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Hemat/Onc EXAM 3
Hemat/Onc EXAM 3 - Hecht Lung Cancer
37
Pharmacology
Graduate
02/03/2012

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Cards

Term
risk factors for lung cancer
Definition
tobacco (10 x RR)

asbestos (5 x RR)

radon/ionizing radiation

occupational exposure

diet: low beta carotene and vitamin E linked to cancer; protective effect from fruits and vegetables

genetic predisposition
Term
smoking and lung cancer
Definition
responsible for about 85% of lung cancer cases

dose-response relationship: amount, duration, tar/nicotine content

risk gradually decreases WHEN STOP SMOKING!!

risk will never get back to baseline though
Term
second hand smoke and lung cancer
Definition
second hand smoke contains > 40 known or suspected carcinogenic substances

3,000 non-smoking adults die each year of lung cancer from second hand smoke

passive smokers 1.5 x risk of developing lung cancer as non-smokers
Term
pathology of lung cancer
Definition
small cell lung cancer (SCLC):
15-20%, most aggressive

non-small cell lung cancer (NSCLC):
adenocarcinoma - 40%, most common type in US, most common type in non-smokers
squamous cell - 30%, slowest growing, strong relation to smoking
large cell - 15%, anaplastic tumor, decreasing incidence
Term
lung cancer screening
Definition
chest x-ray:
more sensitive for adenocarcinoma

sputum cytology:
more sensitive for squamous cell

spiral CT:
new technology, more sensitive in general

summary: detect lung cancer at earlier stage, but no decrease in mortality
Term
National Lung Cancer Screening Trail
Definition
n ~ 53,500

current or former heavy smokers aged 55-74 (> 30 pack year history)

low dose helical CT vs. chest x ray
baseline, year 1, year 2

354 deaths in CT group, 442 in x-ray group

absolute risk reduction was 0.4%
Term
lung cancer prevention
Definition
tobacco avoidance

smoking cessation

chemoprevention:
reversal of pre-malignancy
role for vitamin E??
nothing has been proven effective
Term
lung cancer presentation
Definition
dyspnea

cough

pain

loss of appetite

haemoptysis
Term
clinical evaluation of lung cancer
Definition
physical exam

bronchoscopy - precise tumor location, specimen

fine needle aspirate - cytology

chest x-ray - detect position, size, number of tumors

CT scare - detect chest wall invasion, mediastinal nodes, distant mets

PET scan - lymph node staging

lab tests

mediastinoscopy - visualize and sample nodes
Term
lung cancer diagnosis
Definition
sputum cytology

bronchoscopy

percutaneous needle biopsy

fine needle aspirate (FNA)

open lung biopsy

have to have a biopsy for diagnosis
Term
non small cell lung cancer (NSCLC) positive prognostic factors
Definition
early stage disease

good performance status - can take care of themselves without limitations

no significant weight loss

female gender
Term
non small cell lung cancer staging at presentation
Definition
70% are in stage III or IV

curative potential is determined by if the cancer is operable

stage III-b and up are inoperable
Term
non small cell lung cancer - metastatic spread
Definition
most common sites of metastasis:

bone

bone marrow

brain

liver

lymph nodes

adrenal glands (very common for lung cancer)
Term
NSCLC treatment - surgery
Definition
lobectomy

segmentectomy

wedge resection
Term
NSCLC treatment - radiation
Definition
single agent:
palliation - control local disease and reduce disease related symptoms

combination therapy:
adjuvant (postoperative) - eliminate unknown residual disease in surgical margins
neoadjuvant (preoperative)
Term
NSCLC treatment - combination chemotherapy
Definition
carboplatin + paclitaxel

cisplatin + paclitaxel

cisplatin + gemcitabine

cisplatin + docetaxel

MEDIAN 1 YEAR SURVIVAL NOT DIFFERENT

toxicities are different
Term
NSCLC treatment - single agent chemotherapy
Definition
used in salvage treatment or for patients with metastatic disease that can't handle big chemo

don't use the same agent for two different courses

if got carbo/paclitaxel first time, don't give paclitaxel the second time

paclitaxel
docetaxel
gemcitabine
erlotinib
vinorelbine
Term
NSCLC Treatment
Definition
STAGE 1:

surgery is treatment of choice

clinical trails to evaluate role of chemotherapy

STAGE II:

surgery

chemotherapy

radiation

STAGE IIIA:

neoadjuvant chemotherapy + radiation
THEN
surgery

STAGE IIIB:

chemotherapy + radiation

surgery generally not possible

STAGE IV:

patients who are bed ridden, cannot take care of themselves DO NOT benefit from therapy (only treat those with GOOD PERFORMANCE STATUS)

chemotherapy with bevacizumab:
young, relatively good health-combotherapy + bevacizumab
DO NOT GIVE BEVACIZUMAB TO PATIENTS WITH SQUAMOUS CELL CANCER OF THE LUNG

radiation for symptom palliation

surgery for palliation (adrenal mets, brain mets)

clinical trials

RECURRENT NSCLC:

single agent chemotherapy with bevacizumab (if haven't already received, and if not squamous cell cancer)

erlotinib (reserved for people that have failed 2 types of chemo)
Term
initial chemotherapy regimen for NSCLC
Definition
MUST USE PLATINUM CONTAINING REGIMEN (cisplatin or carboplatin, CARBOPLATIN better tolerated)

can combine with various agents (paclitaxel, docetaxel, gemcitabine, vinorelbine) however CARBOPLATIN/PACLITAXEL is considered standard

add bevacizumab in patients with metastasis IF NOT SQUAMOUS CELL IN ORIGIN
Term
recurrent NSCLC chemotherapy
Definition
only treat good performance status

1st relapse: use chemotherapy + bevacizumab (if haven't had bevacizumab before); single agent chemotherapy

2nd relapse: use biologic therapy (erlotinib)
Term
chemotherapy regimen for NSCLC
Definition
carboplatin + paclitaxel
Term
carboplatin/paclitaxel major counseling points
Definition
ADRs:

quick: hypersensitivity (especially important in patients taking paclitaxel - must be given slowly; often are premedicated with corticosteroid +/- benadryl)

short term: N/V, myelosuppression, mucositis, alopecia, neuropathies (taxanes act on spindle fibers = neuropathies), nephrotoxicity (from carboplatin - STAY HYDRATED)

long term: hepatoxicity
Term
CARBOPLATIN DOSING
Definition
dose = AUC x (CrCl +25)

IBW female = 45.5 + 2.3 (Ht in inches - 60)

IBW male = 50 + 2.3(Ht in inches - 60)

CrCl = [(140-age)(IBW)]/[SCr x 72] multiply by 0.85 if patient is a women
Term
erlotinib
Definition
prolonged survival from 4.7 to 6.7 months

ADRs:

rash (effects EGFR pathway)

N/V/D

VTEs

hepatotoxicity
Term
NSCLC maintenance therapy (stage IIIb/IV)
Definition
pemetrexed IV every 3 weeks until disease progression
median overall survival 13.4 vs 10.6 months
progression free survival 4 vs 2 months
NON SQUAMOUS ONLY

erlotinib also studied, but not approved
Term
small cell lung cancer (SCLC)
Definition
strongest association with cigarette smoking

most aggressive clinical course if untreated

highly sensitive to XRT (radiation) and chemotherapy
Term
SCLC STAGING
Definition
LIMITED:
tumor confined to one lung and/or lymph nodes of one lung

EXTENSIVE:
tumor not confined
crossed into the other lung or has distant metastasis
Term
SCLC paraneoplastic syndromes
Definition
hyponatremia of malignancy

Cushing's syndrome

hypercalcemia

superior vena cava syndrome (tumor spreads so fast it can cut off the vena cava)
Term
SCLC positive prognostic factors
Definition
good performance status

limited stage disease

female gender

normal lactic dehydrogenase (LDH)
Term
limited SCLC prognosis
Definition
response rate 80-90% with chemotherapy

complete response in 50-60%

median survival 18-20 months

2 year survival is 40%

5 year survival rate is 15-25%

SCLC will often metastasize to the brain
Term
limited SCLC treatment
Definition
surgery is very seldom possible b/c patients frequently have multiple tumors

CHEMOTHERAPY

RADIATION
concurrent thoracic XRT + chemo improves survival
prophylactic cranial XRT for patients with complete response

if they have a good response to chemo and radiation to the chest (got rid of everything in the chest) THEN you do prophylactic cranial radiation (likes to hide in the brain)

if they do not have a complete response then DO NOT radiate the brain; have to get rid of the lung cancer first (have to take care of what we know is there before worrying about what might be there)
Term
limited SCLC chemotherapy
Definition
cisplatin/etopside
Term
extensive SCLC treatment
Definition
surgery has minimal to no role

CHEMOTHERAPY
combination chemotherapy is standard therapy

radiation is palliative for symptomatic sites (including brain)
Term
extensive SCLC chemotherapy
Definition
cisplatin/etoposide
Term
extensive SCLC prognosis
Definition
initial response rate is 60-80%

median survival with treatment is 8-10 months

2 year survival is < 10%
Term
SCLC second line therapy
Definition
generally relapse after initial treatment

up to 50% chance of second response

single agent

combination therapy may increase survival, also increases toxicity
Term
etoposide and cisplatin major counseling points
Definition
ADRs:

QUICK:

hypersensitivity

hypotension - etoposide has a diluent in it that causes hypotension; has to be given slowly

SHORT TERM:

N/V (including delayed) - cisplatin

myelosuppression

mucositis

alopecia

neuropathies

nephrotoxicity

ototoxicity - cisplatin causes high frequency hearing loss
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