1. CASE STUDY: Use the following case to answer questions 1 through 3.
JB is a 52-year-old white male with Hodgkin’s lymphoma (a B-cell malignancy), who has recently had a recurrence of the disease. Prior therapy includes 6 cycles of ABVD followed 6 months later by brentuximab vendotin x 8 doses for a recurrence. JB then underwent an autologous bone marrow transplant; 11 months later, he was diagnosed with a recurrence. The hematologist would like to treat JB with an immune checkpoint inhibitor (ICI) and has some questions for you as the pharmacist.

Since ICIs activate lymphocytes to kill the cancer, is there a concern that they will stimulate the growth of the Hodgkin's lymphoma?

2. Which of the following is true regarding immune therapy for JB?

3. Which of the following is true regarding chimeric antigen receptor (CAR) T-cell therapy for JB?

4. CASE STUDY: Use the following case to answer questions 4 and 5.
TO is a 49-year-old male with metastatic colorectal cancer that has spread to the liver and lung. The pathology report includes the following details: KRas mutation positive, deficient mismatch repair (dMMR), microsatellite instability-high (MSI-H), PIK3 wild type, EGFR wild type, and BRAF wild type. Programmed death-ligand 1 (PD-L1) expression is 40%. After a brief response to FOLFOX + bevacizumab chemotherapy, TO now presents with new liver lesions. His labs are within or near normal limits.

Which of the following markers indicates that an immune checkpoint inhibitor will work for TO?

5. What treatment would you recommend for TO at this time?

6. CASE STUDY: Use the following case to answer questions 6 through 8.
JC is an 83-year-old female with metastatic non-small cell lung cancer. A biopsy of a metastatic lesion in her liver reveals that the tumor has the following characteristics: BRAF wild type, EGFR wild type, ALK wild type, NRas wild type, programmed death-ligand 1 (PD-L1) tumor proportion score (TPS) of 42%, moderate expression of EGFR (H-score = 180 [range 0-300]), tumor mutational burden (TMB) of 22 (high), and adenocarcinoma histology type. She is a “healthy” 83-year-old woman and her only chronic medication is a statin for high cholesterol. Current labs are all within normal limits and she is mentally sharp. She desires aggressive therapy.

The oncologist prescribes cisplatin and pemetrexed, but she asks you if there is anything more effective. The best reply is:

7. JC decides to enroll in a clinical trial testing ipilimumab and pembrolizumab plus radiation to the primary lesion (lower back). At her week 10 visit, she presents with dyspnea (grade 2 toxicity) over the last day. Which of the following is the best recommendation?

8. After the pneumonitis from the immunotherapy resolved, JC asked about restarting treatment. The protocol leaves it to the investigators' discretion for grade 2 toxicity. What would be the best recommendation?

9. CASE STUDY: Use the following case to answer questions 9 and 10.
AH is a 59-year-old male with newly diagnosed squamous cell carcinoma of the lung. There is an 11-cm mass in the base of his right lung and lesions in his liver, bones, and adrenal glands. The magnetic resonance image (MRI) of the brain is clear. Testing of the tumor shows the following characteristics: squamous histology, EGFR wild type, ALK wild type, KRAS G12 mutation positive, programmed death-ligand 1 (PD-L1) tumor proportion score (TPS) of 37% (PD-L1 negative), ROS1 negative, and tumor mutational burden (TMB) of 9/Mb. He has a significant smoking history (60 pack-year history) and minor pulmonary symptoms. His performance status is 1.

What treatment would you recommend for AH?

10. Ten weeks after starting pembrolizumab/carboplatin/nab-paclitaxel, AH develops grade 3 pneumonitis, which was initially treated with 160 mg of intravenous methylprednisolone daily without improvement for 2½ days. Which of the following is the most appropriate next step?

Evaluation Questions

11. How confident are you in your decision about treatment for TO in the question above?

12. How confident are you in your decision about treating toxicity for JC in the question above?

13. How confident are you in your decision about treatment for AH in the question above?

« Return to Activity