BCOP Exam A+ Pass 100% Solved
Correctly
dMMR/MSI-H CRC is responsive to what type of therapy? - Answer- Immunotherapy
check point inhibitors
Do dMMR/MSI-H CRC have a good prognosis in stage 2? What does it predict? -
Answer- Yes good prognosis, and does not respond well to 5FU adjuvant therapy
DPD deficiency effects? - Answer- Increased 5FU toxicity since it's not being
metabolized (activity score 0 or 0.5= poor metabolizer)
What is the antidote for 5FU severe toxicity? - Answer- Uridine triacetate PO q6h for 20
doses *start within 96h*
Which drug is affected by UGT1A1*28 polymorphism? - Answer- Irinotecan—significant
toxicity, reduce the dose
In CRC, how do KRAS and EGFR mutations affect treatment? - Answer- Needs to be
KRAS wild-type (no mutation) and must be combined with EGFR MAB plus only left
sided colon cancer
Is it beneficial to have a BRAF V600E mutation in CRC? - Answer- No, poor prognosis.
Must combined with anti-EGFR therapy (cannot use solo anti-EGFR or solo BRAF
inhibitor)
When do you test for HER2 in CRC? - Answer- Only if RAS/BRAF wild-type. If there is a
RAS/BRAF mutation= no need to test for HER2
What age group do you screen for CRC? - Answer- Age 45 to 75 (colonoscopy every 10
years preferred), do not screen age >85
How often do you do a fecal occult or FIT test? (Average risk) - Answer- Every 1 year
How often do you do a FIT-DNA test such as cologuard? (Average risk) - Answer- Every
1 to 3 years
How often for CT-colonography? (Average risk) - Answer- Every 5 years
How often for flexible sigmoidoscopy? (Average risk) - Answer- Every 5 to 10 years
Patients who have IBS should get a colonoscopy how often? - Answer- Beginning 8
years after onset and then every 1-3 years thereafter based on findings
,>= 1 1st degree relative with CRC or confirmed adenoma— how often to test? -
Answer- CRC: colonoscopy starting at age 40 or 10 years before earliest dx
Adenoma: age 40 or at age on onset, whichever is first, then every 5-10 years
2nd or 3rd degree relative with CRC, how often to test? - Answer- Colonoscopy at age
45, then every 10 years
How often to test someone with Lynch syndrome? - Answer- Age 20-25 or 2-5 years
before earliest colon cancer diagnosis if <25, then every 1 to 2 years
What are the preferred treatment options and duration for high risk stage III CRC? -
Answer- FOLFOX for 6 months, or CAPEOX for 3-6 months
How many lymph nodes are necessary for adequate sampling to determine node
positive or node negative disease? (CRC) - Answer- Minimum of 12 lymph nodes
Where is radiation more useful—colon or rectal cancer? - Answer- XRT is more useful
in rectal cancer and has minimal role in colon cancer (can use for palliative or if
unresectable/bleeding tumor)
What side effects are commonly associated with 5FU infusions? - Answer- Hand-foot
syndrome and GI toxicity
What side effects are most commonly associated with bolus 5FU/leuco - Answer-
Hematologic toxicity
CAPEOX frequency? - Answer- Every 21 days (130 mg/m2 oxali, 1000mg/m2/dose BID
cape)
Does neoadjuvant therapy play a role in Colon cancer? - Answer- Not so much but can
be considered for T4b or bulky nodal disease (and if dMMR/MSI-H give neoadjuvant
immunotherapy)
What is the role of neoadjuvant tx in rectal cancer? - Answer- Used in combo with XRT
to increase radiosensitization, 5FU based chemo is recommended
Stage I and II colon cancer treatment? - Answer- Surgery (adjuvant chemo not really
beneficial)—for stage II see if high risk or not can consider cape or 5FU/leuco 6months
Stage III colon cancer adjuvant therapy? - Answer- Yes— starting 4-8 weeks after
surgery up to 6 months
True or False: Capecitabine is clinically equivalent to bolus 5FU/leucovorin in terms of
DFS? - Answer- TRUE
,Which drug do we add to 5FU backbone to increase benefit for stage 3 colon cancer
patients based on MOSAIC trial? - Answer- Oxaliplatin, CAPEOX is considered
acceptable alternative to FOLFOX
Stage II MSI-H/dMMR colon cancer? - Answer- Observation
Which checkpoint inhibitors are recommended by NCCN for neoadjuvant use in
dMMR/MSI-H disease? - Answer- Nivolumab, Pembro or dostarlimab
What is TNT (total neoadjuvant therapy?) - Answer- In the TNT approach in rectal
cancer, pts receive both neoadjuvant chemo and chemo radiation or radiation prior to
surgery, with no adjuvant therapy
Which one has more neutropenia and FN— CAPEOX or FOLFOX? - Answer- FOLFOX
What is recommended for patients with metastatic colon cancer and excellent
performance status? - Answer- FOLFIRINOX
What is 1st line for metastatic colon cancer? - Answer- FOLFOX or FOLFIRI (either can
be 1st, followed by the other regimen in the 2nd line)— can add bevacizumab
Which regimen has more neurotoxicity, grade 3/4 neutropenia and thrombocytopenia?
FOLFOX or FOLFIRI - Answer- FOLFOX
What are the side effects associated with bevacizumab? - Answer- Bleeding,
hypertension, thromboembolic events
When can we add cetuximab or panitumumab to FOLFOX or FOLFIRI in met CRC? -
Answer- KRAS wild-type and left sided tumors
What are the common side effects of cetuximab? - Answer- Cetuximab: infusion
reactions, rash, diarrhea and low Mg
What are the common side effects of panitumumab? - Answer- Paronychia (nail
infection) and mucositis, rash, diarrhea and low Mg
Can you still use bevacizumab in 2nd line metastatic CRC treatment if it was used in the
1st line? - Answer- Yes, continuation of Bev in the 2nd line chemo significantly improved
PFS and OS over chemo alone in pts who had bevacizumab previously (Can also use
irinotecan with ziv-aflibercept or ramu)
Metastatic CRC with BRAF V600E mutation treatment options? - Answer- Encorafenib +
cetuximab or panitumumab (BEACON CRC trial—had progressed on 2 previous
regimens)— can only get this if not prev received anti-EGFR + BRAF inh combo
, Other options for HER2 met CRC subsequent lines of therapy - Answer- 1)
Trastuzumab + lapatinib
2) Trastuzumab + pertuzumab
3) Trastuzumab + tucatinib
4) Fam-Trastuzumab deruxtecan (6.4 mg/kg q21d)
What is unique about fam-Trastuzumab in met CRC and HER2 mutation? - Answer- It
can be used even if patient previously received HER-2 directed therapy (the others
cannot)
Which TKI are indicated in CRC? (After treatment with many first line agents) - Answer-
1) Regorafenib (160mg PO days 1-21 of 28d cycle)
2) Fruquintinib (5mg PO days 1-21 of 28d cycle)
What is trifluridine/tipiracil? - Answer- trifluridine: a nucleoside analog similar to 5FU
tipiracil: a thymidine phosphorylase inhibitor; prevents rapid metabolism of trifluridine,
increasing the bioavailability and half-life of trifluridine
Based on the sunlight trial, what do we combine trifluridine/tipiracil with? - Answer- Add
bevacizumab
KRAS G12C regimens in metastatic CRC (heavily pre-treated) - Answer- 1) Adagrasib +
or - cetuximab
2) Sotorasib + panitumumab or cetuximab
Treatment options for rare NTRK gene fusion mutation in colorectal cancer? - Answer-
Larotrectinib, entretinib, or repotrectinib
Treatment options for RET gene-fusion positive CRC? - Answer- Selpercatinib
If a patient is having surgery, how long do you hold bevacizumab for? - Answer- 6
weeks prior and re-initiation should be delayed until 6-8 weeks after surgery
What is the most appropriate counseling info regarding irinotecan-induced diarrhea?
How do we treat it? - Answer- Acute— cholinergic reaction often accompanied with
sweating and significant stomach cramping— give atropine
CTCAE meaning - Answer- Common Terminology Criteria for Adverse Events
How do we treat uncomplicated chemo induced diarrhea (CID)? - Answer- If grade 2,
hold chemo, stop lactose/alcohol products, oral hydration + freq small meals
Initiate loperamide 4mg x1 followed by 2 mg q4h or after every loose stool (max 16 mg
unless irinotecan induced diarrhea then 24 mg)
Correctly
dMMR/MSI-H CRC is responsive to what type of therapy? - Answer- Immunotherapy
check point inhibitors
Do dMMR/MSI-H CRC have a good prognosis in stage 2? What does it predict? -
Answer- Yes good prognosis, and does not respond well to 5FU adjuvant therapy
DPD deficiency effects? - Answer- Increased 5FU toxicity since it's not being
metabolized (activity score 0 or 0.5= poor metabolizer)
What is the antidote for 5FU severe toxicity? - Answer- Uridine triacetate PO q6h for 20
doses *start within 96h*
Which drug is affected by UGT1A1*28 polymorphism? - Answer- Irinotecan—significant
toxicity, reduce the dose
In CRC, how do KRAS and EGFR mutations affect treatment? - Answer- Needs to be
KRAS wild-type (no mutation) and must be combined with EGFR MAB plus only left
sided colon cancer
Is it beneficial to have a BRAF V600E mutation in CRC? - Answer- No, poor prognosis.
Must combined with anti-EGFR therapy (cannot use solo anti-EGFR or solo BRAF
inhibitor)
When do you test for HER2 in CRC? - Answer- Only if RAS/BRAF wild-type. If there is a
RAS/BRAF mutation= no need to test for HER2
What age group do you screen for CRC? - Answer- Age 45 to 75 (colonoscopy every 10
years preferred), do not screen age >85
How often do you do a fecal occult or FIT test? (Average risk) - Answer- Every 1 year
How often do you do a FIT-DNA test such as cologuard? (Average risk) - Answer- Every
1 to 3 years
How often for CT-colonography? (Average risk) - Answer- Every 5 years
How often for flexible sigmoidoscopy? (Average risk) - Answer- Every 5 to 10 years
Patients who have IBS should get a colonoscopy how often? - Answer- Beginning 8
years after onset and then every 1-3 years thereafter based on findings
,>= 1 1st degree relative with CRC or confirmed adenoma— how often to test? -
Answer- CRC: colonoscopy starting at age 40 or 10 years before earliest dx
Adenoma: age 40 or at age on onset, whichever is first, then every 5-10 years
2nd or 3rd degree relative with CRC, how often to test? - Answer- Colonoscopy at age
45, then every 10 years
How often to test someone with Lynch syndrome? - Answer- Age 20-25 or 2-5 years
before earliest colon cancer diagnosis if <25, then every 1 to 2 years
What are the preferred treatment options and duration for high risk stage III CRC? -
Answer- FOLFOX for 6 months, or CAPEOX for 3-6 months
How many lymph nodes are necessary for adequate sampling to determine node
positive or node negative disease? (CRC) - Answer- Minimum of 12 lymph nodes
Where is radiation more useful—colon or rectal cancer? - Answer- XRT is more useful
in rectal cancer and has minimal role in colon cancer (can use for palliative or if
unresectable/bleeding tumor)
What side effects are commonly associated with 5FU infusions? - Answer- Hand-foot
syndrome and GI toxicity
What side effects are most commonly associated with bolus 5FU/leuco - Answer-
Hematologic toxicity
CAPEOX frequency? - Answer- Every 21 days (130 mg/m2 oxali, 1000mg/m2/dose BID
cape)
Does neoadjuvant therapy play a role in Colon cancer? - Answer- Not so much but can
be considered for T4b or bulky nodal disease (and if dMMR/MSI-H give neoadjuvant
immunotherapy)
What is the role of neoadjuvant tx in rectal cancer? - Answer- Used in combo with XRT
to increase radiosensitization, 5FU based chemo is recommended
Stage I and II colon cancer treatment? - Answer- Surgery (adjuvant chemo not really
beneficial)—for stage II see if high risk or not can consider cape or 5FU/leuco 6months
Stage III colon cancer adjuvant therapy? - Answer- Yes— starting 4-8 weeks after
surgery up to 6 months
True or False: Capecitabine is clinically equivalent to bolus 5FU/leucovorin in terms of
DFS? - Answer- TRUE
,Which drug do we add to 5FU backbone to increase benefit for stage 3 colon cancer
patients based on MOSAIC trial? - Answer- Oxaliplatin, CAPEOX is considered
acceptable alternative to FOLFOX
Stage II MSI-H/dMMR colon cancer? - Answer- Observation
Which checkpoint inhibitors are recommended by NCCN for neoadjuvant use in
dMMR/MSI-H disease? - Answer- Nivolumab, Pembro or dostarlimab
What is TNT (total neoadjuvant therapy?) - Answer- In the TNT approach in rectal
cancer, pts receive both neoadjuvant chemo and chemo radiation or radiation prior to
surgery, with no adjuvant therapy
Which one has more neutropenia and FN— CAPEOX or FOLFOX? - Answer- FOLFOX
What is recommended for patients with metastatic colon cancer and excellent
performance status? - Answer- FOLFIRINOX
What is 1st line for metastatic colon cancer? - Answer- FOLFOX or FOLFIRI (either can
be 1st, followed by the other regimen in the 2nd line)— can add bevacizumab
Which regimen has more neurotoxicity, grade 3/4 neutropenia and thrombocytopenia?
FOLFOX or FOLFIRI - Answer- FOLFOX
What are the side effects associated with bevacizumab? - Answer- Bleeding,
hypertension, thromboembolic events
When can we add cetuximab or panitumumab to FOLFOX or FOLFIRI in met CRC? -
Answer- KRAS wild-type and left sided tumors
What are the common side effects of cetuximab? - Answer- Cetuximab: infusion
reactions, rash, diarrhea and low Mg
What are the common side effects of panitumumab? - Answer- Paronychia (nail
infection) and mucositis, rash, diarrhea and low Mg
Can you still use bevacizumab in 2nd line metastatic CRC treatment if it was used in the
1st line? - Answer- Yes, continuation of Bev in the 2nd line chemo significantly improved
PFS and OS over chemo alone in pts who had bevacizumab previously (Can also use
irinotecan with ziv-aflibercept or ramu)
Metastatic CRC with BRAF V600E mutation treatment options? - Answer- Encorafenib +
cetuximab or panitumumab (BEACON CRC trial—had progressed on 2 previous
regimens)— can only get this if not prev received anti-EGFR + BRAF inh combo
, Other options for HER2 met CRC subsequent lines of therapy - Answer- 1)
Trastuzumab + lapatinib
2) Trastuzumab + pertuzumab
3) Trastuzumab + tucatinib
4) Fam-Trastuzumab deruxtecan (6.4 mg/kg q21d)
What is unique about fam-Trastuzumab in met CRC and HER2 mutation? - Answer- It
can be used even if patient previously received HER-2 directed therapy (the others
cannot)
Which TKI are indicated in CRC? (After treatment with many first line agents) - Answer-
1) Regorafenib (160mg PO days 1-21 of 28d cycle)
2) Fruquintinib (5mg PO days 1-21 of 28d cycle)
What is trifluridine/tipiracil? - Answer- trifluridine: a nucleoside analog similar to 5FU
tipiracil: a thymidine phosphorylase inhibitor; prevents rapid metabolism of trifluridine,
increasing the bioavailability and half-life of trifluridine
Based on the sunlight trial, what do we combine trifluridine/tipiracil with? - Answer- Add
bevacizumab
KRAS G12C regimens in metastatic CRC (heavily pre-treated) - Answer- 1) Adagrasib +
or - cetuximab
2) Sotorasib + panitumumab or cetuximab
Treatment options for rare NTRK gene fusion mutation in colorectal cancer? - Answer-
Larotrectinib, entretinib, or repotrectinib
Treatment options for RET gene-fusion positive CRC? - Answer- Selpercatinib
If a patient is having surgery, how long do you hold bevacizumab for? - Answer- 6
weeks prior and re-initiation should be delayed until 6-8 weeks after surgery
What is the most appropriate counseling info regarding irinotecan-induced diarrhea?
How do we treat it? - Answer- Acute— cholinergic reaction often accompanied with
sweating and significant stomach cramping— give atropine
CTCAE meaning - Answer- Common Terminology Criteria for Adverse Events
How do we treat uncomplicated chemo induced diarrhea (CID)? - Answer- If grade 2,
hold chemo, stop lactose/alcohol products, oral hydration + freq small meals
Initiate loperamide 4mg x1 followed by 2 mg q4h or after every loose stool (max 16 mg
unless irinotecan induced diarrhea then 24 mg)
