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?
A. The CPS score should be greater than or equal to 10 before pembrolizumab is initiated
B. Peripheral neuropathy is a contraindication to pembrolizumab therapy
C. JT must fail 2 prior lines of treatment before pembrolizumab therapy is initiated
D. Pembrolizumab is not indicated for HER2-positive gastric cancer
E. Unsure
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?
A. Trifluridine/tipiracil
B. Docetaxel
C. Pembrolizumab
D. Nivolumab
E. Unsure
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?
A. Methylprednisolone dose-pack: take by mouth as directed
B. Apixaban 5 mg by mouth twice daily
C. Fluticasone propionate 100 mcg by inhalation twice daily
D. Tofacitinib 5 mg by mouth twice daily
E. Unsure
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?
A. Ramucirumab and paclitaxel
B. Carboplatin and paclitaxel
C. Fluorouracil and irinotecan (FOLFIRI)
D. Pembrolizumab
E. Unsure
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?
A. ToGA
B. KEYNOTE
C. TAGS
D. RAINBOW
E. Unsure
6. Which of the following medications is recommended to be given as a single dose prior to administration of trifluridine/tipiracil?
A. Diphenhydramine 25 mg by mouth
B. Famotidine 40 mg by mouth
C. Ondansetron 8 mg by mouth
D. Prednisone 20 mg by mouth
E. Unsure
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?
A. Provide KP with a calendar to help him record his doses
B. Recommend a pill box for KP to fill with all of his medications
C. Recommend KP wait until Monday to start day 1 of cycle 2
D. A and C
E. Unsure
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
A. Human epidermal growth factor receptor (HER) 2, epidermal growth factor receptor (EGFR), KRAS gene mutation, and microsatellite instability (MSI)
B. MSI, HER2, and programmed death-ligand 1 (PD-L1)/combined positive score (CPS)
C. MSI, KRAS, PD-L1/CPS
D. HER2, MSI, PD-L1/CPS, and KRAS
E. Unsure
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?
A. Congestive heart failure (CHF), neutropenia, and GI bleed
B. Neutropenia, GI bleed, and immune-related adverse events
C. GI bleed, immune-related adverse events, and GI obstruction and perforation
D. GI bleed, GI obstruction and perforation, and neutropenia
E. Unsure
10. What can be done to lower JR's risk of having a major upper GI bleed while on ramucirumab plus paclitaxel?
A. Increase pantoprazole dose to 80 mg by mouth twice daily; discontinue ibuprofen
B. Discontinue aspirin and ibuprofen
C. Increase lisinopril dose to 40 mg by mouth daily; discontinue ibuprofen
D. Increase pantoprazole dose to 40 mg by mouth twice daily; increase lisinopril dose to 40 mg by mouth daily
E. Unsure
Evaluation Questions
11. How confident are you in your decision about treatment for RW 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 treatment for BP 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 JR in the questions above?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident