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Case Study 2

For each question, choose the answer you think is correct. See the end of this page for the answers.

K.L. is a 50-year-old female with metastatic pancreatic carcinoma, with ECOG = 2. The patient has been receiving gemcitabine with palliative intent, GIPGEM protocol. The patient returns to the clinic to see her oncologist today (October 21). Patient’s weight on September 3 was 50 kg.

Today’s weight: 46.5 kg Height: 139 cm

Gemcitabine treatment history: Gemcitabine 1400 mg on September 3, 10, 17, 24, October 1, 8 and 15.

Lab results – October 21

  • WBC 4.7
  • ANC 2.7
  • Hgb 108
  • Platelets 257
  • Creatinine 64
1. What is the patient’s BSA today, using the Mosteller equation?
  1. 1.43 m2
  2. 1.34 m2
  3. 1.38 m2
  4. 1.41 m2
2. The doctor has ordered that she receive 1400 mg IV gemcitabine today. Is this dose and interval acceptable?
  1. No, the dose is correct but the interval is incorrect. She should be scheduled to receive chemo on October 22
  2. No, the dose should be 1340 mg and the interval is incorrect. She should be scheduled to receive chemo on October 22
  3. No, the dose should be 1340 mg but the interval is correct
  4. No, the dose is correct but the interval is incorrect. She should be scheduled to receive chemo on October 29
3. K.L.’s ANC = 0.9 and platelets = 180 on the day she is due to start cycle 3, week 1. How would this affect the dose?
  1. There would be no change 
  2. Her dose should be delayed to allow her counts to recover 
  3. Her dose should be reduced to 1050 mg 
  4. It is a clinical decision. The oncologist might choose to reduce her dose to 1050 mg or delay treatment 
4. What is the benefit status of gemcitabine for K.L., considering her diagnosis? What if K.L. had advanced germ cell cancer?
  1. Gemcitabine is a Class I drug for pancreatic cancer but funding is restricted for use in germ cell cancer and requires case-by-case Compassionate Access Program (CAP) approval for this use.
  2. Gemcitabine is a Class I drug for germ cell cancer cancer but requires case-by-case Compassionate Access Program (CAP – formerly known as "Undesignated Indication") approval for use in pancreatic cancer.
  3. Gemcitabine is a Class I drug for both pancreatic cancer and germ cell cancer.
  4. Gemcitabine is a restricted drug for pancreatic cancer and germ cell cancer if the patient does not have metastatic disease.
5. Based on the protocol, how long should K.L. continue treatment?
  1. Continue treatment as long as there is evidence of a clinical response, usually a partial response or stable disease associated with symptom improvement (decreased pain, weight gain, improved performance status), or until there is unacceptable toxicity 
  2. Continue treatment for 6 cycles; if there is no improvement after 6 cycles, consider an alternative protocol 
  3. Continue treatment for 8 cycles; if there is no improvement after 8 cycles, consider an alternative protocol 
  4. Discontinue gemcitabine, as disease progression is a sign that tumour is unresponsive to therapy 

The correct answer is 2. 

 

Rationale: Mosteller equation 

(BSA in metres squared) = square root of ((height x weight) divided by 3600) = square root of ((139cm x 46.5kg) divided by 3600) = 1.34 metres squared 

 

 

 

The correct answer is 4. 


Rationale:

Based on GIPGEM protocol, the dose for gemcitabine in Cycle 2 and subsequent cycles is 1000 mg/m2/week x 3 weeks, followed by 1 week rest.


Calculation of acceptable dose:

Our dose based on our calculated BSA (from question 1): 1000 mg/m2 x 1.34 m2 = 1340 mg gemcitabine. The dose ordered by the physician is 1400 mg, which is correct because initial BSA of 1.39 should continue to be used for subsequent cycles, as per BC Cancer Policy III-10.


Calculation of acceptable interval:

Patient has already received, as Cycle 1, 7 weeks of gemcitabine (September 3 – October 15). According to the protocol treatment plan, she is scheduled for a one week rest period before resuming treatment. Therefore, the patient should not be receiving any treatment on October 21 or 22. Next scheduled treatment date should be October 29.

 

The correct answer is 4. 

 

Rationale: Based on GIPGEM protocol, "Dose modifications, Hematology," if the ANC is between 0.5-1.0 or the platelets are between 50-100, the dose is reduced to 75% or delayed based on clinical assessment. In this scenario, the platelets are normal, however the ANC is between 0.5-1.0 so this warrants either a decrease in dose or a delay.


Original dose = 1400 mg

75% of 1400 mg = 1050 mg

 

The correct answer is 1. 


Rationale: According to the BC Cancer Benefit Drug list, gemcitabine is a Class I drug in several types of cancer. However, case-by-case approval is required for its use in germ cell cancer. Therefore, Compassionate Access Program (CAP) approval must be obtained prior to use of gemcitabine for germ cell cancer.

 

The correct answer is 1. 


Rationale: Based on GIPGEM protocol, "Treatment" plan, treatment is continued as long as there is evidence of a clinical response, usually a partial response or stable disease associated with symptom improvement, or until there is unacceptable toxicity.

 

SOURCE: Case Study 2 ( )
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