1. A 64-year-old woman presents to the emergency department with sudden worsening of chronic left upper arm and shoulder pain. Upon initial evaluation, she is found to have a fracture of her left humerus that appears pathologic and is then diagnosed with metastatic clear cell carcinoma. The treatment plan is to initiate axitinib 5 mg by mouth twice daily and pembrolizumab 200 mg intravenously every 21 days. Which of the following statements best describes the rationale for this combination?
A. It increases resistance to prevent tumor growth
B. It prevents tumor growth by using both oral and intravenous forms
C. It targets different pathways of cancer growth
D. It works synergistically to prevent tumor growth
E. Unsure
2. A 49-year-old premenopausal woman is diagnosed with metastatic breast cancer, which is estrogen receptor/progesterone receptor negative and human epidermal growth factor receptor 2 (HER2) negative. She has metastases to the liver and positive programmed death-ligand 1 (PD-L1) status. The plan is to initiate atezolizumab 840 mg intravenously on day 1 and nab-paclitaxel 100 mg/m2/dose on days 1 and 15 every 28 days. Which of the following toxicities is most likely related to the nab-paclitaxel?
A. Acneiform rash
B. Colitis
C. Hypertension
D. Neutropenia
E. Unsure
3. A 56-year-old male with metastatic renal cell carcinoma was initially treated with pazopanib but experienced disease progression. He is now receiving lenvatinib 18 mg by mouth daily and everolimus 5 mg by mouth daily. Which of the following is an on-target adverse effect of lenvatinib?
A. Hand-foot syndrome
B. Hypocalcemia
C. Hypertension
D. Neutropenia
E. Unsure
4. A 68-year-old woman is diagnosed with extensive-stage small-cell lung cancer. She is due to receive carboplatin (area under the curve [AUC] 5-6), etoposide (80 mg/m2/dose days 1, 2, 3), and durvalumab (1500 mg day 1 every 4 cycles then maintenance). Which of the following toxicities is most likely due to durvalumab?
A. Gastrointestinal perforation
B. Hepatitis
C. Hypertension
D. Neutropenia
E. Unsure
5. A 78-year-old woman with advanced endometrial carcinoma is about to start lenvatinib 20 mg daily plus pembrolizumab 200 mg every 3 weeks. Which of the following statements is true about the adverse effects of this combination?
A. High-dose steroid therapy for treatment of immune-mediated adverse effects is not needed
B. Fatigue is common and likely due to lenvatinib alone
C. Immune-related adverse effects occur in only 10% of patients
D. The most common side effect is hypertension
E. Unsure
6. A 48-year-old male was diagnosed with stage IV colon cancer with metastatic disease in the liver. Biopsy genotyping confirmed microsatellite instability-high status. He has previously been treated with FOLFOX (fluorouracil, leucovorin, oxaliplatin) and FOLFIRI (leucovorin, fluorouracil, irinotecan) and began nivolumab plus ipilimumab about 4 weeks ago. Today, he presents with rash that covers less than 10% of his body surface area. What is the most appropriate treatment?
A. Apply a moderate-potency topical steroid
B. Hold immunotherapy
C. Initiate prednisone 0.5 mg/kg/day orally
D. Obtain a dermatology consult
E. Unsure
7. A 63-year-old male was diagnosed with metastatic colon cancer (KRAS wild-type positive) and is treated with FOLFOX (fluorouracil, leucovorin, oxaliplatin) and cetuximab. Which of the following is an appropriate preventive measure for a common adverse effect of cetuximab (an epidermal growth factor receptor [EGFR] inhibitor)?
A. Antimotility agent
B. Oral minocycline
C. Topical antibiotic
D. 2.5% hydrocortisone cream
E. Unsure
8. A 64-year-old woman with metastatic clear cell carcinoma is treated with axitinib 5 mg by mouth twice daily and pembrolizumab 200 mg intravenously every 21 days. Which of the following statements best describes the appropriate monitoring plan for this regimen? (National Comprehensive Cancer Network (NCCN); American Society of Clinical Oncology (ASCO); adverse effects (AE))
A. Immune-mediated AE monitoring every 4-6 weeks per NCCN/ASCO Clinical Practice Guidelines in Oncology Management of Immunotherapy-Related Toxicities and toxicity monitoring per recommendations in axitinib's package insert and/or drug database
B. Immune-mediated AE monitoring every 4-6 weeks per NCCN/ASCO Clinical Practice Guidelines in Oncology Management of Immunotherapy-Related Toxicities and NCCN/ASCO Clinical Practice Guidelines in Oncology Management of Targeted Therapy-Related Toxicities
C. Toxicity monitoring according to recommendations in axitinib's and pembrolizumab's package inserts and/or drug database
D. Toxicity monitoring recommended by the clinical trial in which this combination was approved for metastatic renal cell carcinoma
E. Unsure
9. A 59-year-old male has been treated with atezolizumab and bevacizumab for advanced non-small-cell lung cancer and has developed grade 2 colitis and hypertension. Which of the following statements about treatment of the colitis and hypertension is correct?
A. Atezolizumab should be discontinued and infliximab should be initiated for colitis; bevacizumab therapy should be held until the blood pressure goal of < 140/90 mmHg has been met for 2 weeks
B. Atezolizumab should be held and prednisone 1 mg/kg/day should be initiated for colitis; standard antihypertensive therapy should be added (e.g., enalapril) with a blood pressure goal of < 140/90 mmHg
C. Atezolizumab should be held and methylprednisolone 2 mg/kg/day should be initiated for colitis; standard antihypertensive therapy should be added (e.g., enalapril) with a blood pressure goal of < 130/80 mmHg
D. Consider holding atezolizumab and administer loperamide for colitis; initiate lifestyle changes with a blood pressure goal of < 140/90 mmHg; if not met within 2 weeks, initiate antihypertensive therapy
E. Unsure
10. A 68-year-old woman with advanced endometrial carcinoma is receiving lenvatinib 20 mg daily plus pembrolizumab 200 mg every 3 weeks. She now has developed grade 2 subclinical hypothyroidism after 3 months of therapy. Which of the following statements about the treatment of hypothyroidism is correct?
A. Continue both therapies and initiate levothyroxine therapy
B. Initiate levothyroxine replacement therapy and hold lenvatinib
C. Initiate levothyroxine replacement therapy and hold pembrolizumab
D. Hold both lenvatinib and pembrolizumab, monitor thyroid hormone levels until return to normal, then reinitiate both therapies at 50% dose reductions
E. Unsure
Evaluation Questions
11. How confident are in your treatment choice for your 48-year-old male with stage IV colon cancer?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
12. How confident are in your preventative therapy choice for adverse effects of cetuximab?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
13. How confident are in your treatment choice for the 68-year-old woman with advance endometrial cancer?
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
