Chemotherapy and supportive pharmacology — formative case

Station status

This is one MedVellum formative structured clinical encounter. The scoring, prompts and performance descriptions are educational feedback tools. They are not an official college station, timing, mark allocation, pass score or reproduced examination format. The encounter assesses the dexrazoxane cardioprotection decision, the antiemetic ladder for a highly emetogenic regimen, colony-stimulating factor prophylaxis and the febrile-neutropenia front-door plan, the vincristine-intravenous-only route rule, and family communication. [1] [3]

Candidate instructions

You are the paediatric registrar in a shared-care oncology clinic with a child about to start a doxorubicin and cisplatin regimen. Establish the cardioprotection plan, the antiemetic ladder, the febrile-neutropenia prophylaxis and front-door plan, and the vincristine route safety. Then address the family's questions and fears. Speak directly to the child and parent. State what you would assess or prescribe; do not perform painful manoeuvres on the actor. [1] [2]

Room setup and observable starting state

The encounter. Leo is eight and sits with his mother in the oncology shared-care clinic. The oncologist has confirmed the doxorubicin and cisplatin regimen, and the candidate is asked to set out the supportive pharmacology plan. The candidate should state the dexrazoxane decision tied to the cumulative anthracycline threshold, the triple antiemetic for cisplatin, the filgrastim or pegfilgrastim prophylaxis, and the febrile-neutropenia front-door advice. [1]

Simulation safety. Leo remains seated throughout and is never examined painfully. Cards or the assessor supply the cumulative-dose record and the blood results. The parent does not obstruct the consultation. [2]

Actor cues

Parent actor

• Begin with, "We've heard doxorubicin can damage his heart. What can you do about that?" If asked what worries her, answer: "Will he need this dexrazoxane? Is it safe?"
• On the vomiting, ask: "He was so sick after the last cycle. Is there anything stronger?"
• On the fever plan, ask: "If he gets a temperature at home, do we wait and see, or come straight in?"
• On vincristine, ask: "The nurse said something about a special check on one of the drugs. What was that?" [2]

Child actor

• Responds shyly to questions about nausea: "I felt sick for days after the last one, even at home." [2]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward the toxicity-to-antidote pairings, the cumulative-dose reasoning, and the route-safety system. [1]

Step 1 — The dexrazoxane cardioprotection decision

The cumulative anthracycline record shows the dose approaching the high-risk threshold. Expected strong behaviour: state that dexrazoxane chelates the iron that catalyses the anthracycline free-radical cascade in the cardiomyocyte, given before each dose at about a ten-to-one ratio, reserved for the child crossing about 300 milligrams per square metre cumulative doxorubicin equivalent, with echocardiography and troponin surveillance; address the secondary-malignancy fear by citing the reassuring Barry data. [1]

Step 2 — The antiemetic ladder for cisplatin

Cisplatin sits at the top of the emetogenic ladder. Expected strong behaviour: state the triple combination of ondansetron (5-HT3), aprepitant (NK1) and dexamethasone, covering the acute and the delayed forty-eight-to-ninety-six-hour window, and warn the family specifically about the delayed window; keep dose-related ondansetron QT prolongation in mind. [2]

Step 3 — Febrile neutropenia prophylaxis and the front door

The regimen is myelosuppressive and high-risk. Expected strong behaviour: state filgrastim at about five micrograms per kilogram per day subcutaneous, or pegfilgrastim at about a hundred micrograms per kilogram subcutaneous once per cycle, with primary prophylaxis at about the twenty per cent risk threshold; and give the family a clear front-door plan — a fever in a neutropenic child is an emergency, come straight in, empirical broad-spectrum antipseudomonal antibiotics within the hour. [3]

Step 4 — The vincristine-intravenous-only route rule

The child is also on vincristine. Expected strong behaviour: state plainly that vincristine is intravenous only and never intrathecal, that intrathecal vincristine is uniformly fatal, and that the prevention is a system — minibag dilution, separate intrathecal timing, and independent double checks. [4]

Step 5 — The extravasation and survivorship advice

Expected strong behaviour: tell the family that if a doxorubicin infusion leaks, dexrazoxane goes in within six hours for three days with no cold compresses; and that the cumulative anthracycline dose drives lifelong cardiac surveillance under the long-term follow-up guidelines. [4] [5]

Marking domains

Debrief prompts

• What is the single most important supportive-pharmacology pairing you taught the family, and how did you explain the mechanism in plain language?
• Which route rule is non-negotiable, and what engineering control prevents the catastrophe?
• How did you balance reassurance about dexrazoxane with the real need for cardiac surveillance?
• If the family hesitated about the febrile-neutropenia front-door plan, how did you convey the urgency without frightening them? [1] [4]