The Fellow on Call: The Heme/Onc Podcast

If you’ve been with us since the beginning, thank you! But we've had a lot of new friends join the party so we thought we'd interrupt our regular programming to re-introduce ourselves! So if you’re new here, welcome to the Fellow on Call! We are so glad you’re here.

Lung cancer is one of the most commonly diagnosed type of cancer and so it is fitting that we start the first of our disease-specific oncology series with this diagnosis. This week, we round out our discussion of early stage lung cancer treatment!* When deciding if a patient can get surgery upfront or not, remember the three “Fellow on Call” criteria for early stage lung cancer:  - Mass invading other structures or mediastinum- Central lymph nodes (single digit)- Tumor >7 cm* If surgery is NOT an option at this time, where do we go from here?- Treat with upfront concurrent definitive chemoradiation- Treat with “induction” chemotherapy or induction concurrent chemoradiation**If surgery is/may be possible***What are the goals of “induction” treatments? - Eradicate microscopic disease- Improved local control, possibly shrinkage- Adding radiation may allow you to downstage tumor or lymph nodes to have a possible improvement in surgical outcomes* What sorts of discussions are being had a thoracic tumor board in patients with newly diagnosed early stage NSCLC? - Is the patient a surgical candidate?- If the patient is not a surgical candidate, then what are the options:--Definitive concurrent chemoradiation (usually) followed by immunotherapy---Pearl 1: Always choose this if surgeon thinks the patient is unresectable in general even with an induction approach---Pearl 2: Always choose this if 2 out of 3 criteria we discussed above are met---Pearl 3: Always choose this if N3 disease- “Induction” regimen with either chemotherapy alone or concurrent chemoradiation followed by surgery * What’s the idea behind “induction” chemo or chemoradiation? - There is a chance that patients with these high risk features may already have micrometastatic disease, so treatment upfront can help address that- There is a chance that after surgery, patient may suffer deconditioning, which may preclude the use of chemo +/- radiation (up to 90% of patients are often eligible for chemoradiation before surgery; this drops to ~60% after surgery)- Local disease control to achieve the best possible surgical outcome (R0 resection) and also prevent any microscopic residual disease from then having the opportunity to spread systemically, especially in areas where the mass may be adjacent to many blood vessels or lymph nodes* What to treat with in the neoadjuvant setting?- Platinum containing regimens (“platinum doublets”):-- Carboplatin + paclitaxel-- Cisplatin + etoposide-- Cisplatin + gemcitable-- Cistplain + pemetrexed- Can combine this with radiation* How does the data about chemotherapy+IO in the neoadjuvant setting fit in here (CHECKMATE 816)?- In patients with Stage IIB to IIIA (8th edition) WITHOUT EGFR or ALK mutation, treatment with NEOADJUVANT chemotherapy q3w x3 cycles (most got cisplatin based therapy) + nivolumab 360mg q3w x3 cycles resulted in improved event free survival (31.6 months vs. 20.8 months) AND pathological complete response was 24.0% vs. 2.2%- Current NCCN guidelines state that if nivolumab is used in neoadjuvant setting, it should not be used in adjuvant setting- There is still uncertainty about how this fits into treatment compared to “traditional” neoadjuvant approaches with chemo+/-radiation*So after neoadjuvant treatment, does everyone go to surgery?- Always re-assess the status of the disease; if there is progression of disease, then will go to definitive chemoradiation- Discuss with surgeons to confirm if the patient is still a surgery candidate* If patient undergoes surgery, then what?- If patient got neoadjuvant therapy and an R0, then they are done with treatment- If R0 resection was not able to achieved, then either radiation “boost” to the area (if they previously got radiation), a course of radiation (if they just got induction chemo) or re-resection- We discuss the adjuvant setting in more detail in Episode 026 (https://www.thefellowoncall.com/tfocpodcast/episode-001disclaimer-wfhgf-ml3b6-9m66a-8rrc4-k8w87-x7xdd-wrzye-4xg8x-t73gt-cxc5s-nmg8f-cfyd6-hgs35-5pcwx-tf6dh-trggt-xzkt7-923gg-rpjzx-6s36p-hk27n-bbpgx-jymml-9lfam-76m4s)** If surgery is not possible*** If patient cannot go through to surgery Definitive chemoradiation:- Same chemotherapy agents as above, but treatment course is longer.- For instance, for NSCLC, total 60Gy in 2Gy divided fractions (5 days/week, 6 weeks of treatment) with chemotherapy* Additional therapy after chemoradiation (PACIFIC Trial) - Found that “consolidation” durvalumab 44% PFS 18 months vs 20% 5year survival benefit 40% vs. ~30% without treatmentReferences:https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450 - NCCN Lung Cancer guidelines https://www.nejm.org/doi/full/10.1056/nejmoa1709937 - PACIFIC Trial (NEJM 2017)https://www.nejm.org/doi/10.1056/NEJMoa2202170 - CHECKMATE 816 (NEJM 2022) Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Lung cancer is one of the most commonly diagnosed type of cancer and so it is fitting that we start the first of our disease-specific oncology series with this diagnosis. An important component of treatment in lung cancer (and many other cancers) is the use of radiation. This week, we continue our discussion about the fundamentals of Radiation Oncology with our guest, Dr. Evan Osmundson. *We hear the terms “hypo-fractioned” and “hyper-fractionated” radiation. What do those mean?- Fractionation, that is breaking up the total dose of radiation into smaller ones, has allowed patients to tolerate the radiation better. The repeat exposure allows the healthy tissue to repair, whereas the tumor is not able to heal as well- Standard fractionation involves keeping the maximum dose per session at 1.8-2Gy/fraction. - Hyper-fractionation is when a patient gets multiple doses per day, each less than 2Gy. This is important in small cell lung cancer, where the standard dose of radiation is 1.5Gy twice daily- Hypo-fractionation os when larger doses are given in each session, typically larger than 2.5-3Gy, often 4-5Gy per fraction. This is analogous to SBRT. *With regards to SBRT, how do you determine the number of sessions? - Typically 3-5 sessions, and this is based on data run through their computer algorithm that allows the dose to be tumoricidal. - More sessions (more likely 5 sessions) if central tumor (<2cm central proximal bronchial tree) or ultra-central tumor (directly abutting bronchial tree/major vessel) or abutting the chest well. Poor outcomes in some studies with fewer sessions; 5 sessions seem to work well in central tumors, based on recent data. - Logistically speaking, five sessions is also typically the maximum that insurance will pay for. *What’s the max size of the tumor that is amenable to SBRT?- Most clinical trials have limited size to 5cm or less, but he has done SBRT to larger tumors. This is a case-by-case basis.* How do you calculate the duration of treatment when we are going to do concurrent chemo-radiation?- Treatment is usually 5 days a week, with the weekends off for patients- In NSCLC, total 60Gy appears to be the standard of care, based on RTOG 0617 study. (J Clin Oncol 2020 Mar 1;38(7):706-714. doi: 10.1200/JCO.19.01162. Epub 2019 Dec 16.); practically this means about 6 weeks of treatment.- In SCLC, Target 45Gy broken up into 1.5Gy TWICE daily OR 66Gy broken up into 2Gy ONCE daily is the standard of care based on CONVERT trial (Lancet Oncol. 2017 Aug;18(8):1116-1125. doi: 10.1016/S1470-2045(17)30318-2. Epub 2017 Jun 20.)* What is your guidance to avoid brain toxicity, for instance with using SRS to the brain for a brain met? - There is a risk of brain necrosis from the synergism between certain chemotherapies/targeted agents that penetrate the blood-brain barrier with SRS that can cause radiation necrosis to the brain. This is particularly an issue with TKIs, such as osimertinib. Dr. Osmundson recommends holding TKIs about 5-7 days, if possible.*What is proton therapy and how does it differ than “traditional” radiation therapy?- With x-rays/photon therapy, the beam is attenuated and there is an exit dose that can affect the neighboring tissues. - With proton beams, there is a “Bragg-Peak” effect, whereby you can specify how deep you want to radiation to deposit with little exit dose. - Per Dr. Osmundson, we are not currently in a position to recommend proton therapy AT THIS TIME, but this may be changing. Research is being done to better be able to maneuver the beam angles. - Proton therapy is also very expensive at this timeA special thank you to our guest, Evan Osmundson, MD, PhD, Associate Professor in the Department of Radiation Oncology and serves as the Medical Director of Radiation Oncology at Vanderbilt University Medical Center in Nashville, TN!Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Lung cancer is one of the most commonly diagnosed type of cancer and so it is fitting that we start the first of our disease-specific oncology series with this diagnosis. An important component of treatment in lung cancer (and many other cancers) is the use of radiation. Here, we discuss the fundamentals of Radiation Oncology with our guest, Dr. Evan Osmundson. Basic vocabulary: - Fraction/Fractionation: The total dose of radiation divided into smaller doses - Grey: Unit of measure of radiation being delivered in each session - Bragg-Peak effect: Specific to proton therapy (as opposed to photon therapy). It describes the sharp increase in concentration of the energy when hitting the tumor, while minimizing the effects to surrounding tissue. - Radiosensitizing chemotherapy: small doses of chemotherapy used to make the cells more responsive to the deleterious effects of radiation Fundamentals of radiation oncology: *When we make a referral to RadOnc, what happens then? - Send over any available imaging that is available - Team reviews the imaging to ensure that staging is completed - Simulation scan: Uses a CT scan to “simulate” the treatment; specifically map out the tumor and the surrounding organs/structures. Multidisciplinary team reviews the scan to maximize the dose to the tumor and minimizes damage to surrounding structures. - Based on the scans, they test run the treatment on a model to ensure that the simulation on the computer is able to be replicated on a model. - The above is why it can take a while for treatment planning to take place*What sorts of imaging modalities are important to have for patients prior to getting to Rad Onc? - Send prior CT imaging - If planning for radiation to the brain, should get thin-sliced MRI w/ and w/o contrast - If prostate cancer, also consider getting MRI*Many patients express concern about the “mask fitting” - what is that? - To ensure that the same dose of radiation is administered each time, it is important for the patient to remain very still and/or the same position every session. The mask is custom fit to ensure patient is in the correct position. *How do you determine the “maximum dose” of radiation in the mediastinal area is? - The maximum dose tolerance is dependent on the structure in question. A structure “in series” such as the bronchial tree would have profound effects if tissue is injured compared to lung parenchymal tissue (If you damage some, there is plenty more that is able to compensate) - Always concern for spinal cord when radiating the mediastinum *What are side effects you counsel patients on, specifically in thoracic radiation? - Fatigue (usually not debilitating), radiation esophagitis, pericarditis (rare) - Radiation pneumonitis (usually 6-8 weeks, but can be up to one year), presents with cough, shortness of breath; likelihood of this is dependent on duration of treatment, dose of radiation, location A special thank you to our guest, Evan Osmundson, MD, PhD, Associate Professor in the Department of Radiation Oncology and serves as the Medical Director of Radiation Oncology at Vanderbilt University Medical Center in Nashville, TN!Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

How do we think about treatment of lung cancer? Recap on staging (see Episode 025) * Pro-tip: Highly recommend that you “forget” about the actual staging and focus more on the individual T, N, and M status * Tumor size:**T1a <1 cm **T1b <2 cm **T1c <3 cm **T2a <4 cm **T2b <5 cm **T3 5-7 cm**T4 cm *Nodal status: **Double digit nodes = hilar or intrapulmonary (peripheral) = N1**Single digit nodes = mediastinal (central ) = N2**Contralateral nodes or supraclavicular = N3*Sites of metastatic diseaseApproach to treatment in a stepwise approach: *Goal: Whenever feasible, we want to consider getting the patient to surgery to remove the cancer. *Surgery or no surgery?**How do we decide if someone is appropriate for surgery: ***Do they want surgery?***Do they have the pulmonary reserve if they were to get surgery ?***Do they have the cardiac reserve to withstand surgery?***Is the tumor size too big? (Usually >7cm)***Is the tumor invading other structures?****If invading other structures, surgery may not be possible; highly consider tumor board discussion***Mediastinal lymph node involvement?****Central lymph node involvement usually requires definitive chemotherapy + radiation (not surgery up-front)***Supraclavicular lymph node or contralateral lymph node?****This would be treated with chemotherapy and radiationSpeaking of surgery, what are the options for types of surgeries for lung cancer?*Sub-lobar:**Wedge (smallest resection)**Segmentecomy - ideally we want to do at least a segmentectomy*Lobar resection:**Lobectomy**PneumonectomyWhat if a patient’s tumor is amenable to surgery, but the patient’s underlying co-morbid conditions preclude him from getting a surgical intervention? *This is where we consider using radiation for treatment, specifically Stereotactic body radiation therapy (SBRT)Characteristics of surgical report?*The “R” status is if there is residual tumor after the surgery. This is a combination of evaluation by a pathologist AND by gross inspection by the surgeon**R0: No evidence of disease**R1: Microscopic sites of disease**R2: Macroscopic sites of disease (visible tumor)*Why does this matter?**If there is residual disease, there may be a role for further resection and/or systemic therapy*When a tumor is >4cm, patients are higher risk for recurrence, even without nodal disease or metastatic disease. We will give these patients chemotherapy in the adjuvant setting.  Approach to adjuvant chemotherapy:*In NSCLC, it is often a two-drug regimen, including a platinum-based therapy*Cisplatin is important**Based on LACE Pooled Analysis (https://ascopubs.org/doi/10.1200/jco.2007.13.9030) ***Cisplatin-based adjuvant therapy vs. placebo showed >5% improvement in survival when using cisplatin-based therapy***For adenocarcinoma:****Give cisplatin with pemetrexed****ALWAYS start patient on B12 and folate at least 1 week before starting pemetrexed and continue this throughout treatment, up to and including 3 weeks after their treatment course***For squamous cell caricnoma:****Give cisplatin with gemcitabine OR docetaxol (taxotere)*Nodal involvement (N1): Give two-drug regimen, as noted above*Additions to two-drug regimen:**IMPOWER 010 Trial: In patients with PDL1 >50%, patients did better with 1 year of immunotherapy (atezolizumab) after adjuvant therapy (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02098-5/fulltext; https://ascopost.com/issues/november-10-2021/impower010-adjuvant-atezolizumab-improves-disease-free-survival-and-nsclc-relapse-in-patients-whose-tumors-express-pd-l1/)**Mutations matter! ADAURA Trial: EGFR with exon 19 deletion or L858R can get osimertinib, which had an improved outcomes (https://www.nejm.org/doi/full/10.1056/NEJMoa2027071)References: https://ascopubs.org/doi/10.1200/jco.2007.13.9030 - LACE Pooled analysis https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02098-5/fulltext - IMPOWER 010 Trial https://www.nejm.org/doi/full/10.1056/NEJMoa2027071- ADAURA Trial Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Lung cancer specialized testing in NSCLC: What do we do if we biopsy a suspected metastatic lesion?* Immunohistochemistry (IHC): **Confirm if it is metastatic NSCLC **Confirms the histology of the NSCLC (such as adenocarcinoma vs. squamous cell)**Used to determine the type of chemotherapy that can be administered for treatment *PDL1 testing: **PDL1 is a protein expressed by certain cancer cells allowing them to evade the immune system (“fake mustache analogy”).**Also confirmed by IHC**This protein is targetable!**Often measured as:***Total protein expression (TPS): The number of positive tumor cells divided by the total number of viable tumor cells multiplied by 100%***Composite protein expression (CPS): The number of positive tumor cells, lymphocytes and macrophages, divided by the total number of viable tumor cells multiplied by 100%*Molecular testing: **We discuss this in detail in Episode 005**Genetic information from the tissue sample**Always better to get sample from soft tissue than from bone**Why is this important?***To be able to identify “driver mutations”****What is it? Important mutations that may be “driving” oncogenesis****Many of these have drugs that directly target these mutationsPrognostic vs. predictive biomarkers:*Prognostic biomarkers: Mutations or changes that give information about the cancer’s overall outcome regardless of therapy*Predictive biomarkers: Mutations that provide information about how a cancer may respond to a particular drug Cell-free DNA (AKA “liquid biopsy”):*Special tests that can detect microscopic amounts of cancer cell DNA within the patient’s blood which may also be used to find prognostic/predictive biomarkers*Ongoing studies to see if this can be used to find relapse of diseasePlease visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Lung Cancer Histology and Staging*Workup for a nodule that is concerning: **Ensure there is a dedicated CT scan of the chest to evaluate **Try to obtain old imaging; the rate of change is important **Can get PET, but even if a lesion if not FDG-avid, but growing quickly we should consider biopsy anyway**Referral to pulmonary medicine, who can assist with biopsy and also regional lymph node evaluation (important – more below)**PFTs are often ordered because it provides information about lung function in anticipation of possible surgery for treatment Lung Cancer Histology: *Non-small cell lung cancer (NSCLC)**Umbrella term for a variety of cancers**Increased risk in smokers**More common types: ***Adenocarcinoma (~50% of all lung cancers)****Most common overall; cancer of the mucus producing cells****IHC: TTF-1, NapsinA, CK7 positive***Squamous Cell Carcinoma (22.7%)****More often seen in patients with a smoking history ****IHC: p63 positive and cytokeratin pearls***Remaining ~15% are the other types of lung cancer / mixed histologies**Small cell lung cancer (SCLC)***Neuroendocrine tumor with very different pathology***Much more aggressive than NSCLC***Oncologic emergency***IHC: Chromogranin and synaptophysin positive IHC pearls: TTF-1 usually means lung cancer (but can be negative in squamous cell lung cancer). This will be important in the future (we promise :])*Staging for NSCLC:**Nodal evaluation: lymph node evaluation is part of the workup for NSCLC**Single digit = central/mediastinal nodes (higher risk)**Double digit = peripheral/hilar/intrapulmonary lymph nodes (lower risk)**“R” vs. “L” is direction *Pearl: Why is this important? If there is nodal involvement, systemic therapy is going to be necessary *Putting it all together: **T: Tumor size: T1-4**N: Nodal involvement***N0: no nodal involvement ***N1: Nodes closest to the primary tumor (double digits)****Ipsilateral peribronchial, hilar, intrapulmonary ***N2: Further away (single digit)****Ipsilateral mediastinal and/or subcarinal LN***N3: Contralateral any node or supraclavicular LN **M: Metastasis – in lung cancer, patients with certain patterns of metastatic disease are still curable! ***M0: no mets***M1a: Contralateral lobe, pleural effusion or pericardial effusion à these are generally still curable!***M1b: single site of metastatic disease à these are generally still curable!***M1c: multiple sites of metastatic disease à these are generally not curable*Staging for SCLC: **Limited stage - meaning it can fit in “one radiation field”**Extensive stage - does not fit in “one radiation field”*Once lung cancer is diagnosed:**Go to NCCN to learn the flow of ongoing management**Complete staging (if not already done):***CT C/A/P (don’t necessarily need if a PET scan is done)***PET Scan***MRI brain à in general this is needed, but there are some exception to this (see NCCN)**Referral to pulmonary for nodal evaluationReferences: NCCN.orghttps://doi-org.proxy.library.vanderbilt.edu/10.1016/j.semcancer.2017.11.019-Article about IHC markers for lung cancer Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Lung cancer is one of the most commonly diagnosed type of cancer and so it is fitting that we start the first of our disease-specific oncology series with this diagnosis. This week, we sit down with guest pulmonologist Dr. Greta Dahlberg to discuss how she thinks about and works up lung nodules concerning for malignancy.Lung nodules: * For discussions about incidental lung nodules and lung cancer screening, check out Episode 197 from our friends, The Curbsiders (link: https://thecurbsiders.com/podcast/197) * Nodule vs. mass:** “Micronodule” is <3mm** “Nodule” is <3 cm** “Mass” is anything bigger *Characteristics of “benign” vs. “malignant” nodule** Most important thing is change over time; therefore always good to have old imaging if possible. ** If growing overtime, even if slowly, that should raise red flags for malignancy** Volume doubling time (link: https://radcalculators.org/volume-doubling-time-vdt-calculator-for-pulmonary-nodules-volume-based/)*** If doubling time <20 days, it’s often infectious*** Average lung cancer doubling times is 100 days* Benign: ** Smooth** Calcifications (diffusely or popcorn calcifications)** Internal fat appearance * What about a spiculated nodule? ** This is when there are nodules with “little hairs” coming off, often thought to be malignant** Dr. Dahlberg reports that odds ratio of it being malignant is 2.5, so it is high, but not that high. So spiculated does NOT necessarily mean malignant. * Workup before referring to Pulmonary: ** Dedicated CT scan of the chest ** Obtain old imaging ** PET CT*** Expert tip: If growing, whether it’s hot or not, it warrants a biopsy*** PET can help identify spread and/or nodal involvement* Biopsy approaches (we don’t know approach which one is better … There are studies ongoing!):** Transthoracic biopsy (CT guided):*** Performed by IR*** Major risk: pneumothorax (20-25% have one after procedure!)*** Benefit: Does not need general anesthesia**Transbronchial biopsy: *** Performed by Pulmonary*** Requires general anesthesia and paralyzing *** Options while doing biopsy:**** EBUS**** Fluoroscopy *** Major risks: Pneumothorax (1.5% have one, less than half need chest tube)*** Benefit: You can also do EBUS to stage mediastinum. Remember- we always look to upstage a cancer and by looking at the mediastinum, this helps to accomplish that* What if someone has two lung nodules on contralateral sides?** Likely both will be sampled** If PET has one nodule that is more FDG-avid than the other, they will go after that first. But they can sample both if safe. * Does PET help with bronchoscopy?** It can help, but appearance during bronchoscopy is more important* When is something NOT amenable to bronchoscopy?** The middle third of the lung is hardest and most technically challenging** Lower lobes of lungs, made difficult by atelectasis** Contrary to common belief, peripheral lesions are easier due to anatomy of the lungsAbout our guest: Dr. Greta Dahlberg (link: https://medicine.vumc.org/person/greta-dahlberg-md) is a pulmonary/critical care fellow at Vanderbilt University Medical Center in Nashville, TN. Thank you so much for joining us! Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

We have now covered the fundamentals of pharmacology. This week, we sit down with Renee McAlister, PharmD, BCOP to learn more about the nuances of pharmacology from an expert that does this day in and day out. *The products/resources we share are our OWN opinions. Naming of resources are not endorsements. We are not sponsored by any of these entities. Pharmacology Capstone: * Irritant vs. Vesicant:** For extravasation, what to do?*** Not a great general source; would recommend checking institutional guidelines. *** Different drugs may require a cold vs. warm compress.*** Some drugs have antidotes - it is best to just look this up when it happens* Why is there a “cut off time” to get in chemotherapy orders?** Many hospital pharmacies are not 24 hours, therefore need prep time. ** Many drugs take a long time to prepare!** A lot verification goes into ensuring that the drugs are correctly ordered, prepared, and handled. Therefore this requires adequate staff to do this safely. * What does "ideal body weight” mean?** Calculated by the patient’s sex, height, and the calculated body weight based on this information ** Helps with drug-dosing to ensure that drugs are not over/under-dosed* What does “AUC” mean?** Incorporates renal function and the amount of exposure you want the patient to have to the drug. Based on the Calvert equation.** It is important to re-calculate each time with a new Cr to ensure that this is updated.** Example: https://reference.medscape.com/calculator/169/carboplatin-auc-dosing-calvert* What is the role of granulocyte colony-stimulating factor (GCSF)?** Helps to prevent the risk of infection, especially from endogenous bacteria.** GCSF helps to minimize the window of neutropenia related to treatment with chemotherapy** NCCN guidelines (www.nccn.org) provides guidelines about febrile neutropenia risk. A risk >20% means that we build in GCSF administration into the treatments. *** If risk 10-20% with certain risk factors, we may consider adding GCSF*** Always look at the paper that was what the approval of the regimen was based off of - they will comment on if/how GCSF was used during the study. *** If patient develops neutropenic fever during a cycle, if even the drug is not traditionally one that we consider GCSF for, it would be appropriate to consider GCSF for future cycles to decrease the risk of febrile neutropenia. * What are the different “types” of GCSF?** Examples:*** Filgrastim (“Neupogen”) - daily dosing, short-acting GCSF*** Pegylated-filgrastim (“Neulasta”) - don’t have to give daily dosing; one time shot because it lasts for longer*** On-body injector (OBI) - a device put on the arm that delivers pegylated- filgastrim at approximately 26 hours after chemotherapy ** Dosing: Very different dosing for all of these medications; pay attention to the dosing! * Supportive care: ** How do you decide what anti-emetics to include?*** NCCN supportive care guidelines is a great place to start*** Regimens with >90% emetic potential should get at least three agents (for example: ddACT, cisplatin based regimens)**** Example: 5-HT3 receptor antagonists, dexamethasone, olanzapine, and aprepetant*** Moderate emetic potential (30-90%), add at least 2 drugs**** Example: 5-HT3 receptor antagonists and dexamethasone*** Lower risk (30%): usually one one drug**** Example:5-HT3 receptor antagonists** If patients have refractory nausea in a cycle, add another agent. When adding drugs, always ensure you are incorporating the patient’s other medical history AND drug-drug interactions* Pharmacists are an amazing source of information! Please reach out with questions!Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Picture this: it's day 1 of fellowship and your attending needs you to "get consent for treatment." Huh? How do you educate your patient? We share our tips! In this episode, we discuss important considerations, including “does my patient need a port?”, “what if drugs extravasate?”, “how do I keep side effects of drug classes straight?!” *The resources we share are our OWN opinions. Naming of resources are not endorsements. We are not sponsored by any of these entities. Pharmacology 101: * Irritant vs. Vesicant:** Each drug is deemed one of these based on the degree of tissue damage that can result if drug extravasates under skin. 
** Vesicant: needs central access
** Irritant: can be given peripherally 
* Does my patient need a port/picc?** If vesicant; for continuous infusions over several days (e.g. 5-FU); some patients with difficult access may request. 
*Advantages of ports: ** Easy access for labs
** Easy access for chemotherapy/fluids
* Disadvantages: ** Risk of infection
** Risk of thrombosis 
* General overview of chemotherapy side effects: ** Going to target the fastest growing cells in the body, which includes cells that line the GI tract, skin, hair/nails, and blood cells
** Therefore side effects are related: *** GI: nausea/vomiting, diarrhea (sometimes constipation), decreased appetite, taste changes
*** Low blood counts **** WBC nadir ~10-14 days (generally), and recover 21-28 days after chemo
* What about unique side effects of chemotherapy classes? How do we keep them straight?** We love keeping “Chemoman” from the USMLE study days in mind!
* Anthracycline*** MOA: Topoisomerase inhibitors
*** Ends in “rubicin”
*** You might hear people call doxorubicin the “red devil”
*** Used in lots of cancers
*** Hair loss occurs with this one
*** Known to cause cytopenias and associated with higher nausea potential 
*** Unique side effects: **** Heart failure (always get baseline echo!)
**** Development of MDS and leukemia 
* Alkylating agents** MOA: Drugs add alkyl group to the guanine base of the DNA molecule, preventing linking of strands
** End in “fosfamide”
** fosfamide or cyclophosphamide (AKA cytoxan)
** Used in lots of cancers
** Known to cause cytopenias and hair loss
** Unique side effects:*** Secondary MDS or leukemia possible 
*** Ifosfamide = neurotoxicity = methylene blue antidote
*** Cyclophosphamide = hemorrhagic cystitis due to acrolein byproduct accumulation = prevent by giving mesna to protect bladder
* Antimetabolites** MOA: Purine analog, pyrimidine analog, folate antagonists; therefore prevent production of base pairs or binds instead of normal base pairs
** End in “abine” - capecitabine, cytarabine, gemcitabine, cladribine, fludarabine
** Also 5-FU and 6-MP in this category so “number followed by dash”
 ** Unique side effects:*** Think bone marrow suppression in this category  
* Platinum agents** MOA: Believed to cause cross-linking of DNA
** End in “platin”
** Associated with high risk of neuropathy 
** Unique side effects: *** Cisplatin: **** Nephrotoxicity 
**** Ototoxicity 
**** High risk of nausea; need special prophylaxis 
*** Carboplatin: cytopenias
*** Oxaliplatin: higher rates GI side effects 
* Microtubule agents** MOA: Impair microtubule function, therefore impacting cell division
** End in “taxel” or vincristine/vinblastine (“V-stine”)
** Unique side effects: Neuropathy
Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast