ONS Chemotherapy Immunotherapy Certificate

ANC calculation

(% polys + % bands) x (WBC)/100

An ANC of less that _____ is considered a risk for infection

1,000

Acute diarrhea lasts:

1-2 days and resolves on its own

These agents are typically categorized as highly emetogenic:

1. Alkylating agents 2. Nitrosoureas

Targeted therapies work by:

1. Blocking angiogenesis 2. Blocking signals inside or outside the cell 3. Delivering toxic substances to the cell 4. Simulating the body's immune system

2 types of therapies that commonly have cutaneous reactions:

1. EGFR inhibitor therapies 2. Antimetabolites

4 different types of medication dosing:

1. Fixed doses 2. Weight-based doses 3. Body surface area (BSA) doses 4. Area under the curve (AUC) doses

Highly emetogenic chemo (HEC) causes CINV in more than ___% of patients

90

Chronic diarrhea lasts:

> 4 weeks

Risk factors for developing neutropenia include:

> 65 years old Hx of neutropenia with previous chemotherapy Hx of chemotherapy or radiation treatment Hematologic malignancy Uncontrolled/advanced cancer Lung cancer

What types of cells are best affected by antimetabolites?

Cells with high division rates

mAbs ending in "-ximab" source

Chimeric human-mouse

Common platinum-based agents:

Cisplatin (Platinol) Carboplatin (Paraplatin)

Adaptive immunity:

Follows innate immunity if unsuccessful. Memory immunity, including: 1. Humoral immunity (production of antibodies or immunoglobulins) 2. Cell mediated immunity (dependent upon T cells) 3. Regulatory T -cells (prevent autoimmune reactions and limit inflammatory responses)

mAbs ending in "-umab" source

Fully human

Common SERD

Fulvestrant

Hypersensitivity reaction (HSR) versus anaphylaxis

HSR- localized tissue injury; generalized Anaphylaxis- severe inflammatory response; systemic; caused by histamine release

What sets immunotherapy apart from traditional chemotherapy?

Highly specific Trained to remember cancer cells

Antiandrogens MOA

Keeps androgens from binding to androgen receptors found in prostate cancer cells (and in some other tissue cells)

Common androgen synthesis inhibitors

Ketoconazole Aminoglutethimide Abiraterone acetate

Define extravasation

Leak of a drug capable of causing tissue damage from the intended vessel into the surrounding tissue or unintended sites

Define infiltration

Leakage of non-vesicant/non-irritant solutions into surrounding tissue

Define thrombocytopenia

Low platelet count

mAbs MOA

Mark cancer cell surface receptor/antigen to make the cell visible to the immune system to destroy

The antitumor abx ___________ is not an anthracycline, but has anthracycline-type properties.

Mitoxantrone

Define receptor

Molecule inside/on surface of a cell that binds to a specific substance and causes a specific effect in that cell

Define ligand

Molecule that binds to a receptor to exert a biologic effect

Define monomer

Molecule that can be bonded to other identical molecules to form a polymer

Examples of passive immunotherapy

Monoclonal antibodies Cytokines

Active immunotherapy MOA

Mount an immune response against tumor *Should remember cancer cells long after treatment has stopped

mAbs ending in "-omab" source

Murine mouse

Antimetabolites work in the ___ phase.

S

Most-common cutaneous reaction seen with 5-FU and Capecitabine:

Palmar-plantar erythrodysesthesia AKA hand-foot syndrome

Immunotherapy categories:

Passive Aggressive Specific Nonspecific

Symptoms of thrombocytopenia

Petechiae or easily bruising Headaches Hypotension and tachycardia Prolonged bleeding (gums, menstruation)

Immune checkpoint inhibitors MOA

Prevent cancer cells from turning off T cells --> allows T cells to infiltrate a tumor and stop it from growing

2 main types of cancer vaccines

Preventative/prophylactic Treatment/therapeutic

Describe the peripheral pathway of CINV

Primarily occurs in the GI tract Associated with acute CINV Neurotransmitter --> serotonin

Describe the central pathway of CINV

Primarily occurs in the brain Associated with delayed CINV Neurotransmitter --> Substance P

Define ligand bonding

Process by which ligand attaches to specific receptor site and activates receptor, activating the signaling pathway

LHRH agonists MOA

Produce an initial increase in LH and FSH, which can cause a flare. Then lower testosterone made by testicles and estrogen & progesterone made by ovaries *Prostate cancer *Estrogen receptor-positive, premenopausal metastatic breat cancer

4 phases of mitosis:

Prophase Metaphase Anaphase Telophase

First thing to do if a HSR occurs:

STOP THE INFUSION IMMEDIATELY

Immune checkpoint inhibitors initially cause tumors to swell, making it appear as if the tumor is growing. This is called _____________

Pseudoprogression

Monitoring necessary with bleomycin:

Pulmonary toxicity Hypersensitivity reactions (esp. in lymphoma patients) Cutaneous reactions Lifetime dose tracking (pulmonary toxicity)

Define single dose

Recommended dose of one antineoplastic agent given at a single point in time

Define course dose (AKA divided dose)

Recommended dose of one antineoplastic agent given over a defined period of time

Adoptive cell therapy MOA

T cells collected from patient T cells grown in laboratory *This increases amount of T cells able to kill cancer cells or fight infections* T cells given back to patient to help immune system

Common SERMs

Tamoxifen Raloxifine Bazedoxifine

Specific immunotherapy MOA

Target tumor markers or tumor-associated antigens (TAAs) to kill cancer cells

Immediate HSR can occur:

Within 5 minutes of start of infusion to 6 hours following infusion

Lifetime dose of doxorubicin should not exceed:

550 mg/m^2

Antimetabolites that commonly cause cutaneous reactions:

5-FU Capecitabine (Xeloda)

NCCN defines neutropenia as an ANC < _______/mm^3

500

Vinca alkaloids are ALL administered _(1)_ and should NEVER be administered _(2)_, as this will result in patient death

1. Intravenously 2. Intrathecally

6 main types of immunotherapy

1. Monoclonal antibodies 2. Immune checkpoint inhibitors 3. Cancer vaccines 4. Nonspecific immunotherapies 5. Adoptive cell therapy (CAR T-cell therapy) 6. Oncolytic virus therapy

3 subcategories of alkylating agents:

1. Nitrogen mustards 2. Platinum-based agents (do not possess an alkyl group but still termed alkylating agents as they work similarly) 3. Nitrosoureas

The 2 most important neurotransmitters involved in vomiting are:

1. Serotonin 2. Substance P

2 types of aromatase inhibitors

1. Steroidal (irreversible) 2. Nonsteroidal (reversible)

Immunotherapy works by the following 3 ways:

1. Stopping or slowing the growth of cancer cells 2. Stopping cancer cells from spreading to other parts of the body 3. Helping the immune system recognize cancer cells and increase its effectiveness at eliminating cancer cells

2 different ways that immunotherapies work against cancer:

1. Triggering the immune system to destroy cancer cells 2. Boost immune system's ability to fight cancer

What 6 patient characteristics make CINV more likely?

1. Younger than 50 years 2. Hx of low alcohol intake 3. Female gender 4. Hx of morning sickness during pregnancy 5. Prone to motion sickness 6. Previous chemotherapy

Minimal-risk emetogenic chemo causes CINV less than ___% of the time

10

Patients on low-potential emetogenic chemo develop CINV ___% to ___% of the time

10-30

Results of immunotherapy agents most commonly occur between ____________ after starting therapy

12-16 weeks

Define dimerization

2 monomers that are side-by-side on cell surface are paired and activated by a ligand, which causes a series of signals

Persistent diarrhea lasts:

2-4 weeks

Moderately emetogenic chemo (MEC) causes CINV in patients ___% to ___% of the time

30-90

Normal WBC count

4,500-10,000

Pulmonary fibrosis is possible when the lifetime dose of bleomycin exceeds:

400 units

Common low-potential IV emetogenic chemo drugs include:

5-FU Cytarabine Docetaxel Etoposide Gemcitabine Methotrexate Mitomycin C Mitoxantrone Paclitaxel Pemetrexed

Normal neutrophil count

54%-62% of WBC

Common CYP17 inhibitors

Abiraterone Orteronel

What is unique about nitrosoureas agents?

Able to cross the blood-brain barrier; can be effective in treating some brain tumors

Common non-anthracycline antitumor abx:

Actinomycin D Mitomycin C Bleomycin

Define phosphorylation

Activation of a chemical process to initiate signaling

Types of CINV:

Acute Delayed Breakthrough Anticipatory Refractory

Define adjuvant therapy

Additional cancer treatment given after the primary treatment to lower the risk that the cancer reoccur

Passive immunotherapy MOA

Administered to initiate an antitumor effect *Do not result in any immunologic memory

Risk factors for HSR and anaphylaxis:

Administration of a known HSR causing agent Hx of allergies Hx of hypersensitivity or anaphylaxis Premedications not ordered/administered

Define dose intensity

Amount of drug delivered over time

3 aromatase inhibitors

Anastrozole Letrozole Exemestane

The two major classifications of antitumor antibiotics are:

Anthracyclines Non-anthracyclines

Common neurokinin-1 antagonists used for CINV:

Aprepitant Fosaprepitant

How does hormone therapy work?

Attempts to add, block, or remove hormones from the body to interrupt cancer cell division

Common antimetabolite drugs:

Azacitidine Capecitabine 5-FU Cytarabine Decitabine Methotrexate

3 steps of interphase:

First growth phase (G1) Synthesis phase (S phase) Second growth phase (G2)

Pre-administration labs for alkylating agents and nitrosoureas:

BUN Creatinine CBC w/ diff

Selective ER downregulators (SERDs) MOA

Binding to and degrading ER

What is the medication Mesna used for?

Bladder protectant with administration of cyclophosphamide or ifosfamide

Common minimal-risk IV emetogenic chemo drugs include:

Bleomycin Bevacizumab Bortezomib Busulfan Cetuximab Fludarabine Trastuzumab Vinca alkaloids

Agents classified as vesicants can cause:

Blistering Significant pain Tissue damage and destruction **Lead to tissue death

Aromatase inhibitors MOA

Block the enzyme aromatase, which turns the hormone androgen into small amounts of estrogen in the body **Less estrogen is available to stimulate growth of HR-positive breast cancer cells

Selective ER modulators (SERMs) MOA

Blocking and downregulating ERs *Can function as ER agonists, antagonists, or mixed agonist-antagonists *Can activate or block estrogen

Define myelosuppression

Bone marrow activity is decreased, resulting in fewer RBCs, WBCs and platelets If severe: myeloablation

How do antimetabolites function?

By blocking DNA and RNA growth by interfering with enzymes needed for normal cell metabolism

How do alkylating agents work?

By causing a break in the DNA helix strand, interfering with DNA replication and causing cell death

How is relative dose intensity (RDI) calculated?

By comparing the dose that the patient ACTUALLY received to the planned dose of the standard regimen

Examples of active immunotherapy

Cancer vaccines

Hypersensitivity can occur with late doses of:

Carboplatin

Common IV MEC drugs include:

Carboplatin Cytarabine Daunorubicin Doxorubicin Epirubicin Idarubicin Ifosfamide Irinotecan Oxaliplatin

Significant side effects of doxorubicin are:

Cardiotoxicity N/V Mucositis Diarrhea Severe myelosuppression Hepatic impairment Secondary cancers

Common IV HEC drugs include:

Carmustine Cisplatin Cyclophosphamide Dacarbazine Mechlorethamine Streptozosin

Common nitrosoureas agents:

Carmustine (BiCNU) Lomustine (CeeNu) Streptozocin (Zanosar)

Common treatment for immunotherapy side effects

Corticosteroids

3 main goals of treatment:

Cure Control Palliation

Common alkylating agents:

Cyclophosphamide (Cytoxan) Ifosfamide (Ifex) Bendamustine (Treanda)

Examples of nonspecific immunotherapy

Cytokines, interleukins, checkpoint inhibitors

Common anthracycline antitumor abx:

Daunorubicin Doxorubicin Epirubicin Idarubicin

Delayed HSR can occur:

Days or weeks after immediate HSR window

Define anemia

Deficiency of RBC or hemoglobin in the blood

Common steroids used for CINV:

Dexamethasone

What cardiac protectant medication can be administered prior to doxorubicin?

Dexrazoxane

LHRH antagonists MOA

Directly inhibits pituitary from releasing LH and FSH *No tumor flare

Common serotonin 5-HT3 antagonists used for CINV:

Dolasetron Granisetron Ondansetron Palonosetron

Define dose density

Drug dose per unit of time

Define xerostomia

Dryness of the mouth caused by damage to or dysfunction of the salivary glands

Symptoms of anemia

Dyspnea Fatigue Dizziness Headaches

Hierarchy of controls when controlling workplace hazards

Elimination Substitution Engineering controls Administrative controls PPE

Define kinase

Enzyme that adds phosphates to other molecules, causing other molecules in the cell to become either active or inactive

Common plant alkaloids:

Etoposide Docetaxel Paclitaxel Vinblastine Vinorelbine

Common side effects of immunotherapies

Fatigue Diarrhea Colitis Musculoskeletal pain Dermatitis

Common side effects of aromatase inhibitors (AI):

Fatigue N/V* Weakness HA* Insomnia Dizziness Hot flashes* Weight gain* Higher cholesterol Increased sweating* Bone/joint pain*

Define neutropenic fever

Fever of 101 F or greater one time OR Fever of 100.4 F lasting one hour or longer

Most common type of breast cancer

Hormone receptor (HR)-positive breast cancer

mAbs ending in "-zumab" source

Humanized mouse

The institute for Safe Medication Practices recommends what route of administration for vincristine?

IV piggyback via gravity

__________ has been described as a way to "fire up the immune system's response to cancer"

Immunotherapy

Agents classified as irritants can cause:

Inflammation Pain Burning ** Rarely cause tissue necrosis comparable to vesicants

Define mucositis

Inflammation of the mucous membranes lining the digestive tract from mouth to anus

Define stomatitis

Inflammatory conditions of the mouth specifically AKA oral mucositis

CYP17 inhibitors MOA

Inhibit the key enzyme that catalyzes biosynthesis of androgens from all sources

Anthracycline antitumor abx work by:

Interfering with enzymes necessary for DNA to replicate in ALL phases of the cell cycle

3 major phases of cell division:

Interphase Mitotic phase Cytokinesis

Common diarrhea-causing agents:

Irinotecan 5-FU Paclitaxel Dactinomycin Capecitabine

2 types of conditioning therapies:

Myeloablative Nonmyeloablative

The most common dose-limiting toxicity of chemotherapy

Myelosuppression

Common side effects of antimetabolites:

Myelosuppression GI toxicities Photosensitivity Hand-foot syndrome

Different types of mAbs used in treatment of cancer

Naked mAbs Conjugated monoclonal antibodies Bispecific monoclonal antibodies

Oncolytic virus therapy MOA

Naturally occurring or genetically engineered virus that can infect and kill a cancer call without harming normal cells

Most common subcategory of alkylating agents:

Nitrogen mustards

Innate immunity:

Non-specific response, either: 1. Barrier (skin, mucous membranes, flora of skin/gut) 2. Cellular components (phagocytes, natural killer cells, granulocytes, macrophages)

Define breakthrough CINV

Occurring despite treatment

Define refractory CINV

Occurring during subsequent cycles when treatment failed in earlier cycles

Define delayed CINV

Occurring from 24 hours to 5 days after treatment

Define acute CINV

Occurring within 24 hours of chemotherapy

Instruct pts receiving ________ to avoid exposure to cold air and consuming cold fluids for 3-4 days following treatment

Oxaliplatin

Nonspecific immunotherapy MOA

Stimulate a large immune response *Given adjuvantly to other anticancer treatment drugs

Nonspecific immunotherapies MOA

Stimulating the immune system in a general way, hopefully leading to a better immune response against cancer cells

Androgen synthesis inhibitors MOA

Stop the adrenal glands from producing androgens

Adrenolytic agents MOA

Suppress testicular and adrenal steroidogenesis, rapidly reducing testosterone levels

Define nadir, and when does it occur?

The point at which blood cell counts are at their lowest following a treatment cycle. Typically occurs 7-10 days following cycle

Define cumulative dose

Total dose of an antineoplastic agent or radiation after repeated exposure to the treatment

Define neoadjuvant therapy

Treatment is given prior to surgery to shrink the tumor

Define conditioning/preparative therapy

Treatments used to prepare a patient for stem cell transplantation

Define anticipatory CINV

Triggered by taste, odor, memories, visions, or anxiety related to chemotherapy

Define mutations

Variations in the nucleotide sequence of a gene

Monitoring necessary with doxorubicin:

Vesicant --> extravasation Cardiac function Lifetime dose tracking (cardiotoxicity)

Common constipation-causing agents:

Vinca alkaloids (vincristine and vinorelbine) Thalidomide Lenalidomide Bortezomib

Examples of specific immunotherapy

mAbs Cancer vaccines