cancer / chemo

breast cancer screening

• 45-55 yearly mammogram

• >55 every 2 years or continue yearly

cervical cancer screening

25-65 pap Q3 years or HPV Q5 years or pap+HPV Q5 years

colorectal cancer screening

>45 FIT/stool DNA or colonoscopy Q10 years or sigmoidoscopy Q5 years

lung cancer screening

50-80 + 20 pack-year history gets annual chest CT

calvert formula

dosing for carboplatin = target AUC x (GFR + 25)

cyclophosphamide, ifosfamide

hemorrhagic cystitis (toxic metabolic acrolein) → present with hydration + mesna for all ifosfamide doses and high-dose cyclophosphamide

busulfan

pulmonary toxicity

carmustine

neurotoxicity (seizures), pulmonary toxicity

cisplatin

• hypersensitivity/anaphylaxis

• nephrotoxicity → prevent with hydration + amifostine and limit dose <100/cycle

• ototoxicity → baseline audiogram

• peripheral neuropathy

oxaliplatin

acute neuropathy worsened by cold → avoid cold exposure

doxorubicin

• cardiotoxicity → monitor LVEF, prevent with dexrazoxane, cumulative lifetime dose capped at 450-550

• red discoloration of urine/fluids

mitoxantrone

blue discoloration

irinotecan

• topo I

• acute diarrhea (atropine) + cholinergic symptoms

• delayed diarrhea (loperamide)

vincristine

• CNS toxicity

• peripheral/autonomic neuropathy (constipation)

• fatal if given intrathecally

• limit dose to 2 mg and prep in small IV piggyback bag

vinblastine/vinorelbine

more bone marrow suppression

paclitaxel

• peripheral neuropathy

• hypersensitivity

• non-PCV bag + 0.22 micron filter

• premedicate

docetaxel

severe fluid retention

fluorouracil/capecitabine

• hand-foot syndrome

• diarrhea

• mucositis

• DPD deficiency = severe toxicity risk

• antidote = uridine triacetate

• DDI = increases INR with warfarin

methotrexate (MTX)

• nephrotoxicity (high dose >500)

• GI toxicity

• leucovorin/levoleucovorin rescue (>500), IV NaHCO3, avoid NSAIDs/salicylates

• antidote = glucarpidase

• treat mucositis with viscous lidocaine 2% or magic mouthwash

arsenic troxide

QT prolongation

bleomycin

• pulmonary toxicity

• limit lifetime dose to 400 units

• hypersensitivity

bortezomib, carfilzomib

herpes reactivation → prevent with acyclovir/valacyclovir

lenalidomide, pomalidomide, thalidomide

• severe birth defects → need 2 neg pregnancy tests

• thrombosis risk

drugs that cause neurotoxicity

carmustine

drugs that cause ototoxicity, high emetogenicity and nephrotoxicity

• cisplatin

• prevent with amifostine and limit cisplatin dose to <100/cycle

drugs that cause mucositis

• MTX, 5-FU, capecitabine

• prevent with leucovorin for high-dose MTX

drugs that cause pulmonary toxicity

• bleomycin, busulfan, carmustine

• prevent with limiting bleomycin dose to 400 units lifetime

drugs that cause cardiotoxicity

• doxorubicin/anthracyclines

• prevent with dexrazoxane and limit doxorubicin dose to 450-550 mg lifetime

drugs that cause hemorrhagic cysitis

• ifosfamide, cyclophosphamide

• prevent with mesna

drugs that cause peripheral neuropathy

• oxaliplatin, vincristine, taxanes

• prevent with avoiding cold (oxaliplatin) and limiting vincristine dose to 2 mg

drugs that cause bone marrow suppression

most chemo except bleomycin, pegarspargase, vincristine

neuropenia

• low WBC

• treat with filgrastim (Neupogen) daily or pegfilgrastim (Neulasta) once per cycle but first dose no sooner than 24H after chemo

  • febrile neutropenia (>101F + ANC<500) → treat with ABx that cover pseudomonas

thrombocytopenia

• low PLTs

• transfusion if <10,000

anemia

• low RBC

• tranfuse if symptomatic

• epoetin alfa, darbepoetin alfa if Hgb < 10, good iron stores, and chemo intent is not curative

CINV regimens

• high risk (cisplatin) → NK1 RA + 5-HT3 RA + olanzapine + dexamethasone

• moderate → 2-3 drugs

• low → 1 drug

  • breakthrough → add a drug with a different MOA

NK1 RA for CINV

aprepitant, fosaprepitan, rolapitant

5-HT3 RA for CINV

• ondansetron, granisetron, palonosetron, dolasetron

• CI with apomorphine

• QT prolongation (limit IV zofran to 16 mg), SS risk

dopamine agonists for CINV

• olanzapine, prochlorperazine, promethazine, metoclopramide, haloperidol

• metoclopramide → decrease dose 50% if CrCl < 60, boxed warning for irreversible TD, avoid in parkinsons

• promethazine → boxed warning not for kids <2, do not give intraartial/SC/IV

treating extravasation for anthracyclines

cold compress + dexrazoxane

treating extravasation for vinca alkaloids

warm compress + hyaluronidase

which targeted therapies produce an acneiform rash that correlates with treatment response?

cetuximab, afatinib, erlotinibh

hormone receptor-positive (ER+/PR+) breast cancer treatment

• premenopausal → tamoxifen

  • postmenopausal → tamoxifen or an AI ta

tamoxifen

• SERM

• prodrug of CYP2D6

• boxed warning → uterine/endometrial cancer, thromboembolism

• SE → hot flashes, vaginal bleeding, decreased BMD (Vit D/Ca)

• teratogenic

• venlafaxine helps hot flashes

fluvestrant for breast cancer

• SERD

• IM injection

• SE = increased LFTs, inj site pain, hot flashes

anastrozole for breast cancer

• AI

• SE → hot flashes, arthralgia/myalgia, increased osteoporosis risk (Ca/Vit D), increased CVD risk

which medication to use for HER2-positive breast cancer

trastuzumab

GnRH agonists for prostate cancer

• leuprolife, goserelin

• initial tumor flare so give with antiandrogen

• SE → hot flashes, impotence, gyne, bone pain, QT prolongation, osteoporosis

GnRH antagonists for prostate cancer

• degarelix, relugolix

• can be given alone → no flare

antiandrogens (1st gen) for prostate cancer

• bicalutamide, flutamide, nilutamide

• bicalutamide CI in females

• SE = hot flashes, gyne

tumor lysis syndrome (TLS)

• rapid tumor cell breakdown → hyperkalemia, hypocalcemia, hyperuricemia, acute renal failure

• tx → IV NS hydration + urate-lowering therapy (allopurinol, rasburicase; ras is CI in G6PD deficiency)

hypercalcemia of malignancy

• nausea, vomiting, fatigue, dehydration, confusion

• tx → IV NS hydration + IV bisphosphonate (pamidronate, zoledronic acid)

  • severe = add calcitonin for up to 48H only

  • refractory to bisphosphonates = denosumab