May 15, 2023
ASCO seeks to advance the education of all oncology professionals and ultimately facilitate and support enhanced patient care. The ASCO Oncology Self-Assessment Series on ASCO Connection consists of free case-based multiple-choice practice questions, educational links, and answer rationales from ASCO-SEP.
Learn more about ASCO’s Educational products, such as the 2022 ASCO-SEP Digital Subscription, which includes the digital book, access to education courses and virtual meeting-related content, plus over 1,000 practice questions in the Question Bank. Oncology trainees and training program directors can visit Education Essentials for Oncology Fellows (EEOF) to learn more and register for the 2022-2023 cycle.
Correct answers are listed at the bottom of the page.
Question 1: Cancer in Older Patients
An 85-year-old man with metastatic prostate cancer who is currently undergoing treatment with leuprolide presents with new sharp bone pain in his pelvis and right hip. He reports that the pain occurs mostly at night, rated 5 of 10 in intensity, with occasional episodes reaching 6 of 10 intensity. His medical history is notable for hypertension treated with hydrochlorothiazide. His prostate-specific antigen (PSA) level is increasing, and restaging scans show progression of bone metastases at the site of the pain. You confirm with radiology and orthopedic surgery that there are no lesions in this area in imminent need of surgical fixation. His Eastern Cooperative Oncology Group (ECOG) performance status is 1. You plan to initiate analgesic medication as well as adding bicalutamide to his cancer-directed therapy. Aside from elevated alkaline phosphatase (300 U/L) and PSA (85 ng/mL) levels, his complete blood counts and comprehensive metabolic panel are within normal range.
Which of the following should you recommend now?
- Oral ibuprofen
- Extended-release oral morphine
- Oral oxycodone
- Oral gabapentin
Question 2: Thoracic Cancer
A 56-year-old woman with no history of smoking presents to the thoracic oncology clinic to discuss further adjuvant therapy for her newly diagnosed lung cancer. Her annual low-dose chest CT showed a 4.5-cm mass in the right upper lobe. Further staging imaging did not show distant disease. She underwent a right upper lobectomy with lymph node dissection. Pathology findings were consistent with adenocarcinoma of lung origin, stage pT2b pN1, with negative margins. PD-L1 was not expressed on her tumor cells; however, an EGFR L858R mutation was detected. She completed four cycles of cisplatin and pemetrexed, which were well-tolerated. Her Eastern Cooperative Oncology Group (ECOG) performance status is 0.
Which of the following is the most appropriate next step?
- Gefitinib
- Osimertinib
- Erlotinib
- Afatinib
Question 1 Rationale and References
Correct answer: A. Oral ibuprofen
Rationale: Nonopiate analgesics are a reasonable first step for this patient given his intermittent pain, age, lack of prior opiate use, and the bony nature of his pain. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are generally the preferred first-line agent for bone pain. This patient does not have known gastric ulcers or other contraindications to short-term NSAID use and his recent creatinine level was within normal limits. Gabapentin and nortriptyline are typically used for neuropathic pain, which this patient does not have. Other reasonable treatment options for this patient could include bisphosphonates, radiation, steroids, and lower dose opiates with careful observation for adverse effects.
References
- Alexander K, Goldberg J, Korc-Grodzicki B. Palliative cancer and symptom management in older patients with cancer. Clin Geriatr Med. 2016;31(1):45062. DOI: https://doi.org./10.1016/j.cger.2015.08.004
- Luchting B, Azad SC. Pain therapy for the elderly patient: is opioid-free an option?. Curr Opin Anaesthesiol. 2019;32(1):86-91. DOI: https://doi.org/10.1097/ACO.0000000000000675
Question 2 Rationale and Reference
Correct answer: B. Osimertinib
Rationale: Patients who had stage IB to IIIA non-small cell lung cancer (NSCLC) with EGFR mutation and received osimertinib for 3 years on the ADAURA study had a longer disease-free survival and lower incidence of central nervous system disease than those who received placebo. No new safety concerns were noted. Overall survival data were immature. Consequently, osimertinib has received FDA approval for this indication. Gefitinib and erlotinib have been tested in this setting with improvement of disease-free survival, but they showed no overall survival benefit and they have not been approved as adjuvant therapies. Afatanib has not been tested in this setting.
Reference
- Wu YL, Tsuboi M, He J, et al. Osimertinib in resected EGFR-mutated non-small-cell lung cancer. N Engl J Med. 2020;383(18):1711-23. DOI: https://doi.org/10.1056/NEJMoa2027071