G.F. is a 54-year-old female diagnosed with advanced stage diffuse large B cell lymphoma and scheduled to begin treatment on the LYCHOPR treatment protocol. Her oncologist has indicated that her treatment plan is for 6 cycles of LYCHOPR. Prior history indicates that G.F. received adjuvant treatment for breast cancer 10 years earlier, using the BRAJAC treatment protocol — full dose chemotherapy was given 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

Cycle 1 is 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. Which of the following best describes what the term "ANC" refers to?

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 cancer drug treatment
   
4. All of the above 

2. Upon review and assessment of the LYCHOPR protocol summary and G.F.’s prior cancer drug  treatment, which one of the following statements best describes how you would address her proposed treatment plan?

1. G.F.’s previous cancer drug treatment was 10 years earlier and therefore sufficient time has elapsed to disregard any previously administered chemotherapy 
2. G.F. reached the recommended maximum lifetime cumulative dose monitoring threshold 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 cumulative 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 monitoring threshold prior to completion of her planned 6 cycles of LYCHOPR treatment. Confirm with the physician that a cardiac assessment will be performed prior to G.F. reaching the cumulative dose monitoring  threshold.
   

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?

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 1.5 and platelets are greater than or equal to 150 
2. Proceed with treatment; however, cancer drug 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 treatment as ordered 

4. After 8 cycles of LYCHOPR, 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