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322 Cards in this Set
- Front
- Back
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Tumors of Epithelial Tissue
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Carcinomas
Adenocarcinomas |
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Tumors of Connective Tissue
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Fibrosarcoma
Osteosarcoma Liposarcoma |
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Tumors of Lymphoid Tissue/ hematopoietic cells
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Hodgkin's lymphoma
Non-Hogdkin's lymphoma Multiple Myeloma Leukemias |
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Tumors of Nerve tissue
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Glioblastoma multiforme
Malignant Melanoma Astrocytomas |
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When to start cancer treatment?
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After definitive diagnosis and tumor stage
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What does T N M stands for?
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T - Tumor
N - Node M - Metastases |
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What does stage I tumor indicates?
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Localized tumor
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What does stage IV tumor indicates?
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Presence of distant metastases
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What are the four primary treatment types for cancer?
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Surgery
Radiation Chemotherapy Biologic Therapy |
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What are the modalities of Biologic Therapies in cancer txt?
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Immunotherapy
Targeted therapies Vaccines |
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Drugs used in immunotherapy:
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Interferons and Interleukins
(Stimulates host immune system) |
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Drugs used in Targeted Biological therapies:
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Monoclonal Antibodies
Tyrosine Kinase Inhibitors |
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Chemotherapy Treatment Types:
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Primary
Palliative Adjuvant Neoadjuvant |
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When primary chemotherapies are used?
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- They are used alone for the treatment of Leukemias
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Function of Adjuvant chemotherapies:
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Given after primary treatment
“Clean up” micrometastatic disease |
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When and why are Neoadjuvant therapies given?
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Preoperative use
Shrink tumors for surgical resection |
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Response to treatment in solid tumors is described as:
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Cure
Complete response Partial response Stable disease Progression |
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Definition of cure in the treatment of solid tumors:
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Free of disease for 5 yrs
-Exception: Breast cancer and melanoma. |
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What cancers have significant risk for relapse after being cured?
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Breast Cancer and Melanoma
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Definition of Complete Response in the treatment of solid tumors:
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- Complete disappearance of cancer
- No evidence of new disease for at least 1 month after treatment - CR is not the same as Cure |
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Definition of Partial Response in the treatment of solid tumors:
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More than 30% decrease in tumor size
No evidence of any new disease for at least 1 month |
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Definition of Stable Disease in the treatment of solid tumors:
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Tumor size neither grows by more than 20% nor shirnks by more than 30%
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Definition of Progression in the treatment of solid tumors:
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20% increase in tumor size
Development of any new lesions while receiving treatment |
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What does Clinical Benefit Response means in the treatment of solid tumors?
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Subjective response
Decreased use of pain medication Better quality of life or performance status |
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What does ALL stand for?
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Acute Lymphocytic Leukemia
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What does AML stand for?
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Acute Myelogenous Leukemia
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What does CLL stand for?
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Chronic Lymphocytic Leukemia
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What does NHL stand for?
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Non-Hodgkin's Lymphoma
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What does MM stand for?
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Multiple Myeloma
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What does MDS stand for?
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Myelodysplastic Syndrome
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What are the four main classes of chemotherapy agents?
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Antimetabolites
Antimicrotubule Agents Topoisomerase-Active Agents Alkylating Agents |
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What chemo drugs are Antimetabolites?
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Azacitidine
Capecitabine Cladribine Cytarabine Decitabine Fludarabine Fluorouracil Gemcitabine 6-Mercaptopurine Methotrexate Pemetrexed 6-Thioguanine Trimetrexate |
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What are the class toxicities for Antimetabolite drugs?
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Myelosuppression
Diarrhea |
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SE of Fluorouracil:
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Stomatitis (DLT, HT)
Diarrhea (DLT, HT) Hand-foot syndrome |
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What drug is a pro-drug of 5FU?
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Capecitabine
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What are the DLT and HT of capacitabine?
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Hand-Foot syndrome
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Warfarin has a significant drug interaction with two antimetabolites:
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5FU and Capecitabine
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What is the particular use of 5FU in chemotherapy treatment?
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Radiosensitizer
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What drug enhances the activity and toxicity of 5FU?
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Leucovorin
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What drugs are classified as Pyrimidine Antimetabolites?
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Cytarabine
Azacitidine Decitabine |
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What is the DLT and HT of cytarabine?
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Cerebellar syndrome
(when dose is at more than 1g/m2) |
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What SE is seen at standard dose of cytarabine?
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Myelosuppression
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What drug requires a neuro check before each dose?
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Cytarabine
(risk of cerebellar syndrome) |
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Describe cerebellar syndrome:
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slurred speech, confusion, ataxia, nystagmus
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What are the SE of azacitidine?
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Myelosuppression
Febrile neutropenia |
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What is the HT of Decitabine?
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Hyperglycemia
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What special information have Azacitidine and Decitabine in common?
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No live vaccines
Cardiac problems in less than 5% |
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What antimetabolite is used for NSCLC and metastatic breast cancer?
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Gemcitabine
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What drugs are classified as Folate Antimetabolites?
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Methotrexate
Pemetrexed |
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What SE are seen at low doses of methotrexate?
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Hepatotoxicity and pulmonary toxicity
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What is the DLT of methotrexate?
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diarrhea
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What are the HT of methotrexate?
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diarrhea
nephrotoxicity |
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What is an important SE to monitor with the folate antimetabolites?
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Mucositis
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DDIs of methotrexate and Pemetrexed:
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Bactrim
NSAIDs |
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How to prevent methotrexate nephrotoxicity?
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Hydrate with Na Bicarb
Keep urine pH more than 7 |
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What rescue medication can be given in case of methotrexate toxicity?
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Leucovorin given 24-36hrs after dose
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Reasoning for Leucovorin and 5FU combo:
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Leucovorin helps 5-FU to work better
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Reasoning for Leucovorin and methotrexate combo:
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to avoid methotrexate work on normal cells decreasing toxicities (mucositis and myelosuppression).
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What is used to prevent Pemetrexed induced mucositis?
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Folic acid
Vit B12 |
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What type of drugs are considered antimicrotubule agents?
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Taxanes
Vinca alkaloids |
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What drugs are classified as Taxanes?
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Docetaxel
Paclitaxel Paclitaxel NAB Cabazitaxel |
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What drugs are classified as Vinca alkaloids?
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Vinblastine
Vincristine Vinorelbine |
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What is the class SE for antimicrotube agenst?
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Peripheral Neuropathy
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What is the DLT of paclitaxel?
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Peripheral Neuropathy
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What is the HT of paclitaxel?
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Complete allopecia
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What are important SE for paclitaxel?
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PN
Complete allopecia Hepersensitivity Severe Myalgias |
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How to prevent hypersensitivity reactions due to paclitaxel or cabazitaxel?
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Pre-med with:
-Dexamethasone -Diphenhydramine - H2 antagonist |
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What is the DLT of Paclitaxel NAB?
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Myelosuppression
(PN is less severe than paclitaxel's) |
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What is the HT of Docetaxel?
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Edema
(PN (58%), and Complete alopecia (76%) |
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How to prevent edema induced by docetaxel?
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Dexamethasone
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PVC products should be avoided when administering the following drugs:
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Paclitaxel
Docetaxel Cabazitaxel |
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Common SE of Cabazitaxel:
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Neutropenia
N/V Diarrhea Hypersensitivity |
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What is the DLT of Ixabepilone?
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PN
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Common SE of Ixabepilone include:
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PN
Hypersensitivity Malalgias Cardiac dysfuncition |
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Ixabepilone is contraindicated in patients with...
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Hepatic disease
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How to prevent Ixabepilone hypersensitivity reaction?
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Pre-med with Benadryl and H2 antagonist
(Use dexa only if reaction takes place) |
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What taxane drugs are metabolized by CYP3A4?
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Cabazitaxel
Ixabepilone |
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What drug is a non-taxane microtubule inhibitor?
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Eribulin
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Uses of eribulin
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Metastatic breast cancer previously tx’d w/ anthracycline
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What is DLT of eribulin?
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PN
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Common SE of eribulin include:
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Neutropenia
PN QT prolongation |
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What drugs are classified as Vinca alkaloids:
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Vincristine
Vinorelbine Vinblastine |
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What is the DLT and HT of vincristine?
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PN
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What are common SE of vincristine?
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PN
Constipation (it requires stool softener and laxative for up to 3 wks) |
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What drugs are considered Vesicants?
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Vinca Alkaloids:
Vincristine Vinblastine Vinorelbine Anthracyclines: Doxorubicin Daunorubicin Idarubicin Epirubicin |
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What drugs cannot be intrathecally administered?
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Vincristine
Vinblastine Vinorelbine |
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Common SE effects of Vinorelbine:
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Neutropenia
PN |
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What is the DLT of Vinblastine?
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Myelosuppression
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What drugs are classified as Topoisomerase I inhibitors?
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Irinotecan
Topotecan |
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What drugs are classified as Topoisomerase II inhibitors?
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Daunorubicin
Doxorubicin Epirubicin Etoposide Teniposide Mitoxantrone |
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What is the DLT and the HT of irinotecan?
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Delayed diarrhea (life-threatening)
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How to treat acute diarrhea due to irinotecan?
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Atropine 0.25 – 1 mg IV
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How to treat delayed diarrhea due to irinotecan use?
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Loperamide 4 mg at onset and 2 mg q2h until resolution of delayed diarrhea for 12 hrs
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Common SE of etoposide and teniposide:
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Orthostatic hypotension
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PVC products must be avoided when using one of the topoisomerase II inhibitors, which one?
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Teniposide
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SE of anthracycline drugs:
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- Vesicants
- Produce radiation recall - Produce red urine |
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What to do to prevent extravazation due to anthracycline administration?
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Apply ice
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What is the DLT and HT of all anthracyclines?
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Cardiotoxicity
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What drugs are classified as anthrcyclines?
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Doxorubicin
Daunorubicin Idarubicin Epirubicin |
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What exam has to be done at baseline before treatment with anthracyclines?
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Ejection Fraction
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What is the life time dose limit of doxorubicin and daunorubicin?
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550mg/m2
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What is the life time dose limit of idarubicin?
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150 mg/m2
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What is the life time dose limit of Epirubicin?
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900 mg/m2
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What is the life time dose limit of doxorubicin or daunorubin for a patient with preexisting cardiac issues?
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450 mg/m2
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What drugs produces Blue-green discoloration of urine, sclera, skin as a SE?
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Mitoxantrone
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What is the max life time dose of Mitoxantrone?
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140 mg/m2
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Most common alkylating agents:
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Busulfan
Cisplatin Carboplatin Oxaliplatin Cyclophosphamide Ifosfamide |
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Common risk for alkylating agents is:
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Overall increased risk of permanent sterility/infertility
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Busulfan Characteristics:
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Readily crosses BBB
Pulmonary fibrosis (Busulfan lung) |
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What is the HT of cisplatin?
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N/V
(It is the most emetic agent) |
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Common SE of cisplatin:
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N/V
PN Ototoxicity Nephrotoxicity |
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How to protect kidneys due to cisplatin use?
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Hydrate with NS
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Most common SE of carboplatin:
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Thrombocytopenia and leukopenia
Less PN, oto, n/v and nephrotoxicity than cisplatin |
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What is the DLT and HT of oxaliplatin?
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PN (Exacerbated by cold)
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How to help avoid the PN caused by oxaliplatin?
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- Mg/Ca bolus before and after
- Extend infusion time to 4 hrs |
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How to calculate carboplatin dose?
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Dose = (CrCl + 25) * AUC =
|
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What is the HT of cyclophosphamide and ifosfamide?
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Hemorrhagic cystitis
(can occur months later) |
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How to prevent or treat hemorrhagic cystitis due to alkylating agents?
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Use mesna if dose of cyclophosphamide is more than 1g/m2.
ALWAYS use mesna with Ifosfamide |
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How to protect CNS from Ifosfamide toxicity?
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Use methylene blue until drug is cleared from system.
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What are the non-classic alkylating agents?
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Procarbazine
Temozolomide |
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What agent produces a disulfiram-like reaction when combined with alcohol?
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Procarbazine
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SE of temozolomide:
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Constipation
nausea vomiting HA seizures (it readily crosses BBB) |
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What agent is classified as Antimetabolite/Alkylating agent?
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Bendamustine
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SE of bendamustine:
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Skin reactions:
- SJS - TEN (Toxic Epidermal Necrolysis) - Rash |
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What is the HT of Bleomycin?
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Interstitial pneumonitis
and pulmonary fibrosis |
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What is the agent with the greatest risk of mortality?
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Bleomycin (50%)
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Effects of bleomycin in lung and skin:
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It turns it brownish due to low levels of aminohydrolase in these organs.
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What is the HT of Arsenic Trioxide?
|
Retinoic Acid Syndrome
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What are the S/S and txt of Retinoic Acid Syndrome?
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fever, dyspnea, weight gain, pulmonary infiltrates, and pleural effusion
Must be treated with corticorsteroids immediately (dex 10 mg IV bid) |
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What agents are classified as anti-angiogenesis agents?
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Thalidomide
and Lenalidomide |
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What is the HT of Thalidomide?
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Teratogenicity
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SE of Thalidomide:
|
Teratogenicity
PN (may be irreversible) Constipation (stool softener and laxative needed) Drowsiness |
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What is the HT of lenalidomide?
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Fatigue
(very severe and it may impaired complience) It also cause teratogenicity |
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What particular risk is increased with the use of thalidomide or lenalidomine and dexamethasone?
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DVT / PE
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What is the HT of peginterferons?
|
Flu-like syndrome = it may improve with treatment
- fever - chills - malaise - myalgias - HA |
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What is the DLT of peginterferons?
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Neurologic toxicities = they may worse with continue treatment
- Dizziness - Memory loss - depression |
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What type of cancer is treated with pefinterferons?
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Malignant Melanoma
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What type of cancers are treated with interleukin-2?
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Renal cell carcinoma
Malignant melanoma |
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SE of interleukin-2
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- Hypotension
- fluid retention - Acute renal dysfunction - GI hemorrhage or stomatitis (use H2 ant.) - Capillary leak syndrome (at high doses) - High incidence of infections (use keflex) |
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What agents are classified as histone deacetylase inhibitors?
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Romidepsin
Vorinostat |
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SE of Romidepsin
|
Arrhythmias
QT prolongation E-lyte abnormalities (K+, Mg+, Phos, Na+) Hyperglycemia |
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SE of Vorinostat:
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DVT/PE
QT prolongation Hyperglycemia |
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What drugs are classified as mTOR inhibitors?
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Temsirolimus
Everolimus |
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What is the HT of temsirolimus and Everolimus?
|
Increase in triglycerides
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|
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SE of temsirolimus:
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Hyperglycemia (86%)
Incr triglycerides (HT) (83%) Hypophosphatemia (49%) Hypersensitivity (9%) |
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SE of everolimus:
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Hyperglycemia (57%)
Incr triglycerides (HT) (77%) Incr lipids (57%) Stomatitis (86%) |
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Role of corticosteroids in cancer txt:
|
are part of treatment. They attack the tumor and are not just for nausea and vomiting.
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BSA formula:
|
BSA = Sqrt [ht(cm) * wt(kg)/3600]
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What is the most common dose-limiting side effect of chemo agents?
|
Myelosuppression
|
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How to calculate Absolute neutrophil count?
|
ANC = (% Segs + % Bands) x WBC x 1000
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Define neutropenia:
|
Absolute neutrophil count (ANC) < 500 cells/mm3
- ANC <1000 cels/mm3 and an expected drop to > 500/mm3 within 48 hours |
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What is the time of neutrophil recovery for busulfan use:
|
3-6 weeks
the next chemo session would not be sooner than 6 weeks |
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When to administer Colony Stimulating Factors:
|
- High risk pts for neutropinic fever
- Start 24-72 hrs after chemo ends - They can cause bone pain - They can increase pulmonary toxicity |
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How to treat bone pain caused by CSF?
|
APAP
Claritin |
|
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What agents are classified as CSF?
|
Filgrastim
Sargramostim Pegfilgrastim |
|
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What is the dose of filgrastim?
|
5 mcg/kg SQ
10 mcg/kg for BMT SQ |
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SE of CSFs?
|
Bone pain
injection site reaction splenic rupture |
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Dose of sargramostim:
|
250 mcg/m2 SQ
|
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Dose of Pegfilgrastim:
|
6mg SQ
|
|
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Define Neutropenic fever:
|
Single oral temp. of 38.3 C or 101F
A temp of 38C (100.4F) for more than 1 hour without an abvious cause |
|
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Rapid death can occur if a neutropenic fever is related to what type of organisms?
|
Gram negative
Escherichia coli Klebsiella Enterobacter species Pseudomonas aeruginosa (serious |
|
|
What antibiotics can be used in monotherapy to treat neutropenic fever?
|
Ceftazidime
Cefepime Imipenem-cilastatin Meropenem piperacillin-tazobactam |
|
|
Dual abx txt w/o vanco:
|
- Use with history of Pseudomonas aeruginosa infection
Aminoglycoside PLUS - ticarcillin/clavulanate - piperacillin/tazobactam - Cefepime - ceftazidime Cipro PLUS (if renal dysf.) - ticarcillin/clavulanate - piperacillin/tazobactam |
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When can Vanco be included in abx therapy for neutropenic fever?
|
Evidence of severe catheter infection
Positive blood cultures with gram+ bacteria Known colonization (MRSA or PCN or Ceph resistant S. pneumoniae) Ciprofloxacin or Bactrim prophylaxis AND severe mucositis (risk of Group B strep viridans) Soft tissue infection Hypotension or septic shock |
|
|
How to cover gram + bacteria in vanco resistance pts?
|
Linezolid 600mg IV or PO BID
Daptomycin Quinupristin/dalfopristin |
|
|
Does mucusitis require the use of Vanco for treatment?
|
No. if cefepine, imipenen or zosyn are being used.
(They have excellent gram + coverage) |
|
|
What to do if pt still neutropinic with fever after 3 days of abx txt?
|
- Broaden coverage if pt instable
- Not recommended to start vancomycin with continued fever empirically |
|
|
What to do if pt still febrile after 4-7 days of abx txt for neutropenic fever?
|
- Start fungal coverage
|
|
|
What antifungal can be used after day 4-7 to treat neutropenic fever?
|
Caspofungin*
Fluconazole (mostly for prophylaxis) Voriconzole Pozaconzole (for refractory ONLY) |
|
|
Symptoms of anemia
|
Peripheral edema
Sustained tachycardia Chest pain Dyspnea on exertion Orthostatic lightheadedness/syncope Fatigue (generally unrelieved by rest) |
|
|
When epoetin should be considered for a pt with anemia?
|
When HGB is less than 10 g/dL
|
|
|
Why ESAs should not be used in pts with curable cancers?
|
due to the risk of shorten survival.
ESA are only indicated in txt for prolonging life or palliative care. |
|
|
Risk of using ESAs:
|
Thrombotic events
Potential ↓ survival Shortened time to tumor progression Development of ESA antibodies |
|
|
What programs have to be completed in order to use ESAs?
|
REMS
APPRISE |
|
|
Dosage of epoetin alpha:
|
40000 units weekly SQ
if not response in 4 weeks, increase dose If not response in 8 wekss discontinue |
|
|
SE of epoetin alpha:
|
Mylagias, HTN, seizures (rare) Tumor progression, decreased survival, thromboembolism
|
|
|
Dosage of Darbapoetin alpha
|
100 mcg/week
If no response in 6 weeks increase dose If no response in 9 weeks discontinue |
|
|
SE of Darbepoetin:
|
Mylagias, HTN, seizures (rare) Tumor progression, decreased survival, thromboembolism
|
|
|
What to do if HGB increases by more than 1g in 2 weeks of erythropoietin?
|
Decrease dose by 25-50% due to increase risk of HTN and seizures.
|
|
|
What to do is HGB in more than 11g/dL during erythropoietin therapy?
|
Hold doses until HGB falls below 11 g/ml
|
|
|
What mineral should be administer with Epoetin to prevent functional deficiency?
|
Iron
|
|
|
What is the iron product most difficult to tolerate?
|
Iron Dextran (InFed)
|
|
|
What are the two most common drugs that cause a thrombocytopenia:
|
Procarbazine
Tositumonab (delayed 4-7 weeks) |
|
|
Usually how low PLT have to be in order to have a transfussion?
|
< 10K
|
|
|
What drug is indicated for the prevention of thrombocytopenia?
|
Oprelvekin (Neumega, IL-11)
|
|
|
Most common drugs to produce mucositis?
|
Methotrexate
Fluorouracil Doxurubicin |
|
|
Common way to prevent infections due to mucositis:
|
Rinse mouth with baking soda/saline several times daily
|
|
|
What medications are in a Magic Mouthwash?
|
Viscous lidocaine
diphenhydramine dicyclomine |
|
|
What medication is Used to prevent severe mucositis in bone marrow transplant?
|
Palifermin (Kepivance)
|
|
|
What are the medications that commonly cause diarrhea?
|
Fluorouracil
HD methotrexate capecitabine irinotecan (acute and delayed) |
|
|
Drugs to used once infection has been ruled out in a pt with diarrhea:
|
Loperamide
Lomotil Octreotide |
|
|
How to counsel a pt on the use of loperamide for diarrhea?
|
If it occurs within the first 24 hours it usually does not need treatment. If it occurs more than 12 hours after your dose, take loperamide 2 caps at onset of diarrhea, then 1 cap every 2 hrs until diarrhea has stopped for 12 hours
|
|
|
What medication can cause total body alopecia?
|
Paclitaxel
Docetaxel |
|
|
What chemo drugs can enhance radiation if given concurrently or within one week of radiation?
|
Cisplatin, fluorouracil, gemcitabine, paclitaxel
|
|
|
What drugs can produce radiation recall even if radiation treatment was weeks to years before?
|
Doxorubicin*
dactinomycin bleomycin gemcitabine paclitaxel |
|
|
What chemo drugs require warm compresses applicanton to prevent extravasation?
|
Vinca alkaloids
(vincristine / vinblastine) |
|
|
What is the only drug with indication for extravasation?
|
Dexrazoxane (totec) an anthra
|
|
|
What is the most important step in the therapy of hypercalcemia?
|
Rehydration with 0.9% NS and diuretics (Lasix)
|
|
|
What agent can be used for rapid calcium reduction?
|
Calcitonin
|
|
|
What drugs are useful when treating bone metastasis?
|
Bisphophonates
|
|
|
Serious SE of Bisphosphonates?
|
osteonecrosis of the jaw (ONJ)
|
|
|
Very expensive drug indicated for bone pain with metastases:
|
Denosumab
(Not 1st line treatment) |
|
|
Very expensive drug indicated for bone pain with metastases:
|
Denosumab
(Not 1st line treatment) |
|
|
What is the agent that causes the most PN?
|
Vincristine
|
|
|
What agents should be tried first in the treatment of neuropathic pain?
|
Pregabalin
Lamotrigine |
|
|
What are the risk factor for cardiotoxicity when using doxorubicin?
|
Mediastinal radiation
Pre-existing heart disease Hypertension Age (young and elderly) High drug peaks |
|
|
What are the signs and symptoms of hemorrhagic cystitis?
|
Pain on urination
Blood in the urine Urinary urgency |
|
|
Characteristic of SCLC?
|
Faster growing
More aggressive disease Poor prognosis |
|
|
Treatment of choice for Limited disease SCLC:
|
Concurrent chemotherapy and radiation therapy (chemoradiation)
|
|
|
Treatment of choice for Extensive disease SCLC:
|
Chemotherapy for palliation and extended survival.
|
|
|
Best chemo treatment for limited stage SCLC:
|
Cisplatin plus etoposide (EP) for 4-6 cycles
PLUS concurrent radiation |
|
|
What risk is increase with the combination of etoposide and radiation?
|
Esophagitis and pulmonary toxicity
|
|
|
Treatment for extensive disease SCLC with good performance status:
|
Cisplatin or carboplatin with etoposide for 4-6 cycles
Irinotecan with cisplatin or carboplatin |
|
|
What is the role of Radiation therapy for extensive disease SCLC?
|
Symptom palliation
|
|
|
SCLC relapse txt:
|
single agent if relapse happen less than six month.
If more than six months use original txt. |
|
|
NSCLC characteristics:
|
Slower growing
Txt of choice: surgery Hypercalcemia seen more commonly than in SCLC |
|
|
Meaning of Stage I NSCLC:
|
tumor confined to lung
|
|
|
Meaning of Stage IV NSCLC:
|
Contralateral lung, pleural effusions or distant metastases
|
|
|
Prognosis for an EGFR positive NSCLC:
|
- It will benefits from EGFR-TKI txt
- Usually only adenocarcinoma |
|
|
Prognosis for an ERCC1 positive NSCLC:
|
Longer survival after surgery
High levels poor response to platinum agents |
|
|
Prognosis for a K-ras positive NSCLC:
|
Shorter survival
Associated with smoking No benefit from EGFR-TKI |
|
|
Prognosis for a RRM1 positive NSCLC:
|
Longer overall survival
Poor response to carbo/gem therapy |
|
|
Prognosis for a EML4-ALK positive NSCLC:
|
Resistant to EFGR-TKI
Crizotinib is DOC |
|
|
Treatment of NSCLC Stage I with negative margins:
|
Observation after surgery
Chemotherapy for high-risk patients |
|
|
Treatment of NSCLC Stage II with negative margins:
|
Chemotherapy
|
|
|
Treatment of NSCLC Stage III with negative margins:
|
CheomRT if can tolerate
(either before or after surgery) |
|
|
Preferred txt for NSCLC stage I-III
|
Cisplatin + vinorelbine
|
|
|
Options for combination of cisplatin in the txt of stage I-III NSCLC:
|
vinblastine
etoposide gemcitabine pemetrexed or docetaxel |
|
|
Option for a pt who does not tolerate cisplatin txt in stage I-III NSCLC:
|
Carboplatin + paclitaxel
|
|
|
DOC for a EGFR positive stage I-III NSCLC:
|
erlotinib (first line treatment)
|
|
|
Drugs used as second line txt for stage I-III NSCLC with good performance status:
|
Docetaxel
Pemetrexed Erlotinib |
|
|
Txt for Stage IV NSCLC non-squamous performance status 3-4
|
Best supportive care
|
|
|
txt for stage IV non-squamous NSCLC EGFR positive:
|
Erlotinib +/- chemo
|
|
|
txt for stage IV non-squamous NSCLC EGFR negative:
|
Cisplatin/pemetrexed*
or Chemo + bevacizumab* |
|
|
txt for stage IV non-squamous NSCLC ALK positive:
|
Crizotinib (adenoca only)
|
|
|
txt for stage IV non-squamous NSCLC with performance status 0-2
|
Chemo ± bevacizumab*
Cisplatin/pemetrexed* Vinorelbine/cisplatin/Cetuximab |
|
|
txt for stage IV squamous NSCLC EGFR positive
|
Testing not recommended
|
|
|
txt for stage IV squamous NSCLC EGFR negative:
|
Cisplatin/gemcitabine
Cisplatin/vinorelbine/cetuximab |
|
|
txt for stage IV squamous NSCLC ALK positive
|
Testing not recommended
|
|
|
txt for stage IV squamous NSCLC with performance status 0-2
|
Chemotherapy OR
Vinorelbine/cisplatin/ cetuximab |
|
|
Txt for Stage IV NSCLC squamous performance status 3-4
|
Best supportive care
|
|
|
Bevacizumab can be added to txt of NSCLC stage IV if:
|
Performance status 0-1
Non-squamous cell NSCLC No recent history of hemoptysis No untreated CNS metastases All due to the risk of bleeding |
|
|
Single-Agent therapy used in advanced NSCLC:
|
Gefitinib (Iressa)
|
|
|
SE of crizotinib:
|
Severe pneumonitis
infections diarrhea vision disorders QT porlongation |
|
|
The two most important risk factors for breast cancer are:
|
Female gender
Increasing age |
|
|
ACS screening recommendations for women in their 20's:
|
Monthly Breast Self Exam
|
|
|
ACS screening recommendations for women after 20 yo:
|
Clinical breast exam every 3 yrs.
|
|
|
ACS screening recommendations for women age 40:
|
Clinical breast exams yearly
Mammogram yearly |
|
|
Meaning of breast cancer stage I:
|
small and confined to breast
|
|
|
Meaning of breast cancer stage IV:
|
distant metastases
|
|
|
What is the most common type of breast cancer?
|
Infiltrating ductal carcinoma
|
|
|
Lobular carcinoma in situ txt:
|
Not a pre-malignant lesion but increases risk of invasive breast cancer. Txt for prevention:
- Tamoxifen for all women - raloxifene only for postmenopausal women |
|
|
Ductal carcinoma in situ txt:
|
Pre-malignant lesion:
- Mastectomy or lumpectomy with XRT followed with tamoxifen for ER+/PR+ patients |
|
|
First 4 Factor affecting breast cancer prognosis:
|
-Number of involve axillary lymph nodes (most important)
- Age: < 35yrs more aggressive disease and >70yrs more indolent disease. - Ethnicity: African American - ER/PR status: positive have better prognosis |
|
|
Second 3 factors affecting breast cancer prognosis:
|
HER-2/neu tumors have a poor prognosis.
The higher the grade the poorer the prognosis The larger the tumor the poorer the prognosis |
|
|
txt options for patients with HER-2/neu + breast cancer:
|
- pts elegible for trastuzumab therapy
- Anthracycline containing regimens have better outcomes |
|
|
Factors to consider for the size of breast tumors:
|
Tumor < 2 cm & axillary node (-)
Favorable prognosis (96% 5-year survival) Tumor > 5 cm and axillary node (-) poorer prognosis (82% 5-year surivival) |
|
|
What type of pt can use Mammaprint or Oncotype DX to evaluate the risk of breast cancer recurrence?
|
Node positive pts
|
|
|
Treatment strategy for breast cancer:
|
Surgery
Systemic adjuvant therapy - Chemotherapy and/or - Endocrine therapy Radiation |
|
|
In what two situations neoadjuvant chemo is allowed:
|
Stage III tumor too big to get it out
Stage II patient who qualifies for lumpectomy but the tumor is more than 5mm in size. |
|
|
Neoadjuvant chemotherapy for HER2/neu + tumors:
|
trastuzumab and/or lapatinib
then, debulk tumor and use traditional chemo regimens |
|
|
What pts would benefit from neoadjuvant ENDOCRINE stage II - III:
|
ER+/PR+ unresectable tumors
Other comorbidities making chemotherapy risky |
|
|
Endocrine therapy:
|
Premenopausal – tamoxifen
Postmenopausal – aromatase inhibitor or tamoxifen |
|
|
What are potential problems from lymph node dissection:
|
Lymphedema
Sensory loss Pain |
|
|
Adjuvant therapy breast cancer stage I - II
|
Chemo if lymph node involvement
or Tumor >1cm Hormone therapy if ER+/PR+ - tamoxifen or aromatase inhibitor |
|
|
Breast Cancer txt node + or > 1cm and HR + / HER-2 +
|
Chemo + trastuzumab + endocrine therapy
|
|
|
Breast Cancer txt node + or > 1cm and HR + / HER-2 neg
|
Endocrine therapy +/- chemo
|
|
|
Breast Cancer txt node + or > 1cm and HR neg / HER-2 +
|
Chemo + trastuzumab
|
|
|
Breast Cancer txt node + or > 1cm and HR neg / HER-2 neg
|
chemo
|
|
|
What type of adjuvant chemoregimen is preferred in stage I-II for node positive breast cancer?
|
Anthracycline containing regimens
|
|
|
What agent should be add to regimen if breast tumor is HER2/neu positive and it has more than 1cm in size?
|
trastuzumab
|
|
|
What two drugs when use together increase the risk of rapid cardiomyopathies?
|
Antracyclines and trastuzumab
|
|
|
What endocrine therapy should be used after surgery and/or chemo in stages I - III of breast cancer?
|
Tomaxifen for 5 years
|
|
|
Adjuvant endocrine therapy for pre-menopausal pt (1):
|
Tamoxifen for 5 years
± ovarian suppression if remain premenopausal |
|
|
Adjuvant endocrine therapy for pre-menopausal pt (2):
|
Tamoxifen for 2-3yrs if becomes post-menop. Aromatase Inhibitor for 2-3yrs
|
|
|
Adjuvant endocrine therapy for pre-menopausal pt (3):
|
Tamoxifen for 5 years if becomes post-menop. aromatase inhinitor for 5 yrs
|
|
|
Adjuvant endocrine therapy for post-menopausal pt:
|
1. tamoxifen 2-3yrs + AI 2-3yrs (5yrs total)
2. tamoxifen 2-3yrs + AI 5yrs (total 7-8yrs) 3. tamoxifen 5 + AI 5yrs (total 10 yrs) |
|
|
Can we use adjuvant endocrine therapy for ER-/PR- pt?
|
NOPE
|
|
|
List antiestrogen agents:
|
tamoxifen
Toremifene Fluvestrant |
|
|
Dose of tamoxifene:
|
20mg PO daily
|
|
|
Important SEs of antiestrogen agents:
|
thromboembolism and endometrial or uterine cancer
|
|
|
List Aromatase Inhibitor agents:
|
Anastrozole
Letrozole Exemestane |
|
|
Dosage of Anastrozole:
|
1mg PO daily
|
|
|
Dosage of letrozole:
|
2.5mg po daily
|
|
|
Dosage of Exemestane:
|
25mg PO daily
|
|
|
Important SE of Aromatase Inhibitor agents:
|
decreased bone density, increased risk of fracture (calcium and vit D supplement needed)
|
|
|
What type of txt is preferred for stage IV metastatic breast cancer?
|
Endocrine therapy (similar results to chemo txt)
|
|
|
Txt for premenopausal stage IV breast cancer:
|
1st line txt: Antiestrogen (Tamoxifen or toremifene)
Used until resistance shows or progression of disease. THEN, surgical hysterectomy and oophorectomy or LHRH agonist (NO AROMATASE INHIBITORS if premenopausal) |
|
|
What agents are LH-RH agonists?
|
Goserelin
leuprolide triptorelin |
|
|
Txt for postmenopausal stage IV breast cancer:
|
1. Non-steroidal aromatase Inhibitor (Anastrozole or Letrozole)
Raloxifene SHOULD NOT be used for txt 2. Steroidal AI: Exemestane after non-AI failure 3. Antiestrogens: Tamoxifen or Toremifene 4. Fulvestrant: used after progression on endocrine therapy |
|
|
What is the main difference in the initial txt for pre vs post-menopausal stage IV breast cancer?
|
For premenopausal stage IV initial therapy is tamoxifen. For postmenopausal initial therapy is an aromatase inhibitor.
|
|
|
When chemo therapy should be introduced in the txt of stage IV breast cancer?
|
When after different regimens of endocrine therapy we reach the point of No response, then chemo is added.
|
|
|
What agent is a good option for a patient HER2/neu + with brain metastasis?
|
Lapatinib (crosses BBB) +
capecitabine SE: severe diarrhea |
|
|
What type of chemo regimen should be added for a stage IV HER2/neu + pt.?
|
Trastuzumab based regimen
|
|
|
What are the preferred trastuzumab regimens for HER2/neu + for stage IV breast cancer?
|
Pertuzumab, trastuzumab, docetaxel
Pertuzumab, trastuzumab, paclitaxel Therapy with trastuzumab is indefinitely. |
|
|
What is the difference between trastuzumab regimens for adjuvant therapy compared to metastatic disease?
|
In adjuvant AC + taxal + trastuzumab
In metastatic disease Pertuzumab is also included with trastuzumab |
|
|
SE of trastuzumab:
|
Heart failure (monitor EF)
hypersensitivity (delayed up to 12 hrs after dose) |
|
|
Considerations of pertuzumab dosage:
|
If dose is held for >6 weeks, loading dose (840 mg) needs to be repeated
|
|
|
SE of pertuzumab:
|
CHF (monitor EF)
Myelosuppression |
|
|
What agent can be used for taxane resistant breast cancer?
|
Ixabepilone (alone or in combination with capecitabine)
SE: PN |
|
|
Radiation therapy would be required if:
|
Partial mastectomy
Positive/close margins Skin involvement > 5cm tumor 4 or more axillary lymph nodes Neoadjuvant chemotherapy Local recurrence Palliation (bone or brain mets) |
|
|
txt for bone metastases in breast cancer:
|
1. Bisphosphonates
2. Denosumab (if bisphosphonates are not tolerated) SE: ONJ (no good txt for it) Calcium and B12 supplementation needed for all agents |
|
|
What are the risk factors for prostate cancer?
|
AGE: > 65yr
RACE: African American Family History: especially young age of diagnosis DIET: High fat intake |
|
|
Prostate cancer Screening tools:
|
DRE
PSA TRUS (needs to be done after PSA b/c it can elevate it) |
|
|
Drugs that can decrease PSA levels by 50% after 6-12 months of use:
|
Finasteride
Dutasteride Bicalutamide Flutamide Herbs (Saw Palmetto) |
|
|
According to the ACS how prostate cancer screening should be done?
|
Offer PSA testing at age 50
Discuss Pros and Cons Patient/physician should decide |
|
|
What requirements have to be met in order to do staging of prostate cancer?
|
Life expectancy > 5 yrs
or Symtomatic |
|
|
What does Gleason's scores mean (Scale 1 - 5):
|
Total: 2-4 (well), 5 or 6 (moderately), 7-10 (poorly)
Poorly differentiated grow faster (poor prognosis) Well differentiated grow slower (better prognosis) |
|
|
Requirements for a prostate cancer patient to have Active surveillance (observation) as txt:
|
Very low risk prostate cancer patients and life expectancy < 20 years
Low risk prostate cancer patients and life expectancy < 10 years TUMOR WILL PROGRESS under this txt |
|
|
What pts qualify for a radical prostatectomy?
|
Reserved for patients with > 10 year life expectancy
Only those with disease confined to prostate are eligible |
|
|
Treatment of Locally Advanced prostate cancer:
|
Radical prostatectomy OR
3D – CRT/IMRT with - Long-term LH-RH agonist therapy (2-3 years) OR - Short-term LH-RH agonist therapy (3-6 months) Follow up due to high rate of recurrence |
|
|
txt of recurrence prostate cancer for pts who had prostatectomy:
|
Radiation +/- ADT (androgen depravation therapy)
|
|
|
txt of recurrence prostate cancer for pts who had radiation therapy:
|
Prostatectomy
or ADT therapy |
|
|
txt of prostate cancer recurrence for patients NOT on therapy but with clinical metastases (non castrate):
|
ADT:
- Bilateral orcheitomy - LH-RH agonist +/- antiandrogen - Gonadotropin Releasing Hormone antagonist |
|
|
In what situations is Bilateral Orchiectomy the preferred initial txt for recurrence prostate cancer with clinical mets?
|
Pts with impending spinal cord compression or ureteral obstruction
|
|
|
List LH-RH agonist agents:
|
Goserelin
Leuprolide Triptorelin |
|
|
SE of LH-RH agents
|
Tumor flare (antiandrogens may be helpful)
DM Cardiovascular disease Weight gain hot flashes sexual dysfunction Osteoporosis (vit D and Ca suppl.) |
|
|
List GnHR antagonist agents:
|
Degarelix
Abaralix |
|
|
What is the advantage of GnHR txt vs LH-RH txt?
|
Castrate levels achieved within 7 days (vs. 28 with LHRH agonist)
No tumor flare seen Same calcium/vitamin D replacement as with LHRH agonist |
|
|
Antiandrogen agents:
|
Bicalutamide
Flutamide Nilutamide To prevent tumor flare or additive with LHRH agonist – use for 1 week May be associated with DECREASED SURVIVAL when used alone |
|
|
Hormone Refractory Prostate Ca – Chemotherapy:
|
Docetaxel or Cabazitaxel + prednisone
|
|
|
Drug options for patients who have failed Docetaxel txt for Hormone refractory Prostate cancer:
|
Abiraterone (take on empty stomach and use with prednisone)
Enzalutamide (SE: seizures and severe infx) Sipuleucel-T (its a vaccine and requires sterility report) very expensive $$$$ |
