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ONCOLOGY
ONCOLOGY
Background
Most of the classic chemotherapy agents can be broken down into two
categories, however we don’t have to memorize which chemotherapy is
cycle specific or not unless you are an oncology specialist.
o Cell Cycle Specific & Cell Cycle Non-specific (Targeted therapies
are usually better tolerated, because they target specific receptors
or proteins on a tumor cell, they don't focus on the cell cycle at all.)
o The bulk of targeted therapies fall into two categories: Monoclonal
Antibodies (IV) & Tyrosine Kinase Inhibitors (PO usually).
Most chemo agents are dosed on Body Surface Area (BSA,). This helps
make the dose of a drug less sensitive to outliers (like extreme obesity, or
amputee).
o Most doses are in unit mg/m2
o g: give 80mg/m2 of oxaliplatin to a patient whose BSA is 2.0. In this
case, the total dose would be 160mg.
Warning signs of cancer: Change in bowel/bladder habit; A sore that does
not heal; Unusual bleeding/discharge; Thickening or lump in breast or
other area; Indigestion, difficulty swallowing; Obvious change in
wart/mole; Nagging cough or hoarseness
Tumor Lysis Syndrome (TLS): when chemo kills those cancerous cells, the
content spill out. What lives inside our cells? Potassium, phosphate, and
uric acid. The high potassium levels cause heart arrhythmias. The uric
acid and phosphate crystallize in the kidneys and cause acute renal
failure, this further raises the potassium and leads to an emergency state
called TLS.
Adverse effect of chemotherapy
o classic cytotoxic chemotherapy doesn't do good at discriminating
healthy cells from cancerous cells. Some healthy cells that divide
more rapidly than others. E.g: GI tract, hair follicles, bone marrow.
This is where most side effects of classic chemotherapy come from:
anemia, hair loss, sores/ulcers in the mouth and esophagus
(mucositis), nausea/vomiting.
o Low WBCs open up to infections (suffice it to say: low neutrophils =
low immune system), low platelets introduce bleeding risk, and low
RBCs leave patients suffering anemic and tired.
Colorectal cancer: Colonoscopy, signoidoscopy @ age 50: yearly fecal
occult blood test (gFOBT), fecal immunochemical test (FIT).
Anthracyclines
Drugs (mnemonic: all ends with “rubicin”): Daunorubicin (Cerubidine),
daunorubicin liposomal (DaunoXome), doxorubicin (Adriamycin),
doxorubicin liposomal (Doxil), epirubicin (Ellence), idarubicin (Idamycin),
mitoxantrone (Novantrone)
SE: very effective but limited by cardiac toxicity (consider
cardioprotective agent dexrazoxane -Zinecard), red urine/body secretion
(all anthracyclines are bright red in color, just like rifampin can cause
urine, tears, and other secretions to look like cherry fruit smack,
mitoxantrone has blue urine). Severe tissue damage w/ extravasation
(antidote- dexrazoxane (Totect)). Hand-foot syndrome (higher incidence w/
liposomal products)
There is lifetime dosing limit (again, in mg/m2) for each anthracycline to
limit cardiac toxicity.
Platinum-based
Monoclonal antibodies
Drugs (all end with “nib”): Imatinib (Gleevec), erlotinib (Tarceva), lapatinib
(Tykerb®).
MOA: targeted therapy, act on a gene level by inactivating cell signaling
cascades. Cell expression has on-off switches, of which the cancerous
cells are mutate and stuck in the "on" position, so the cell is unable to
shut the factory down and lead to uncontrolled growth. Include many
types: BCR inhibitors, EGFR (endothelial growth factor) inhibitors.
Most given by PO, get rid of the inconvenience of traveling to infusion
center.
Toxicities: every TKI can cause rash and diarrhea, 3A4 substrate (hepatic
toxicity), hypothyroidism, QT prolongation.
Risk of drug interactions, particularly with acid-suppressing agents.
Antiandrogens (po)
Alkylator
Angiogenesis inhibitor
Immunomodulator
Decrease angiogenesis
SE: preg cat X, all specialist must enroll in RevAssist/STEPS program,
neutropenia, thrombocytopenia
Drugs: Thalidomide (Thalomid), lenalidomide (Revlimid)
Vinca alkaloids
Taxanes
Trelstar® (triptorelin)
Topoisomerase inhibitors
5HT3 antagonist
Anemia
Thrombocytopenia (TCP)
Anticoagulation
DVT and PE are the leading causes for mortality and morbidity in cancer
patients, recommends LWMH and new oral anticoagulants.
LMWH is contraindicated in dialysis and needs to be dose adjusted in renal
failure.
Avoid warfarin, many drug interactions.
Mucositis
Hypercalcemia
Diarrhea
NAPLEX Pearls
At minimum level, you should focus on these for NAPLEX.
Each of the above class has cytoprotective agent as follows, they are not always
used clinically, but if you can match them up with the drug used to protect
against, you'll do fine.
Anthracyclines - Dexrazoxane
Ifosfamide/Cyclophosphamide - Mesna
Cisplatin – Amifostine
Know how to treat side effects of chemotherapy. Drugs and supportive care are
written in the order of popularity. (CINV is placed at the top of supportive care,
since it is such a hot topic for the exam).
Besides the above, knowing nitty-gritty details not mentioned in the pearls, you
will be more than covered for NAPLEX.