Devita, Hellman, and Rosenberg's Cancer

LWBK1006-45 LWW-Govindan-Review December 13, 2011 15:32

564 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

Question 45.15. John is an 80-year-old man with ECOG PS 2 and metastatic hormone

refractory prostate cancer to the bones. He is treated with Taxotere,

bisphosphonates, and ibuprofen. His pain is initially controlled well on

60 mg twice per day of long-acting morphine with short-acting morphine

15 mg every 6 to 8 hours as needed. If his pain is increased, all of these

approaches may be reasonable, EXCEPT:

A. Increase morphine by 50% to 100%

B. Add corticosteroids

C. Treatment with strontium-89 or samarium-153

D. Change to methadone 60 mg by mouth twice per day

Question 45.16. In this patient, anticipated adverse effects of morphine include all of the

following, EXCEPT:

A. Sedation

B. Respiratory depression

C. Nausea and vomiting

D. Constipation

Question 45.17. You eventually increase John’s morphine to 120 mg twice per day with

30 mg as needed, which he takes every 3 hours, and add corticosteroids.

Unfortunately, the patient’s pain is still poorly controlled, and he develops

increasing sedation and drowsiness. Further evaluation shows normal

electrolytes and no evidence of further disease progression. You refer him

to a palliative care specialist who recommends switching to methadone

at a dose ratio of 6:1. Properties of methadone that make it somewhat

difficult to use include:

A. Cost

B. QT prolongation

C. Requires up to 1 week to achieve steady state

D. B and C

Question 45.18. John achieves good pain control on methadone 40 mg/d and enjoys a

good quality of life with his family. Which of the following best explains

his response to methadone?

A. He reached a maximum tolerated dose of morphine.

B. He developed tolerance to morphine.

C. NMDA receptor plays a critical role in opioid tolerance and may

explain the dramatic reduction in dosage when his medication is

switched from morphine to methadone.

D. Both B and C.

Question 45.19. Which of the following medications are effective as adjuvants in treating

neuropathic pain?

A. Tricyclic antidepressants

B. Anticonvulsants

C. Local anesthetics

D. All of the above