Facts read from oncc.org · last checked Nov 7, 2026
This is the second half of area II, which carries 45% together with cancer treatment: treatment-related symptoms and their timing, drug and non-drug symptom care, palliative care, controlled-substance safety, and how cancer, treatment and other illnesses interact.
Practice questions
60 questions written to the AOCNP outline; each choice is explained once you pick.
Complementary, alternative and integrative therapies.
Treatment-related symptoms: causes, incidence and timing, acute, late and long-term.
Palliative care.
Symptom management: pharmacologic and nonpharmacologic.
Disease, treatment and comorbidity: how each changes the others.
Controlled substance safety.
2
Grading comes before the decision
Most toxicity decisions start with a grade on NCI's Common Terminology Criteria for Adverse Events (CTCAE). For immune-related adverse events, ASCO's 2021 guideline gives the usual pattern: grade 1, continue with close monitoring; grade 2, hold the checkpoint inhibitor and consider corticosteroids; grade 3, hold it and start high-dose corticosteroids; grade 4, stop it for good, with exceptions for endocrine events controlled by hormone replacement.
Endocrine events are the exception to watch. Thyroiditis, hypophysitis and type 1 diabetes are managed by replacing the missing hormone, and the inhibitor can often continue. With hypophysitis, cortisol replacement starts before thyroid hormone, because levothyroxine first can tip a patient into adrenal crisis.
3
Palliative care runs alongside treatment
ASCO's 2017 guideline on integrating palliative care recommends dedicated palliative care services early in advanced cancer, alongside active treatment, with referral within 8 weeks of diagnosis. Palliative care has no prognosis threshold and does not mean stopping chemotherapy or immunotherapy; hospice is the separate end-of-life benefit (cancer continuum).
4
15 supportive-care decisions
0 / 15 answered15 questions
Tap an option: why each one is right or wrong appears under it.
Symptom Management and Supportive Care
Ten days after pegaspargase, a 24-year-old with ALL has severe epigastric pain radiating to the back, a lipase of 6 times the upper limit of normal, and necrotizing pancreatitis on CT. The APRN:
Necrotizing pancreatitis after pegaspargase is a labeled reason to stop all asparaginase products for good, because re-exposure carries a high risk of recurrent, potentially fatal pancreatitis.
A lower dose does not make re-exposure safe; severe pancreatitis rules out any rechallenge.
Octreotide does not prevent asparaginase pancreatitis, and continuing the drug through necrotizing disease risks death.
Switching to Erwinia asparaginase is the strategy for hypersensitivity or silent inactivation; it does not avoid asparaginase-induced pancreatitis.
A patient with breast cancer has a painful lytic metastasis destroying 70% of the cortical width of the proximal femur and has pain on weight-bearing. The APRN's FIRST recommendation is:
Protected weight-bearing delays but does not prevent fracture of a femur with this much cortical loss.
A bone-modifying agent belongs in long-term care of bone metastases, but it works over months and does not come first when the femur is about to fracture.
Lytic destruction of more than half the cortex in a weight-bearing bone with pain on loading carries a high fracture risk, so the femur is fixed prophylactically first and irradiated afterward.
Radiation relieves pain but does not restore strength and can weaken bone in the short term, so it follows fixation rather than coming first.
During peripheral administration of vincristine, the APRN finds swelling and pain at the site. After stopping the infusion and aspirating, the APRN orders:
Topical DMSO with cold is an anthracycline extravasation measure; cold keeps vinca alkaloids in place and worsens the injury.
Vinca alkaloid extravasation is treated with hyaluronidase injected around the site and warm compresses, which disperse the drug and speed absorption.
Sodium thiosulfate is the antidote for mechlorethamine extravasation.
Dexrazoxane is the antidote for anthracycline extravasation, not vinca alkaloids.
A patient with oropharyngeal cancer is starting concurrent cisplatin and radiation. Per MASCC/ISOO, which intervention is recommended to prevent oral mucositis?
Oral cryotherapy works for short-half-life bolus drugs such as 5-FU or high-dose melphalan, not radiation given over weeks.
MASCC/ISOO recommends intraoral photobiomodulation to prevent mucositis in head and neck chemoradiation, alongside basic oral care.
Chlorhexidine is recommended against for preventing radiation mucositis in head and neck cancer.
MASCC/ISOO recommends against sucralfate rinse for preventing radiation mucositis.
A patient receiving doxorubicin plus cyclophosphamide gets an NK1 antagonist, a 5-HT3 antagonist, and dexamethasone. Per MASCC/ESMO 2023, dexamethasone is given:
Days 1 to 4 is the dexamethasone schedule for cisplatin-based regimens, not for AC.
Omitting the day-1 dose removes dexamethasone from the acute phase, where it matters most.
Dexamethasone stays a core part of the regimen with an NK1 antagonist; only its dose is reduced because of the CYP3A4 interaction with aprepitant.
For anthracycline-cyclophosphamide regimens, dexamethasone is given on day 1 only when an NK1 antagonist is used, since extra days add little control and add steroid toxicity.
A patient with grade 3 checkpoint-inhibitor colitis has not improved after 72 hours of IV methylprednisolone 2 mg/kg/day; infection has been excluded. The APRN adds:
Mycophenolate is the escalation for immune-related hepatitis, where infliximab is avoided.
Checkpoint inhibitors are not dose-reduced for toxicity, and grade 3 colitis needs the drug held.
Colitis that does not respond to IV steroids within 48–72 hours is steroid-refractory, and ASCO recommends adding infliximab or vedolizumab.
Raising the steroid dose adds toxicity without evidence of benefit.
A 58-year-old with breast cancer will start dose-dense doxorubicin and cyclophosphamide every 2 weeks. The APRN's plan for neutropenia is:
Secondary prophylaxis waits for a complication that the dose-dense schedule makes predictable.
Treating afebrile neutropenia with G-CSF is not recommended and does not keep the 2-week schedule.
Dose-dense AC every 2 weeks depends on growth factor support to keep the schedule, so pegfilgrastim prophylaxis starts with cycle 1.
Fluoroquinolone prophylaxis is for expected prolonged profound neutropenia (ANC below 100 for more than 7 days), not dose-dense AC, where G-CSF keeps the schedule.
A patient with metastatic pancreatic cancer and an expected survival of weeks to a few months has anorexia and weight loss and wants something to improve appetite. Per ASCO cachexia guidance, the APRN may offer:
With an expected survival of weeks to a few months, ASCO allows a short corticosteroid trial to improve appetite, limited to weeks because of toxicity.
Thalidomide has no reliable appetite benefit and adds neuropathy and clot risk.
Evidence is insufficient for ASCO to recommend dronabinol for cancer-related anorexia.
Mirtazapine did not improve appetite in its randomized trial in patients with cancer.
A patient on panitumumab develops a papulopustular rash covering 40% of the body surface, with pain that limits self-care. The APRN's management is to:
Acne drying agents such as benzoyl peroxide irritate EGFR-inhibitor rash, which is not true acne.
A topical antibiotic alone is not enough for grade 3 rash, and continuing the drug lets it worsen.
Rash correlates with response, and most patients resume at a reduced dose after improvement, so permanent discontinuation is premature.
A rash over 30% of the body that limits self-care is grade 3, so panitumumab is held until it improves to grade 2 or less while an oral tetracycline and a topical steroid treat the rash.
A patient on chemotherapy completes a routine ESAS: pain 2, tiredness 4, anxiety 3, depression 8 (0–10 scale). The APRN's next step is to:
An ESAS depression score of 8 is a positive screen that needs a structured assessment, such as the PHQ-9 with its self-harm item, before treatment decisions.
A benzodiazepine does not treat depression and can worsen mood and cognition.
Rescreening later ignores a severe score and delays evaluation.
Methylphenidate targets fatigue; tiredness of 4 is not the problem flagged here.
A 76-year-old receiving cisplatin takes olanzapine 10 mg each morning as part of a four-drug antiemetic regimen and reports marked daytime sedation. Nausea is controlled. The APRN:
Prochlorperazine is a rescue antiemetic and is less effective for delayed nausea after cisplatin.
Treating a dose-related side effect with a stimulant adds a drug instead of adjusting the cause.
Lorazepam adds sedation and lacks olanzapine's effect on delayed nausea.
Olanzapine 5 mg is an accepted antiemetic dose with less sedation, especially in older adults, and bedtime dosing moves residual sedation into sleep hours.
A woman taking anastrozole for early breast cancer has joint pain that is only partly relieved by NSAIDs and asks for a non-drug option. Per SIO-ASCO 2022, the APRN recommends:
Omega-3 fatty acids did not beat placebo for aromatase inhibitor arthralgia in SWOG S0927.
Reflexology has no supporting evidence for aromatase inhibitor joint pain.
Glucosamine lacks evidence for this symptom and is not a non-drug option.
SIO-ASCO 2022 recommends acupuncture for aromatase inhibitor-related joint pain, based on a sham-controlled randomized trial.
A patient has resected T3N1 (low-risk stage III) colon cancer. Per the IDEA collaboration, which adjuvant plan limits oxaliplatin neuropathy without meaningfully compromising outcomes?
For low-risk stage III colon cancer (T1–3, N1), the IDEA analysis found 3 months of CAPOX nearly as effective as 6 months, with far less lasting neuropathy.
Calcium-magnesium infusions did not prevent oxaliplatin neuropathy in a randomized trial, and 6 months keeps the full exposure.
Capecitabine alone omits oxaliplatin's benefit in stage III disease, and 12 months is not a standard duration.
Six months adds oxaliplatin exposure and neuropathy for little gain in low-risk disease.
During carboplatin-paclitaxel for ovarian cancer, a woman reports numbness and tingling in both feet. Which finding is most atypical for chemotherapy-induced neuropathy and warrants further workup?
Onset in the toes is the typical length-dependent start of taxane neuropathy.
Platinum and taxane neuropathy is predominantly sensory, symmetric, and length-dependent, so asymmetric motor weakness points to another cause, such as radiculopathy, cord compression, or an inflammatory or paraneoplastic neuropathy.
Loss of ankle reflexes is common with paclitaxel, which affects large sensory fibers.
Reduced distal vibration sense is an early, expected finding in taxane neuropathy.
A patient begins 5 weeks of radiation therapy alone to the upper abdomen, a moderate emetic-risk field. Per MASCC/ESMO, the APRN orders:
Skipping prophylaxis fits minimal-risk fields such as the breast or extremities, not a moderate-risk upper-abdominal field.
Upper-abdominal radiation carries moderate emetic risk, and MASCC/ESMO recommends a 5-HT3 antagonist before each fraction, with or without a short course of dexamethasone.
Olanzapine belongs to highly emetogenic chemotherapy regimens and is not standard prophylaxis for fractionated radiation.
NK1 antagonists have not been established for radiation-induced emesis.
A running total sits here; it fills in after your last pick.
5
Supportive-care traps, symptom by symptom
Opioid constipation. Start a bowel regimen with the opioid; tolerance develops to sedation and nausea, not to constipation. A stool softener alone is not a regimen.
Cold helps one drug and hurts another. Oral cryotherapy reduces mucositis with bolus fluorouracil and high-dose melphalan (MASCC/ISOO), but cold triggers oxaliplatin's acute throat and hand dysesthesia, so patients on oxaliplatin avoid ice and cold drinks.
Established painful neuropathy. Duloxetine is the one drug ASCO's neuropathy guideline recommends for treatment.
Anticoagulation in luminal tumors. ASCO's 2023 VTE guideline accepts DOACs for cancer-associated clots but warns of more bleeding with some of them in gastrointestinal and genitourinary cancers.
Does the CDC opioid guideline apply to cancer pain?
No. The CDC's 2022 guideline states that it does not cover cancer-related pain, palliative care or end-of-life care, so its outpatient dose thresholds are not the standard for metastatic cancer pain.
Are palliative care and hospice tested separately on the AOCNP?
They sit in different areas: palliative care in area II, end-of-life care in area I's plan of care.