OncologyCh.9

Goodman

Defined as a large group of diseases characterized by uncontrolled cell proliferation and the spread of abnormal cells

Terms used interchangeably:neoplasm, tumor, malignancy, carcinoma

Cancer

Does the person know they have cancer? If YES, then what implications for PT? If NO, then what next?

Thoughts on Review

Differentiation

DEFINITIONS Physical and

structural changes in cells

In CA cells, the cell loses identity from parent cell

The cell is considered to be undifferentiated or ANAPLASTIC

Less differentiation>>faster metastases

Dysplasia

More Definitions Disorganization of

cells Reversible Usually caused by

some type of irritation

Metaplasia

Hyperplasia

More definitions! Step 1 of dysplasia Cell changes from

one type to another Reversible

increased #of cells Normal alteration BUT, if it is neoplastic

hyperplasia, it is an abnormal process of tumor formation

Neoplasms These are abnormal growths that serve no

useful purpose May harm the host by: using resources,

taking up space, interfering with function of structures

Benign vs. malignant **main difference is that malignant tumors

can metastasize Primary vs. secondary primary arises from local cells Secondary have metastasized from another

part of the body

TUMORS

Classified on the basis of : cell type, tissue of origin, degree of differentiation, anatomic site and benign vs. malignant

**benign tumors can become large enough to distend, compress and obstruct normal tissue and can cause death

5 tissues of origin: epithelium, connective, nerve, lymphoid and hematopoetic

CLASSIFICATIONOF NEOPLASM

STAGING AND GRADING

Staging is more predictive Than grading

Staging is the process of describing the extent of the disease at the time of diagnosis

Aids in treatment planning

Predict clinical outcome

Compare results across treatment approaches

Grading (1-4) is another way to classify the degree of malignancy and differentiation

Lower grade cells more close to normal, more localized

Higher grade poorly differentiated cells, tend to metastasize

Systems of staging(0-4) or (TMN) 0=in situ (premalignant, preinvasive) 1=early local 2=increased risk of spread due to size 3=local has spread 4=spread and disseminated to distant sites

TMNT=tumor (0-4)N=regional lymph nodes(0-4)M=metastases 0,1 (no,yes)

Incidence, mortality and prevalence of 26 cancers available from International Agency for Research on Cancer (IARC)

Gender –based Incidence Men: prostate, lung and

bronchus,colon/rectum Women: breast, lung and bronchus,

colon/rectum

Incidence

Variable causes Divided into endogenous (genetic) and

exogenous (environmental) Multi-causal ‘webs’ are likely Carcinogen: something known to cause

cancer Approx. 500 different known carcinogens Can classify as : viral, chemical, physical

ETIOLOGY

RISK FACTORS A. 9 modifiable risk factors (responsible for

>1/3 of worldwide cancer) B. Aging- most significant risk factor for

cancer, directly proportional to risk C. Lifestyle

PATHOGENESIS

Somatic mutation theory Current theory of Oncogenesis

◦ Oncogenes◦ Antioncogenes

Tumor biochemistry and pathogenesis

Seed vs. soil theory: cancer cell (seed) has to find the right microenvironment (soil)

Incidence of metastasis: approx. 30% of people with newly diagnosed cancer have detectable metastases

Approx. 30-40% have hidden metastases Mechanism of metastasis: lymph>>blood

stream

INVASION AND METASTASIS5 common sites: lymph nodes, liver, lung, bone, brain

Lung (pulmonary) Liver (hepatic) Bone (skeletal) Brain and spinal cord (CNS) Lymph nodes (lymphatic)

CLINICAL MANIFESTATIONS OF METASTASIS

Depends on whether the cellular structure is similar enough to the primary growth

If unable, then the malignant tissue is called “carcinoma of unknown primary”

DIAGNOSIS OF METASTASIS

Disease free survival= time between diagnosis and recurrence or relapse

Recurrences may be local, regional, disseminated

Predictors of recurrence: stage at time of initial therapy and histological findings

Recurrence can be recognized by:◦ Return of systemic symptoms◦ Metabolic or toxic effects of the disease

(hyponatremia, hypercalcemia)

CANCER RECURRENCE

Local and Systemic◦ Most cancers are asymptomatic at first and have

to advance before showing signs and symptoms◦ With progression, symptoms and signs of the

involved tissue can appear◦ Advanced malignant cancer and its treatment can

lead to nausea, vomiting and retching (NVR) accompanied by anorexia and weight loss

CLINICAL MANIFESTATIONS

Most common symptom of cancer 50-70% in early stages, 60-90% in late

stages Pain >depression/anxiety>pain>>>>> >>>depression/anxiety>increased pain Some patients have a fear of tolerance or

meds, fear of addiction, fear of side effects and can lead to underreporting of pain> pain induced loss of function

CANCER PAIN

Multifaceted 1. nerve impingement 2. interference of blood supply to nerves 3. bone metastases>mild to intense bone

pain; pathological fractures>subsequent pain; muscle spasm

4. diagnostic or therapeutic procedures (surgery, radiation, chemotherapy)

5. inflammation can progress to infection, necrosis

ETIOLOGY AND PATHOGENESIS

How will the body react to pain?

1. signs of mild-moderate superficial pain>increased sympathetic nervous system involvement◦ Hypertension, tachycardia, tachypnea

2. Signs of severe or visceral pain> increased parasympathetic nervous system involvement◦ Hypotension, bradycardia, nausea, vomiting, weakness,

fainting

CLINICAL MANIFESTATIONS OF PAIN

*May depend on underlying etiology *Also depends on pain being acute or

chronic *IF acute: gain control and sustain *Prior to pain therapy, physician determines

underlying mechanism and diagnoses the pain syndrome

*Approach: treat the cause as much as possible; treat the effect when needed◦ Example: radiation/chemo treat the CAUSE◦ Example: narcotics treat the EFFECT

PAIN CONTROL

Based on client preference and clinical judgment Can reduce procedural pain and distress Examples: cryotherapy, thermotherapy, electrical

stimulation, immobilization, exercise, massage, biofeedback and relaxation techniques

*direct pressure over a tumor is discouraged; although no evidence that massage can spread cancer

*Neuropathic pain is difficult as traditional analgesics don’t always work; options include infrared, anti-depressants, antiepileptics, steroids

NON PHARMACOLOGICAL APPROACHES TO PAIN CONTROL

CRF syndrome is a collection of symptoms with multiple characteristics/problems

Fatigue is nearly universal in people receiving chemotherapy and radiation

Up to 30% of survivors report loss of energy for years after treatment

Reassurance that treatment related fatigue is not necessarily an indicator of disease progression

fatigue is a symptom and attempts to identify causes may lead to identifying whether or not it can be classified as CRF

CANCER RELATED FATIGUE (CRF)

In addition to local effects of tumor growth, cancer can produce systemic signs and symptoms that are indirect effects of the tumor

Etiology not well understood Clinical manifestations: important as they may provide an early

clue to the presence of cancer Non-specific symptoms: neurological changes, anorexia,

malaise, diarrhea, weight loss and fever may be the first clinical manifestations

Musculoskeletal manifestations include weakness from proximal>distal (common with small cell lung CA) and similar to weakness pattern of people taking prednisone (corticosteroid)

Medical management: serodiagnostics, MRI, biochemical markers may identify syndromes BUT finding the underlying malignancy is crucial for successful resolution

PARANEOPLASTIC SYNDROME

Prevention! Primary prevention: screening,

chemoprevention (agents used to inhibit and reverse cancer)> focus has been on diet derived agents (green and black tea phenols), cancer vaccine research (vaccines against viruses), using person’s own tumor cells which are radiated to inactivate and reinfused to build antibodies

MEDICAL MANAGEMENT

Secondary prevention: preventing morbidity and mortality via early detection and treatment

Tertiary prevention: managing symptoms, limiting complications, preventing disability

More prevention

1. Medical history/exam 2. lab values 3. radiography 4. endoscopy 5. isotope scan 6. CT scan 7. mammography 8. MRI 9. biopsy 10. tumor markers

DIAGNOSIS

Curative: surgery, XRT, chemotherapy, biotherapy (immunotherapy), hormonal

INTENT TO CURE

Palliative: radiation, chemotherapy, physical therapy, alternative medicine, naturopathic, hospice

SYMPTOM RELIEF

TREATMENT

New movement of combining alternative medicine with mainstream conventional therapies

Curative vs. palliative More evidence for palliative

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)

1. Surgery 2. Radiation therapy (RT, XRT): can be internal

(brachytherapy) or external (beam) 3. Chemotherapy: chemical agents to destroy cancer

cells (widespread) 4. Biotherapy: still experimental ; use of biologic

response modifiers (BRMs) to strengthen the response against tumor cells

5. Antiangiogenic therapy: stops pathologic angiogenesis (can kill tumor cells and stop /reduce metastases)

6. Hormonal therapy: beneficial if cancer cells rely on hormones (breast cancer thrives with estrogen)

MAJOR MEDICAL TREATMENTS

Moderate habitual exercise is a potentially protective measure against certain types of cancer

Exercise for the person with cancer: LOTS to think about!

1. Seems to have a beneficial influence on clinical course

2. Do a Screening and assessment◦ Caution regarding fatigue and pain◦ Recent labs helpful◦ Chemotherapy can lead to cardiac dysfunction years

after treatment

CANCER, PHYSICAL ACTIVITY AND EXERCISE TRAINING

3. Monitoring vitals; depending on variations in response, may use THR and/or RPE and monitor responses relative to absolute demands

4. Exercise during and after chemotherapy 5. Exercise for cancer-related fatigue 6. Prescriptive exercise 7. Exercise and lymphedema 8. Exercise and advanced cancer 9. Exercise for cancer survivors

EXERCISE GUIDLEINES (continued)

A. Incidence and Overview: * 8400 children in US diagnosed each year * 2000 deaths in US (<19 years old)

attributed to cancer B. Types of Childhood Cancer *Most common: acute lymphocytic leukemia

(ALL), lymphomas, brain tumors, embryonal (ovary, testicular) tumors and soft tissue sarcomas

CHILDHOOD CANCER

**Advances have greatly improved prognosis; however with increased survival rates, there is growing concern of late effects (damaging effects of surgery, radiation, chemo as well as social, emotional, economic effects)

*Late effects can include CNS deficits: intelligence, hearing, vision, endocrine abnormalities such as short stature or hypothyroidism, or delayed secondary sexual development

LATE EFFECTS AND PROGNOSIS

*The role of the physical therapist in the care of a cancer patient :

May be involved in all phases of care: prevention, restoration, support and palliative care

Physical therapists can be involved in the early stages of cancer treatment to assist with: weakness, inflexibility, risk of falls, altered breathing patterns, lymphedema, fatigue and psychosocial issues

PHYSICAL THERAPIST IMPLICATIONS

Assisting with management of side effects of treatment

Accomodations and/or assistive devices Physical agents/modalities Sexual issues QOL!

OTHER WAYS WE CAN HELP

uscnorriscancerhospital dukehealth.org vetmed.ucdavis.edu tdi-dog.org classroomdogs.wikispaces

Resources

Andrea C. Mendes PT, DPT in collaboration with Sean M. Collins PT, ScD

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