Oncology Certification Nursing Exam 125 Questions with Verified Answers
infiltration - CORRECT ANSWER passage or escape of IV administered drugs into
... [Show More] the tissue
extravasation - CORRECT ANSWER leakage of drugs capable of causing tissue damage into the subcutaneous or subdermal tissue or other unintended sites.
irritation - CORRECT ANSWER a localized inflammatory reaction at the infusion or injection site
flare reaction - CORRECT ANSWER a local allergic reaction along a vein caused by irritating drugs.
infusion reactions - CORRECT ANSWER reactions mediated by the immune system (hypersensitivity, anaphylaxis, cytokine release syndrome)
DNA-binding vesicants - CORRECT ANSWER vesicant binds to nucleic acids in the DNA of healthy cells in the tissue, causing cell death. the dead cells then release complexes, which are taken up by adjacent healthy cells. this process causes a continuing cycle of tissue damage as the vesicant is retained in the tissue for a long period of time.
NON-DNA binding vesicants - CORRECT ANSWER the vesicant has an indirects effect on healthy cells. it does not bind to cellular DNA. it is metabolized in the tissue and is more easily neutralized.
cabazitaxel (jevtana) - CORRECT ANSWER a taxane where infiltration has not caused skin or tissue impairment
Docetaxel (taxotere) - CORRECT ANSWER extravasation may cause hyperpigmentation, erythema and tenderness.
paclitaxel (taxol) - CORRECT ANSWER injection site reactions, including reactions secondary to extravasation, usually mild and consist of erythema, tenderness, skin hyperpigmentation or swelling at injection site. seen more often with 24 hour infusions than with 3 hour infusions. severe reactions such as phlebitis, cellulitis, induration, skin exfoliation, necrosis and fibrosis have been reported. onset has been delayed by a week to 10 days.
recall reactions - CORRECT ANSWER recurrence of skin reactions at the site of previous extravasation following paclitaxel injection at a different site.
docetaxel and paclitaxel - CORRECT ANSWER classified as exfoliants or drugs that may cause inflammation and peeling of skin without causing underlying tissue death.
factors affecting tissue damage severity following a vesicant extravasation - CORRECT ANSWER 1. DNA binding vesicants cause greater tissue damage than non-dna binding vesicants
2. the higher the concentration and greater amount of a vesicant the more damaged caused.
3. location of the extravasation such as those with little subcutaneous tissue and overlying veins, arteries and nerves are likely to have more damage.
4. older age, comorbidity and impaired immunocompetence cause more damage.
risk factors for peripheral extravasation - CORRECT ANSWER 1. small, fragile veins
2. previous multiple venipunctures
3. sensory deficits
4. application of topical skin numbing agents prior to venipuncture
5. limited vein selection d/t lymph node dissection
6. impaired cognition, altered mental status or somnolence
7. probing during IV catheter insertion
8. administration site in areas prone to movement
9. use of rigid IV devices.
10. prior treatment with irritating or sclerosing drugs
11. administration of a vesicant peripherally when the manufacturer stipulates it should be administered via a central line.
possible etiologies of peripheral extravasations - CORRECT ANSWER 1.vein wall puncture, piercing or trauma.
2. dislodgement of the catheter from a vein
3. administration of a vesicant in a vein below a recent venipuncture site.
4.administration of a vesicant in a vein below or recent or non-healed vesicant extravasation site.
5. inadvertent intramuscular or subcutaneous vesicant administration.
Risk factors for extravasation from central VADs - CORRECT ANSWER 1. difficulty encountered during device insertion
2. inadvertent slicing, piercing or nicking of catheter prior to insertion
3. device misplacement with catheter tip outside of the venous system.
4. insufficient length of non coring needle (implanted port)
5. presence of a fibrin sheath or thrombus at the catheter tip.
6.catheter migration
7. long dwell time of catheters inserted using a subclavian approach, in which the catheter is placed between the clavicle and first rib
possible etiologies of extravasations from central VADs - CORRECT ANSWER 1. inadvertent misplacement of catheter tip outside of the venous system during insertion procedure.
2. vein perforation during insertion
3. post insertion vein erosion, catheter leakage, rupture or fracture.
4. separation of the catheter from a portal body.
5. incomplete insertion of a non coring needle into an implanted port
6. non coring needle dislodgement from an implanted port.
7. backflow of vesicant along the catheter to the venotomy site secondary to fibrin sheath or thrombus at the catheter tip.
signs and symptoms of vesicant extravasation - CORRECT ANSWER 1. vein irritation and flare reactions may mimic signs of vesicant extravasation.
2. vein irritation and flare reactions only occur in peripheral chemo administration
3. if it happens in CAD it is d/t catheter tip placement outside of the venous access device or erosion of the vein wall.
4. this may cause SOB and shock to secondary blood loss.
additional signs and symptoms of vesicant extravasation - CORRECT ANSWER 1. IV flow rate that slows or stops
2. resistance during IV bolus vesicant administration
3. leaking around the IV catheter or implanted port needle.
consequences of untreated vesicant extreavasation - CORRECT ANSWER 1. blistering (usually happens within 3 to 5 days.
2. peeling and sloughing of skin (usually begins 2 weeks after extravasation)
3. tissue necrosis (usually evident two or three weeks after extravasation.
4. DNA binding vesicants stay in the tissue for a long time, the area of necrosis becomes larger and deeper over time.
5. non-dna binding vesicants are more easily metabolized in the tissue. it is localized and improves over time.
6. damage to tendons, nerves and joints
7. functional and sensory impairment of the affected area.
8. disfigurement
9. loss of limb.
Flare reaction - CORRECT ANSWER 1. itchy blotches or hives; pain and burning uncommon
2. raised red streak, blotches or hive-like erythema along the vessel; diffuse or irregular pattern.
3. usually appears suddenly and dissipates within 30-90 minutes.
4. swelling unlikely.
5. blood return usually noted but not always intact.
6. flush vein slowly w/ saline and observe for resolution of flare, usually within 45 minutes.
7. an antihistamine may be used to treat a flare reaction and for premedication w/ subsequent cycles.
8. do not resume the infusion through the IV site until flare reaction resolves completely.
9. document the flare reaction.
Vessel irritation - CORRECT ANSWER 1. aching and tightness
2. erythema and dark discoloration along vessel.
3. usually appears within minutes after injection. coloration may only appear later in the process.
4. swelling is unlikely.
5. blood return usually noted but not always intact.
initial management of extravasation - CORRECT ANSWER assess the site and patient symptoms at the first sign of extravasation, during the time the IV device is assessed and after initial management
steps to take when a vesicant extravasation occurs or is suspected. - CORRECT ANSWER 1. immediately stop administering the vesicant and IV fluids
2. disconnect the IV tubing from the IV device. do not remove the IV device or non coring port needle
3. attempt to aspirate residual vesicant from the IV device or port needle using a small ( 1-3 ml) syringe.
4. remove the peripheral IV device or port needle.
5. initiate appropriate management measures according to policy.
Grading for adverse event of infusion site extravasation - CORRECT ANSWER grade 1: painless edema
grade 2: erythema with associated symptoms ( edema, pain, induration, phlebitis)
grade 3: ulceration or necrosis, severe tissue damage; operative intervention indicated.
grade 4: life-threatening consequences; urgent intervention indicated
grade 5: death.
mechlorethamine hydrochloride (nitrogen mustard, Mustargen) - CORRECT ANSWER 1. alkylating agent
2. apply cold pack for 6-12 hours following sodium thiosulfate antidote injection
3. sodium thiosulfate neutralizes mechlorethamine to form non toxic thioesters that are excreted in the urine.
4. to prepare 1/6 (4.14 g) molar solution of sodium thiosulfate per 100 ml of sterile water for injection
5. inject 2 ml of the sodium thiosulfate solution for each milligram of mechlorethamine suspected to have extravasated. inject the solution SC into the extravasation site using a 25 gauge or smaller needle. dose may be divided into 3-4 syringes to inject around the site of extravasation. the needle should be changed with each new injection.
6. assess the extravasation area for pain, blister formation and skin sloughing periodically.
7. instruct patients to monitor extravasation site and ot report fever, chills, blistering skin sloughing and worsening pain.
8. instruct patient to report arm or hand swelling and stiffness.
Trabectedin (Yondelis) - CORRECT ANSWER 1. apply cold pack for 15-20 minutes at least 4 times/ day for the first 24 hours.
2. no known antidote or treatment exists.
3. assess the extravasation area for pain, blister formation and skin sloughing periodically.
Anthracenedione (Mitoxantrone, Novantrone) - CORRECT ANSWER 1. apply cold pack for 15-20 minutes at least 4 times/day for the first 24 hours.
2. no known antidote or treatment exists.
3. extravasation typically causes blue discoloration of the infusion site area and may require debridement and skin grafting.
4. assess the extravasation area for pain, blister formation, and skin sloughing periodically as needed
antitumor antibiotics (anthracyclines) ex. daunorubicin, cerubidine, doxorubicin (adriamycin), Epirubicin (Ellence), Idarubicin (Idamycin) - CORRECT ANSWER 1. apply cold pack but remove at least 15 minutes prior to dexrazoxane treatment.
2. dexrazoxane for injection is the treatment.
3. the recommended dose of dexrazoxane is based on the patient's body surface area. day 1: 1,000 mg/m; day 2: 1,000 mg/m, day 3: 500 mg/m. the maximum recommended dose is 2,000 mg on days 1 and 2 and 1,000 mg on day 3. the dose should be reduced 50% in patients with creatinine clearance values < 40 ml/min.
4. prepare each 500 mg vial of dexrazoxane must be mixed with 50 ml diluent. the patients dose is then added to a 1,000 ml normal saline infusion bag for administration.
5. storage: store at room temperature between 15 C -30 C.
6. initiate the first dexrazoxane infusion asap and within 6 hours of the anthracycline extravasation.
7. infuse dexrazoxane over 1-2 hours in a large vein in an area other than the extravasation area. the same arm should be used only when the patient's clinical status precludes us of the unaffected arm and a large vein above the extravasation site should be used for dexrazoxane administration.
8. dimethyl sulfoxide should not be applied to the extravasation area. assess the extravasation area for pain, blister formation, and skin sloughing.
9. instruct patients w/ peripheral extravasation to report arm or hand swelling or stiffness. instruct patients about treatment side effects such as: N/V, diarrhea, stomatitis, bone marrow suppression, elevated liver enzyme levels, infusion site burning.
10. monitor patients complete blood count and liver enzyme levels.
antitumor antibiotics ex. dactinomycin (actinomycin D, cismegen) Daunorubicin and cytarabine (cyxeos), doxorubicin hydrochloride liposome (doxil), Mitomycin (mutamycin) - CORRECT ANSWER 1. apply cold pack for 15-20 minutes at least 4 times/day for the first 24 hours.
2. no known antidotes or treatment exists.
3. assess the extravasation area for pain, blister formation and skin sloughing.
plant alkaloids and microtubule inhibitors. ex. Vinblastine( velban), vincristine (oncovin) - CORRECT ANSWER 1. apply warm pack for 15-20 minutes at least 4 times/day for the first 24-48 hours. elevate extremity. (peripheral extravasations)
2. antidote: hyaluronidase. it degrades hyaluronic acid and promotes drug dispersion and absorption
3. prepare per package insert. do not dilute. use solution provided. store at room temperature.
4. administer 150 units of hyaluronidase solution as 5 separate injections, each containing 0.2 ml of hyaluronidase, subcutaneously into the extravasation site using a 25 gauge or smaller needle.
5. assess the extravasation area for pain, blister formation and skin sloughing.
6. instruct patients to monitor the extravasation site and to report fever, chills, blistering, skin sloughing and worsening pain.
7. instruct patients w/ peripheral extravasation to report arm or hand swelling or stiffness.
Taxanes Ex. cabazitaxel (jevtana), docetaxel (taxotere), paclitaxel (taxol), paclitaxel protein-bound particles for injectable suspension (abraxane) - CORRECT ANSWER 1. apply cold pack for 15-20 minutes at least 4 times/day for the first 24 hours.
2. no known antidotes or treatment exists.
3. assess the extravasation area for pain, blister formation, and skin sloughing. instruct patients to monitor for extravasation site and to report fever, chills, blistering, skin sloughing and worsening pain.
4. instruct patients w/ peripheral extravasation to report arm or hand swelling and stiffness.
key elements of vesicant extravasation documentation - CORRECT ANSWER 1. date and time of extravasation
2. type and size of peripheral venous access device or type of CVAD.
3. number and locations of venipuncture attempts.
4. description and quality of blood return before and during vesicant administration.
5. vesicant administration technique
6. concentration and estimated amt of extravasated vesicant.
7. symptoms reported by patient.
8. description of administration site that include date and time
9. assessment of extremity for range of motion and discomfort with movement
10. immediate nursing interventions
11. extravasation antidote or treatment administered.
12. follow up recommendations
13. patient teaching.
dexrazoxane injection antidote. - CORRECT ANSWER 1. the only antidote that has a 98% efficacy for treating anthracycline extravasation
2. patient follow up is key
3. assess pts receiving IV dex on each day of the 3 day treatment and again for 4-7 days after completing treatment.
4. assess pts receiving other treatments on the day after the suspected extravasation and again 4-7 days after.
5. assessment may include inspection and measurement of the extravasation area, skin integrity, presence of pain or other symptoms, arm and hand mobility and sensation.
6. obtain follow up photos
7. educate pts to protect the extravasation area from sunlight, monitor the site, and report fever, chills, blistering, skin sloughing and worsening pain.
irritants - CORRECT ANSWER 1. agents that inflame and irritate peripheral veins
2. examples include: bleomycin, carboplatin, carmustine, dacarbazine, etoposide, floxuridine, gemcitabine, ifosfamide, liposomal daunorubicin liposomal, doxorubicin streptozocin and topotecan.
measures to reduce irritation during infusion - CORRECT ANSWER 1. increase dilution when possible and/or infusion w/ concurrent fluid administration
2. administer via larger rather than smaller peripheral. eins for peripheral infusions.
3. apply a warm pack to the administration site.
4. assess the administration site and monitor for pain, redness, and swelling in patients receiving irritating agents.
Bendamustine hydrochloride (bendeka, treanda) - CORRECT ANSWER 1. irritant (usually), vesicant rarely
2. infiltration may cause painful erythema
3. infiltration include hospitalization for erythema, marked swelling and pain.
4. precautions should be taken to avoid extravasation.
5. apply cold pack for 15-20 minutes at least 4 times/day for 24 hours.
6. assess infiltrated area for pain, blister formation and skin sloughing.
7. instruct patients to monitor the infiltration site and to report fever, chills, blistering, skin sloughing and worsening pain.
Irinotecan (Camptosar) - CORRECT ANSWER 1. irritant (usually)
2. exfoliative dermatitis may occur
3. flush skin with sterile water and apply cold pack for 15-20 minutes at least 4 times/day for the first 24 hours.
4. assess the infiltrated area for pain, blister formation and skin sloughing
5. instruct pt to monitor for infiltration site and to report fever, chills, blistering, skin sloughing and worsening pain
6. topical flushing of the skin with sterile water and application of ice
Melphalan (Alkeran0 - CORRECT ANSWER 1. irritant usually, vesicant rarely
2. infiltration may cause local tissue damage
3. apply cold pack for 15-20 minutes 4 times/day for 24 hours.
4. assess for pain, blister formation, skin sloughing
5. instruct pt to monitor the infiltration site and to report fever, chills, blistering, skin sloughing and worsening pain.
6. administer over 15-20 minutes into a fast running IV solution into an injection port on the IV tubing. do not administer by direct injection into a peripheral veing.
Oxaliplatin (Eloxatin) - CORRECT ANSWER 1. irritant usually, vesicant rarely
2. infiltration can lead to redness, swelling, pain and necrosis.
3. a warm pack may reduce local pain and inflammation
4. apply warm pack for 15-20 minutes at least 4 times/day for the first 24 hours.
5. elevate extremity for peripheral extravasation
6. high dose dexamethasone (8 mg twice daily for up to 14 days)
7. assess the infiltrated area for pain, blister formation and skin sloughing.
8. instruct patients to monitor the infiltration site and to report fever, chills, blistering, skin sloughing and worsening pain.
9. instruct patients to report arm or hand swelling and stiffness.
10. reports describe induration, edema, red-brown skin discoloration, hyperpigmentation and rare cases of tissue necrosis.
Vinorelbine (Navelbine) - CORRECT ANSWER 1. irritant usually, vesicant rarely
2. extravasation may cause local tissue extravasation
3. apply warm pack for 15-20 minutes at least 4 times/day for the first 24-48 hrs
4. elevate extremity for peripheral extravasations
5. assess for pain, blister formation and skin sloughing
6. instruct patients to monitor the site and report fever, chills, blistering, skin sloughing and worsening pain.
7. instruct patients with peripheral extravasation to report arm or hand swelling and stiffness.
Vinorelbine (Navelbine) - CORRECT ANSWER 1. both an irritant and a vesicant
2. reports have described skin discoloration, chemical phlebitis, localized rash, urticaria, blistering and rarely, skin sloughing.
3. rapid IV infusion over 6-10 minutes followed by a flush of more than 75-125 ml of fluid may reduce vinorelbine-induced irritation.
drugs associated with hypersensitivity reactions and cytokine release syndorme - CORRECT ANSWER 1. blinatumomab
2. axicabtagene ciloleucel
3. tisagenlecleucel
4. interferon alpha
5. interferon beta
6. interferon gamma
7. aldesleukin
8. denileukin diftitox
9. ibritumomab tiuxetan
10. tositumomab
11. brentuximab
12. cetuximab
13. rituximab
14. alemtuzumab
15. bevacizumab
16. gemtuzumab ozogamicin
17. trastuzumab
18. ipilimumab
19. ofatumumab
20. panitumumab
Anaphylaxis - CORRECT ANSWER 1.hypersensitivity reaction that is a systemic allergic reaction. can be life threatening.
2. reported with rituximab, trastuzumab and cetuximab.
3. flushing, itching, angioedema, cough, nasal congestion, SOB, wheezing sensation of choking, change in voice quality, tachycardia, fainting, hypo or hypertension, loss of consciousness, N/V. cramping/diarrhea, impending sense of doom, tunnel vision and back/chest or pelvic pain.
risk factors for hypersensitivity and anaphylaxis - CORRECT ANSWER 1. administration of chemotherapy or immunotherapy agent
2. pre existing allergies to food, drugs and bee stings.
3. premedicate with fosaprepitant
4. previous exposure to the agent with mild symptoms of allergy
5. failure to administer known effective prophylactic medication
6. first 5 to 15 minutes from the start of the infusion.
cytokine release syndome - CORRECT ANSWER 1. life threatening systemic inflammatory reaction after infusion of agents targeting the immune system
2. develops after cells are damaged and complement pathways are activated which results in an increase in systemic inflammatory cytokines and interleukins.
3. occurs with chimeric antigen receptor T cell therapy and agents such as rituximab and flinatumomab and may result in organ failure or death.
S/S of CRS - CORRECT ANSWER 1. mild: fevers (days to weeks), tachycardia, chills, nausea, anorexia, myalgia, and headaches.
2. life threatening: capillaries leak fluid, which results in third spacing into the lungs and interstitial tissue, leading to intravascular depletion. can occur as late as 7 days after completion of the infusion. can result in thrombocytopenia and increased risk of thrombosis. AKI can occur w/ CRS as a result of changes d/t decrease in renal blood flow.
CAR T cell therapy - CORRECT ANSWER 1. form of immunotherapy using genetically modified CD19 positive T cells to produce receptors called chimeric antigens in the tx. of B cell malignancies.
2. the T cells are isolated and modified using a lentiviral vector to cause apoptosis of CD19-positive cells commonly expressed on B-cell lymphomas and acute lymphoblastic leukemia.
3. CRS is the main complication experienced after cell infusion. it is seen within the first 12 hours to 3 days in patients with leukemia and 2-10 days in patients with lymphoma.
4. tocilizumab is a mAb used to treat CRS. it targets interleukin-6 and resolves symptoms within 24-48 hours.
5. first infusion of rituximab: greater than 50% incidence.
preadministration guidelines to prevent hypersensitivity reactions, anaphylaxis and infusion reactions. - CORRECT ANSWER 1. obtain and record baseline VS
2. review pts allergy hx.
3. administer premedications
4. ensure emergency equipment and meds
5. obtain provider orders for emergency treatment before drug administration
6. monitor for reactions- majority of reactions. occur during the first or second exposure.
emergency management of anaphylaxis - CORRECT ANSWER 1. stop drug infusion immediately and remove the allergen
2. maintain an IV line w/ normal saline or another appropriate solution
3. state with patient. notify the teamf
4. place the pt in comfortable position and assess the airway. maintain in upright position if SOB or nausea. have the pt lie flat and elevate legs if hypotensive.
5. monitor VS every 12 minutes until pt is stable, then every 5 minutes for 30 minutes, then every 15 minutes.
6. maintain airway, assessing the patient for increasing respiratory tract edema. give oxygen if needed.
7. administer emergency meds
8. provide emotional support
9. document all treatments and the patient's response.
10. symptoms of anaphylaxis may recur hours after initial intervention so pt should remain in hospital and monitored.
clinical management of CRS - CORRECT ANSWER 1. stop infusion and observe the patient until symptoms resolve, usually within 30 minutes.
2. administer corticosteroid
3. resume infusion at a slower rate after resolution of symptoms and titrate the rate slowly.
4. for severe reactions, administer emergency meds.
clinical management of localized hypersensitivity reaction - CORRECT ANSWER 1. observe and evaluate symptoms
2. administer diphenhydramine, ranitidine or corticosteroids,
3. monitor VS at least every 15 minutes for 1 hr.
4. document the episode and pt. response.
protection - CORRECT ANSWER defense against foreign pathogens
Homeostatisis - CORRECT ANSWER elimination of damaged or dead cells and initiation of tissue repair
surveillance - CORRECT ANSWER inhibition of tumor growth
innate immunity - CORRECT ANSWER 1. first line of defense
2. does not generate immunologic memory.
3. components include: physical barriers, mechanical barriers, chemical barriers, inflammatory barriers and complement activation
4. acute-phase protein production-recruit phagocytes to site of infection or tissue injury.
5. production of large granular lymphocytes (kill and digest pathogens)
Adaptive or Acquired Immunity - CORRECT ANSWER 1. secondary line of defense
2. involves immunologic memory, specificity and collaboration of B cells and T cells
3. three types: cell mediated, regulatory T cells and humoral immunity
humoral immunity - CORRECT ANSWER B cells produce antibodies after exposure to specific antigens; type of adaptive immunity, the result if the production of immunoglobulins or antibodies.
cell-mediated immunity - CORRECT ANSWER type of immunity produced by T cells that attack infected or abnormal body cells; involves cytotoxic T cells and helper T cells.
regulatory T cells - CORRECT ANSWER 1.limit the activity of other immune effector cells.
2. prevent the onset of immunity to normal tissue of the body and limit the inflammatory response.
3. absence of Tregs may trigger inflammatory disorders involving bowel, skin and liver.
Cells of the immune system - CORRECT ANSWER 1. Made up of leukocytes
a) Granulocytes (Neutrophils, eosinophils, basophils)
b) Lymphocytes (T-Cells, B-Cells, natural killer cells)
c) Monocytes (precursor to macrophage)
d) Dendritic cells (antigen presenting cells; APC)
2. Produced in the bone marrow
myeloid cells - CORRECT ANSWER 1.myeloid immune cells called granulocytes and include neutrophils, eosinophils and basophils.
2.neutrophils are the first responders, phagocytosing infection and initiating inflammation.
3. give rise to red blood cells and platelets.
Lymphoid cells - CORRECT ANSWER T cells and B cells
helper t cells - CORRECT ANSWER coordinate the immune response and cell mediated immunity.
Cytotoxic T cells - CORRECT ANSWER A type of lymphocyte that kills infected body cells and cancer cells
TREgs/ suppressor T cells - CORRECT ANSWER interfere with the development of an immune reaction when recognizing an antigen. primary role is to modulate the severity of inflammation produced infection and prevent autoimmunity.
memory t cells - CORRECT ANSWER Remember antigen and quickly stimulate immune response on reexposure
B lymphocytes - CORRECT ANSWER form in the bone marrow and release antibodies that fight bacterial infections
IgM - CORRECT ANSWER first antibody produced
IgA - CORRECT ANSWER present in body secretions and helps to prevent infections.
IgD - CORRECT ANSWER may have some antibody function for penicillin, diphtheria and insulin
IgE - CORRECT ANSWER allergic reactions
memory cells - CORRECT ANSWER General term for lymphocytes that are responsible for immunological memory and protective immunity.
natural killer cells - CORRECT ANSWER A type of white blood cell that can kill tumor cells and virus-infected cells; an important component of innate immunity.
cytotoxic T lymphocyte antigen 4 - CORRECT ANSWER 1. ligands of CTLA-4 bind to antigen presenting cells
2. this downregulates T cell activity
3. CTLA-4 expression decreases the activation of T cells
4. it sends inhibitory signals to the T cells
5. it enhances Treg's immunosuppressive activity
Programmed cell death protein 1- PD-1 - CORRECT ANSWER 1. an inhibitory receptor on T cells
2. interacts with its ligand, programmed cell death-ligand 1
3. the interaction inhibits T cell proliferation and cytotoxic function
4. induces T cell regulatory function.
5. induces T cell apoptosis
6. PD-L1 overexpression in tumors in correlated with poor prognosis.
Epidermal growth factor receptors (EGFR) - CORRECT ANSWER 1. membrane bound surface proteins
2. three components: extracellular portion that binds circulating growth factors; a transmembrane portion; intracellular portion that interacts with cell signal transduction pathways.
3. communicate extracellular growth signals through the internal cell signal transduction pathways to the cell nucleus, this causes gene activation.
4. this activation is termed dimerization
5. occurs thru interaction with circulating growth factors or by a neighboring EGFR.
6. they are a member of the ErbB family of membrane-bound tyrosine kinase receptors.
7. often mutated or overexpressed in malignant tumors.
8. mutations occurs in the pathway with the absence of the correct extracellular growth signal, resulting in tumor growth.
cytokines - CORRECT ANSWER proteins secreted by cytotoxic T cells to aid in antigen destruction
chemokines - CORRECT ANSWER A chemical secreted by blood vessel endothelium and monocytes during an immune response to attract phagocytes to an area
phases of immune response - CORRECT ANSWER 1. antigen recognition
2. lymphocyte activation
3. effector phase
4. contraction
5. memory
antigen recognition - CORRECT ANSWER circulating antibodies recognize a foreign antigen, which activates the immune system.
lymphocyte activation - CORRECT ANSWER B or T cells are activated to proliferate and differentiate into effector lymphocyte.
effector phase - CORRECT ANSWER foreign antigen is inactivated or destroyed
contraction - CORRECT ANSWER T cell expansion is inhibited or activated cells are eliminated by apoptosis, facilitating the immune system's return to a resting state and limiting tissue damage and chronic inflammation
memory - CORRECT ANSWER lymphocytes that survive the immune response become memory cells that can recognize a former antigen and initiate a rapid response.
immune interaction with targets - CORRECT ANSWER immune system interacts with the body by recognizing and evaluating characteristic structures on circulating cells.
immune surveillance - CORRECT ANSWER immune system identifies cancerous and or precancerous cells and eliminates them before they cause harm; if this fails a tumor forms
angiogenesis - CORRECT ANSWER development of new blood vessels
grading and differentiation - CORRECT ANSWER GX-grade cannot be assessed
G1-well-differentiated
G2-moderately-differentiated
G3-poorly-differentiated
G4-undifferentiated
Staging - CORRECT ANSWER T=tumor- local involvement, invasion
N=nodes-lymph node involvement
M=metastasis-distant
Stage 1 - CORRECT ANSWER early disease, tumor confined to one area; node negative
Stage 2 - CORRECT ANSWER early disease tumor spread to moveable ipsilateral nodes
stage 3 - CORRECT ANSWER locally advanced disease tumor spread to the superficial structures. involvement of ipsilateral internal lymph nodes
stage 4 - CORRECT ANSWER advanced or metastatic disease, metastasis present at distant sites, such as bone, liver, lungs, and brain including supraclavicular lymph node involvement.
characteristics of cancer cells - CORRECT ANSWER 1. abnormal cell proliferation
2. lack of controlled growth and division
3. ability to spread and invade other tissue
4. can involve any bodily tissue
5. evade natural cell death.
Treatments - CORRECT ANSWER 1. surgery
2. radiation therapy
3. chemotherapy/hormonal therapies
4. biotherapy/targeted therapies
adjuvant therapy - CORRECT ANSWER Assisting primary treatment. Drugs are given early in the course of treatment, along with surgery or radiation to attack deposits of cancer cells that may be too small to be detected by diagnostic techniques.
neoadjuvant therapy - CORRECT ANSWER a cancer treatment that precedes other treatment, such as administering chemotherapy or radiation therapy to a patient before surgery
chemoprevention - CORRECT ANSWER the use of natural or synthetic substances such as drugs or vitamins to reduce the risk of developing cancer, or to reduce the chance that cancer will recur
myeloablation - CORRECT ANSWER Procedure involving the elimination of the hematopoietic system, including its components residing in the bone marrow, often achieved through the application of a toxic drug and whole-body radiation
immunosuppression - CORRECT ANSWER treatment to repress or interfere with the ability of the immune system to respond to stimulation by antigens-stem cell transplant
combination therapy - CORRECT ANSWER The administration of two or more antimicrobial medications simultaneously to prevent the growth of mutants that might be resistant to one of the antimicrobials
dose intensity - CORRECT ANSWER dose over total delivery time
dose density - CORRECT ANSWER Chemotherapy - shorter interval between doses. (limitation= toxicity)
dose reduction - CORRECT ANSWER Every long-term or life-long therapy should have "*reduce dose to lowest required*" as part of the dosing strategy
This is to *reduce the adverse effects*
goals of cancer therapy - CORRECT ANSWER Prevention
Cure
Control
Palliation
phases of clinical trials - CORRECT ANSWER Phase 1: small number of healthy volunteers to measure safety, toxicity, and pharmacokinetics
Phase 2: small number of sick volunteers with disease of interest to measure treatment efficacy, optimal dosing, and adverse effects
Phase 3: large number of randomly assigned either to treatment under investigation of to the best available treatment (or to placebo group to compare the new treatment to the current standard of care or placebo
Phase 4: Postmarketing surveillance trial of patients after approval to detect rare or long-term adverse effects
alkylating agents - CORRECT ANSWER cell cycle non-specific
breaks DNA helix strand, thereby interfering with DNA replication
Cisplatin (Platinol) - CORRECT ANSWER alkylating agent
nephrotoxicity-monitor Cr, hydration, I's & O's, weights, diuretics, replace K+, Mg
GI-N/V, acute and delayed
Neurologic-peripheral neuropathies, ototoxicity
vesicant potential
make sure you have blood return
cisplatin makes the kidneys go splat
Carboplatin (Paraplatin) - CORRECT ANSWER alkylating agent
myelosuppression-thrombocytopenia, neutropenia
GI-N/V
irritant to veins
hypersensitivity reaction
dosing based on AUC
doses 6-8 of carbo has an increased risk for hypersensitivity reaction.
Cyclophosphamide (Cytoxan) - CORRECT ANSWER alkylating agent
hemorrhagic cystitis-irritates the bladder, hydration, administer oral dose in the am
GI-N/V
myelosuppression
secondary malignancies-increased risk for leukemia/breast cancer or other cancers.
acroline-eats away at the bladder lining.
mesna-med to protect the bladder
daily UA for blood, give hydration
Ifosfamide (flex) - CORRECT ANSWER alkylating agent
GU-hemorrhagic cystitis-daily UA for blood, mesna infusion, hydration, BUN, Cr.
GI-N/V
Cutaneous-alopecia
Myelosuppression
Neurologic-neuro checks-confusion, coordination
irritant to veins.
mesna is always given with ifosfamide.
can give methylene blue to help with neurologic confusions.
neuro checks especially in older patients.
Melphalan (Alkeran) - CORRECT ANSWER nitrogen mustard alkylating agent
myelosuppression
N/V
Mucositis-irritates mucosal-hold ice in mouth while giving this therapy to help decrease the mucositis.
be aware of blood counts
bone marrow transplant
Oxaliplatin (Eloxaitin) - CORRECT ANSWER alkylating agent
peripheral neuropathy-made worse with cold
myelosuppression
ideal to use with D5W
irritant with vesicant potential to veins
cannot have ice or cold drinks for 3-5 days after administration and should also avoid cold air.
check blood cts before giving, may have to hold drug.
Bendamustine - CORRECT ANSWER alkylating agent (nitrogen mustard)
used in tx of CLL, NHL
bone marrow suppression
rash
irritant with vesicant-like properties
nausea-pre med with zofran/dex
hypersensitivity reaction including anaphylaxis. this is more common with second or subsequent cycles.
hepatic and renal impairment
clinical pearls of alkylating agents - CORRECT ANSWER 1. hypersensitivity may occur with late doses of carboplatin (6-8)
2. tumor lysis syndrome-high tumor burden
3. assess BUN/creatinine, CBC w. differential
4. highly emetogenic lots of N/V
5. if oral route is given, administer in the am.
6. mesna (bladder protectant) is required for doses of ifosfamide, cytoxan.
7. for tumor lysis syndrome-give allopurinol to decrease of for prevention
8. also respuricase with help with tumor lysis syndrome
9. does not discriminate between cancer and non-cancer cells.
10. baseline audiogram for high dose cisplatin
11. alopecia
12. avoid exposure to cold during treatment of eloxatin (oxaliplatin)
antimetabolites - CORRECT ANSWER 1. act in S phase-cell cycle specific
2. common side effects include: myelosuppression, GI toxicities, cutaneous toxicities
3. routes: IV, SC, PO, IM, intrathecal, intraarterial.
Azacitidine (Vodaza) - CORRECT ANSWER antimetabolite
myelosuppression
monitor Cr
N/V/D
erythema at injection site-do not use ice on site and bruising
divide doses > 4 ml into two syringes
contraindicated in patients with sensitivity to Mannitol
drug is thick and causes bruising
roll drug between hands to warm
Capecitabine (Xeloda) - CORRECT ANSWER antimetabolite
oral route: take on full stomach with plenty of water
GI toxicities-N/V, mucositis, diarrhea, hepatotoxicity
cutaneous-hand-foot syndrome-monitor for redness, tingling and numbness
myelosuppression, anemia
potential drug interaction with warfarin
often taken at home-pt education is important
Clofarabine (Clolar) - CORRECT ANSWER antimetabolite
bone marrow suppression
risk for tumor lysis syndrome
N/V/D
hepatotoxicity
renal toxicity
potential for inflammatory response/ capillary leak syndrome
with capillary leak syndrome-altered mental status, swelling and hypotension.
may give dexamethasone for side effects; increased risk for older patients.
monitor K+. Mg, uric acid, Cr and BUN
Cytarabine (ARA-C; Cytosar-U) - CORRECT ANSWER antimetabolite
myelosuppression
N/V, mucositis, diarrhea, hepatotoxicity
cutaneous-rash, alopecia
high doses-->
keratitis: eye drops-drug comes out in tears.
cerebellar toxicity-check handwriting and gait.
can cross the blood brain barrier (walking, balance, coordination)
2 cerebellar assessments on day getting the drug.
Fluorouracil (5-FU) - CORRECT ANSWER antimetabolite
GI cancer pts.
IV form of xeloda
myelosuppression
N/V, mucositis, diarrhea
cutaneous-alopecia, rashes, dry skin, hyperpigmentation, nail changes, photosensitivity
irritant-central line for continuous infusions
may take infusion home with pump, good pt education needed.
lose hair, eyelashes and eyebrows.
Gemcitabine (Gemzar) - CORRECT ANSWER antimetabolite
myelosuppression
N/V
flu-like symptoms-achy, feverish
specific infusion rate-ordered to go in about an hour and a half if you go in longer, increased risk of side effects.
called the gentle gem
causes burning in PIV-warm blanket, increase fluid rate w/ med
sarcome-given over hour and a half.
don't do central line for lower doses.
Methotrexate - CORRECT ANSWER antimetabolite
can be given for ALL intrathecally
hides in pockets of fluid/protein-lots of side effects
given for RA and ectopic pregnancy
N/V, mucositis, diarrhea, hepatotoxicity
rashes, alopecia, photosensitivity
hypersensitivity, fever, chills
high dose:
renal-hydration to alkalinize urine
avoid folic acid, NSAIDS, sulfa drugs during infusion
check methotrexate levels and leucovorin rescue
neurological checks
rescue drug= glucarpidase (Voraxaze)
IV=bright yellow color/ urine is the same color
check UA for ph > 7/8
leucovorin brings down methotrexate levels.
confusion
protect kidneys given sodium bicarb or acetate or dramox.
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