L8 Cancer Flashcards
Cancer Prevention Pathway
Education in adhereing to cancer screening, meeting physical activity and nutrition guideles, smoking cessation and sun protection
Survivor pathway
disease related impairments
treatment related impairments (acute, late, persistent)
goals are restorative and patient education
Treatment pathways for cancer
Prevention
Survivor
End of life
Cancer definition
group of disease characterized by uncontrolled growth and spread of abnormal cells that can result in death if not treated
Causes of cancer
external factors = tobacco, infectious organisms, chemicals, radiation
internal factors = inherited mutations, hormones, immune conditions, mutations from metabolism
Cancer classification
- Tissue of origin/histogenesis
- Stage of cancer –> TNM staging OR Stave 1-4 system
- Tumor grade
- Receptor Status
Tumor grade
how closely the cell resembles normal cells
TNM staging
T = extent of tumor
N = extent of spread to lymph nodes
M = presence of metasteses
Types of cancer receptors
hormone –estrogen, progesterone, testosterone
epidermal growth factor
vascular endothelial growth factor
Why are cancer receptors important?
they can lead to increased cell proliferation of tumor cells
they can be a therapeutic site for stopping the diviion or growth of tumor cells
Malignant
cancer cells invade neighboring tissues, etner blood vessels, and metastasize to different sites
Benign
not cancer
tumor cells grow only locally and cannot spread by invasion or metastasis
Metastatic Cancer
cancer that has spread from the palce where it first started to another place in the body
has the same name and type of cancer cells as the original cancer
all malignant cancer types can metastasize
difficult to treat
Metastatic disease process
- primary tumor
- metastatic clone evolves
- proliferation of the clone and invasion of lymphatic or venous
- transported by circulation
- new tumor formation at the site of metastasis
it is a dynamic interaction between cancer cell and environmnet
specific organs harbor metastases from one type of cancer by stimulating their growth
Bone metastases and exercise
pre-exercise screening and exercise modifaction are required for safe exercise in patients with bone metsE
Exercise screening for bone mets
MD clearnace prior to exercise OR
minimum level of functioning that includes independent ambulation and self care OR
absence of unstable bone mets or pain related to lesion
Exercise mods for bone mets
=decreased load, pain free exercise, decreased reps
modified strength programs can improve strength and physical function without adverse effect
proceed with cautioN! exercises should be modified and monitored
High risk individuals for bone met execise
those with functional impairments
unstable mets
bone pain
Weight bearing precautions for bone mets
if patient has bone mets in weight bearing bone, ask radiologist to calculate what percentage of the cortex is involved
> 50% = NWB
25-50% = PWB
0-25% = FWB
use pain as your guide is the expert opinion
Spine mets and fracture
patients are often not referred to PT for education
PT role is to teach spine precaution ed for comfort, pain management, and to maintain independence
no evidece for role of spine precatutions to prevent pathologic fracture
Take home message of met disease
- document location
- Location impacts PT assessment
- Mets will impact PT treatment –> bone protection w/fractures, aerobic capacity with lung mets, strengthening potential w/neuro mets
Tumor classification
histogenesis/receptor status
dictates medical treatment, as you should be treating related impairments
screening for mets
Stage importance
extensiveness of disease
dictates medical treatment
location of known disease and mets
disease related impairments could impact PT plan
Grade importance
aggressiveness of cancer
dictates medical treatment
prognosis of patient and POC impacted
Oncology surgeon
remove tumor and provide clean margins
preform sentinel lymph node dissection and perform full lymph node dissection
Pathologist
describe the tumor characteristics
Medical oncologist
chemo, given systemically, to kill any cancer cells that were not removed during surgery
perform tests to see if the cancer has spread to distant sites
bioagent therapy to control growth of any tumor that has not been killed
follow patient closely to watch for cancer recurrence
Radiation Oncologist
radiate the area where cancer was found to prevent local recurrence
PT treatment planning tips
What are the possible effects of the disease on systems for mobility?
what are the possible effects of treatment on systems of mobility?
if there are multiple impairments, how do you prioritize and formulate a treatment plan?
What is the therapeutic goal of medical treatment?
CURE (no recurrence)
Prolongation of life
Palliation of symptoms
Cancer treatment options
Can include any one or all of the toptions. Sequence depends on cancer characteristics
surgery
chemo
radiation
bioagents (hormonal and targeted)
Surgery
often part of treatment for patients with solid tumors (vs blood cancers)
local treatment
often have impacts to the surrounding systems
Nervous System, impacts of surgery
pain–hyperalgesia and allodynia
weakness
numbness
impairments are based on cancer type and surgery performed
CNS cancers often have surgery as part of treatment
peripheral nerves can be injured during surgery
Lymphatic system impacts of surgery
at risk for lymphedema
Skin and fascia impacts of surgery
adhesions /scar tissue
MSK system impacts of surgery
amputation (common for osteosarcoma)
decreased ROM
weakness
adhesions/scar tissue
myofascial restrictions limiting ROM. worse if there is an infection or ROM restrictions w/post op
PT role is to address the impairments and related activity restrictions as you would for patients that have these problems w/out cancer
Bone marrow impacts of surgery
complex treatment related issues
Common cancers that involve surgical lymph node removal
Breast
Ovarian
Prostate
Melanoma
Head and Neck
Bottom Line for PTs and Surgery
read surgical report to find out what anatomy was involved
ask surgeon about post op restrictions
seek mentorship, oncology residency, or con-ed to learn about common surgeries by cancer type
Chemotherapy
systemic control of cancer
affect any dividing cell in the body, especially those that rapidly divide
given via port or PICC line. avoid manual therapy near them b/c you can dislodge them
they are at risk for blood clot with PICC, report vein engorgement ASAP
Chemo side effects
General: blood cells, hair cells, mucosa of GI tract
Drug specific: depends on the drug
RBC and chemo
signs of anemia
PTS should monitor lab values
WBC and chemo
increased risk for infection
practice infection protocols
Platelets and PT
decreased clotting ability
GI mucosa
nausea, vomiting, diarrhea
cocktail of steroids during chemo
Hair follicles and chemo
alopecia
Ovary/testes suppression and chemo
may elect to harvest eggs
Cancer related fatigue
severe persistnt fatigue
can be physical, cognitive, emotional
Chemobrain
difficult to wuantify
decreased memory, feeling in a brain fog
Pattern of General ADRs of Chemo
1st chemo = notice changes in lab values
PT should occur at the beginning of the first week and then the third week, as the patient is preparing for their 2nd chemo, as they are usually feeling better
try to time it so that you are working either during the “up times” or tat the beginning of the chemo
Acute vs persistent chemo related impairments
Severity, timing, and persistence of impairments depend on
1. Cumulative dose
2. amount of time to recover between doses
3. Co-morbidities
most acute resolve over time, but can become persistent
Dose
described in mg/m
given in cycles
adjuvant
after surgery
neoadjuvant
before surgery
dose dense
every 1 to 2 weeks rather than every 3 weeks
Nadir
time point between chemo cycles where blood values drop to their lowest point
different for each drug, the dose, and how close it was given to the previous dose
Bioagents
targeted systemic therapy
include monoclonal antibodies, hormone suppressors, hormone and other receptor blockers
Monoclonal antibodies
MAB drugs
flags cells to be cleaned up by the immune system
Testosterone and Bioagents
inhibitors are given to men with prostate cancer as long as it continues to control cancer cell growth and there aren’t intolerable side effects
PT: myopathy/weakness is observed with LT. S/S similar to menopause
Estrogen Bioagents
Arinatase inhibitors are given to women with ER+ breast cancer
does not block estrogen production
used in post-menopasual women
PT: increased risk for osteoporosis and fx. given for 2-5 years after completion of other treatment
Estrogen REceptor Blockers
also called selective estrogen receptor modulators
SERMS inhibit ER in the brest, but activate ER in the bone and endometrium
PT: strengthens bone, increased risk for uterine cancer, increased blood clots and stroke, menopause like s/s (joint pain), given 2-10 years after completion
Bottom line for PTs with bioagents
it is not sufficient to document that patient received chemo or bioagents
you need to know specific medications
investigate common side effects of those drugs
Radiation
local control of cancer
not given to every patient, depends on cancer type and radiosensitivity of tumor
causes direct and indirect damage to cell DNA resulting in cell death
only affects tissues that are in field of radiation
does cause cancer related fatigue
Radiosensitive Tissues
rapidly dividing tissue like skin or tumor
acute effects, damage within weeks to months of exposure
temporary effects
normal cells are capable of repair
dependent upn dose-time-volume
Radioresistant tissues
not rapdily dividing, nerve, blood vessels, fascia
late effects
damage months or years after first exposure
permanent changes
damage becomes more severe as time goes on
dependent on dose, time, volumen
Acute Integumentary Effects
typically short lived, lasting from a few weeks to months
skin erthema, inflmmation
dry desquamation =
Wet desquamation =
Wet desquamation
takes weeks to resolve, new cell proliferation is inadequate and dermis is exposed w/oozing of serum
Dry desquammation
dry, flaking, scaling that resolves 1-2 weeks after
Late/persistent skin effects
severity is dependent on total dose
hyperpigmentation
decreased tissue mobility (contraction, adhesions, fibrosis, pain)
Phase 1 Radiation induced fibrosis
Pre-fibrotic phase
chronic inflamm
increased vascular permeability
edema formation
firbroblast proliferation and activation
Phase 2 Radiation induced fibrosis
weeks to months after radiation
damaged tissue is made of activated fibroblasts that are depositing collagen in a disorganized ECM
BEST TIME TO BEGIN MANUAL THERAPY
Phase 3 Radiation induced fibrosis
fibroatrophic phase
months to years after
loss of parenchymal cells and retraction
ECM becomes dense and tissue is poorly vascularized
Aerobic Exercise Helps with
cancer related fatigue
general deconditioning
nerve health
prevention
recurrence
Aerobic Exercise Considerations
monitor blood labs if taking chemo
modify as necessary
start off low and increase as fatigue decreases
Strengthening Exercise Helps with
cancer related fatigue
general deconditioning
post surgical weakness
drug related weakness (prednisone and testosterone suppressing)
Strengthening considerations
ensure they don’t have post op lifting restrictions
know how to modify for other impairments
may need manual therapy for ROM
compression garments with lymphedema
mod intensity
Stretching and Manual Therapy, Joint Mobs, Helps with
help regain ROM of joint and soft tissue after radiation and/or surgery
decrease pain b/c of soft tissue restrictions
Stretching Considerations
Post op: AROM and dynamic
Radiation fibrosis: long hold to help realign collagen
Manual therapy considerations
can begin 4-6 weeks after surgery/radiation, progressing to more intense 6-8 weeks
avoid PORT, monitor edema, infection, open skin
Gait Training Helps with
improve gait after amputation
improve gait with peripheral neuropathy
Gait Training considerations
consider AFO/orthootics, prosthetist
look for gait deviations when fatigued
consider pool
Balance Training Helps with
decrease fall risk
increase confidence in ambulating with variable conditions
Patient education helps with
lymphedema
faill risk
peripheral neuropathy management
Prevention of Breast Cancer
exercising strenuously for more than 4 hours a week is associated with reduced breast cancer risk
average RR reduction is 30-40%
effect may be reatest for premenopausal women of normal or low body weight
Local recurrence breast cancer
changes to breast skin color
swelling
lumps
thickening
Regional recurrence breast cancer
difficulty swallowing
change in sensation
pain of shoulder/arm
lump near breastbone/collar bone
swelling/lump in axillary lymph nodes
Distant recurrence breast cancer
numbness or weakness
persistent dry cough
changes to vision/headaches/nausea
pain in bones
balance issues
seizures
Prostate cancer
288,300 cases of prostate cancer
RF: non hispanic black men, 65+ older
local survival rate >99%
distant survival rate = 31%
S/S Prostate Cancer
difficulty urinating
frequent urination
weak or interrupted flow of urine
painful or burning urination
blood in urine or semen
erectile dysfunction
pain in hps/back
Benign Prostatic Hyperplasia
common condition in older men
causes difficulty urinating
puts pressure on urethra
Prostate specific antigen
blood test
usually <4 is normal
4-10 = 25% of cancer
>10 = 50% of cancer
BUT CHANGE IN NUMBER is most important
Other factors that can cause elevated prostate specific antigen
enlarged prostate
older age
prostatitis
Treatment for Prostate Cancer
active surveillance
surgery w/lymph node removal
radiation
hormonal treatment
chemo (NOT FIRST LINE OF TREATMENT)
bioagent
Active surveillance
recommended for slow growth or in older men
MD visits every 3-6 months, PSA test
teratment begins when significant increase in PSA, change in rectal exam or positive biopsy results
also called expectatnt management or watchful waiting
Cancer is common…
high likelihood treating someone in active treatment
even higher likelihood of treating a survivor
remember that there will be persistent treatment impairments, be aware of red flags of reoccurence and secondary cancers
Treatment considerations–> disease related issues
know staging, grade, type
is the disease progressing or responding to treatment –> changes plan of care
Clinical findings can be related to undiagnozed mets
Treatment considerations, treatment related issues
What treatment have they already received?
–specific surgery, chemo, radiation
What treatment are they receiving in the future? –> patient education, prospective screening
Timing of treatment side effects–> acute vs late vs persistent
