week 3 Flashcards
1
Q
cancer is the [] killer of children in the US
pediatric CA
A
1
- 1/5 won’t survive –> when they do, 2/3 suffer long term effects
- 12+ types, 100s of subtypes
today, 90% of kids with most common cancers survive
2
Q
what type of cancer has highest survival rate for childhood cancer
pediatric CA
A
- ALL: acute lymphoblastic leukemia
3
Q
efficacy/survival rates have [], but side effects are []
pediatric CA
A
- survival rates have improved, but side effects are increasingly damaging
- secondary cancer, heart/lung damage, infertility, chronic hepatitis, alterations in growth and development, impaired cognitive abilities, psychosocial impact
- 2/3 of survivors experience at least 1 side effect
4
Q
pediatric vs adult cancer
pediatric CA
A
5
Q
most common childhood cancer diagnosis
pediatric CA
A
- leukemia
- 28% of childhood cancers
- cancer of the bone marrow and blood
- most start in early (precursor) forms of white blood cells
- symptoms: pallor, fatigue, bruising/bleeding, fever, bone/joint pain in different joint
- most common types: acute lymphoblastic leukemia (93% survival rate), acute myeloid leukemia (75% survival rate)
6
Q
medical treatment “road map” for childhood cancer
pediatric CA
example
A
- induction: 4 weeks, to put into remission
- consolidation: 4-8 weeks, treatment into spine
- interim maintenance: 6-8 weeks, “rest” phase
- delayed intensification: 8 weeks, reduces hiding cells
- maintenance: 2-3 years
- allows the team to know meds, side effects to expect
7
Q
brain and CNS tumors in childhood cancer
pediatric CA
A
- 26% of childhood cancers
- variable treatment plans due to variable tumors/types
- most tumors start in lower parts of brain (cerebellum, brain stem)
- symptoms: HA, NV, visual changes, dizziness, seizures, ataxia, weakness
8
Q
red flags for cancer in young child
pediatric CA
A
- increased fussiness or irritability
- mildly pale
- bruising/bleeding/nosebleeds
- leg pain –> refusal to walk, wanting to be carried
- regression in developmental skills
- screening: regression of skills, change in mobility, difficulty keeping up with peers, increase in clumsiness, tripping or falling, walking or moving differently
9
Q
red flags for cancer in older child
pediatric CA
A
- complaints of fatigue and tiredness
- change in eating habits
- weight loss
- night sweats
- bone/joint pain
- fever and respiratory symptoms
- screening in adolescents/YA: trouble running/jumping/stairs, walking differently, feeling more tired or exhausted, change in activity levels, tingling or numbness in hands or feet, tripping or falling
more like adult S&S
10
Q
chemotherapy side in children
pediatric CA
A
- chemo: peripheral neuropathy –> distal deficits
- steroids: steroid mypathy –> proximal deficits
- cardiac effects, fatigue, avascular necrosis, orthopedic procedures
11
Q
radiation side effects in children
pediatric CA
A
- skin burns, blistering, reddness –> can produce ROM deficits (painful to move)
- fatuge, pain
- joint contracture
- osteoporisi
- cardiac and vascular disease
12
Q
peripheral neuropathy in children
pediatric CA
A
- common, under-diganosed
- 83% of children treated for non-CNS cancers with vincristine have clinically or sub-clinically significant peripheral neuropathy
- clinical findsings: strength deficits, impaired DTRs, impaired sensation, poor balance
- functional imapcts: foot drop (tib ant), gait compensations, imapired balance, impaired proprioception
permanent in adults
at 3 months post treatment, 30% improvement
13
Q
cancer-related fatigue in children
pediatric CA
A
- persistent, distressing, subjective sense of physical/emotional/cognitive exhaustion that is not proportional to recent activity
- no relief with rest or nap
- prevalence ranges 59-100%
- execise in small doses
14
Q
cancer long-term side effects in children
pediatric CA
A
- compaired to siblings, adult survivors of childhood cancer are more likely to experience issues related to general health, mental health, functional impairments, activity limitations
15
Q
role of PT in childhood cancer
pediatric CA
A
- minimize impairments and maximuze activity in age-appropriate life roles in home, school, and community
- cancer impacts child’s entire life, not just body
- occurs during critical developmental periods – can alter course of development
16
Q
PT intervention in childhood cancer
what does the literature say
pediatric CA
A
- safe and feasible
- improvements demonstrated in fatigue, strength, CP endurance, balance
- positive effects on QOL, activity levels, physical function
- supportive of need for comprehensive, proactive models of pediatric oncology rehab
- lab count considerations: patients with cancer always have low platelets/blood counts, so instead of letting numbers dictate, use S&S to dictate PT/treatment
17
Q
orthoses for pediatric cancer
pediatric CA
A
- for ease of walking, increased participation, willingness to exercise
18
Q
considerations for PT evaluation in childhood cancer
pediatric CA
A
- activity and participation
- ADLs, school, after school activities, recreational activities, peer and sibling interactions, age appropriate play, family community outings
- gaite analysis, function task and movement, developmental screen, QOL measures, patient specific functional scale (PSFS), AMPAC
- impairments
- ROM deficits, sensory impairments, muscle weakness, balance deficits, poor endurance or fatigue, motor planing and coordination, pain, gait deviation, motor skills and functional mobility
- MMT, ROM, SLB, PBS, light touch, pediatric modified total neuropathy scale, 2 or 6 minute walk test, 10 m walk test, TUG, TUDS, modified ashworth
19
Q
final thoughts on childhood cancer
pediatric CA
A
- children and adolescents with cancer often have high rehab needs and potential
- create an active partnership with families to determine priorities and model of care for rehab
- providing education to promote self-management and lifestyle strategies is key to optimal outcomes
20
Q
goals of cancer treatment/medical interventions
A
- diagnosing a tumor (biopsy)
- removing a “precancerous lesion”
- debulking tumor
- correction of life-threatening condition caused by cancer
- fracture prevention
- palliation
- cure
21
Q
current anti-cancer approaches
A
- surgery: remove unknown tumor masses
- radiation: kill rapidly dividing tumor cells including tumor cells in adjacent tissues
- chemotherapy: kill rapidly dividing cells
- hormone therapy: inhibit growth and survival of homrone-dependent tumor cells
- targeted therapy: specifically inhibit processes required for tumor cell growth
- immunotherapy: recruit the immune system to attack tumor cells
22
Q
quantifying toxicity
A
- national cancer institute (NCI) common terminology criteria for adverse events (CTCAE)
- 1 - mild
- 2 - moderate
- 3 - severe
- 4 - disabling/life-threatening
- 5 - death
- people don’t want to talk about toxicity and have to stop “cure”
23
Q
myelosuppression
common treatment-related side effects
A
- suppressing everything in myeloid line
- white blood - focus on neutrophils, immune deficient
- platelets –> bleeding risk
- red blood cells –> anemia
- most common dose-limiting toxicity
- onset depends on lifespan of blood cells: neutrophils (5.5 days), RBC (20-190 days), monocytes (1-3 days), platelets (8-9 days)
- drug, dose, and regimen-specific
24
Q
neutropenia
common treatment-related side effects
A
- high risk of contamination/illness (no fresh flower or fruit)
- due to radiation therapy and/or chemo - kills cells that grow at fast rate
- normal neutrophil count is 1,500-8,000 cells/mm^3
- management
- neutropenic precautions: wash hands, minimize exposure from sick people and large crowds
- treatment: boost WBC production
- granulocyte colony-stimulating factor (GC-SF)
- side effect - bone pain
25
thrombocytopenia
| common treatment-related side effects
* low platelets
* normal is 150,000-350,000/mm^3
* consider fall risk, muscle trauma (resistance exercise)
* consider normals for patient
* watch for increased brusing/petechiae, prolonged bleeding times, concomitant medications (anticoagulation)
* management: platelet transfusion
26
anemia
| common treatment-related side effects
* S&S: fatigue and cardiac systems
* risk factors: tratement, malignancy, age, hemoglobin level, comorbidities
* critical value < 7-8 g/dL
* **management**
* RBC transfusions
* erythropoietic stimulating agents - boost RBC production: epoetin alfa (procrit), darbepoetin (aranesp)
* FDA mandated black box warning - serious or life-threatening risk, increases clot risk
27
alopecia
| common treatment-related side effects
* common
* scalp hair > other body hair
* onset 1-2 weeks, max 3 weeks
* reversible: regrowth in 2-3 months
* risk varies by class:
* lowest risk is hormones, targeted agents
* low-moderate risk is antimetabolites and platinum agents
* high risk is classic alkylating agents
* very high risk is anthracyclines, taxans
28
diarrhea
| common treatment-related side effects
* mucosa of GI tract has high cell turnover rate - attacked by chemo
* **types**
* acute
* chronic: more than 24 hours after treatment, dehydration (hypovolumic, hypotensive), treat with imodium
29
nausea and vomiting
| common treatment-related side effects
* acute: onset minutes to hours, resolves within 24 hours
* delayed: onset > 24 hours after chemo, can last 6-7 days
* anticipatory: conditioned resposne to past experience with CINV (chemotherapy induced NV)
* breakthrough: occurs despite appropriate emetic prophylaxis therapy
* refractory: occurs despite prophylaxis and breakthrough emesis treatment
30
cancer related fatigue
| common treatment-related side effects
* distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning
* CRF is more severe, more distressing, and less likely to be relieved by rest
31
chemo-related cognitive dysfunction
| common treatment-related side effects
* **chemo brain/fog**
* found in up to 75% of patients
* subtle shifts in cognitive function
* may be seen early or late
* may improve over 6 months - 2 years after treatment
* **mechanism unknown**
* not a result of anemia, fatigue, or depression
* cumulative effect with chemo
* **effects**
* difficulty concentrating
* difficulty handling/performing multiple tasks
* difficulty with STM
32
cancer toxicity in perspective
* early recognition is better chance to recover
* every patient has some toxicity, but no one gets all of them
* grades 1-2 most common: accepted by oncology providers, dose reduction not warranted
* grades 3-4 toxicity likely, hold doses to permit recovery, reduce subsequent doses, prevention important if possible, risk no recovery from symptoms
* grade 5: toxicity uncommon
* weigh risks and benefits
33
taxanes and vinca alkaloids
* **MOA**: interefere with mitosis (M phase)
* taxanes: binds to stabilized microtubules, interfere with disassembly
* vinca alkaloids: inhibit microtubule assembly
* **side effects**
* peripheral neuropathy - distal to proximal: stocking and glove, motor nerve impairment leading to loss of DTR and ataxia, paralysis (foot and wrist drop), irreversible or minimally reversible
* cardiotoxicity: arrythmias - bradycardia, hypotension, heart failure
34
taxanes
paclitaxel, docetaxel, cabzitaxel
| of taxanes and vinca alkaloids
35
vinca alkaloids
vinblastine, vincristine
| of taxanes and vinca alkaloids
36
alkylating agents
* **MOA**: prevent cell division by cross-linking DNA strands (S phase)
* increase bonds between bases to prevent separation and synthesis of DNA
* intra and inter strand cross links
* cell continues to synthesize other cell constituents (RNA, protein) and imblanace occurs --> cell dies (G1/G2 phase)
* **side effects**
* myelosuppresion: primary dose-limiting toxicity, leukopenia (immune suppression, decreased WBC levels)
* hemorrhagic cystitis: more common in poorly hydrated or patients with renal disease, hematuria
* neurotoxicity: encephalopathy manifested by cerebellar ataxia, mental confusion, complex visual hallucinations
37
alkylating agents
cyclophosphamide, ifosfamide
38
anthracycline
* the rubicins
* **MOA**: prevent cell division by intercalation between DNA base pairs (S phase), sits in DNA helix and blocks DNA synthesis --> inhibit DNA replication
* **side effects**:
* cardiotoxicity: acute (pericarditis, arrhythmias), chronic (congestive cardiomyopathy and HF) --> HR risk increases with escalating dose of doxorubicin
* hand-foot syndrome: erythema, swelling, dysesthesia - painful itching and burning in cold, blistering and desquamation (shedding of skin)
39
anthracylcines
rubicins
doxorubicin, adriamycin (red devil)
40
HF risk and doxorubicin
risk increases at 550 mg/m2
41
targeted therapy
| HER2 monoclonal antibodies
* for breast cancer
* human epidermal growth factor receptor 2 (HER 2)
* HER2 is a growth promoting protein - HER2 receptors overexpressed in some breast cancers
* **MOA**: binds to HER2 receptor preventing receptor activation and slowing growth
42
hormone therapy
* block receptor activation --> interrupt cell growth and signaling cascade
* especially in prostate and breast cancer
* anti-estrogen agents: blocks estrogen production, block aromatase (enzyme that catalyzes estrogen formation)
* anti-estrogens: selective estrogen receptor modulator (SERM)
43
anti-estrogen agents and anti-estrogens
AEA: anastrozole (arimidex), side effects are hot flashes, joint pain, osteoporosis
AE: tamoxifen (nolvadex), impacts receptors on tumor, side effects are thromboembolic events, hot flashes
| hormone therapy
44
other hormonal agents
* **androgen ablation/androgen deprivation** therapy for prostate cancer -- anti-androgens decrease testosterone synthesis
* examples: bicalutamide, enzalutamid, apalutamide
* SE: hot flashes, arthralgia, seizures, falls, fractures
* **luteinizing hormone release hormone (LHRH) agonists**: increases testosterone followed by suppression
* examples: leuprolide (lupron, eligard), gosrelin (zoladex)
* SE: hot flashes, feminization, tumor flare
45
radiation therapy (XRT)
* attempts to isolate tumor
* external beam radiotherapy (XRT) - works by damagin DNA of exposed tissue
* beams targeted to tumor to increase "absorbed dose" in radiation field, try to limit normal tissue exposure
* non-selective: impacts CA and other fast-dividing cells in the area
* goals: cure/slow CA progression, shrink tumor for palliation, shrink tumor for surgical resection
46
brachytherapy
* internal radiotherapy - radiation source within the body, attempts to limit side effects
* radiation sources ("radioactive seeds") are placed in or next to area of treatment/tumor
* localized and precise therapy for multiple types of cancer - prostate, cervical, breast, skin, brain
47
common side effects of radiation therapy (toxicities)
* immunosuppression: radioation to long bones, ilium, sternum
* skin changes: fragile skin, erythmatous skin, radiation burn, tissue fibrosis (acute or chronic), myofascial adhesions
* GI changes: NV --> impaired nutrition, protein deficiency, muscle catabolism
* fatigue: cumulative over course of XRT, may resolve when XRT complete or last 6 months - 1 year
* avascular necrosis (AVN): loss of blood supply to an area resulting in necrosis of tissue (hip most common --> result in femoral head collapse and fracture), sx are pain with WB, ache in groin and anterior thigh, minimal relief with rest
* radiation myelitis - especially in CNS tumors: damage to small blood vessels in spinal column resulting in loss of blood flow, necrosis, demyelination, typically 4-12 months after completion of radiation, symptoms include sensory dysfunciton and motor weakness
48
bone marrow transplant
* process: induction chemo/radiation --> transplant --> engraftment
* autologous/autogenic: transplant cells come from patient themselves
* allogenic: transplant from donor, HLA matching, sibling/family member, matched unrelated donor (MUD)
* side effect - graft vs host disease): donated cells recognize recipients cells as foreign, trigger immune response
