Cancer Flashcards
How is cancer defined/characterized
Abnormal cells that divide without control over division. DNA of cells becoming damaged leading to abnormal gene function
What are the differences in structure between a normal cell and a cancer cell?
Normal: large cytoplasm, single nucleus with smooth border, single nucleolus, fine chromatin
Cancer: small cytoplasm, multiple nuclei with irregular border, multiple large nucleolus, coarse chromatin
True or false hyperplasia of cells is abnormal tissue
False. Hyperplasia is still an abnormality in the transition to invasive cancer, but at this point it is still normal tissue, just an increase in the number of normal cells
Describe the 5 steps from a normal cell to invasive cancer
normal cell –> cell mutation –>hyperplasia (normal tissue) –> dysplasia –> cancer in situ (more abnormal than normal cells) –> invasive cancer
Describe dylpasia
Abnormal changes in cellular shape, size or organization. There is a replacement of a mature cell type with a less mature cell type.
True or false, in situ tumors do not invade the basement membrane
true
True or false, benign tumors continue to grow in size abnormally
true, however they will not invade other unrelated tissues or organs in the body
Describe a malignant tumor
Cells that invade the basement membrane and invade other parts of the body
Name two ways malignancy occurs
Direct extension: neighboring organs, tissues
Indirect extension: to distant sites via the vascular, lymphatic system or seeding of CA cells into body cavities
Carcinoma arises from what tissue?
Skin or tissues that line or cover internal organs
How are cancer categorized?
The tissue which they arise
Sarcoma arises from
supportive and CT: bone, cartilage, fat, muscle, blood vessels
Which is more malignant carcinoma or sarcoma?
Sarcoma
Where does leukemia arise from
blood forming tissue/bone marrow
Where does lymphoma and myeloma arise from
cells of the immune system
Where does CNS cancer arise from
brain and SC
Most breast cancers are categorized as what kind?
Carcinoma
how many CA survivors are there in the US
15.5 million
Talk about the overall estimated trends in cancer prevalence and survivor rate
CA survivors is going to increase, however more people are going to be diagnosed with CA
What is the most prevalent CA among men? women?
Prostate
Breast
What is a major risk factor for CA?
AGE: the older you are the more at risk
What is the lifetime probability of having cancer in your lifetime for males? females?
Males: 1 in 2
Females: 1 in 3
Where age is 89% of CA prevalence located?
50+
True or false, more people are surviving their CA diagnosis as time goes on
true
What are african american women more likely to be diagnosed with?
triple negative breast cancer, they are not positive on three hormone receptors making it much more difficult to breast
True or false, african americans have lower survival rates than whites for most cancer types
true: later stage diagnosis, lower likelihood of receiving quality treatment, triple negative breast cancer
What cancer is the leading cause of death in men an women?
lung and bronchus CA
What mechanism does radiation work through vs. chemotherapy?
Radiaiton: direct damage to DNA (CA cells are more fragile than healthy ones so they will die more easily)
Chemotherapy: targets an aspect of cell growth cycle
Name the phases of the proliferative cycle
GI: postmiotic period - protein synthesis and cell growth
Synthesis: DNA replication
G2: premiotic: cell checks DNA and gets ready to divide
Mitosis: cell division
Chemo agents target what?
Either one phase of cell growth (postmitotic, synthesis, premitotic, mitosis) or all phases
Define neoadjuvant chemotherapy
before surgery: shrinks the CA to allow it to be removed
Define adjuvant chemotherapy
after surgery: used to kill undetected cells that have traveled from the tumor
Metastatic disease
goal is to keep CA at bay
Name the neurotoxic chemotherapy agents
- Taxanes: commonly used with breast cancer
- Alkaloids
- Platinum based
- epothilones
- PI
- Thalidomine and lenalidomide
- Eribulin
- Nelarabine
Chemotherapy targets what kind of cells
rapidly dividing ones
What is alopecia
hair loss
What is the premise of targeted therapy
specifically attach to different receptors on CA hormones
How do targeted therapies differ from standard chemo?
Targeted act on specific molecular targets where chemo acts on all rapidly dividing cells
Targeted are cytostatic (block proliferation) and chemo is cytotoxic (kill cells)
What kind of therapy is SERM and Aromatase inhibitor? and what are they generally used for?
Hormone therapy commonly used for breast cancer
What kind of therapy is HER2 and herceptin and what CA is it gernally used for?
Monoclonal antibodies used for breast cancer
Autologous, syngeneic, allogenic transplants generally used for what kind of CA?
Blood/liquid
Define: autologous, syngeneic, allogenic in terms of transplants
Autologous: your own stem cells have been removed and used
Syngeneic: identical twin
Allogenic: someone who is a relatively close match to you
What is BMT and PBSCT?
And why are they used in cancer treatment?
What types of CA are treated with it?
BMT: bone marrow translplant
PBSCT: peripheral blood stem cell transplantation
Used in CA treatment bc with high dose chemo and/or radiation can destroy pts bone marrow. They can no longer make WBC, WBC, platelets. This allows them to
Commonly used in liquid CA’s (leukemia, lymphoma, multiple myeloma, neuroblastoma)
How are stem cell transplantations received? and how long does an individual stay in the hospital for?
IV then you wait for engraftment (in hospital for 100 days)
What is GVHD
graft vs. host disease: long term complication of transplants
Name some less common treatments of CS
vaccines, cyrosurgery, hyperthermia, lasers, photodynamic
Name the 3 decreasing CA diagnosis
3 increasing?
Decreasing: Colorectal, prostate, lung
Increasing: thyroid, melanoma, liver
50% of CA death due to which four diagnoses
Lung, prostate, breast, colorectum
BRCA 1 and 2 are what?
tumor suppressor genes, therefore when they have a mutation cells go crazy
Change in CA population in head and heck cancers
Then and now
Whats the difference?
Then: 50+ males, alcohol and tobacco use
Now: 30+ females or males, no h/o ATOH or smoking
Difference = HPV!
Breast CA screening recommendations
40?
45-54?
>55?
Known BRCA mutation, 1st degree relative, 25% lifetime risk of breast cancer start at when
40: start annual exams if hx of breast CA
45 - 54: annual screens for all
> 55: biennial screening and should continue as they have a life expectancy >10 yrs
High risk: Start at 30 yrs
What makes you high risk for breast cancer?
- known or likely BRCA mutation and other gentic syndroms
- treated with chest wall radiation for Hodgkin disease
Down the line radiation used to treat Hodgkins lymphoma led to what?
Breast CA
When should an individual be referred to a genetic counselor (concerning breast CA)
family hx of multiple relatives w/breast or ovarian CA, or if relative was diagnosed <50 yrs old
What are the five red flag signs for CA?
1) unexplained weight loos >10 lbs
2) fever, chills, night sweats
3) rest/night pain
4) Fatigue
5) skin changes
ABCDE’s of melanoma
A: assymetry B: border C: color D: dimeter (pencil eraser) E: enlargement or evolving
Signs and symptoms of CA
CAUTION
C: change in bowel and bladder A: A sore that is not healing U: unusal bleeding or discahrge T: thickening or lump I: indigestion or trouble swallowing O: obvious change in wart/mole N: nagging cough or hoarseness
CA staged as In situ:
In situ: abnormal cells are present only in the layer of cell in which they developed
CA staged as regional
CA has spread beyond primary site to nearby lymph, tissues or organs
CA staged as localized
CA is limited to organ which it began without evidence of spread
CA staged as unknown
not enough to determine stage
CA staged as distant/metistatic
CA has spread to distant tissue, lymph or organs
Explain the T of cancer staging
T: size or extent of tumor
Tis: in situ T1: <20mm T2: 50<20 mm T3: >50 mm T4: any size with direct extension to the chest wall and or to the skin
Explain the N of cancer staging
N: amount spread to lymph nodes
pN0: no regional lymph node metastasis
pN1: 1-3 axillary lymph nodes
pN2: 4-9 nodes
pN3: > or = 10 nodes
Explain the M of cancer staging
M: metastasis
0: non
1: metastasis
Stage IV CA means what
CA has spread to distant tissue or organs
Stage 0 CA means what
In situ: not within the membrane
Tests used for stagin
Physical exam, imaging, lab tests, pathology reports, surgical reports
What were the most common functional cited problems in CA patients in the cited study
Balance and ambulation
True or false oncology clinicians adequately document functional problems in CA patients
False!
True or false oncology is a specialization by the ABPTS?
True
In what stage (pre-screening, screening, treatment etc) is rehab appropriate?
Most appropriate?
Always appropriate but particularly pre-treatment
Does a PT’s role in CA care include diagnose?
According to her slide yes
What does the following describe?
Brief investigation of:
Anatomical & physiological status of body systems
Communication ability, affect, cognition, learning style
Review of “red flags” and other screening data
A systems review
What is an orange flag?
Psychiatric symptoms
What is a yellow flag?
Beliefs and judgments
Name some causes of concern or red flags that occur with CA rehab?
Compression of neurologic tissue
Cardiac ventricular funciton
Bone health
Anemia, neutropenia, thrombocytopenia
Common location of metastasis for breast cancer?
bone, liver, lung, pleura
Common location of metastasis for colorectal cancer
Liver, periotoneal cavity
Common location of metastasis for small cell lung cancer
Non small
bone, liver, opposite lung, brain, pancreas, adrenal glands
Opposite lung, brain
Common location of metastasis for multiple myeloma
Osteolytic bone lesions
Common location of metastasis ovarian
peritoneal cavity
Common location of metastasis pancreatic cancer
liver, lungs, local tissues
Common location of metastasis prostate cancer
Bone
Common location of metastasis for sarcoma
Lung
The metastatic sites to know
Breast Small lung Multiple myeloma Pancreatic Prostate
Breast: bone Small lung: bone Multiple myeloma: Osteolytic bone lesions Pancreatic: liver, lung, local tissue Prostate: bone
What are the precautions for >50% of cortex involvement?
This is high risk of pathologic fracture
No twisting, or exercises!
Do: Touch down, NWB, use of AD, AROM exercise,
What indicates high risk for bony metastasis
cortical lesions >2.5-3 cm
> 50% cortical involvement
Painful lesions
Unresponsive to radiation
What are the precautions for 25-50% cortex involvement
This is moderate risk
No stretching, lifting, straining
Do: PWB, light aerobic activity
What are the precautions for 0-25% cortex involvement
None, full WB
When risk of pathologic fracture is high what kind of things do you avoid? focus on?
Avoid: Open chain exercises, ballistic movements, risk of falling
Focus on : WB exercises (except with cortical involvement >50%), general conditioning
What level of hematocrit would you not exercise someone
25%
What level of hemoglobin would you not exercise someone?
<8g/dL
What WBC count would you not exercise someone at
<5.0 10^9 w/ fever
What platelet count would you not exercise someone at
<20 k/uL
Common CA causing spinal cord compression
Thoracic, breast, lung, lumbar, prostate, melanoma, GI
Most commonly extradural mass from vertebral metastasis: 60% in Tspine
Common CA causing malignant pericardial effusion
BREAST, chest wall radiation
What diagnosis does SBP fall in and why
malignant pericardial effusion
they have a space occupying fluid in the pleura therefore there is too much pressure against the heart when they inhale
Common CA causing superior vena cava syndrome.
MEDIASTINUM LOCATION: lung, lymphoma, breast
What is this?
Early Recognition CRITICAL Most commonly extradural mass from vertebral metastasis Location: 60% in thoracic spine 30% in LS spine 10% cervical spine
Acute spinal cord compression
Common symptoms of acute SC compression
worsening back pain, NIGHT PAIN, change in neurological status
What are these common treatments for?
high dose steroids, focused radiotherapy to shrink the tumor, surgical resection
Acute SC compression
Prognosis for acute SC compresion
3-6 months survival
1 yr survival rate 30%
Pre-treatment ambulatory status and acute SC compression
if they were not ambulating before it is very unlikely they will resume ambulating after
Vena Cava syndrome is loss of what?
drainage to the head, neck, arms and upper thorax
Symptoms of Superior vena cava syndrome
Jugular venous distention, facial edema, collateral veins of chest, SOB, arm edema
True or false Superior vena cava syndrome is emergently life threatening?
false
Name common treatments for superior vena cava syndrome
High dose steroids, intravascular stenting, localized radiotherapy
When does tumor lysis occur?
After stem cell therapy, shortly after chmotherapy = when a large number of neoplastic cells are killed rapidly
What is very common in hematologic CA issues?
DVT’s
Who does neutropenic fever occur in?
What does it present like
pts recieving chemo
Neutropenia at onset –> temperature –> septic shock
What are the Wells rules used for?
Determine risk of DVT’s
Tumor lysis syndrome and hypercalcemia are what kind of cancers?
Metabolic
What classification of cancer are the following symptoms related to?
- Fatigue, bone pain, polyuria
- GI: Constipation, abdominal pain
- Neurological: muscle weakness, lethargy, confusion, delirium, and coma
- Cardiac: EKG changes, MI
Hypercalcemia - a metabolic cancer
Cancers with rapidly proliferating cells
- Acute lymphoblastic leukemia
- High grade lymphomas
Solid tumors that are chemo sensitive
-Neuroblastoma, breast, small-cell lung
Tumor lysis syndrome - a metabolic cancer
Score of ______ on Well rules = 75% probability of _____
> or = to 3
DVT
Unexplained unilateral limb swelling is a tumor or clot unless what?
PROVEN OTHERWISE
What are unusually engorged or numerous veins in atypical local called and what do they indicate
Collateral veins: indicate tumor, clot and is a red flag unless hx offers an explanation
Name some common neuromuscular complications in CA pts
nerve palsy (eye movement), plexopathy, dystonia, peripheral neuropathy
Explain somatic pain
localized, activation of peripheral nociceptors (no damage to peripheral nerve or CNS); sharp, reproduced by movement
Explain visceral pain
diffuse, difficult to localize, referred to superficial structure, activation of nociceptors of thoracic, pelvic, or organs/viscera
Explain neuropathic pain
burning, stabbing, shooting, damage to somatosensory NS.
Dysethesias: abnormal sensations
Allodynia: pain from normally non-painful
Contraindications to superfiial heat
acute inflammation, over tumor, recently irradiated area, impaired sensation, mental status, DVT, over area of long term steroid use
Contrainications to superficial cold
post radiation, impaired sensation, cold hypersensativity or intolerance, Raynaud’s
When do we commonly see dysvascular tissue?
Post-radiation
Contraindications to ESTIM
carotid sinus, implanted device, thrombosis
TENS can be very helpful for what kind of pain
bone pain
When is NMES contraindicated
increased fracture risk
When is US contraindicated
thromosis/thrombophlebitis, malignancy, breast implants, internal stimulators, pregnancy, central nervous tissue
True or false, US is generally a modality used in the CA population
FALSE! usually contraindicated - increased tumor growth and metastatic spread in mice
What is CIPN
Chemotherapy induced peripheral neuropathy
Neurotixic chemotherapy agents
TAXANES: commonly used in breast CA PLATINUM BASED Vinca-alkaloids Epothilones PI's Thalidomide, and lenalidomide Eribulin Nalarabine
Treatment for CIPN
dose reduction
Severity of CIPN based on what generally
dose and duration of medication
When does CIPN come on and how long does it last
Comes on 24 hrs after chemo infusion
May last for weeks, months or indefinitely
CIPN symptoms
Neurogenic issues: burning, allodynia, electric, cold sensitivity, feels like wearing gloves or stockings
Automomic: diarrhea, constipation, irregular heart beat
Motor: less common if present - foot drop
PT exam for CIPN
sensory testing, deep tendon reflexes, strength, balance/proprioception, gait
CIPN treatment
Neuromuscular electrical STIM, education, falls prevention (balance and gait training, orthotics, AD), exercises, desensitization, compression
hallmark of CA fatigue
not proportional to recent activity and interferes with usual functioning
when does CRF present
nearly every day or every day
What causes CRF in patients lives?
Everything
What score on the numeric rating scale for fatigue shows that patients have decreased functioning and should be referred to PT
> or = 7/10
What has shown to be the most effective non-pharma intervention for CRF?
Exercise
True or false: Exercise reduces CA related fatigue both during and after CA treatment?
True
What two CA is the evidence for aerobic exercises strongest?
Breast and prostate
3 guidelines for CA exercise
Activity enhancement
Across all stages of survivorship
AVOID INACTIVITY!!!!
True or false: exercise is safe during and after most types of CA treatment
Both unsupervised and supervised have shown to be helpful
TRUE!
True!
True or false for exercising: Time is more important than distance
True
one major consideration for pts exercise prescription
pretreatment aerobic fitness
What kind of exercise is good for prostate CA and why
resistance, aerobic: they have lost testosterone with medication
Moderate-intensity, resistance exercise (3–6 METs, 60%–80% 1-RM) reduced CRF more so than those engaging in lower intensity resistance or aerobic exercise of any level of physical exertion (Brown et al., 2011)
duration and frequency have been reported to have no effect on magnitude of CRF reduction in studies across mixed cancer types and delivery methods
What is the best mode of exercise for CA treatment
aerobic and resistance training = largest treatment effect
What is the montra for CA exercise programs
Start low, progress slow
Moderate vs. vigorous intensity exercise
Moderate: talk but not sing, 3 on modified borg (12-14), 50-79% maxHR
Vigorous: can only say a few words, 70-85% max, 5 on modified borg (>14)
Caution performing exercise with any of the following
boney metastasis
thrombocytopenia (low plateltes)
Anemia
neutropenia
General exercise program for someone who can tolerate moderate exercise
30 min of moderate aerobic exercise 5 days a week
resistive exercise 2-3x a week (not to failure)
Flexibility
Balance
Radiation fibrosis through what mechanism
cell death via free radial mediated DNA damage: radiations goal is to cause inflammation so cells die, ongoing response in normal tissue = fibrosis
phases of fibrosis
prefibrotic = inflammation
organized fibrosis = high myofibroblasts
Fibroatrophic phase: skin tightens
Radiation causes what kind of tissue, what does this mean for PT
Avascular
Don’t crank on it
Global radiation side effect short term and long term
fatigue!!
Result of radiation on soft tissue (3)
decreased vascular perfussion
Decreased ability to heal
Decreased ability to disperse heat
However it is relatively tolerant of radiation and able to heal post expsure, the issues are due to the vascular changes
What is cervical dystonia
SCM so tight = torticollis
Radiation symptom
What is Trismus
masseter msucle becomes tighter so they cannot open their mouth
Radiation symptom
What is L’Hermitte’s sign
flex their head they get shooting sensation in lower half of body
Radiation symptom
Tissue fiborsis and scaring interventions
myofascial techniques, compression, kinesio tape for mobilization of scar tissue when patient moves
Flexibility exercises LONG TERM for shoulder and trunk AROM (if supraclavicular add C-spine)
When shoud you not mobilize a scar
while they’re in chemo or radiation because this will create even more rapidly dividing cells
Where is the breast implant placed
beneath pec major
TRAM, DIEP and SIEA are what kind of procedures
autologous breast reconstruction surgery
Explain a TRAM
transverse rectus abdominis myocutaneous flap
Release rectus abdominus, free all the tissue on the abdomen wall and fold it over to make a breast
Sentinel node
- lymph node to which cancer cells are most likely to spread from a primary tumor.
What is the following procedure?
A surgeon injects a radioactive substance, a blue dye, or both near the tumor to locate the position of the sentinel lymph node. The surgeon then uses a device that detects radioactivity to find the sentinel node or looks for lymph nodes that are stained with the blue dye. Once the sentinel lymph node is located, the surgeon makes a small incsion (about 1/2 inch) in the overlying skin and removes the node.
Sentinel Lymph Node Biopsy
Axillary Lymph Node Dissection requires what
retracting pec major and minor
Any kind of breast surgery is trauma to the chest wall. They have a very short pec major and minor creating a kyphosis, then they get radiation and again shorten the tissue and put it at risk for fibrosis
Women have altered resting scapular alignment due to protective posturing (fear pain)
Reduced tissue flexibility –> altered alignment
What is the one movement we talked about at the shoulder that decreases tension on the pec major?
Flexion to 90 degrees
Pec minor dysfunciton leads to what
Reduced scapular posterior tilt therefore elevation is compromised
More internal rotation during elevation
What is the cause of axillary cording?
Portions of the neurovascular bundle getting inflammed and stuck after surgery
What do you do for axillary cording?
Nerve glides (mediaN) and ROM exercises
What does the Spinal accessory nerve innervate
SCM and trap
TORS surgery
Trans oral robotic surgery
TLM used for what
transoral laser micosurgery: access to tumors the robot can’t reach (oropharyngeal and laryngeal)
Radial, modified or selective neck dissection
Removal of cervical level I-V lymph nodes, spinal accessory nerve (SAN), internal jugular vein (IJV), and sternocleidomastoid (SCM)
Radical
Radical, modified or selective neck dissection:
Removal of cervical level I-V lymph nodes, but preserves at least 1 of the following structures: SAN, IJV, and SCM
Modified radical neck dissection
Radial, modified or selective neck dissection
One or more cervical lymph node levels removed during radical neck dissection are preserved
selective neck dissection
True or false: Above the clavicle there are 50 lymph nodes?
False: 200
Explain the level of nodes
the higher the number of level, the more nodes that are dissected traveling down the head and neck area
I II III IV V level of nodes
I: submental II: upper jugular III: middle jugular IV: lower jugular V: posterior triangle - generally the spinal acessory nerve with get damaged with surgery here
Scapular flip sign is to show what?
if pt has spinal accessory nerve palsy
Plus test
looking at serratus function: arm is in flexion with thumb up and you apply pressure
If someones spinal acessory nerve is weak so their scap is flying all over the place, but they need to strengthen their serratus, how can you accomplish this?
Supine! their body weight will stabilize the table
GVHD is a risk for what kind of tranplant
allogeneic
What is key to working with GVHD patients
Joint contractures: ROM and soft tissue work, thermal modalities
Steroid myopathy: exercises for proximal muscles, transfer and balance training
surgical release is NOT effective
