Oncology: Principles in Oncology Rehab 1 Flashcards
WHY do PTs need to know about pts w/ Cx
- ALL systems affected
- ALL ages affected
- Cx and Tx affects function + mobility
-
ICF
- Body function and Structure==Impairments
- Activity=Limitations
- Participation=Resstrictions on life situations
-
ICF
PT settings where you will see oncology pts
ALL of them!!!
Estimated New Cx Cases in US
see pics
Carcinogenesis Terminology:
what is Cx?
- Alteration of differentiation so that malignant cells cannot be recognized by its origin parent cells
- **ANAPLASTIC
Carcinogenesis Terminology:
Dysplasia
- GENERAL disorganization of cells
- MAY BE REVERSIBLE
Carcinogenesis Terminology
Metaplasia
- DISORDERLY cell patterns
- REVERSIBLE AND BENIGN
Carcinogenesis Terminology
Hyperplasia
- INCd # of cells creating a tissue mass
- NEOPLASTIC HYPERPLASIA
Tumor, Neoplasm, Malignancy
- a NEW growth
- Any abnormal mass or tissue which exceeds the growth of NORM tissue
- SERVES NO USEFUL PURPOSE
- Benign OR malignant
Cx defined:
A group of dis’s characterized by uncontrolled growth and spread of abnorm cells
Benign
Characteristics:
- SLOW growing
- Encapsulated (one area)
- NON-invasive
- Tumor cells are SIMILAR to originating tissue
- HIGHLY differentiated
- **can still be very serious or life-threatening depending on location or size
Malignant
Characteristics:
- RAPID uncontrolled growth
- NON-encapsulated (spread out)
- Destructive to surrounding tissue
- NOT WELL-DIFFERENTIATED
- **Ability to metastasize
Dx of Cx:
S/S
- PAIN
- Fatigue
- Palpable lump
- Wt. Loss—-often unexplained
- Fx***
- iatrogenic fx’s
- *sometimes FIRST sign of metastatic cx
- Dis specific sx’s
Dx of Cx
S/S
Paraneoplastic Syndromes
- Tumor producing s/s AWAY from primary or metastatic site
- thru production/secretion of hormones
ONLY WAY TO DEFINITIVELY Dx A Cx
BIOPSY ***
Dx: Exams and Tests to detect Cx
- Blood tests
- Palpation + Clinical exam
- Radiography
- US
- MRI
- Bone Scan****
- Lab tests
- stool sample
- sputum
- cytology
-
Site specific Tests
- colonoscopy
- mammography
- sigmoidoscopy
- Pap smear
- bronchoscopy
-
BIOPSY***
- ONLY definitive way to Dx Cx
BIOPSY
*only way to definitively Dx Cx
Different methods:
- Curettage (Pap smear)
- fluid aspiration
- Fine needle aspiration
- Core needle biopsy
- Dermal punch
- Endoscopy
- open excision
- Sentinel lymph node biopsy
- stereotactic biopsy
- robotic needles
Dx of Cx and Genetics???
Only a SMALL portion of cx’s linked to a single gene are inherited
*only 5-10%
Dx of Cx: Genetics
MOST COMMON Cx WITH A FAMILIAL PATTERN:
PBOC
- Prostate
- Breast
- Ovarian
- Colon
Dx of Cx: Genetics
Oncogenes
- Ability to transform norm cells INTO malignant cells by hyperactivation
Dx of Cx: Genetics
Tumor suppressive genes
- Regulate growth and inhibit carcinogenesis
Dx of Cx: Genetics
What leads to aggressive cell proliferation? (dividing and spreading of cx cells)
- Defects in BOTH oncogenes and tumor suppressive genes leads to aggressive cell proliferation
- MORE oncogenes and LESS tumor suppressive genes==> Aggressive cell proliferation
Research ID and cataloguing genes that are assoc’d w/ Cx
- BRCA 1, BRCA2
- Cx suppressor is mutated
Dx of Cx: Genetics
In contrast to genetics, ________ all cx may be caused by environmental agents (carcinogens) OR viruses
50%
NON-modifiable risk factors for Cx
Age
Genetics+Family Hx
Gender
Race
Ethnicity
MODIFIABLE Risk Factors for Cx
-
Dietary improvements
- HIGH fruits+veggies
- limtd animal meat/fat
- multivitamin w/ folate–> DNA repair
- Limtd alcohol intake
- safe sex
- wt. control + obesity prevention
- Phys activity
- tobacco prevention+cessation
- environmental exposure including sun protection
- participating in screenings
Staging of Cx
What is Staging used for?
Process to describe extent of disease
- aids in Tx planning
- Predicts clinical prognosis
- Compares results of tx
2 types of staging in terms of clinical vs. disease state
Clinical staging vs. Pathologic staging
Types of Staging
- I-IV
- TNM
- Grades
- In situ-distant spread
Staging Cx
See pics for ENTIRE CHART
Staging Cx I-IV
Stage 0
In situ, pre-malignant
Staging Cx: I-IV
Stage I
- <2 cm
- LIMTd to LOCAL site therefore easily resectable
- *BEST CHANCE OF SURVIVAL– 70-90%
Staging Cx: I-IV
Stage II
- 2-4/5cm
- Invasion to organ OR adjacent tissue
- Microinvasion to lymphatic system
- Resectable BUT uncertain of clear margins
- Survival rate ~50%
Staging Cx: I-IV
Stage III
- 5 cm
- Invasion INTO lymphatic system
- Operable but not resectable
- Survival ~20-25%
Staging Cx: I-IV
Stage IV
- 10cm
- Metastatic lesions (regional OR distant)
- Inoperable for resection
- *Survival 5%
MOST commonly used system for Staging
Particularly for Solid Tumors
TNM
- T=Tumor size
- N=absence of presence of Lymph Nodes
- M=absence or presence of Metastases
TNM Staging
T=Tumor size
Tumor size
- Tx: primary tumor cannot be assessed
- T0: NO evidence of primary tumor
- T1-T4: Progressive INC in tumor size
TNM Staging
N= regional Lymph Node involvement
N=Lymph Node involvment
- Nx: nodes cannot be assessed
- N0: No metastases to local lymph nodes
- N1-3: Progressive involvement to regional lymph nodes
TNM Staging
M=presence of distant Metastases
M=distant Metastases
- Mx: presence of distant mets cannot be assessed
- M0: No distant metastases
- M1: Presence of distant metastases
Grades of Tumor or Cx
Explain…
- Provides measure of differentiation
- Information on size, shape, rate of cell division
- indicates Aggressiveness
Grades of Tumor or Cx
3:
- LOW: Better predictive and prognostic outcome
- INTERMEDIATE
- HIGH: Poor cellular differentiation, likely to metastasize EARLY
In Situ to Distant Spread
Broken down into 5 categories
- In-Situ
- Local spread
- Regional spread
- Distant spread
- Carcinomatosis
In situ to Distant spread
In-situ
Orig layer of cells which are contained w/in tissue
In situ to Distant spread
Local spread
- Penetration OUTSIDE orig layer of tissue
In situ to Distant spread
Regional spread
- Spread to nearby tissue or lymph nodes in area of origin
In situ to Distant spread
Distant spread
- Spread to other organs or areas of body
In situ to Distant spread
Carcinomatosis
- WIDESPREAD end-stage disease
Mechanisms of Metastasis
Primary Disease
- cells CAN BE ID’d from primary organ
Mechs of Metastasis
When does Metastases occur?
- occurrs when cells break from primary tumor and travel by circulatory OR lymphatic system to DISTANT AREAS of the body
- tumor cells become trapped in the capillaries of distant organs
Metastases occurs in other ways:
- Growth extension and invasion into adjacent tissue
Metastasis is often to body areas of _________
Examples?
High blood flow
- Lungs
- Liver
- Brain and CNS
- Lymphatic system
- Skeletal system
Pts found w/ and w/out metastases
- 30% pts found w/ metastases on Dx
- 30-40% pts w/ hidden mets @ Dx
Eval of Metastases
Methods:
- Radiograph
- Bone scans
- CT
- MRI
- *particularly for spinal involvement
-
PET scan
- *for cells that metabolize glucose unusually fast
- Lab tests
- Ca* lvls
- Serum markers
Eval of Mets
*PET scans
what should you know??
BEST to eval loc and size of mets in pts w/ advanced mets disease
Brain Mets
30% of all brain tumors
Brain Mets
Common Cx’s that metastasize to brain
Lung
Breast
Melanoma
Kidney
Brain mets
prognosis
3-6mos
Brain Mets
S/S
- HA
- nausea/vom
- fatigue
- seizures
- confusion
- diff concentrating
- falls
- double vision
- other neuro deficits
Brain Mets
Leptomeningeal Disease
what is this?
- Spread INTO meninges and CSF
-
Often FROM:
- Breast cx, lung cx, melanoma
Approx ____________ of all cx will metastasize to BONE
50%
Bone Mets
Common Cx’s
see chart
Bone Mets
S/S
- PAIN
- swelling
- palpable mass
- sensory and/or motor changes
- functional changes
- Gait disturbs
- Fx
- Systemic sx’s
Metastatic Bone Dis
what is COMMON?
PAIN @ NIGHT
Metastatic Bone Disease
OsteoLYTIC Mets
- Cx cells cause bone DESTRUCTION
- renal cell cx
- lung cx (NON SMALL CELL)
- melanoma
- thyroid cx
Metastatic Bone Dis
OsteoBLASTIC mets
- Cx cells cause BONE FORMATION
- prostate cx
- lung cx (SMALL CELL)
This Lung Cx is osteoLYTIC
NON-small cell
This Lung Cx is osteoBLASTIC
SMALL-cell
Metastatic bone disease
Mixed (osteolytic + blastic)
- causes bone destruction AND formation
- Breast Cx *****
This type of Cx is MIX of osteolytic and osteoblastic
Breast Cx
Evaluation of Fx Risk
Mirel’s Scoring System (see pics)
What else are we looking for?
- Immobility vs. ambulation/limtd WB
- compression fx’s and cord compression
-
Tx:
- Sx
- Radiation
- Protected WB
Lung Mets
Lung tumors originate where ?
OUTSIDE lung tissue
Lung Mets
Tumors commonly metastasize from:
- Primary breast
- Primary bone
- Primary renal
- Primary colorectal
- Primary testicular cx’s
Lung Mets
Tx
depends on primary tumor AND prognosis
Lung Mets
Sx’s
SOB
Hemoptysis–coughing up blood
dry, persistent cough
Lung Mets
PT implications
- Asses/monitor HR
- PulseOX
- RPE–Borg
Tx of Cx’s
Various tx’s
- Sx
- Chemo
- Radiation
- Biologic therapies
- Hemapoietic Stem Cell Transplant
- Supportive Tx; complementary vs alternative therapies
-
Tx may be in Combination
- Adjuvant vs. Neoadjuvant
Tx of Cx
Factors in determining Tx:
- Type/Stage of Cx
- Gen health of Pt
- QOL
- Effectiveness of Tx
- Financial strains
- Social supports
MOST COMMON TYPE OF Cx Tx
Surgery!!!
Cx Tx
Sx
- Determined by:
- Cx type
- Cx location
- Pts functional status
Cx Tx
Sx GOALS:
- Biopsy—–only definitive way to dx cx
- Removal of tumor
- complete resection or tumor debulking
- Correction of life threatening condition
- Pain relief and palliation
Chemotherapy
More useful for tx of what???
WIDESPREAD or Metastatic disease
**SYSTEMIC (whole body) Tx
Chemotherapy
- WIDESPREAD or METASTATIC DIS
- Affects cell DNA synthesis
- SINGLE agent or COMBO therapy
- Delivery
- PO
- subcutaneously
- IM
- IV
- injection
- wafers
- Single dose or Multiple doses in rounds to min. SEs
-
Affects tissue w/ high rate of cell division
- GI
- Hair
Cx Tx
Chemotherapy GOALS
- DESTROY or SHRINK tumors
- Slow progression of dis.
- Palliation
- Reduction of tumor size to allow for sx resection
Common Chemotherapy agents
- Cisplatin
- Ifosfamide
- Cytarabine
- Methotrexate****
- Doxorubicin
- Vincristine****
- Tamoxifen
- B-interferon
Cx Tx
Radiation
MORE USEFUL TO WHAT
LOCALIZED lesions
Cx Tx
Radiation
- LOCALIZED lesions
- destroys cells by damaging DNA to impair cell replication
- attempt to minimize damage to healthy tissue
-
affects tissues w/ high rate cell division
- skin
- GI
- hair
-
**Hyperfractionation
- SMALLER doses @ HIGHER freq
Cx Tx
Radiation
GOALS:
- DESTROY or SHRINK tumors
- Curative OR Palliative
- Reduction in tumor size to allow for complete sx resection OR reduced amt of sx intervention
Types of Radiation
- Teletherapy–external beam radiation
- Sealed source–brachytherapy (radioactive implants)
- Intensity Modulated Radiation Therapy–IMRT
- 3D beams
- Cyberknife—robotic/precision mapping
Biologic Therapies (Targeted Therapies)
4 types
- Monoclonal antibodies
- Small molecules
- Antiangiogenic Therapy
- Hormonal Therapy
Biologic Therapies (Targeted Therapies)
Monoclonal antibodies
- Pharmaceutical antibodies that specifically act against particular antigen
- Marks the cells so that other components from bodys own immune system will attack it
- Antibodies can be carriers for chemotherapies—minimizes SE’s
Biologic Therapies (Targeted Therapies)
Small Mc’s
BLOCK enzymes and receptors to PREVENT growth and proliferation
Biologic Therapies (Targeted Therapies)
Antiangiogenic Therapy
BLOCKS formation of new blood vessels supplying the tumor
Biologic Therapies (Targeted Therapies)
Hormonal Therapy
BLOCKS hormone receptors for hormone that supplies tumor
Hemopoietic Stem Cell Transplant
Used for Tx of what ?
- Leukemia,
- MDS (Myelodysplastic Syndrome)
- Lymphoma
- Aplastic anemia
Hemopoietic Stem Cell Transplant
- leukemia, MDS, lymphoma, aplastic anemia
-
High Dose chemotherapy AND whole body radiation kills cx but creates bone marrow destruction
- Stem Cell transplantation to REBUILD marrow found in bone marrow and circulating blood
- Autologous–pts own body OR Allogenic–donor
Hemopoietic Stem Cell Transplant
GOALS
- Rid body of diseased marrow and replace it w/ fresh healthy functioning marrow
Cx Tx
Stem Cell Harvest
MAIN POINTS
- pt given G-CSF to produce high vol of circulating stem cells
- Collection from BONE MARROW
-
Allogenic (from donor) transplants–> HLA (human leukocyte antigen)
- must be matched***
Cx Tx
Supportive Tx: Complementary and Alternative Tx
- Integrative medicine
- acupuncture
- reiki
- hypnosis
- yoga
- meditation***
- massage
- tai chi
- Qi gong
Tx Outcomes
No Evidence of Disease
NED:
- ALL signs of disease have disappeared after tx from 0-5yrs
Tx Outcomes
Durable Remission
NED for prolooooonged period
Tx Outcomes
Cure:
W/out evidence of dis @ 5 yrs POST-Dx
Tx Outcomes
What about people who are cured?
STILL REMAIN w/ sig limitations and impairs
affects function***
Karnofsky Performance Scale
What is it?
- measures ability of cx pts to perform ordinary tasks
-
Can be used to determine:
- prognosis
- participation in clinical trial
- measure changes in pt function
HIGHER SCORE==HIGHER lvl of function
LOWER SCORE==LOWER chance of survival
Eastern Cooperative Oncology Group Performance Scale
ECOG
what is it??
- Determines HOW a pts disease is PROGRESSING
- HOW dis affects ADLs
- Determining ability of pt to tolerate tx
- Assists in prognosis
Progression of Care
4 Steps
- Preventative
- Restorative
- Supportive
- Palliative
Progression of Care
Preventative
PRIMARY PREVENTION
- 1/2 ALL cx deaths could be prevented thru screening tests and healthier lifestyle
-
Epigenetics: Block formation and progression of cx
- Nutrigenetics: change gene sequencing and function AND DNA sequencing w/ foods/beverages
-
Chemo prevention: use of agents to inhibit and reverse cx by eliminating pre-malig cells and blocking progression of norm cells into tumors
- NSAIDs, green/black tea, Vit D/E
-
Cx vaccines: using a persons OWN cx cells that have been inactivated to stimulate immune system to make antibodies which will respond in the event of reoccurrence
- HPV vaccine
Progression of Care
Preventative
SECONDARY PREVENTION
- EARLY detection and QUICK tx to reduce morbidities and mortality
Progression of Care
Preventative
TERTIARY PREVENTION
- Sx mgmt
- limiting comps and preventing disability
- Active role of PT: GOAL to improve and maintain
Role of PT in Prevention
Morano MT, et al
See study below
Progression of Care
RESTORATIVE
- GOOD oncologic prognosis and functional potential
- GOAL: MAXIMIZE phys, social, psycho, vocational function
- Tx: impairment or disability***
- Active Role of PT: maintain function and prevent further impairment or disability
Progression of Care
SUPPORTIVE
- LIMITED oncologic prognosis and functional pot.
- Focus: on home and family support, QOL
- Maintaing function thru survivorship and/or progress of disease
- Active Role of PT: PREVENTION of further impairment or disability
Progress of Care
Palliative Care
What is Palliative Care?
- approach that improves the QOL of life of pts and their families facing proble assoc’d w/ life-threatening or serious illness
- Thru prevention and relief of suffering by means of:
- EARLY ID and impeccable assessment and Tx of pain and other problems, physical, psychosocial and spiritual
Progress of Care
Palliative Care
More on Palliative Care
- Curative options EXHAUSTED
- Regardless of lifespan
- **Multidisciplinary approach
-
AIMS:
- sx mgmt
- MIN SEs from dis. or Tx
- address psychological, social, spiritual concerns
Progress of Care
Hospice Care
What is Hospice Care ?
- Death is imminent, support and care given for people in the last phase of an incurable dis so they may live as fully and comfortably as possible
Progress of Care
Hospice Care
More on Hospice Care
- Focus on QOL rather than length of life
- life expectancy <6mos
- Family centered
-
AIMS:
- PAIN control
- MAX activity w/out restricts
- emotional and psycho. support for pt and fam
Medicare Req’s for Hospice Care
- Phys and medical director use clinical judge. to certify pt is terminally ill w/ life expectancy <6mos if dis runs normal course
- enrolls in Medicare approved hospice
- PT services included
Role of PT in Palliative and Hospice Care
-
Improve/maintain LOF**
- pt indep.
- reduced burden on caregivers
- Max. comfort
- Implement pain mgmt
-
Positioning**
- protect skin integrity
- Max pulm function
- Energy conserv.
- Home mods
- caregiver training/edu.
- respect goals of pt/fam
Effects of PT on Pain and Mood in pts w/ terminal Cx: Pilot RCT
See study below
What is a Survivor?
*someone who has completed active cx tx
Healthy People 2020
- INC proportion of Cx survivors who are living 5yrs or longer after Dx
- Baseline- 66.2% >5yrs survival
- TARGET: 72.8%
Macmillan Cx Support
-
Survivor: someone who is living w/ or beyond cx
- completed initial cx mgmts and has no apparent evidence of active dis.
- living w/ progressive dis and may be receiving tx but is NOT in terminal phase of illness
- has had cx in past
- edu, resources, fundraising
Primary Needs of Survivors
- prevention/detection
- monitor for reoccurrence, spread, 2* cx’s
- interventions for cx and tx SEs
- coordination of med. team
- monitor for delayed or prolonged sx’s
Role of PT in Survivorship
- Address Impairments!!!!!
- PAIN
- dec ROM
- Balance
- Weakness
- Limtd mobility
- fatigue
- Posture
Cx Rehab: Overview of Current Need, Delivery Models, Lvls of Care
- Impairments + disability reduces QOL, reduces part. in society, INCs healthcare utilization
- survivors have several issues that must be addressed
- survivors need continuous ex related edu from EARLY in tx, adapted thru tx and cont’d thru survivorship
- ACSM cert for Cx exercise!!! GET IT!!!
Cx Rehab
Delivery Models
Prospective Surveillance Model
Eval @ dx to deterine baseline, enlarged scope to cover wellness and surivorship care, web-based and telemedicine
Cx Rehab
Delivery Models
Referral Trigger Model
automated referral for certain dx’s like lymph node dissection, imbedded screening during onco appts
Cx Rehab
Delivery Models
Established Rehab Care Delivery Pathways
impairments and adverse sx’s bring pts to hospital or clinic and pt is referred for tx of functional decline
Cx Rehab
Delivery Models
ICF, Disability and Health
mapping ICF impairments to outcome based functional measures but little impact on clinical practice
Cx Rehab
Delivery Models
Center Based Programs
Reconditioning program for pts during and after cx tx
similar to cardiopulm rehab
Cx Rehab
Delivery Models
Exercise for Rehab and Fitness
Conditioning from dx for aerobic fit, strength/endurance,
mitigates toxicity, optimize function, 2* cx prevention benefit