1. Which of the following is the appropriate management of severe diarrhea (7 stools a day) for a patient with metastatic melanoma being treated with nivolumab?
A. Loperamide, following the direction on the OTC label
B. High dose loperamide 4 mg at onset, then 2 mg every 2 hours until diarrhea free
C. Prednisone 100 mg po daily until controlled, then taper dose
D. The diarrhea is self-limiting, but hydration with electoral electrolyte solution is essential
E. Unsure
2. A 52-year-old female patient with metastatic non-small cell lung cancer is being treated with pembrolizumab. At 6 weeks into therapy regimen, new lesions are seen on imaging scan. Which of the following is the best recommendation for this patient at this time?
A. Discontinue pembrolizumab and begin a platinum doublet (carboplatin/gemcitabine)
B. Continue pembrolizumab treatment
C. Continue pembrolizumab and add a platinum doublet (cisplatin/pemetrexed)
D. Discontinue pembrolizumab and begin tisagenlecleucel
E. Unsure
3. A 45-year-old male patient is to start atezolizumab for metastatic urothelial cancer and he asks you how the drug will work to fight his cancer. Which of the choices below is the best response?
A. It is a monoclonal antibody drug that stimulates the immune system
B. It is a monoclonal antibody drug that down regulates PD-1/PD-L1 expression
C. It is a monoclonal antibody drug that tags the tumor cells for destruction by the immune system
D. It is a monoclonal antibody drug that releases the brakes on the immune system
E. Unsure
4. PM is a 68 year old, white male who presents with non-small cell lung cancer. HPI: He presented in the ER 2 weeks prior to admission with complaints of cough and sputum, dyspnea, hoarseness, and progressive weight loss. Additionally, he complained of a tingling sensation with weakness in the left arm. PMH: COPD x 4 years. FH/SH: 37.5 pack-year smoking history. Drug history: Ipratropium. NKDA.
Physical Exam : Findings are generally within normal limits except for findings consistent with COPD/lung cancer.Laboratory : Findings are generally within normal limits, with the exception of a slight increase in LDH and decrease in albumin.Patient Workup
A. Cisplatin/gemcitabine/radiation
B. Carboplatin/paclitaxel/bevacizumab
C. Nivolumab
D. Cisplatin/etoposide/radiation – durvalumab
E. Atezolizumab
F. Unsure
5. Durvalumab was not approved via prior authorization. What is the next best step?
A. Substitute w/ atezolizumab (another PD-L1 inhibitor)
B. Substitute w/ ipilimumab (a CTLA-4 inhibitor)
C. Substitute w/ nivolumab (a PD-1 inhibitor w/ activity in NSCLC)
D. Fight the rejection by sending a letter of need and the PACIFIC Trial data (and/or package insert)
E. Unsure
6. A 66-year-old female with advanced melanoma is being treated with pembrolizumab. After cycle 1,she presents with a mild erythematous maculopapular rash on her arms, chest and back. The team determines this mildly symptomatic rash (Grade 1) to be immune mediated dermatitis from the pembrolizumab. How do you treat the rash?
A. Hold pembrolizumab and treat with topical steroids
B. Continue pembrolizumab and treat with topical steroids
C. Hold pembrolizumab and treat with prednisone 1 mg/kg followed by taper over 1 month
D. Continue pembrolizumab and treat with prednisone 1mg/kg followed by taper over 1 month
E. Unsure
7. The Consensus Statement on Improving the Prior Authorization Process includes all of the following recommendations except:
A. Continuity of Patient Care
B. Prior Authorization Program Review and Volume Adjustment
C. Transparency and Communication Regarding Prior Authorization
D. Placing prior authorization on all new I-O therapies
E. Automation to Improve Transparency and Efficiency
8. Which of the following is not a Real World Issue facing I-O therapy in 2018?
A. Quality measures that do not include a patient's functional status
B. Greater investment in analytics to support nimble feedback
C. Development and implementation of patient-reported outcomes
D. Patient navigation of the increasingly complex cancer care system
E. Comparative effectiveness based on real-world evidence
9. Strategies to manage immune-related toxicity and care coordination include all of the following except:
A. Triage patients on the basis of symptoms
B. Establish standard of practice guidelines for irAE management
C. Identify patients who have received or are receiving immunotherapy
D. Hospitalizing patients receiving their first does of an I-O therapy
E. Developing same-day care models.
10. When education patients (and their families) starting IO therapy, which information point is not true?
A. Tumors may get bigger before they shrink
B. Early intervention with steroids for toxicity does not preclude patients from receiving more IO therapy
C. Toxicity from IO therapy can happen months after starting treatment
D. If a patient switches from one I-O therapy to another, similar toxicities will always occur
E. Early recognition of adverse reactions is essential to effective treatment
