Chemotherapy Side effects

Name the platinum based agents and describe them

Cisplatin, exaliplatin, carboplatin
Oldest agents, still used nowadays

What are the key side effects of platinum based chemo?

Nephrotoxicity
neurotoxicity
ototoxicity
GI (N&V)
Alopecia
Hematologic toxicity

Amongst platinum based chemo which one is the most nephrotoxic? What shall be done?

Cisplatin
Check GFR before prescribing

If after ordering eGFR we find that the pt has kidney disease, but platinum agent is necessary, what should be done?

Switch to Carboplatin

In a person with renal disease, the choice of Carboplatin administration was made, what are the risks now? What should be ordered before making this choice?

Infections (neutropenia)
Bleeding (thrombocytopenia)
Order CBCD-crea

Amongst platinum based chemo which one is the most emetic? What is tye mechanism?

Cisplatin, acts on area postrema in the brain

Rapunzel is diagnosed with ovarian cancer, the choice of a platinum based agent is made. Which one must be avoided and why?

Cisplatin => Alopecia
Carboplatin and Oxaliplatin => more hair protective

Rapunzel is so worried about her hair, what additional measures can be taken?

Cold capping, although controversial (expensive, uncomfortable, reduced BF to brain) can be considered

After taking all precautions, Rapunzel still loses her hair… what should we tell her?

Alopecia is temporary , hair will start regrowing 3-4 weeks after chemo cessation

Amongst platinum based chemo which one is the most neurotoxic? What shall be done?

Oxaliplatin
Keep asking the pt about parasthesia and grade it

Beethoven comes to you with testicular cancer, the choice was made towards a platinum based agent. Which drug must be avoided? Wat must be always done before prescribing this agent?

Cisplatin
ENT referral

When evaluating side effects of chemo, what should be done?

GRADING! GRADING ! GRADING!
CTCAE is a great app

In summary, oxaliplatin is used in …. its major toxicity is …. it is … protective

Gastric , colon
Neurotoxicity

In summary, cisplatin is used in …. its major toxicity is …. it is … protective

Lung, testes cancers
Nephro, oto, alopecia and highest in nausea
Very aggressive not protective

In summary, Carboplatin is used in …. its major toxicity is …. it is … protective

Renal impairment
Hematologic
Hair and nephro protective

Anthracyclines are ….. name an agent

Antitumour antibiotics
Doxorubicin

What is the other name of doxorubicin

Adriamycin

Doxorubicin is … (colour)

Strawberry red yum yum

A lady comes for X cancer , the choice of anthracycline usage is made (doxorubicin). Cancer X is most likely …

Breast cancer
Lymphoma

A lady comes for X cancer , the choice of anthracycline usage is made (doxorubicin). Before this choice was made she was…?

Referred to a cardiologist for cardiac function assessment

A lady comes for X cancer , the choice of anthracycline usage is made (doxorubicin). What should we be aware of?

Possibility of dilated cardiomyopathy
Severe alopecia

A junior resident is taking history from a lady that comes for breast cancer therapy. She was treated for lymphoma in her childhood but doesn't recall the name of the drug used… all she mentioned is that it was red in color. The resident doesn't pay much attention to this detail and prescribes her Adriamycin. What is the issue here?

In case that red drug was adriamycin, then the records of dosage must be obtained because this drug has a cumulative effect and the maximum lifetime dose is of 450-550 mg/m²

The junior resident that prescribed adriamycin to the lady with a hx of lymphoma cure, remembered his course about this drug and made sure the dosages are still within acceptable limits. The patient however dies from HF. What should've been done?

Cardio checkups every 3 months

Mr X comes for … cancer , you prescribe 5-fluorouracil which is an…

GI
Antimetabolite (primitive analogue)

In 5-fluorouracil we should watch out for?

Mucositis :
Ulcers
Pain
Diarrhea
GI bleed

How is 5 fluorouracil administered ?

IV over 46 hours (2 nights in hosp)
Or via a pump at home

Mr X to whom you prescribed 5-FU presents with mouth ulcers , what can you recommend

A mouthwash

With the usage of mouthwash, Mr. X to whom u prescribed 5-FU still develops severe ulcers and blood in stool! What are you suspecting

DPD deficiency

If your suspicion was correct, Mr X on 5-FU must be switched to? How is it administered

Capecitabine , PO
2 weeks on 1 week off (21 day cycle)

What is the problem with capecitabine?

Poor compliance

Capecitabine might cause… (side effects)

Diarrhea
Hand- foot syndrome

With which chemo agent nail polish must be avoided and why?

Taxanes => nail toxicity (onycholysis, onychomycosis)

With which chemo agents we must be aware of extravastaion?

5FU and taxanes => locally aggressive

Name the 2 most known taxanes?

Paclitaxel
Docetaxel

Paclitaxel is called in hosp?

Taxol

Docetaxel is called in hosp?

Taxotere

Paclitaxel is widely used in … over …

Paclitaxel is widely used in breast cancer over 12 cycles

Docetaxel is used in…, in fact taxanes are used …

Breast, lung….
In almost all solid tumours

Name the side effects of taxanes

Immunosuppressive
Neuropathy
Diarrhea
Nail toxicity

Amongst chemo (and particularly taxanes) which drug is most neurotoxic?

Paclitaxel

Before administering taxanes we might need to inject…

GSF to counteract the immunosuppressive property of the treatment

Lymphoma is often addressed by a specific regiment, what is it?

ABVD
Anthracycline
Bleomycin
Vinblastine
Dacarbazine

Before using this regiment (lymphoma) what must be done inevitably?

"PFTs , check if ""DLCO is safe for belomycin"""

Bleomycin is used in…. an it causes … (toxicity)

Lymphoma, testicular cancers
Lung fibrosis

Name the topoisomerase I inhibitors

Topotecan , irinotecan

Irinotecan is used in …. cancer

Colon

Patients on Irinotecan must take…. because they are af high risk of …

Anti cholinergic agents
Dehydration (severe diarrhea)

Hormonal therapy is a targeted therapy, in premenopausal women with breast cancer we prefer giving?

Tamoxifen (anti estrogen)

What are the side effects of Tamoxifen ?

Endometrial hyperplasia/cancer
Thrombosis

What to do about the risk of thrombosis in tamoxifen?

Avoid in bedridden
Anticoag on long flights

What to do about the risk of endometrial hyperplasia in tamoxifen?

Visit GYN doc twice a year

What should be administered alongside tamoxifen in high risk pt?

a-GNRH
It suppresses the receptors of GnRH in pituitary thus LH and FSH are lowered => ovarian function suppressed
On estrogen circulating in high amounts
=> less risks of hyperplasia

What is the hormonal therapy of choice in breast cancer in postmenopausal women?

Aromatase inhibitors

What is the major side effect of aromatase inhibitor? What to do about it?

Osteoporosis
Baseline DEXA scan and yearly FU

Breast cancers might be ER+ and/or PR+ , but also HER2/neu +. What to do about this marker?

Anti -Her2
Transtuzumab and Pertuzumab

What is trastuzumab called ?

Herceptin

Anti-HER2 is used in breast and.

GI

What are the side effects of anti-HER2

Dilated cardiomyopathy
Pertuzumab : allergy , diarrhea

In which drug cardiomyopathy is also a side effect? Compare

Anthracycline: cumulative, max ,ifetime dose 450-550 mg/m²
Anti-HER2: reversible, no cumulative effect, dose depending

Vessels play a major role in cancer development, growth , spread … what drug targets them?

Anti-VEGF

Give me an anti-VEGF drug name

Bevacizumab

Bevacisumab is also called?

Avastin

In what cancers AVvastin is used?

GI
H&N
Ovarian

Avastin reduces….. in gastric and ovarian cancers

Ascites

When Avastin should be avoided ? Why?

Pre surgery or right after
Risk of perforation

What are the side effects of bevacizumab?

Vascular:
HTN, bleeding, thrombosis
Perforation

Anti-VEGF targets endothelium, anti…. targets epithelium (+name)

Anti-EGFR Cetuximab

Cetuximab is used in ?

Colorectal cancer

2 patients with colorectal cancer are put on cetuximab, one of them develops a rash. They come together asking why only one of them developed this skin manifestation and what does sit mean?

Acneiform rash is a side effect of cetuximab and it indicates response
However
No rash =/= no response!!!

Cetuximab side effect? What to do about it?

Acneiform rash
Wear sunscreen

Immunotherapy has revolutionized treatment in oncology, name one type

PD1/PDL1 inhibitors

What are the side effects of PD1/PDL1 inhibitors?

Hepatitis
Thyroiditis
Pneumonitis
Colitis

Which side effect of PD1/PDL1 is fatal if not monitored?

Pneumonitis

Before PD1/PDL1 therapy, what tests must be ordered?

LFTs
TSH, FT4

What should be done if a pt on immunotherapy develops colitis?

Grade and treat accordingly