1. JT is a 75-year-old male with human epidermal growth factor receptor 2 (HER2)-positive, microsatellite-stable (MSS) metastatic gastric adenocarcinoma. He presents for restaging scans following 6 months of first-line therapy with 5-fluorouracil, oxaliplatin, and trastuzumab. His symptoms are significant for peripheral neuropathy, cold sensitivity, fatigue, and reflux. JT's scan shows progression of disease and the physician would like to switch to pembrolizumab 200 mg intravenously every 3 weeks. JT's combined positive score (CPS) is 3. Why is this therapy NOT appropriate for JT?

2. RW is a 58-year-old female with microsatellite-stable (MSS), human epidermal growth factor receptor 2 (HER2)-negative recurrent metastatic esophagogastric junction adenocarcinoma with liver metastases and malignant ascites. Her combined positive score is 17. She experienced disease progression on first-line therapy with 5-fluorouracil plus oxaliplatin and second-line therapy with ramucirumab plus paclitaxel. She has lost 40 pounds over the last 3 months due to persistent dysphagia. She cannot swallow more than a few sips throughout the day and relies on a feeding tube for administration of all medications and meals. What would be the most appropriate option for third-line therapy?

3. You are the pharmacist reviewing oncology treatment plans and doses for patients arriving in the infusion center for treatment. During your review, you encounter an order for pembrolizumab 200 mg intravenously every 21 days for a patient with metastatic esophagogastric junction adenocarcinoma and a combined positive score of 37. You review the current medication list for the patient. Which home medication makes you question the appropriateness of pembrolizumab therapy?

4. BP is a 63-year-old male with microsatellite-stable (MSS), human epidermal growth factor receptor 2 (HER2)-negative metastatic esophagogastric junction adenocarcinoma; he is experiencing disease progression on first-line therapy with oxaliplatin and fluorouracil. His Eastern Cooperative Oncology Group Performance Status is 0 to 1 and he would like to continue pursuing treatment. BP's combined positive score is 11. What is the preferred second-line treatment option for BP at this time?

5. WF is a 64-year-old male with newly diagnosed esophagogastric junction adenocarcinoma with metastases to the liver and peritoneum. His tumor is human epidermal growth factor receptor 2 (HER2) positive and microsatellite stable (MSS); his combined positive score is 12. The oncologist would like to initiate first-line systemic treatment with 5-fluorouracil plus cisplatin and trastuzumab. Which of the following landmark trials provided the data to support the use of this combination?

6. Which of the following medications is recommended to be given as a single dose prior to administration of trifluridine/tipiracil?

7. KP is a 75-year-old male with metastatic gastric adenocarcinoma. He is taking trifluridine/tipiracil; he was prescribed 20 mg/8.19 mg tablets: take 4 by mouth twice daily on days 1 through 5 and 8 through 12 of a 28-day cycle. Today, he presents to clinic prior to initiating day 1 of cycle 2. His labs are within normal limits. KP admits that he “had a lot of difficulty with this cycle”: he states that he was confused with what days he was supposed to take pills and how many pills he was supposed to take. What recommendations can be used to help KP be compliant with his trifluridine/tipiracil?

8. What biomarkers should be included in JR's metastatic work-up that may influence how his EGJ cancer is treated? CASE STUDY: Questions 8-10

9. JR’s cancer is identified as HER2 positive. He is started on 5-fluorouracil plus oxaliplatin and trastuzumab. Unfortunately, he experiences disease progression after only 4 cycles of treatment.
The attending oncologist would like JR to start ramucirumab plus paclitaxel. Assuming JR's labs and medications are the same as above, what adverse events are you concerned about in JR?

10. What can be done to lower JR's risk of having a major upper GI bleed while on ramucirumab plus paclitaxel?

Evaluation Questions

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

12. How confident are you in your decision about treatment for BP in the question above?

13. How confident are you in your decision about treatment for JR in the questions above?

« Return to Activity