Oncology Flashcards
What is cancer
uncontrolled growth of abnormal cells
can arise from any type of cell in the body
Normal tissues are able to balance the rate of
new cell growth and old cell death
In cancer, this balance is disrupted resulting in uncontrolled growth or loss of cells ability to undergo cell death (apoptosis)
what are the four major subtypes of cancer
carciomas
sarcomas
lymphomas
leukaemias
carcinomas are?
the most common forms of cancer arise from epithelial tissue such as the skin and lining of body cavities and organs eg. lung carcinoma breast carcinoma colon carcinoma prostate carcinoma
what are sarcomas
found in connective and supportive tissue such as bone, cartilage, nerve, blood vessels, muscle and fat
eg.
what are lymphomas
arise in the lymph nodes and tissues of the body’s immune system
what is leukemia
cancers of the immature blood cells that grow in the bone marrow and tend to accumulate in large numbers in the bloodstream
cancer prefix - adeno
gland
cancer prefix - chondro
cartilage
cancer prefix - erythro
red blood cell
cancer prefix - hemangio
blood vessels
cancer prefix - hepato
liver
cancer prefix - lipo
fat
cancer prefix - lympho
lymphocyte
cancer prefix - melano
pigment cell
cancer prefix - myelo
bone marrow
cancer prefix - myo
muscle
cancer prefix - osteo
bone
benign tumours
non cancerous
unable to spread by invasion or metastasise, and depending on the location and size are often left in situ
malignant
cancerous
cells invade neighbouring tissues, enter blood vessels, and metastasise to different sites
Metastasis
metastatic cancer has spread to another part of the body from the primary origin
90% are the result of metastasis
majority can not be cured by rather controlled
all types of cancer have the potential to spread but rare for blood and lymphatic cancers
cancer cells can travel through the blood or the lymphatic system until they find a suitable location to settle and re-enter the tissue
detection of cancer cells in lymph nodes plays an important role in tumour staging
Staging - TNM staging system
T= tumour size 0-4(4 being the largest) N= Nodal involvement 0-3(3 being most involved) M= metastasis 0/1 (1 being metastases present)
eg. T4N2M1
T1N0M0
What is the main sites of metastasis for breast cancer
lungs, liver, bones
What is the main sites of metastasis for colon
liver, peritoneum, lungs
What is the main sites of metastasis for kidney
lungs, liver, bones
What is the main sites of metastasis for melanoma
lungs, skin/muscle, liver
What is the main sites of metastasis for lungs
adrenal gland, liver, lungs
What is the main sites of metastasis for ovary cancer
peritoneum, liver, lungs
What is the main sites of metastasis for pancreas
liver, lungs, peritoneum
What is the main sites of metastasis for prostate
bones, lungs, liver
What is the main sites of metastasis for rectum
liver, lungs, adrenal gland
What is the main sites of metastasis for stomach
liver, peritoneum, lungs
What is the main sites of metastasis for thyroid
lungs, liver, bones
What is the main sites of metastasis for uterus
liver, lungs, peritoneum
two types of cancer treatment
curative intent
palliative intent
curative treatment
a ‘cure’ is when the rate of death for that particular cancer population is the same rate as the general population
however, it can reoccur
should be considered as prolonged remission instead of a cure
palliative treatment
When a curative treatment option is not available
Focus is on maximising survival time and quality of life
Does not mean that the patient is going to die in the next 3 months or 6 months.
Equipment
Pain Mx
treatment options
surgery
radiotherapy
chemotherapy
immunotherapy
radiotherapy
treatment using iodising radiation to cause cell damage of death
radiotherapy (XRT)
delivered via two methods
- external beam radiation/therapy (teletherapy), usually via a linear accelerator (also tomotherapy)
Bracytherapy (implants/seeding) -direct placement of radioactive source into the region of treatment (“hot” patients )
side effects of radiotherapy
mostly site specific
- radiation induced diarrhoea
- nausea and vomiting
- xerostomia (dry mouth)
- oral mucositis (painful inflammation and ulceration of the mucous membranes lining the digestive tract)
- skin reactions /burns/fibrosis
general side effects
fatigue
depression
loss of ROM
pain
chemotherapy
Using cytotoxic chemical agents to treat cancer
Can be used in conjunction with other therapies
Currently more than 50 different cytotoxic drugs are used and over 200 protocols with haematology patients alone.
side effects of chemotherapy
can cause systemic issues more so than XRT
common acute reactions to chemotherapy include
- gastrointestinal toxicity (N&V)
-neutropenia
Gastrointestinal toxicity
manifested by anorexia, nausea and vomiting
can occur prior to chemo treatment (anticipatory nausea) and can last for several days post treatment
Anti-emetic medication is very important & may be required to complete a physiotherapy session
Mouth care and other fact sheets are important (Dietician or Speech are usually involved)
Neutropenia
Diminished ability to fight infections and at high risk of becoming infected
Depending on the severity of the neutropenia you may be required to wear a plastic apron, gloves and a mask (single room & signs)
Try and see these patients first
Respiratory infection- prophylactic treatment is important in these patients
Chemotherapy precautions
Chemotherapy can be excreted via all body fluids, especially urine for 48 hours post dose but can be longer
No safe level of exposure - goal to reduce risk of exposure to As Low As is Reasonably achievable (ALARA)
Possible exposure routes:
-Inhalation, ingestion, dermal absorption, Mucosal absorption
Main risk for PT s is exposure to contaminated urine, faces or vomit.
*Sputum is not considered a risk.
Use cytotoxic precautions for 7-10 days after chemotherapy.
In case of exposure, remove self from the pt/ area immediately and wash the affected area with copious amounts of soapy water for 15 mins.
Cleanse eyes, mouth or nose that has been splashed with cytotoxic drug or contaminated waste with clean water for 15 mins
pain can arise from
A tumour compressing or infiltrating tissue
Or treatments and diagnostic procedures
Can last long after treatment has ended
XRT burns – 2-3/52 post Tx
Chemo – peripheral neuropathy
Pain
The presence of pain depends mainly on the location of the cancer and the stage of the disease.
At any given time, about half of all patients with malignant cancer are experiencing pain.
75% of pain is caused by the illness itself
Bone pain
Most common source of pain
Cancer invades the bone -tenderness, with constant background pain -spontaneous or movement- related exacerbation -frequently described as severe.
Neuropathic pain
Caused by diseased or damaged Nerves
-Often presents as burning, P&N, sharp shooting
Breast anatomy
Female breast
Lobules (milk-
producing glands)
Ducts (tubes carry milk from lobules to nipple)
Stroma (fatty tissue and connective tissue surrounding ducts and lobules)
Lymphatic system
Part of body’s defense system
Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes)
Some connect to lymph nodes inside the chest (internal mammary nodes) and some to those above the collar bone (supraclavicular nodes)
Lumpectomy/WLE
Removes the tumor with a rim of normal tissue (clear margins – 1cm)
almost always followed by radiation therapy
-decreases the likelihood of the cancer coming back in the breast by more than 50%
Mastectomy
Removal of the entire breast including the nipple and areola, leaving the pectoralis major intact
With a mastectomy, radiation is usually not necessary
sentinel lymph node biopsy
Sentinel lymph node is the first lymph node to receive drainage from the breast or a tumor in the breast
Injection of radiotracer +/- blue dye into the skin
A gamma probe used to detect radioactivity in the axilla
Only nodes that are hot and/or blue are removed
axillary clearance
An important part of staging breast cancer is determining if the lymph nodes under the arm are involved with cancer
If nodes are +ve SNB > AC
10 – 40 lymph nodes are removed during an AC
Was once standard of care for breast cancer patients
Shoulder
Shoulder ROM can be significantly limited due to
- Pain (surgery, wound, bruising, drain)
- Scar tissue
- Axillary web syndrome (cording) ! Seroma
Physiotherapy
Pre-op (gain pre-morbid levels)
- Check sh ROM and function
- UL measures
- Cancer Council handout – review stage 1 & 2 exercises
- Education re: role of physio, expectations post op, return to work/activity and Lymphoedema
- Sh ROM to 90deg only while drain insitu (4-10 days draining less than 100mls/day)
- Post op exercises – circulation, DBExs, Sitting out of bed and reg Mob
post op physio
Day 1 post op
-Review stage 1 & 2 exercises (90 deg if drain
insitu)
-Circ exs, DBExs, SOOB, Mob, Stairs Ax (if req)
-Review Education
-Book appt for 2/52 post op
outpatient appt 2/52
Review UL measures & Sh ROM
- Progress Sh ROM exercises (drain removed) ! Posture retraining & Pec stretch
- Scar advice & Mx
- L/O ex s
- Cording edu & Mx
follow up
R/V 1,6 &12 Months for UL measurements and monitoring
- Seen fortnightly during XRT (incresed risk of L/O)
- ? More regularly with Sh dysfunction, complex scaring and ongoing cording & L/O
cording (axillary web syndrome
Can be seen after any axillary surgery
Presents as a series of tender, cord-like structures that are visible and palpable beneath axillary skin
Cords can extend down the arm, into forearm
“Cording” is due to disruption of lymphatic vessels during axillary surgery
Incidence:
- 20% after sentinel node biopsy
- 44%-72% after axillary clearance
Develops in early post-operative period (within first 6/12)
Limits range of motion
Can present as burning pain
treatment of cording
The aim of treatment is to either stretch the cords or to break the cords
- Modified stretching
- Deep tissue massage and self massage
- Reassurance
- Heat
- Strengthening
contraindications
Reddening of the scars
Radiation - manual techniques should not be carried out in an area subjected to radiation until two weeks post
Metastasis in the axilla
lymphoedema
Lymphoedema can occur as result of lymph nodes being removed from surgery or if they are damaged from radiotherapy.
Definition = Reduced lymphatic transport capacity which is overloaded by a normal lymphatic load
what is lymphoedema
Lymphoedema is the swelling of one or more parts of the body that occurs when the lymphatic system does not function properly
Once the lymphatics are damaged swelling can occur at any time. It may develop gradually or immediately and affect all or part of a limb
Can occur weeks, months or years later, triggered by an incident which overloads the lymphatic system
lymph nodes
All lymph passes through one or more nodes which are largely arranged in regional groups. Macrophages in the nodes break down proteins and fight infections. They are unable to regenerate once removed.
signs and symptoms of lymphoedema
Tightness
Fullness/constricting
feeling
Discomfort/pain
Persistent/fluctuating swelling
Deepening of skin folds
Indentations in skin from clothing
Assessment
Detailed history required
Photos and detailed descriptions
Surgical history ! When/where was the surgery ! Lymph node status (number removed, number positive) ! Cancer status ! Post op healing/complications ! Type of sx ! XRT/Chemo ! Medical history (contraindications, respiratory problems- COPD, emphysema)
Swelling
! Onset on swelling
! When is swelling worse?
! What reduces oedema?
Other allied health input
Work
Social situation
Previous musculoskeletal injuries
visual inspection
Where is the swelling visible?
Extent of swelling?
Where are the scars situated?
Condition of scar – healed, thickened, mature
Skin condition
-Radiation fibrosis, fragile, blistered, thickened, nodular skin changes, ulcerations, pigmentation changes
Palpation
Texture of the skin and underlying tissue
- Scars (Mobility of the scars, thickened, soft, adhesions, raised)
- Extent of fibrosis
Consistency of Oedema
-pitting, non pitting, fibrosis
treatment goals
Reduce oedema
Improve elasticity of radiated/fibrotic areas !
Increase shoulder ROM
Reduce scarring
management of lymphoedema
Skin care and protection
Elevation
Deep breathing
Self Massage
Exercises
Compression
Manual Lymphatic Drainage
contraindications
Infection to treatment area (cellulitis)
Skin breakdown due to radiation (pain and
infection control)
Current radiation treatment
Mets
education includes
Skin Care
No sunburn or hot baths
Avoid Cuts, scratches & bruises to affected arm
No needles & blood pressure cuffs
Avoid heavy lifting
Exercise & UL movement/ elevation
Compression: wear for long distance travel and for heavy work…
Ongoing Surveillance
