximab vedotin
CD30
Cetuximab
EGFR
Irbitumomab Tiuxetan
radioactive particle CD20
Ofatumumab
CD20
Panitumumab
EGFR
Rituximab
CD20
Tositumomab
Radioactive particle, CD20
Trastuzumab
HER2
BSA formula *****
square root of (height (cm) x weight (kg) / 3600) (verify weight)
Calvert Formula

is for and is....
for carboplatin

Dose (mg) = AUC x (CrCL +25)
Want baseline labs depending on drugs being used
WBC, ANC, PLT..

..ECHO for cardiotoxic scan

prolly liver and renal
Renal Adjustmented drugs....
Carbo
Cisplatin
Bleomycin
Cytarabine
Methotrexate

Lots of others but those are big ones
Hepatic dose adjustment
vincas and ~anthrcyclines..?

Doxorubicin, daunorubicin

vincristine, vinblastine....

-if elevated LFT nothing to do with cancer then dose adjust if not then possible full dose
Factors affecting response
-tumor cell heterogeneity

-dose intensity- performance status may determine intensity (ECOG and Karnofsky)

-pt specific factors
Response Criteria
CR- Complete Response- dissappearance or no new disease least 1 month

PR- Partial Response- 30% or more decrease tumor size or other objective marker

Stable disease- no more diff by 20%

Progression- 20% increase while on tx

Clincal beneficial response- improved QOL
Extravasation is
-complication of IV chemo admin

-escape of drug from vessel to surrounding tissue

-Vesicant- can cause tissue necrosis, bind irreversibly-- put in syringes!!!

-Irritant- cause local inflammatory rx w/o necrosis-- can be bagged
Vesicants- are
anthracyclines,

vinca alkaloids,

taxanes,

alkylating agents (sum mitomycin)
next we have vesicants and antidotes...
so there
Anthracyclines
- antidote Dexrazoxane w/i 6 hours, COLD PACK
Mitomycin
antidote DSMO, COLD PACK
Vinca Alkaloids, Etoposide, Paclitaxel
-Antidote- Hyaluronidase, WARN COMPRESS (COLD FOR PACLITAXEL)
Cisplatin, Mechlorethamine
Antidote- Sodium Thiosulfate 4%, COLD PACK
Hematologic tox which drugs is it DLT
Carboplatin

doxorubicin

Fludarabine

Florouracil

Irinotecan

MTX

Mitomycin
Neutropenia

colonating stim factors
decrease duration of neutropenia, 24h after chemo

Filgrastim- 5mcg/kg SC, until post nadir recovery
also Pegfilgrastim

-Prophylaxis- NCCN recommend CSF for chemo regimens >20% chance FN
Thrombocytopenia
less than 100,000

transfusion when under 10,000

carboplatin, gemcitabine, mitomycin, procarbazine, vinorelbine
ESAs doses

epo

darpo
Epoetin Alfa- 150 U/kg SC TIW or 40,000 U SC weekly

Darbepoetin Alfa- 2.25mcg/kg SC wk or 500mcg SC q3wk
Anthracycline induced CARDIOTOX

monitoring
ECHO or MUGA, baseline , q3 months

NEED ejection fraction

dose related and irreversible
Anthracycline induced CARDIOTOX

freq in drugs
Doxorubicin > Daunorubicin > Idarubicin > mitoxantrone > Epirubicin

NOT THE DLT for these (BMS is)
Trastuzumab tox
Cardiotox- not dose related and largely reversible
Nephrotoxicity
Cisplatin
HYDRATION, hyponatremia, hypomagnesemia
Nephrotoxicity

Cyclophosphamide/Ifosfamide
Hemorrhagic cystitis


Ifosfamide REQ MESNA!
Nephrotoxicity

MTX
acute tubular necrosis

alkalanization of urine w/ sodium bicarb want pH 7

no PPIs
Nephrotoxicity

Pentostatin
dose limiting- increase serum creatinine
Peripheral Neuropathy

drugs?
Oxaliplatin- DLT !!!!

Paclitaxel- more with shorter infusion
Autonomic Constipation
:- doesnt resolve

Vinca alkaloids
Alopecia
Taxanes- lose hair everywhere

7-14 days after tx
Hypersensitivity Rxns
Bleomycin- test dose

Paclitaxel- excipient
PREMEDICATE- diphenhydramine, dexamethasone, H2 agonist

also Paclitaxel nonPVC bags and tubes
Infusion related rxn
Monoclonal abs..
first infusion (not allergic)
cytokine release

Rituximab, Alemtuzumab, Trastuzumab, Cetuximab

-Fever, chills, flushing, itching, HR/BP, chest discomfort
Pulmonary Tox
Pulmonary fibrosis
Pulmonary fibrosis

Bleomycin- max 400 units lifetime
Mucositits
cant eat cant swallow

Majic mouth wash... lidocaine/diphenhydramine/nystatin

Palifermin (growth factor)- prior transplant

5FU, doxorubicin, MTX, bleomycin
Anorexia and Cachexia
use:

Megase- optimal 800mg daily (can also use for breast cancer..way smaller)

Dronabinol-less effective but good with NnV and need eating....2.5mg/day
Diarrhea
F5U, Irinotecan, MTX, cytarabine

Uncomplicated (<6 stools/day) hydration...

Complicated
Loperamide!!! max 16 day 1, max 24 day 2

If persists 48h then octreotide and inpt
Emesis
types
acute

delayed
anticipatory

breakthrough
Delayed emesis drugs
Cisplatin, carboplatin, cyclophosphamide, ifosfamide, doxorubicin
High emetic risk drugs
-Carmustine,
cisplatin,
cyclophosphamide>1500,
dacarbazine,
mechlorethamine
High emetic risk

Prop w/
Day1- 5-HT3 + Dexamethasone + [Aprepitant or Fosaprepitant (only day 1)]


Day2-4 - Dexamethasone + Aprepitant ....
Moderate Emetic Risk

agents
-Carboplatin,
cyclophosphamide<1500,
cytarabine>1g,
anthracyclines,
ifosfamide,
irinotecan,
oxaliplatin
Moderate Emetic Risk

Prop w/
5HT3 and Dexamethasone 3 days (decrease dex day 2-3 to 8)
Low emetic Risk
-Docetaxel, etoposide, 5 FU, gemcitabine, mitomucin, paclitaxel, topotecan

Prop w/
Day1-4 Dexamethasone or metocloperamide or prochlorperazone
FOR ALL EMETIC RISK LORAZEPAM AND ANTACID are +/-
fyissss
5HT3 antagonists
Ondansetron

Dolasetron

Granisetron

Palonosetron- long acting!! preferred agent in mod high, also good delayed
Neurokinin 1 Receptor Antag
Aprepitant

Fosaprepitant- equivalent
Breakthrough NnV
use diff class

Lorazepam- anterograde amnesia

Metocloperamide- 3 MOAs- block dopa receptors----EPS at high doses

Prochlorperazine,

Promethazine

Routine 5HT3

also possible: Dronabinol, corticosteroids, olanzapine(just approved)
Hypercalcemia of Malignancy...
Ca lvl >12 mg/dL

correct for hypoalbuminemia: Corrected Ca = (4 - albumin lvl) * 0.8 + Serum Ca

nausea, polyuria, thirst, dehydration, lethargy, confusion, stupor, coma

Can be local (attaches and breaks down bone) or humoral (associated tumor secretion PTHrP)
Hypercalcemia of Malignancy

tx
Hydration- NS

Loop Diuretic- flush Ca

Calcitonin- only 48 h until bisphosphonate kicks it, block resorption

Bisphosphonate- chelates
Pamidronate
Zolendronic Acid- preferred- potent, shorter infusion, better w/ PTHrP

Watch osteonecrosis of jaw
Superior Vena Cava Syndrome

is
when happens
tx
tumor obstructing SVC blood flow

common lung and lymphomas

radiation, glucocorticoids, chemotherapy- SHRINK TUMOR!!
Tumor Lysis Syndrome

happens w/
what electrolytes
when prevent
like infusion related syndrome

Rituximab...

lysis of cells releases intracellular contents into systemic circulation

hyperkalcemia, hyperphosphatemia, hyperuricemia

prevention in high risk- bulky dx and rapid response
Tumor Lysis Syndrome

prevention
Hydration

Prop allopurinol- decrease formation uric acid

Rasburicase- increase elimination of uric acid, converts to allantoin

reserved high risk pt- baseline uric high or renal insuff

CI in glucose-6-phosphate dehydrogenase deficiency

single dose
Anticoagulation in Cancer pts
drugs
cancers
High risk drug- Tamoxifen, thalidomide, lenalidomide, bevacizumab

High risk CA- pancreas, stomach, brain, kidney, ovary, lung, lymphoma, metastasis
Anticoagulation in Cancer pts

Prop
Hospitalized- LMWH, fondaparinus, UFH
Lenalidomide/Thalidomide- LMWH or findaparinus, Warfarin
Tx VTE
LMWH or fondaparinux for 6 months...no bridge
know ur coag doses
bitchin
Colon Cancer

Risk Factors- Nonmod
Elderly,
Male,
Inflammatory bowel disease
,
hereditary syndromes (FAP)(lynch syn)
Colon

Risk Factors-Mod
Dietary intake redmeat/ sat fat, tobacco, alcohol, obesity, inactivity
colon

Screening
Fecal occult blood test or FIT

Flexible Sigmoidoscopy

Annual FOBT or FIT and Flex sig

Colonoscopy- most sensitive and specific

Double Contrast barium enema
colon
Presentation
change bowel habits, ab pain, fatigue (secondary to anemia)

advanced- jaundice
Stage I tx
surgery
stage II tx
surgery +/- chemo (only in high risk- T4, perforation, bowel obstructed, poorly differentiaed)

Chemo- FOLFOX- 5FU + leucovorin + oxaliplatin
stage III tx colon
surgery + chemo

Chemo- FOLFOX 6 months
stage IV tx colon
chemo and targeted

Chemo FOLFOX
or FOLFIRI- 5FU + leucovorin + irintoecan

if progession- Cetuximab or Panitumumab

Targeted- Bevacuzimab
5FU
about
toxicities
antimetabolite, inhib DNA syn via TS

Bolus or continous

Bolus DLT-neutropenia

Continous DLT- hand/ foot syndrome
Leucovorin
synergistic effect w/ 5-FU, enhancing
Oxaliplatin

about
DLT
non specific, Platinum derivative

DLT- peripheral neuropathy (dose reduce)

avoid exposure to cold...
Stage III if cant tolerate FOLFOX can use
capecitabine

oral 5FU

SE- hand foot syndrome

single agent adjuvant in stage III

DI with warfarin
Irinotecan

works..
SE and avoiding them
block DNA syn

NvN, diarrhea:

early onset- use atropine

late onset- loperamide- with that max 16 -> max 24 -> octreotide regimen
Bevacizumab

works on
ADE
VEGF inhib- prevent angiogensis

AD- HTN, thromboembolism, proteinuria, wound healing, GI perforation

wait 1 months after surgery
Cetuximab

works on
toxicity
EGFR inhib- second line salvage as single or w/ irinotecan

infusion related itchy, hypotension, SOB

dermatological tox!!!- mild clinda/hydrocortisone....severe-oral minocyclin

rash shows tumor response

benedryl premed!!!!!!!
Panitumumab

works on
toxicity
EGFR inhib- third 4th line as monotherapy

ADR- also derma rash ---benedryl premed!!!!!!!

electrolyte disturbance-watch em
Prostate Cancer

Risks
Age, AA, FHx, high fat intake

Blacks have more testosterone....is that why their...nvm
Prostate

Screening
Digital rectal exam and prostate specific antigen over 50 q 1 year

PSA lvl >/= 4ng/ml (if on 5 alpha redutase inhib- double number)

AA or first degree relatives - test 45

multiple relatives- tests starting 40
Prostate

Local dx

Advanced dx

Dx
-asymptomatic, ureteral dysfunction, impotence

back pain, weight loss, anemia, fractures

elevated PSA and abnormal DRE shows
TRUS-ultrasound
Prostate biopsy confirms
Localized disease (stage I-II) prostate tx
active surveillance- low risk pts

surgery
radical prostatectomy- reserved pts >10yr life expectancy, nerve sparing procedure

radiation- alternative to surgery
external beam..? or brachytherapy

brachytherapy- lil radioactive pellets placed inside prostate
Locally Advanced Stage III
Radiation +/- short term ADT (4-6 months)

Radical prostatectomy

Androgen deprivation therapy (select pts when not candidates for above)
-LHRH agonists, and antiandrogens, orchiectomy, medical castration=surgical castration.
Metastatic Disease Stage IV
ADT- when there are tumor related symptoms or overt metastasis

once fail ADT- chemo therapy

Docetaxel + prednisone

Mitoxantrone + prednisone

Cabazitaxel

Sipuleucel T - immuno therapy for less advanced disease
LHRH agonists

work on
how
SE
decrease FSH and LH release from pituitary gland

advanced III -IV as mono or combo

initial flare during first week

need antiandrogen drugs for that time

Degarelix LHRH antagonist used when rapid androgen suppression needed(no flare)
LHRH agonists
Goserelin

Leuprolide

Triptolerin

Degarelix antag
Androgen receptor blockers

how use and drugs
always adjunct for flare up not mono

flutamide
bicalutamide
nilutamide
Castrate resistant disease tx
Docetaxel
Mitoxantrone
Cabazitaxel
Docetaxel
tox
info
BMS, hepatic dose adjust, vesicant, alopecia, mucositis

possible dexamethasone prevent edema

nonPVC bag
Mitoxantrone
info
BMS, mucositis, CARDIOtox
Cabazitaxel
info
premedicate w/ antihistamine, corticosteroid and H2

if fail docetaxel
Bone Metastasis
start bisphosphonates IV

-Zolendronic acid, pamidronate IV

or Denosumab- RANKL inhibitor (higher incidence osteonecrosis jaw)