1. Mr. Sandberg is a 59-year-old male recently diagnosed with metastatic non-small cell lung cancer. He is scheduled to begin treatment with the combination of carboplatin, pemetrexed, and pembrolizumab. Which of the following is true regarding treatment-related toxicities with this regimen?
A. Immune-related adverse events are rarely seen with pembrolizumab.
B. Immune-related adverse events occur within the first month of pembrolizumab therapy and are self-limiting.
C. Immune-related adverse events may occur at any time following initiation with pembrolizumab therapy.
D. Immune-related adverse events are easy to differentiate from chemotherapy-related toxicities.
E. Unsure
2. Ms. O'Malley is a 66-year-old female with bladder cancer. She was initially treated with cisplatin and gemcitabine followed by surgery. Recent scans indicate that she now has metastatic disease, and she is considering a number of treatment options. One of the treatments that was discussed at her last visit with the oncology care team was the immune checkpoint inhibitor avelumab. What is the appropriate counseling to provide Ms. O'Malley regarding the immune-related adverse events and avelumab?
A. Ms. O'Malley should report a fever greater than 100.4°F to the healthcare team as she is at risk for infections secondary to neutropenia.
B. This treatment-induced nausea and vomiting usually occurs on the day following treatment. Ms. O'Malley will be given antiemetics prior to each dose of avelumab to mitigate this toxicity.
C. . It is important that Ms. O'Malley report any new or changing symptoms to the oncology healthcare team.
D. Ms. O'Malley should be assured that evaluation prior to each infusion is sufficient to identify any irAE.
E. Unsure
3. Mr. Kane is a 62-year-old male with history of diabetes managed with metformin, hypertension managed with lisinopril/hydrochlorothiazide, and depression that is currently untreated with drug therapy. He was recently diagnosed with poor risk advanced renal cell cancer and has started therapy with a combination of ipilimumab and nivolumab about one month ago. This week following treatment, he noted abdominal pain and new onset diarrhea. Mr. Kane notified his oncology care team, and upon further assessment was determined to have irAE grade 3 colitis. The decision was made to hold ICI therapy at this time and to initiate therapy with immunosuppressive therapy. The treatment plan includes prednisone 2 mg/kg/d PO. Which of the following is an appropriate recommendation for Mr. Kane to help optimize therapy?
A. Mr. Kane should be encouraged to monitor blood glucose and blood pressure at home daily to best assess the impact of corticosteroids on his comorbidities.
B. Mr. Kane should double the dose of metformin, as corticosteroids will increase his blood glucose.
C. Recommend to the oncology healthcare provider to decrease the prednisone dose to 1 mg/kg/d PO due to the concern of corticosteroids on comorbidities.
D. Mr. Kane should be hospitalized to better evaluate the impact of prednisone on his comorbidities.
E. Unsure
4. James is a nursing student that is beginning a 3-month clinical rotation in the ambulatory oncology clinic. He will be working with the oncology healthcare team in a number of clinics and was told that he should become familiar with the toxicities of the different drug therapies used in the treatment of cancer. What is the most comprehensive reference James can use for information on the assessment and management of immune-related adverse events seen with immune checkpoint inhibitor therapy?
A. Published clinical guidelines from organizations such as ASCO and NCCN.
B. Package insert information on the individual immune checkpoint inhibitors.
C. Patient information materials for immune checkpoint inhibitors.
D. Review articles on organ specific irAEs.
E. Unsure
5. Ms. Paula is a 35-year-old woman diagnosed with metastatic triple-negative breast cancer. Her tumor expressed PDL1, and the decision was made to begin therapy with the combination of paclitaxel protein-bound and atezolizumab. Of note, Ms. Paula is premenopausal and has inquired about birth control options to prevent pregnancy during treatment. Which of the following is correct?
A. Ms. Paula should be counseled that pregnancy prevention is not needed during treatment with ICI but is recommended due to the combination with protein-bound paclitaxel.
B. Ms. Paula should be counseled to use effective preventive birth control during and following therapy with ICI, as there is a potential increased risk of spontaneous abortion with PDL1 inhibitors.
C. Pregnancy prevention during therapy is not needed, as chemotherapy-induced menopause may occur at some point during treatment.
D. Ms. Paula should be counseled to use effective preventive birth control during therapy with ICI, as there is an increased risk of fetal abnormalities with ICI therapy.
E. Unsure
6. Mr. Abboud is a 51-year-old male presenting to the emergency department with increasing diarrhea. Mr. Abboud has a history of colitis related to durvalumab therapy for maintenance following chemotherapy and radiation for adenocarcinoma of the lung. He was initially treated with high-dose steroids with a good response, but his symptoms of diarrhea and crampy abdominal pain have escalated with the recent tapering of corticosteroids. Which of the following is true?
A. Mr. Abboud is now corticosteroid resistant, and steroids should be discontinued as they are no longer preventive.
B. Infliximab, a TNFα inhibitor, may be considered for treatment of ICI-related colitis.
C. Infliximab, a monoclonal antibody that binds to the α4β7 integrin and blocks the interaction of the integrin with mucosal addressing cell adhesion molecule-1 (MAdCaM-1), may be considered for the treatment of ICI-related colitis.
D. Vedolizumab, a TNFα inhibitor, may be considered for the treatment of ICI-related colitis.
E. Unsure
7. Mr. Smith, a gentleman with metastatic non-small cell lung cancer is scheduled to begin nivolumab following disease progression after platinum-based combination chemotherapy. He is meeting with Latonya, the clinical pharmacist that works with the oncology care team, to discuss his planned treatment. Mr. Smith states that he does not understand the difference between nivolumab, an immune checkpoint inhibitor, and his previous chemotherapy. She explains to him, unlike traditional chemotherapy, immune checkpoint inhibitors (ICIs) function by:
A. amplifying the therapeutic benefit of chemotherapy and should only be used in combination with chemotherapy.
B. downregulating the immune system and helps to prevent tumor growth.
C. increasing the number and activity of his neutrophils to fight malignant cells.
D. inhibiting, or deactivating proteins that inhibit the immune system. Inhibition of these proteins ultimately allows for an increased immune response to the cancer cells.
E. Unsure
8. Ms. Stark, a 57-year-old woman with a history of melanoma, s/p treatment, who presented to the emergency room with a cough and shortness of breath during flu season. She was worked up for a respiratory infection and empirically started on broad spectrum antibiotics. While waiting for the imaging results in the ER, Ms. Stark became increasingly short of breath and hypoxic, resulting in emergency intubation and transfer to the ICU. It was determined that Ms. Stark had pneumonitis. Jessica, a nursing staff educator at the hospital has been asked to review this recent event and help to develop education for staff as a result of this sentinel event. What information should Jessica include in her education efforts for the hospital staff regarding this event?
A. This was an unfortunate event of rapid symptom progression that was not preventable due to the patient's age and diagnosis. Ms. Stark has completed her therapy so her cancer history and cancer treatment history is not a pertinent issue in the case.
B. Based on her diagnosis of melanoma, Ms. Starks should have been proactively intubated following triage to prevent symptom exacerbation.
C. Based on Ms. Stark's symptoms, diuretics should have been ordered to reduce fluid volume overload contributing to respiratory compromise.
D. Based on her cancer diagnosis, it is essential to confirm past treatment history with a high suspicion for irAE.
E. Unsure
9. Mr. Mars is an 82-year-old male with locally advanced recurrent head and neck cancer who is receiving an immune checkpoint inhibitor as part of a clinical trial. When asked, he doesn't remember the name of the medication, but knows it is already marketed for other types of cancer. Which of the following materials would be good to provide to Mr. Mars to share with other healthcare professionals involved in his overall care (eg, primary care provider)?
A. The NNCN Immunotherapy Guidelines for Patients
B. An immunotherapy pocket card that lists the name of the medication and contact number for the oncology care team
C. His discharge summary sheet from his last treatment
D. His electronic health record application to share his health records
E. Unsure
10. Jasper, a Doctor of Pharmacy candidate currently doing an Advanced Pharmacy Practice Experience, is developing a presentation for his team on a patient with myeloma who has had uveitis, an uncommon irAE. Which of the following resources provide a tumor-specific perspective related to the management of multiple myeloma?
A. The Society for Immunotherapy of Cancer (SITC) Cancer Immunotherapy Guidelines
B. The NCCN Clinical Practice Guidelines in Oncology Management of Immunotherapy-Related Toxicities
C. The Oncology Nursing Society Chemotherapy-Immunotherapy Guidelines and Recommendations for Practice
D. Management of Immune-Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guidelines
E. Unsure
Evaluation Questions
11. How confident are you in your counseling recommendation for Ms. O'Malley?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
12. How confident are in your therapy recommendations for Mr. Kane?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
13. How confident are in your treatment choice for Mr. Abboud?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
