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What are the warning signs of cancer?
- Change in bowel or bladder habits
- A sore that does not heal
- Unusual bleeding or discharge
- Thickening or lump in breast or elsewhere
- Indigestion or difficulty swallowing
- Obvious change in wart or mole
- Nagging cough or hoarseness
When should you start taking mammograms, and how often?
At the age 40, and yearly
How often should a woman get a clinical breast exam?
When b/t 20-30 y/o, every 3 yrs. When 40 or more, every year.
When should women start breast self-exams?
In their 20s
When should men and women start screening for colon CA, which includes sigmoidoscopy, colonoscopy, barium enema, or CT scan and annual fecal occult blood test (FOBT) or fecal immunochemical test (FIT)?
In their 50s
When should women start screening for cervical cancer?
3 years after they start sexual intercourse, but no later than 21 y/o
How often should women test for cervical cancer?
Annually, with the Pap test; or every 2 yrs, with the new liquid-based Pap test. However, after 70 y/o, w/normal results, women can stop
When should men start screening for prostate cancer? What if they have a family hx of prostate CA, or what if they're black?
At age of 50. If family hx or black, start at 45 y/o.
What is the standard when screening for prostate cancer?
PSA blood test with or w/o digital rectal exam
What is one sign that the cancer will not relapse?
Pt is cancer free for 5 yrs
Define the following responses to tx: complete, partial, stable, progression
- Complete: No evidence of CA for at least 1 month
- Partial: > / = 50% decrease of tumor size
- Stable: <25% decrease or increase in tumor size
- Progression: > / = 25% tumor growth or new tumor growth
In general, how do you tx CA?
- Surgery --> Chemotherapy
- Neoadjuvant (or induction) therapy: used prior to start of primary tx regimen to shrink tumor (i.e., radiation)
- Adjuvant therapy: given after primary therapy to get rid of residual disease (i.e., radiation, hormone tx)
Can you use chemo in pregnancy and breastfeeding?
No, you shouldn't - tell couples to use contraceptives
How is chemo dose? What equation is used?
BSA=0.007184 x [weight (kg)^0.425] x [height (cm)^0.725]
Use actual wt, or AdjBW if obese
What is the MOA of alkylators? What are some alkylators?
- Cross-link DNA
- Cyclophosphamide (Cytoxan), Ifosfamide (Ifex), Temozolomide (Temodar)
What are some alkylators that cause pulmonary toxicity?
- Busulfan (Myleran)
- Carmustine (BiCNU, Gliadel - wafer for brain CA)
- Lomustine (CeeNU)
What are some alkylators that can cause neurologic toxicity (seizures, encephalopathy)?
- *Chlorambucil (Leukeran)
- *Temazolamide (Temodar)
- *Ifosfamide (Ifex)
- *Thiotepa (Thioplex)
Which alkylators can cause skin pigmentation changes?
Which alkylator causes flu-like sxts?
Which alkylators can cause bladder toxicity (hemorrhagic cystitis)?
- High doses of cyclophosphamide (Cytoxan)
- ALL doses of ifosfamide (Ifex)
How do you protect against Cytoxan's and Ifex's bladder toxicities?
Give MESNA (Mesnex) and provide adequate hydration
Which alkylator is like an MAOI?
Which alkylator is taken PO, dosed QHS w/antiemetic?
How do antiandrogens work? What are some of them? How are they usually taken, and for what indication?
- Block androgens at receptor site.
- Bicalutamide (Casodex) and flutamide (Eulexin)
- Taken PO daily, w/LHRH agonists, for prostate CA
What are some side effects of antiandrogens?
- Gynecomastia, hot flashes, decreased libido, impotence
- Flutamide - more GI toxicity
- Nilutamide (Nilandron) - visual disturbances, night blindness
What is the name of the androgen production inhibitor? How does it work?
- Abiraterone acetate (Zytiga)
- Pregnenolone analog that blocks CYP450 c17, rate limiting enzyme in androgen production
What is the name of the GRH antagonist? What is the indication? How is it different from LHRH agonists?
- Degarelix (Firmagon)
- Prostate CA
- No tumor flare
How do LHRH agonists work? What are their indications? What are some of them?
- Increase production of estrogens and androgens, then negative feedback, down regulation
- Prostate CA, or endometriosis, fibroids, and breast CA in women
- Goserelin (Zoladex), Leuprolide (Lupron)
What are some major side effects of LHRH agonists?
- *Injection site pain/swelling
- *Impotence, gynecomastia, hot flashes
- *Bone pain, osteoporosis risk - need Ca2+, vitD, wt-bearing exercise, DEXA screening
- Also, initial disease flare: metastatic bone pain, paralysis
- Dyslipidemia, QT prolongation, peripheral edema
What dosage form do all aromatase inhibitors come as?
What is the MOA of aromatase inhibitors? Indications? What are the names of some of the AIs?
- Stop conversion to estrogen, andorgen, corticosteroid, mineralocorticoid
- For breast, prostate, or adrenal CA
- All these 3 are for breast CA (selective for estrogens): anastrozole (Arimidex), exemestane (Aromasin), letrozole (Femara) or FAA
What are the major side effects of aromatase inhibitors?
- Menopause sxts, hot flashes
- Decreased bone density, osteoporosis risk - add Ca2+, vitD, wt bearing exercise, DEXA
- Increased CV disease risk compared to SERMs
What are 2 non-selective aromatase inhibitors?
Aminoglutethimide (Cytadren) and mitotane (Lysodren)
How do antiestrogens/SERMs work? What kind of tumors do they work on? What dosage forms do they come in?
- Selectively block estrogen at receptor
- For breast CA, hormone receptor (+) tumor (est/proges)
- All PO except fulvestrant (Faslodex) which is IM
List some SERMs
- Tamoxifen (Nolvadex)
- Raloxifene (Evista)
- Fulvestrant (Faslodex)
Which SERM is used for osteoporosis and pt is at risk for breast CA?
What are some major side effects of SERMs? What is a BBW of theirs?
- Menopausal sxts, hot flashes, flushing, N/V, edema, wt gain
- BBW: Increased risk of thromboembolic events
What is the MOA of anthracyclines?
- Intercalate into DNA
- Inhibit topoisomerase II
- Make O2 free radicals
What are some common anthracyclines?
Doxorubicin (Adriamycin), epirubicin (Ellence)
What are some major side effects of anthracyclines?
Cardiotoxicity, N/V, red body secretions/urine; also radiation recall reactions occur
When a pt gets extravasation from anthracyclines, what are the antidotes?
Dexrazoxane (Totect) or dimethyl sulfoxide
You got to Double Dig it out
For anthracyclines, which dosage form is associated with a higher incidence of hand-foot syndrome and allergic reactions?
What are the max lifetime doses of doxorubicin, daunorubicin, and epirubicin?
- Doxorubicin: 400-500 mg/m2
- Daunorubicin: 550 mg/m2 (400 mg/m2 w/chest radiation)
- Epirubicin: 900 mg/m2
How often do you monitor CO with anthracyclines?
At baseline and when you exceed 250 mg/m2 for doxo and 320 mg/m2 for dauno
When you start to exceed 300 mg/m2 with doxorubicin (Adriamycin), what cardioprotectant should you consider using?
Explain how mitoxantrone (Novantrone) is different from the other anthracyclines.
- 3 (not 4) ring structure
- Turns secretions blue, not red
What is MOA of epothilone? What is the name of the drug in this class?
- Microtubule stabilizer enhancing polymerization of tubules, halting at metaphaseIxabepilone (Ixempra)
What causes the hypersensitivity reaction with Ixempra?
Cremophor EL - polyoxethylated castor oil solvent system
What is the MOA of folate antimetabolites? What is one drug in this class, and what is the dose?
- Prevent DNA synthesis
- MTX: 7.5-22.5 mg Q wk (lower doses in RA and psoriasis)