1. Use the following patient CASE to answer questions 1 through 3:
A. Pembrolizumab 200 mg intravenously (IV) every 3 weeks
B. Ipilimumab 3 mg/kg IV every 3 weeks x 4 doses
C. Ipilimumab 3 mg/kg IV + nivolumab 1 mg/kg IV every 3 weeks x 4 doses, followed by nivolumab 480 mg IV every 4 weeks
D. High-dose interleukin-2
E. Unsure
2. JT returns to clinic for a toxicity check prior to his 4th cycle of ipilimumab 3 mg/kg + nivolumab 1 mg/kg. According to his physical exam and subjective assessment, he has tolerated therapy well to date and has not had any delays in treatment. All his lab findings are WNL with the exception of alanine transaminase (ALT), which is 131 U/L (approximately 3x the upper limit of normal [ULN]) and aspartate transaminase (AST), which is 140 U/L (approximately 3.5x ULN).
A. Discontinue ipilimumab and proceed with nivolumab 480 mg as monotherapy
B. Proceed with cycle 4 of ipilimumab 3 mg/kg + nivolumab 1 mg/kg
C. Decrease ipilimumab to 1 mg/kg and increase nivolumab to 3 mg/kg
D. Defer cycle 4 treatment for 1 week; recheck LFTs prior to proceeding at that time
E. Unsure
3. JT returns in 1 week for his lab recheck, and his ALT is 313 U/L (7.5x ULN), AST is 164 U/L (~4x ULN), and total bilirubin is still WNL. He is started on oral prednisone 1 mg/kg/day and pantoprazole 40 mg orally daily, and he is advised to return every other day for repeat LFTs.
A. Taper prednisone over at least 4 weeks, with LFT checks and dose re-escalation if needed
B. Switch to methylprednisolone Dose-Pak to allow for rapid taper over 6 days
C. Taper prednisone over 2 weeks, with follow-up LFTs at that time
D. Recommend switch to mycophenolate for steroid-sparing therapy
E. Unsure
4. Use the following patient CASE to answer questions 4 through 8:
A. Encorafenib 450 mg daily + binimetinib 45 mg twice daily x 12 months
B. Pembrolizumab 200 mg intravenously (IV) every 3 weeks x 18 cycles
C. Ipilimumab 3 mg/kg IV every 3 weeks x 4 doses
D. Nivolumab 3 mg/kg + ipilimumab 1 mg/kg IV every 3 weeks x 4 doses
E. Unsure
5. You have been asked by the physician and nurse to review pembrolizumab patient education with AM. Which of the following tools and teaching points would you utilize and discuss with her?
A. Discussion of common side effects, such as fatigue
B. Discussion of potential immune-mediated adverse effects that could affect different areas of the body, including instructions about when to notify the provider
C. Providing a wallet card with clinic and hospital contact information and a quick reference of concerning adverse effects
D. Reminders to let her medical team know if she starts taking any new prescription or over-the-counter medications and to avoid the use of corticosteroids unless prescribed by her oncologist
E. All of the above
F. Unsure
6. AM has completed 7 cycles of her adjuvant pembrolizumab and is tolerating therapy well. Her surveillance ultrasounds and restaging scans to date have all indicated no evidence of recurrence. She has been more fatigued than normal the last few weeks but has been able to push through and maintain her usual active lifestyle. She does express feeling depressed and frustrated about this and acknowledges that it is likely related to her treatment, but she does not want to stop pembrolizumab therapy. Her thyroid panel labs reveal a thyroid-stimulating hormone (TSH) level of 26 mU/mL (above the upper limit of normal) and a free T4 level of 0.93 ng/dL (lower limit of normal).
A. Start replacement levothyroxine, proceed with pembrolizumab as planned
B. Start replacement levothyroxine, delay pembrolizumab for 3 weeks
C. Proceed with pembrolizumab, repeat thyroid function tests in 1 month
D. Initiate hydrocortisone 15 mg in the morning and 10 mg in the evening and delay pembrolizumab for 4 weeks
E. Unsure
7. AM goes on to complete 1 year of adjuvant therapy and proceeds with scheduled restaging scans. She is feeling great and remains active, but 3 months later, magnetic resonance imaging (MRI) of her brain reveals 3 new lesions (smallest, 0.5 cm; largest, 0.8 cm) and computed tomography (CT) of the chest, abdomen, and pelvis reveals new lesions in her liver, as well. She does not have any neurologic symptoms. After conducting online research, she has become worried about the long-term effects of whole brain radiation.
A. Stereotactic radiosurgery, followed by pembrolizumab 400 mg IV every 3 weeks
B. Carboplatin with an area under the curve (AUC) of 6 + paclitaxel 175 mg/m2 IV every 3 weeks
C. Ipilimumab 3 mg/kg + nivolumab 1 mg/kg IV every 3 weeks x 4 doses, followed by nivolumab 480 mg IV every 4 weeks
D. Vemurafenib 960 mg by mouth twice daily
E. Unsure
8. AM goes on to receive all 4 cycles of ipilimumab + nivolumab and is looking forward to moving on to the maintenance phase of nivolumab 480 mg IV every 4 weeks. Five days after she receives her nivolumab dose, AM begins having 5 to 6 episodes of diarrhea per day and comes in to the emergency room for management. She is started on IV fluids, a CT of the abdomen/pelvis is obtained, and a stool sample is sent off for infectious evaluation. After speaking with the on-call medical oncologist, AM is started on IV methylprednisolone 1 mg/kg/day. The dose is increased to 2 mg/kg after 2 days of no improvement in symptoms and CT results showing diffuse edema in the colon and inflammation consistent with colitis. Two days later, her diarrhea has improved to 4 episodes per day, but the volume has not changed.
A. Infliximab 5 mg/kg IV
B. Budesonide 9 mg by mouth daily
C. Vedolizumab 300 mg IV
D. Mycophenolate mofetil 500 mg by mouth twice daily
E. Unsure
9. Use the following patient case to answer questions 9 and 10: BRAF -wild-type metastatic melanoma involving the lung; he was initiated on pembrolizumab 200 mg IV every 3 weeks as first-line therapy. He now returns to the clinic for a toxicity check prior to cycle 3 of pembrolizumab. He is still walking his dog around the neighborhood every morning, and his only new complaint after starting this treatment is some mild joint pain for a few days after the infusions.
A. Liver function tests (LFTs)
B. Thyroid function tests (TFTs)
C. Cortisol and adrenocorticotropic hormone (ACTH)
D. A, B and C
E. A and B
F. Unsure
10. After receiving an additional 4 cycles of pembrolizumab, EF has started experiencing more headaches and generalized fatigue, which has begun to limit his daily activities. He notifies his oncologist, who orders several adrenal labs to evaluate for hypophysitis. The laboratory results are consistent with adrenal insufficiency, and he is started on physiologic doses of oral hydrocortisone 20 mg in the morning and 10 mg in the afternoon/early evening, as well as levothyroxine replacement for central hypothyroidism.
A. Once his cortisol and TFT values normalize, he can discontinue these supportive medications
B. He should remain on these medications indefinitely, with further dose adjustments as indicated according to symptom follow-up and laboratory assessment
C. He should taper his hydrocortisone down over a 4-week period but continue the levothyroxine
D. He should continue hydrocortisone and levothyroxine while he is on pembrolizumab, but he can discontinue these new medications once he completes therapy with pembrolizumab
E. Unsure
Evaluation Questions
11. How confident are in your treatment choices for JT in the post-test?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
12. How confident are in your treatment choices for AM in the post-test?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
13. How confident are in your treatment choices for EF in the post-test?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
