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Case Study 3

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

​G.F. is a 54-year-old female scheduled to begin treatment on the LYCHOPR treatment protocol. The oncologist has indicated that the treatment plan is for 6 to 8 cycles of LYCHOPR chemotherapy, to be reassessed after cycles 4 and 6. Prior history indicates that G.F. received adjuvant treatment for breast cancer 10 years earlier, using the BRAJAC treatment protocol — full dose chemotherapy for 4 cycles. Her height and weight as well as her laboratory test results are reported from 1 week earlier and are as follows:

Weight: 57 kg Height: 168 cm

  • WBC 9.9
  • ANC 6.3
  • Platelets 392
  • Bilirubin 5
  • LDH 206

The medications are ordered as follows:

  • Cyclophosphamide 1200 mg IV on Day 1
  • DOXOrubicin 81 mg IV push on Day 1
  • VINcristine 2.3 mg IV push on Day 1
  • PredniSONE 75 mg PO daily on Days 1-5
  • RiTUXimab 611 mg IV on Day 2
1. To what does the term "ANC" refer?
  1. ANC refers to the time after the administration of a myelosuppressive drug in which the lowest cell counts (neutrophils or platelets) are observed in the bloodstream 
  2. ANC refers to the absolute neutrophil count and measures the total number of circulating neutrophils 
  3. ANC refers to the blood cells that are least affected by myelosuppressive chemotherapy 
  4. All of the above 
2. Upon your review and assessment of the LYCHOPR protocol summary and G.F.’s prior chemotherapy treatment, which one of the following statements best describes how you would address her proposed treatment plan?
  1. G.F.’s previous chemotherapy treatment was 10 years earlier and therefore sufficient time has elapsed to disregard any previously administered chemotherapy 
  2. G.F. reached her recommended maximum lifetime dose of anthracycline therapy upon completion of her BRAJAC chemotherapy 10 years ago; therefore, her DOXOrubicin dose should be replaced by etoposide 50 mg/m2 IV on Day 1 and 100 mg/m2 PO on Days 2 and 3 
  3. The maximum lifetime dose of anthracyclines should not be a concern since G.F.’s previous chemotherapy was for a different tumour site and this is her first cycle of LYCHOPR therapy
  4. G.F. will reach the recommended lifetime maximum anthracycline dose prior to completion of her planned 6 to 8 cycles of LYCHOPR chemotherapy. Confirm with the physician that a cardiac assessment will be performed prior to G.F. reaching her maximum limit

Three weeks later, G.F. returns for her second cycle of LYCHOPR chemotherapy and the physician orders the same drugs and doses to be administered as given in the previous cycle. Her current weight is 55 kg and the laboratory test results, reported from one day earlier, are as follows:

  • WBC 1.6
  • ANC 0.6
  • Platelets 123
3. Which one of the following statements best describes how G.F. should be treated this cycle of chemotherapy?
  1. Delay treatment. G.F. should return in one week with new laboratory test results (CBC and differential) and treatment should proceed if her ANC is greater than or equal to 1.50 and platelets are greater than or equal to 150 
  2. Proceed with treatment; however, chemotherapy doses should be reduced to 75% of the full dose due to G.F.’s low blood counts. Contact the physician to have new orders written to reflect this dose reduction 
  3. Proceed with treatment at full doses as ordered and treat with filgrastim so that G.F.’s WBC count may recover to allow full dose treatment as scheduled. Ensure that the physician has written a filgrastim prescription for G.F., to be filled in a community retail pharmacy 
  4. Proceed with treatment at full doses as ordered. Since G.F.’s reported lab results are within 24 hours of her scheduled treatment and her ANC is close enough to the lower treatment limit, it is reasonable to proceed with the chemotherapy as ordered 
4. After 8 cycles, the pharmacist receives orders for a 9th cycle of treatment. How should the pharmacist proceed?
  1. Proceed with treatment as ordered, as long as the dose interval and doses ordered are acceptable 
  2. G.F. has completed the maximum 8 cycles recommended in the protocol, so the pharmacist should contact the physician and arrange for a rest period before G.F. can continue treatment 
  3. G.F. has completed the maximum 8 cycles as recommended in the protocol, so the pharmacist should contact the physician and ask that Compassionate Access Program (CAP) Approval be requested. Approval must be granted before proceeding 
  4. Patients starting on the 9th cycle of this protocol can only do so at a 50% dose reduction. The pharmacist should ensure that the orders received reflect this dose reduction, then should proceed as ordered  

The correct answer is 2.

Rationale: ANC (absolute neutrophil count) is a measurement of the total number of circulating neutrophils, as explained in the Clinical Pharmacy Guide, Laboratory Test Interpretation - Hematological and Associated Laboratory Tests.

The correct answer is 4.



Mosteller equation

(BSA in metres squared) = square root of ((height x weight) over 3600) = square root of ((168cm x 57kg) over 3600) = 1.63 metres squared


G.F’s Previous DOXOrubicin:

DOXOrubicin dose in BRAJAC protocol = 60 mg/m2/cycle x 4 cycles. 
60 mg mg/m2 x 1.63 m2 = x 4 cycles = 391 mg.
Alternate method for calculation: 60 mg/m2 x 4 = 240 mg/m2.


Maximum Lifetime Dose:

As outlined in the Clinical Pharmacy Guide, Appendix C: Guidelines for Anthracycline Monitoring Threshold, the recommended maximum lifetime dose for DOXOrubicin is 300 mg/m2. Individual protocols may exceed these guidelines, provided that cardiac function is adequate before initiating therapy and monitored during therapy. The LYCHOPR protocol recommends cardiac assessment if the lifetime dose exceeds 450 mg/m2. We will use 

450 mg/m2 as it is specific to the protocol:

450 mg/m2 x 1.63 m2 = 733 mg.


Amount of DOXOrubin G.F. can receive before exceeding the recommended maximum lifetime dose:

Recommended maximum – dose already received = allowable amount remaining 
    733 mg – 391 mg = 342 mg 
Alternate method for calculation: 450 mg/m2 – 240 mg/m2 = 210 mg/m2.


Number of Cycles of LYCHOPR before recommended maximum is reached:

DOXOrubicin dose in LYCHOPR protocol dose is 

50 mg/m2/cycle 
    50 mg/m2 x 1.63 m2 = 81 mg. 
The maximum number of cycles before the recommended maximum dose is exceeded = allowable amount remaining ÷ dose per cycle 
    342 mg ÷ 81mg = 4.2 cycles 
Alternate method for calculation: 

    210 mg/m2 ÷ 50 mg/m2 = 4.2 cycles

Further therapy with DOXOrubicin after the first 4 cycles of LYCHOPR would require that cardiac assessment be performed first, as detailed in the Precautions Section of the LYCHOPR protocol. The LYCHOPR protocol is usually continued for 6-8 cycles.


The correct answer is 3.

Rationale: Based on LYCHOPR protocol, "Dose modifications," when the ANC is less than 0.8, 100% of the dose is given with the addition of filgrastim 300 mcg daily x 5 days, starting 7 days after each IV chemotherapy.

The correct answer is 3.

Rationale: Based on LYCHOPR protocol, the maximum number of treatment cycles is 8. Any further treatments would be considered a deviation from the protocol, and would require approval from the BCCA Compassionate Access Program (CAP) prior to G.F. receiving cycle 9.

SOURCE: Case Study 3 ( )
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