Oncology Flashcards
What is cancer?
- a disease caused by an uncontrollable division of abnormal cells in a apart of the body
- a malignant growth or tumor resulting from the division of abnormal cells
Cancer may be inherited such as
- “germline”
- BRCA 1, BRCA 2 mutations
- lynch syndrome
Cancer may be enbironmental such as:
- pollution
- lifestyle: heavy drinking, smoking
- obesity
germline mutation
- occurs in the sperm cell or egg cell
- passed from parent to child at time of conception
- mutation of that initial cell is copied into every ell within the body
- 5-20% of all cancers
acquired mutation
- Occurs from damage to genes in a particular cell during a person’s life
- “sporadic cancer”
- these are not found in every cell and are not passed from parent to child
- factors that cause these mutations: tobacco, radiation, viruses, age
Tumor supressor Genes
Limit cell growth through:
- monitoring how quickly cells divide
- repair mismatched DNA
- control when a cell dies
DNA repiar genes
- fix mistakes made when DNA is copied
- function like tumor supressor genes
treatment options
- surgery
- radiation
- chemotherapy
- hormonal tx
What is personalized medicine?
- tailors tx of a disease to specific personal characteristics of the patient and charcateristics of the tumor to produce the most effective tx for each person’s disease
goals for personalized medicine
- fewer side effects
- more effective t
- improved identification risk of cancer development or reoccurance
tumor profile
- molecular testing on the DNS, RNS and proteins to identify the biomarkers driving a patient’s tumor
- whole genome sequencing: genetic comparison of paired tumor and normal cells
factors considering when selecting tx:
- cell type, size, and location
- presence of HER2 protein
- presence of hormone receptors on cancer cells
- BRCA1,or 2
- Pre/post menpausal
- age
HER2( human epidermal growth factor receptor 2)
- growth promoting protein found on the outside of breast cells
- dictate type of chem
Lynch syndrome
- germline mutation with alternations in several genes that function in DNA mismatch repair
- incr risk of developing multiple cancers
- family hx
- early and freq colonospcopy and uterine US for early identifictaion of tumor
immunotherapy
- type oc cancer tx that boosts the body’s natural defenses to fight cancer
-may use substances naturally occuring in the body or substance created
in a lab: can distinguish between healthy and unhealthy cells
side effects from chemotherapy and radiation
- are due to cells being damaged
- may not resolve
- EX: neuropathy
side effects from immunotherapy
- due to overactive immune system
- can still be very serious, even life threatening
- skin reactions
- flulike symptoms
- SOB
- swelling in extremities
- diarrhea
- Hormone changes
Tumor lysis Syndrome
- when tumor cells are destroyed by tx, cells release their contents into the blood stream
- tumor lysis syndrome is an electrolyte and metabolic disturbances caused by excessive CA, K, phosphate and uric acid in the blood
- diagnosis of syndrome requires 2 or more metabolic abnormalities that occur 3 days before or 7 days after initiation of therapy
- major risks renal insufficiency, seizures, cardiac dysrhythmia, death
General rehab considerations while tx:
fatigue
- incorporate energy conservation and pacing eductaion/strategies
- eductaion on importance of exercise to combat fatigue
- decr intensity or length of tx
General rehab considerations while tx:
neuropathy
- may need to incorporate balance assessment/ training or recommend AD
General rehab considerations while tx:
timing of tx
- see pt before tx administered
- inconsideration of nausea
General rehab considerations while tx:
prevention of loss of motion (radiation)
- education of AROM/stretching to decr risk of contratcures in radiated areas
General rehab considerations while tx:
chemo holidays
- occurs when pt takes a break from chemo due to inability to tolerate side effects
- may see large improvements in strength, endurance or function during chemo holidays
Childhood acute lymphoblastic leukemia
- accounts 75% of childhood leukemia
- involves lymphoblasts: prevent production of normal cells; starts in marrow can spread to the CNS and lymph nodes
Risk factors for childhood acute lymphoblastic leukemia
- male> female
- white/Hispanic Race
- Previous exposure to radiation/chemotherapy
- HX genetic disorder: DS, neurofibromatosis, kunefelter syndrome,etc
S/S of childhood acute lymphoblastic Leukemia
- night sweats
- discomfort in bones or joints
- enlarged splee, liver or lymph nodes
- pain or feeling of fullness below the ribs
- unexplaines weight loss or loss of appetite
Diffuse Large B-cell lymphoma
- most common subtype of non-hodgkin lymphoma usually >60 yrs
- very aggresive form of cancer
- can develop in lymph node or any organ may be spread out or localized
risk factors for Diffuse Large B-Cell lymphoma
- over 64 yrs old
- male
- non-asian or african american
- immunocompromised
- HX exposure to radiation and chemotherapy
S/S of diffuse large B-cell lymphoma
- lump in th egroin, armpit, or neck
- fever
- night sweats
- weight loss
- belly or chest pain or pressure
- SOB or cough
- itching
Multiple myeloma
- blood cancer that involves plasma cells
- trigger osteoclasts to work more: lead to frail bones, incr CA levels in blood
S/S of myeloma
- bone pain, weakness, fatigue, weight loss, infection, pathological frcatures
complication of all blood disorders
- anemia- low level of red blood cells: fatigue SOB, dizzy, pallor
- thrombocytopenia: low level of platelets: bruising, prolonged bleeding, nosebleeds, blood in urine, bleeding gums, petechiae
- leukopenia- low levels of white blood cells: infection,fever
myeloablative conditioning
- whole body radiation and chemotherapy to kill the bone marrow cells in preparation for stem cell transplantation
- can be done inpatient or outpatient
stem cell transplantation
- use of healthy immature blood cells found in the bone marrow or blood to replace those that have been destroyed by cancer or cancer tx
- can be down inpatient or outpatient
autologous stem cell transplant
- call are harvested from the patient’s own bone marrow before chemotherapy and are replaced after cancer tx
- little to no risk of rejection or graft versus host disease
- graft failure can occur
Allogeneic stemcell transplant
- stem cells from a donor who most closely matches the patient
- used to treat disease that involve cells in the bone marrow,such as leukemia
- generate a new immune system response to fight cancer: Graft-vs-cancer effect, engraftment
- increased risk of rejection or GVHD
stem cell Donors
- matched with eligible donors by human leukocyte antigen typing
- the closer the match between the HLA markers of the donor and the less risk of the body rejecting the new stem cells
-usually first degree relative
HLA - human leukocyte antigen
- HLA are proteins that exist on the surface of most cells in the body
- HLA markers help the body distinguish normal cells from foreign cells, such as cancer
side effects of stem cell transplantation
- incr risk of infections
- low blood counts
- mouth and; throat pain
- Nausea/vomiting
- diarrhea
- loss of appetite and weight
- Pain
- fatigue
- GVHD
Graft vs Host disease
- Donor’s T-lymphocytes do not recognize the patient’s cells and attacks them
- occurs in about 50% of allogeneic SCT patients
Acute GVHD
- develops during the first 100 days s/p transplant first 3 mo
chronic GVHD
- develops after 100 days s/p transplant 2-24 mo
S/S of GVHD
- Eyes: Dry eyes, sensitivity to light
- Lungs: SOB, cough, fatigue
- Mouth: sores, pain, irritation, difficulty opening
- genitals: dryness, irritation, painful intercourse
- skin: rash,sensative, itchym dry , darkened, peeling skin , restricted ROM
- GI: diarrhea, nausea, loss of appetite, abdominal cramps, weight loss
- Liver: enlarged liver, incr LFT, abdominal tenderness
Roles of Physical Therapy
- maintain/restore/ maximize independence with functional mobility
- promote strength and endurance
- prevent decline
- recommend adaptive and durable medical equipment
- prepare pt and fmaily for safe discharge home or to next level of care
Car-Tcell therapy
- t cells are removed, reprogrammed to find and kill cancer cells, and reentered into the body
- car-T cells can multiple in the body
- most common use in liquid tumors
Why tcells?
- specifically target cells that express peptides (caner)
- potentially long clonal life
- potentially significant expansion/replication in vivo
cell harvetsing
- T cells are removed from blood via leukopheresis
- t cells are preserved and sent to lab for engineering
- modified with viral insertion of specific CAR
- cells expanded into the hundred of millions-can take 1 to several weeks
- quality assurance measures
types of CAr-T
FDA approved
- Yescarta
- kymriah
Non-FDA approved:
Juno
typical trx course for CAR-T cell
- Lymphodepleting phase: currently inpatient ~3-5wks; soon will become outpatient for some patient
- administrtaion phase: Day 0, similar to transfusion (30 min). now monitor for fever & neurotoxicity
- Recovery Phase: 2-3 weeks pending no major complications. blood cell recovery. bone marrow aspiration day 30
Cytokine Release Syndrome
- large rapid release of cytokines into the blood stream
- Primary anticipated effect after T-cell therapy
- –Symptoms: FEVER,nausea, HA, rash, rapid heartbeat, low blood pressure, and trouble breathing
**cytokine: proteins secreted by leukocytes that modulate immune and inflammatory response
Cytokine Release Syndrome
Grade 1
Mild reaction, infusion not interrupted
– Fever, nausea, fatigue, headache, myalgia, malaise
– Symptomatic treatment only
Cytokine Release Syndrome
Grade 2
Moderate reaction, infusion interrupted – Hospitalization required for treatment – Some signs of organ dysfunction – Oxygen requirement <40% – Hypotension responsive to fluids/ low dose vasopressors – Responds quickly to treatment – Grade 2 organ toxicity
Cytokine Release Syndrome
Grade 3
Severe reaction, will not respond immediately to treatment
– Oxygen requirement >/= 40%
– Hypotension requires high dose/multiple vasopressors
– Grade 3 organ toxicity
Cytokine Release Syndrome
Grade 4
Grade 4: Life threatening complications of hypotension and/or hypoxia
– Require ventilator support
– Grade 4 organ toxicity
Cytokine Release Syndrome
Grade 5
Death
CRS tx with Actemra
- Actemra: immunosuppresive drug that binds to cytokines and prevents continued immune repsonse
- resolve CRS without interfering with T-cell function
- Pt under CAR-T can receive up to 2 doses
- can increase risk for potentially fatal infections
CRS tx with Corticosteroid
Not first line of defense
• Lymphotoxic
– Reduce the effect of CAR-T cell therapy
– Recommended only for cases of tocilizumab-refractory CRS
Neurotoxicity
- reversible
- symptoms: TREMOR, confusion, aphasia, attention deficits, handwriting, apraxia, ataxia
PT treatment progression during CAR-T
- Pre-CAR-T: maintain, HEP, walking, eductaion
- Early CAR-T: monitor fevers, neuro checks, subtle changes
- middle CAR-T: onset CRS/neurotoxicity
- Late CAR-T: address lasting effects/DC planning
