Lung cancer remains a leading cause of cancer-related mortality worldwide, presenting significant challenges in both prevention and treatment. However, recent years have seen remarkable advancements in its management, largely driven by a deeper understanding of its molecular biology. The treatment landscape has shifted dramatically from a one-size-fits-all chemotherapy approach to a personalized medicine paradigm, utilizing targeted therapies and immunotherapies based on specific biomarkers. For PharmD students, a comprehensive knowledge of lung cancer pathophysiology, staging, and the complex, rapidly evolving therapeutic options for both Non-Small Cell and Small Cell Lung Cancer is crucial for providing optimal pharmaceutical care and contributing to the multidisciplinary oncology team. This MCQ quiz will test your knowledge on the key aspects of lung cancer.
1. The single most significant risk factor for the development of lung cancer is:
- A. Radon gas exposure
- B. Asbestos exposure
- C. Tobacco smoking
- D. Family history of lung cancer
Answer: C. Tobacco smoking
2. Lung cancer is broadly divided into two main histological types: Small Cell Lung Cancer (SCLC) and:
- A. Mesothelioma
- B. Carcinoid Tumor
- C. Non-Small Cell Lung Cancer (NSCLC)
- D. Adenoid Cystic Carcinoma
Answer: C. Non-Small Cell Lung Cancer (NSCLC)
3. Which histological subtype of NSCLC is the most common, particularly in non-smokers?
- A. Squamous cell carcinoma
- B. Large cell carcinoma
- C. Adenocarcinoma
- D. Small cell carcinoma
Answer: C. Adenocarcinoma
4. Small Cell Lung Cancer (SCLC) is characterized by:
- A. Slow growth and late metastasis.
- B. A weak association with smoking.
- C. Rapid growth, early metastasis, and its association with paraneoplastic syndromes.
- D. A frequent location in the periphery of the lung.
Answer: C. Rapid growth, early metastasis, and its association with paraneoplastic syndromes.
5. Which of the following is a common paraneoplastic syndrome specifically associated with SCLC?
- A. Hypercalcemia of malignancy (more common with squamous cell)
- B. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
- C. Dermatomyositis
- D. Thrombocytosis
Answer: B. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
6. The staging system for NSCLC is the TNM system. For SCLC, a simplified two-stage system is commonly used, which consists of:
- A. Early Stage and Late Stage
- B. Limited-Stage and Extensive-Stage
- C. Resectable and Unresectable
- D. Localized and Metastatic
Answer: B. Limited-Stage and Extensive-Stage
7. In the management of metastatic NSCLC, what is the most critical initial step to guide first-line therapy?
- A. Assessing the patient’s nutritional status.
- B. Performing comprehensive molecular biomarker testing (e.g., for EGFR, ALK, ROS1, BRAF, PD-L1).
- C. Measuring the size of the primary tumor only.
- D. Obtaining a complete blood count.
Answer: B. Performing comprehensive molecular biomarker testing (e.g., for EGFR, ALK, ROS1, BRAF, PD-L1).
8. Osimertinib is a third-generation EGFR tyrosine kinase inhibitor (TKI) that is particularly effective against:
- A. ALK rearrangements
- B. Both sensitizing EGFR mutations (e.g., exon 19 deletion, L858R) and the T790M resistance mutation
- C. ROS1 fusions
- D. BRAF V600E mutations
Answer: B. Both sensitizing EGFR mutations (e.g., exon 19 deletion, L858R) and the T790M resistance mutation
9. For a patient with newly diagnosed metastatic NSCLC found to have an ALK rearrangement, which of the following would be an appropriate first-line targeted therapy?
- A. Pembrolizumab
- B. Cisplatin and Pemetrexed
- C. Alectinib or Lorlatinib
- D. Osimertinib
Answer: C. Alectinib or Lorlatinib
10. Pembrolizumab, Nivolumab, and Atezolizumab are immunotherapy agents that work by:
- A. Directly killing cancer cells via chemotherapy.
- B. Inhibiting EGFR tyrosine kinase.
- C. Blocking the interaction between PD-1 and PD-L1, thereby restoring T-cell activity against tumor cells.
- D. Preventing angiogenesis.
Answer: C. Blocking the interaction between PD-1 and PD-L1, thereby restoring T-cell activity against tumor cells.
11. The expression of which biomarker on tumor cells or immune cells is often used to predict response to PD-1/PD-L1 inhibitors in NSCLC?
- A. EGFR
- B. KRAS
- C. PD-L1 (Programmed death-ligand 1)
- D. ALK
Answer: C. PD-L1 (Programmed death-ligand 1)
12. The standard first-line chemotherapy regimen for most advanced non-squamous NSCLC (without targetable mutations) often consists of:
- A. Etoposide alone
- B. A platinum agent (cisplatin or carboplatin) plus pemetrexed
- C. Gemcitabine alone
- D. Docetaxel and Ramucirumab
Answer: B. A platinum agent (cisplatin or carboplatin) plus pemetrexed
13. The standard first-line treatment for Limited-Stage SCLC (LS-SCLC) is typically:
- A. Surgery alone
- B. Palliative radiation only
- C. Concurrent chemoradiation (e.g., etoposide and cisplatin with thoracic radiation)
- D. Immunotherapy monotherapy
Answer: C. Concurrent chemoradiation (e.g., etoposide and cisplatin with thoracic radiation)
14. For Extensive-Stage SCLC (ES-SCLC), the current first-line standard of care involves:
- A. A platinum agent (cisplatin/carboplatin) plus etoposide, combined with immunotherapy (e.g., atezolizumab or durvalumab).
- B. Targeted therapy with an ALK inhibitor.
- C. High-dose chemotherapy with stem cell rescue.
- D. Palliative care only, with no active treatment.
Answer: A. A platinum agent (cisplatin/carboplatin) plus etoposide, combined with immunotherapy (e.g., atezolizumab or durvalumab).
15. A common class-specific adverse effect of EGFR inhibitors like erlotinib and osimertinib is:
- A. Severe peripheral neuropathy
- B. Hemorrhagic cystitis
- C. Papulopustular (acneiform) rash and diarrhea
- D. Hand-foot syndrome
Answer: C. Papulopustular (acneiform) rash and diarrhea
16. Immune-mediated adverse events (irAEs) such as pneumonitis, colitis, hepatitis, and endocrinopathies are potential toxicities associated with which class of lung cancer drugs?
- A. ALK inhibitors
- B. EGFR inhibitors
- C. Immune checkpoint inhibitors (e.g., pembrolizumab, nivolumab)
- D. Platinum-based chemotherapy
Answer: C. Immune checkpoint inhibitors (e.g., pembrolizumab, nivolumab)
17. Pemetrexed, a chemotherapy agent used for non-squamous NSCLC, requires supplementation with which two vitamins to reduce hematologic and GI toxicity?
- A. Vitamin C and Vitamin D
- B. Folic acid and Vitamin B12
- C. Vitamin A and Vitamin E
- D. Thiamine and Niacin
Answer: B. Folic acid and Vitamin B12
18. Prophylactic Cranial Irradiation (PCI) is considered for patients with:
- A. Stage I NSCLC after surgery.
- B. SCLC (especially LS-SCLC) who have responded to initial chemoradiation, to reduce the risk of brain metastases.
- C. All patients with metastatic NSCLC.
- D. Only patients with pre-existing brain metastases.
Answer: B. SCLC (especially LS-SCLC) who have responded to initial chemoradiation, to reduce the risk of brain metastases.
19. For a patient with unresectable Stage III NSCLC whose disease has not progressed after definitive chemoradiation, the standard of care is consolidation therapy with:
- A. One year of adjuvant chemotherapy
- B. Observation only
- C. Consolidation immunotherapy with durvalumab
- D. Prophylactic cranial irradiation
Answer: C. Consolidation immunotherapy with durvalumab
20. Which of the following is a platinum-based chemotherapy agent known for causing significant nephrotoxicity, ototoxicity, and chemotherapy-induced nausea and vomiting?
- A. Carboplatin
- B. Cisplatin
- C. Pemetrexed
- D. Etoposide
Answer: B. Cisplatin
21. A patient with metastatic NSCLC has a BRAF V600E mutation. Which targeted therapy combination would be appropriate?
- A. Osimertinib
- B. Alectinib
- C. Dabrafenib (a BRAF inhibitor) and Trametinib (a MEK inhibitor)
- D. Pembrolizumab and Pemetrexed
Answer: C. Dabrafenib (a BRAF inhibitor) and Trametinib (a MEK inhibitor)
22. Crizotinib is a tyrosine kinase inhibitor that targets several oncogenes, but it was first approved and is effective for NSCLC harboring which specific alterations?
- A. EGFR mutations
- B. KRAS mutations
- C. ALK rearrangements and ROS1 fusions
- D. MET exon 14 skipping mutations only
Answer: C. ALK rearrangements and ROS1 fusions
23. Squamous cell carcinoma of the lung is most strongly associated with:
- A. Non-smokers
- B. A history of tobacco smoking and is typically located centrally in the larger airways
- C. Asbestos exposure
- D. Female gender
Answer: B. A history of tobacco smoking and is typically located centrally in the larger airways
24. The management of immune-related adverse events (irAEs) from checkpoint inhibitors often involves:
- A. Increasing the dose of the checkpoint inhibitor.
- B. Withholding the immunotherapy agent and initiating high-dose corticosteroids.
- C. Administering broad-spectrum antibiotics.
- D. Observation without intervention, as they are always mild.
Answer: B. Withholding the immunotherapy agent and initiating high-dose corticosteroids.
25. A patient with metastatic non-squamous NSCLC is found to have high PD-L1 expression (e.g., >50%) and no targetable driver mutations. A suitable first-line treatment option would be:
- A. Chemotherapy with cisplatin and etoposide
- B. Single-agent immunotherapy with pembrolizumab
- C. Osimertinib
- D. Observation until symptoms develop
Answer: B. Single-agent immunotherapy with pembrolizumab
26. Adjuvant chemotherapy (chemotherapy after complete surgical resection) is typically considered for patients with:
- A. Stage IV NSCLC
- B. Resected Stage II or III NSCLC to reduce the risk of recurrence
- C. All stages of SCLC
- D. Only for patients who are current smokers
Answer: B. Resected Stage II or III NSCLC to reduce the risk of recurrence
27. What is the primary reason that traditional chemotherapy has a more central role in SCLC compared to biomarker-driven NSCLC?
- A. SCLC is less sensitive to chemotherapy.
- B. SCLC has a high initial response rate to chemotherapy, but targetable driver mutations are rare.
- C. Chemotherapy is less toxic in SCLC patients.
- D. There are no effective chemotherapy agents for SCLC.
Answer: B. SCLC has a high initial response rate to chemotherapy, but targetable driver mutations are rare.
28. A common dose-limiting toxicity of carboplatin is:
- A. Nephrotoxicity
- B. Ototoxicity
- C. Myelosuppression, particularly thrombocytopenia
- D. Severe diarrhea
Answer: C. Myelosuppression, particularly thrombocytopenia (Its dosing is often based on target AUC using the Calvert formula).
29. What is the role of surgery in the management of SCLC?
- A. It is the primary treatment for all stages of SCLC.
- B. It has a very limited role, possibly only for very early-stage (e.g., T1-2, N0) disease, which is rarely diagnosed.
- C. It is used for palliative symptom control only.
- D. It is used after chemotherapy for extensive-stage disease.
Answer: B. It has a very limited role, possibly only for very early-stage (e.g., T1-2, N0) disease, which is rarely diagnosed.
30. The term “adjuvant therapy” in lung cancer refers to treatment given:
- A. Before surgery to shrink a tumor (neoadjuvant).
- B. After the primary treatment (like surgery) to eradicate micrometastatic disease.
- C. For metastatic disease.
- D. In combination with radiation.
Answer: B. After the primary treatment (like surgery) to eradicate micrometastatic disease.
31. A patient with lung cancer develops hypercalcemia. This is most commonly associated with which histological type, often due to tumor production of parathyroid hormone-related protein (PTHrP)?
- A. Adenocarcinoma
- B. Small cell carcinoma
- C. Squamous cell carcinoma
- D. Large cell carcinoma
Answer: C. Squamous cell carcinoma
32. The management of bone metastases from lung cancer may include:
- A. Only pain medication
- B. Palliative radiation and bone-modifying agents like zoledronic acid or denosumab
- C. High-dose chemotherapy exclusively
- D. Surgical resection of all bone metastases
Answer: B. Palliative radiation and bone-modifying agents like zoledronic acid or denosumab
33. Pemetrexed is a chemotherapy agent that is generally NOT used for which histology of NSCLC due to lower efficacy?
- A. Adenocarcinoma
- B. Large cell carcinoma
- C. Squamous cell carcinoma
- D. It is used for all NSCLC histologies equally.
Answer: C. Squamous cell carcinoma
34. A patient is receiving cisplatin. Which of the following is a critical supportive care measure to prevent its major toxicity?
- A. Prophylactic anti-diarrheals
- B. Aggressive pre- and post-hydration and antiemetics
- C. Administration of Vitamin B12
- D. Allopurinol for tumor lysis syndrome
Answer: B. Aggressive pre- and post-hydration (to prevent nephrotoxicity) and antiemetics (for severe nausea/vomiting)
35. Ipilimumab is an immune checkpoint inhibitor that blocks ________, while nivolumab blocks ________.
- A. PD-1; CTLA-4
- B. CTLA-4; PD-1
- C. PD-L1; PD-1
- D. EGFR; ALK
Answer: B. CTLA-4; PD-1
36. A patient with metastatic NSCLC with an NTRK gene fusion could be treated with which targeted agent?
- A. Osimertinib
- B. Alectinib
- C. Larotrectinib or Entrectinib
- D. Dabrafenib
Answer: C. Larotrectinib or Entrectinib (These are “tumor-agnostic” approvals for NTRK fusions).
37. The primary goal of treatment for extensive-stage SCLC is:
- A. Curative, with long-term disease-free survival common.
- B. Primarily palliative, aiming to improve symptoms, quality of life, and prolong survival, as cure is rare.
- C. To surgically resect the primary tumor.
- D. To avoid all chemotherapy due to poor response rates.
Answer: B. Primarily palliative, aiming to improve symptoms, quality of life, and prolong survival, as cure is rare.
38. Which of the following is a common screening method for lung cancer recommended for high-risk individuals (e.g., based on age and smoking history)?
- A. Annual chest X-ray
- B. Annual low-dose computed tomography (LDCT) scan
- C. Sputum cytology every 3 years
- D. There are no recommended screening methods for lung cancer.
Answer: B. Annual low-dose computed tomography (LDCT) scan
39. The term “TKI” in lung cancer therapy stands for:
- A. Total Kinase Inhibition
- B. Tyrosine Kinase Inhibitor
- C. Tumor Killing Ingredient
- D. T-cell Kinase Interactor
Answer: B. Tyrosine Kinase Inhibitor
40. A common mechanism of resistance to first- or second-generation EGFR TKIs in NSCLC is the development of:
- A. An ALK rearrangement
- B. A KRAS mutation
- C. The T790M “gatekeeper” mutation in the EGFR gene
- D. High PD-L1 expression
Answer: C. The T790M “gatekeeper” mutation in the EGFR gene (This is specifically targeted by osimertinib).
41. The role of the pharmacist in managing patients with lung cancer includes all of the following EXCEPT:
- A. Educating patients on the administration and side effects of oral targeted therapies and immunotherapies.
- B. Managing chemotherapy-induced nausea and vomiting and other treatment-related toxicities.
- C. Performing bronchoscopy to obtain tissue for diagnosis.
- D. Verifying chemotherapy doses and regimens.
Answer: C. Performing bronchoscopy to obtain tissue for diagnosis.
42. Which chemotherapy agent used for SCLC works by inhibiting topoisomerase II?
- A. Cisplatin
- B. Pemetrexed
- C. Etoposide
- D. Gemcitabine
Answer: C. Etoposide
43. A patient receiving immunotherapy for lung cancer develops severe diarrhea and abdominal pain. The pharmacist should recognize this as a potential sign of:
- A. A normal response to therapy.
- B. Immune-mediated colitis, which requires prompt medical evaluation and likely treatment with corticosteroids.
- C. An expected, mild side effect that will resolve on its own.
- D. A drug-food interaction.
Answer: B. Immune-mediated colitis, which requires prompt medical evaluation and likely treatment with corticosteroids.
44. What is the primary difference in the treatment approach for limited-stage versus extensive-stage SCLC?
- A. Limited-stage is treated with curative intent using concurrent chemoradiation, while extensive-stage is treated palliatively.
- B. Limited-stage is managed with surgery, while extensive-stage is managed with radiation.
- C. Extensive-stage is treated with targeted therapy, while limited-stage is not.
- D. There is no difference in the treatment approach.
Answer: A. Limited-stage is treated with curative intent using concurrent chemoradiation, while extensive-stage is treated palliatively.
45. For a patient with NSCLC being treated with pemetrexed, what additional medication is often co-administered on the day of chemotherapy to reduce the risk of skin rash?
- A. An antihistamine
- B. Dexamethasone (a corticosteroid)
- C. Allopurinol
- D. A proton pump inhibitor
Answer: B. Dexamethasone (a corticosteroid)
46. The term “Liquid Biopsy” in the context of lung cancer management refers to:
- A. A surgical lung biopsy.
- B. Analysis of tumor cells or tumor DNA (ctDNA) from a blood sample to detect molecular biomarkers.
- C. A biopsy of liver metastases.
- D. Sputum cytology.
Answer: B. Analysis of tumor cells or tumor DNA (ctDNA) from a blood sample to detect molecular biomarkers.
47. Which of the following is a major advantage of targeted therapy over traditional chemotherapy in lung cancer?
- A. It is effective for all patients, regardless of tumor biomarkers.
- B. It has no adverse effects.
- C. It can be highly effective in patients whose tumors harbor the specific molecular target, often with a different and potentially more manageable side effect profile.
- D. It is always administered orally.
Answer: C. It can be highly effective in patients whose tumors harbor the specific molecular target, often with a different and potentially more manageable side effect profile.
48. In NSCLC, KRAS was historically considered “undruggable.” However, new targeted therapies have been developed to inhibit specific KRAS mutations, most notably:
- A. KRAS G12D
- B. KRAS G12C
- C. KRAS Q61H
- D. All KRAS mutations are now easily targetable.
Answer: B. KRAS G12C (e.g., with drugs like sotorasib, adagrasib).
49. The combination of chemotherapy and immunotherapy as first-line treatment for some metastatic NSCLC patients (even with low PD-L1) is thought to work by:
- A. Chemotherapy reducing the side effects of immunotherapy.
- B. Chemotherapy causing tumor cell death, which may release tumor antigens and enhance the immune response elicited by checkpoint inhibitors.
- C. Immunotherapy increasing the potency of chemotherapy.
- D. Both agents targeting the same cellular pathway.
Answer: B. Chemotherapy causing tumor cell death, which may release tumor antigens and enhance the immune response elicited by checkpoint inhibitors.
50. What is a crucial counseling point for a patient starting an oral targeted therapy like an EGFR or ALK inhibitor for lung cancer?
- A. The medication can be stopped if they feel well for a week.
- B. The importance of adherence to the daily schedule and how to manage common side effects like rash or diarrhea.
- C. The need for frequent intravenous infusions.
- D. That this therapy is a short, one-time cure.
Answer: B. The importance of adherence to the daily schedule and how to manage common side effects like rash or diarrhea.