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?
A. Yes; ICIs should not be used for lymphocyte-based disease(s)
B. Yes, but we can determine the effect by testing the tumor for programmed cell death protein 1 (PD-1) expression
C. No; B-cells do not express tumor antigens
D. No; ICIs reactivate exhausted T-cells that have already recognized the cancer cells
E. Unsure
2. Which of the following is true regarding immune therapy for JB?
A. Phosphorylation of the cytotoxic T-lymphocyte-associated protein 4 (CTLA4) pathway should be considered prior to initiation of ipilimumab
B. The expression of CD30 should determine if pembrolizumab can be used
C. Nivolumab is highly active in this setting, regardless of biomarkers
D. Avelumab plus rituximab would be the treatment of choice if Epstein-Barr virus is detected
E. Unsure
3. Which of the following is true regarding chimeric antigen receptor (CAR) T-cell therapy for JB?
A. It is not currently shown to have benefit in Hodgkin's lymphoma
B. It must be used in combination with a PD-L1 inhibitor
C. It is associated with an 80% complete remission rate, which will likely result in some cures
D. It is not appropriate, since JB underwent a transplant
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?
A. KRas mutation
B. dMMR
C. PD-L1 expression
D. EGFR wild type
E. Unsure
5. What treatment would you recommend for TO at this time?
A. Durvalumab
B. Pembrolizumab
C. Ipilimumab
D. Atezolizumab
E. Unsure
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:
A. Nivolumab plus ipilimumab is more effective
B. Cisplatin plus ipilimumab is more effective
C. Pembrolizumab plus axitinib is more effective
D. There is nothing more effective
E. Unsure
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?
A. Start albuterol
B. Draw blood samples to evaluate cardiac function
C. Start prednisone 60 mg by mouth daily (1 mg/kg)
D. This is expected; maximize lung function with mild/moderate exercise and it will go away
E. Unsure
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?
A. The therapy should be restarted but at half the dose
B. The therapy should be restarted at the full dose, but the interval between doses should be extended from 3 weeks to 4 weeks
C. The treatment can be resumed without a dose reduction
D. The treatment should be permanently discontinued
E. Unsure
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?
A. Cisplatin pemetrexed
B. Nivolumab plus cabozantinib
C. Atezolizumab plus bevacizumab plus carboplatin plus paclitaxel
D. Pembrolizumab plus carboplatin plus nab-paclitaxel
E. Unsure
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?
A. Addition of an antiviral drug is necessary since the steroids have ruled out immune-related pneumonitis
B. Treatment should be changed to rituximab
C. Continue to monitor and anticipate changes if no improvement is seen in 7 to 10 days
D. Add infliximab 5 mg/kg and get a pulmonary consult
E. Unsure
Evaluation Questions
11. How confident are you in your decision about treatment for TO in the question above?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
12. How confident are you in your decision about treating toxicity for JC in the question above?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
13. How confident are you in your decision about treatment for AH in the question above?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident