O ncology

1. Oncology Ch.9 Goodman

2. Cancer • 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

3. Thoughts on Review • Does the person know they have cancer? • If YES, then what implications for PT? • If NO, then what next?

4. DEFINITIONS • Differentiation 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

5. More Definitions • Dysplasia Disorganization of cells Reversible Usually caused by some type of irritation

6. More definitions! • Metaplasia Hyperplasia 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

7. TUMORS • 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

8. CLASSIFICATIONOF NEOPLASM • 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

9. STAGING AND 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 Staging is more predictive Than grading

10. 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 TMN T=tumor (0-4) N=regional lymph nodes(0-4) M=metastases 0,1 (no,yes)

11. Incidence • 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

12. ETIOLOGY • 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

13. 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

14. PATHOGENESIS • Somatic mutation theory • Current theory of Oncogenesis • Oncogenes • Antioncogenes • Tumor biochemistry and pathogenesis

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

16. CLINICAL MANIFESTATIONS OF METASTASIS • Lung (pulmonary) • Liver (hepatic) • Bone (skeletal) • Brain and spinal cord (CNS) • Lymph nodes (lymphatic)

17. DIAGNOSIS 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”

18. CANCER RECURRENCE • 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)

19. CLINICAL MANIFESTATIONS • 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

20. CANCER PAIN • 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

21. ETIOLOGY AND PATHOGENESIS • 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

22. How will the body react to pain?

23. CLINICAL MANIFESTATIONS OF 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

24. PAIN CONTROL • *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

25. NON PHARMACOLOGICAL APPROACHES TO 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

26. CANCER RELATED FATIGUE (CRF) • 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

27. PARANEOPLASTIC SYNDROME • 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

28. MEDICAL MANAGEMENT • 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

29. More prevention • Secondary prevention: preventing morbidity and mortality via early detection and treatment • Tertiary prevention: managing symptoms, limiting complications, preventing disability

30. DIAGNOSIS • 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

31. TREATMENT • Curative: surgery, XRT, chemotherapy, biotherapy (immunotherapy), hormonal • INTENT TO CURE • Palliative: radiation, chemotherapy, physical therapy, alternative medicine, naturopathic, hospice • SYMPTOM RELIEF

32. COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) • New movement of combining alternative medicine with mainstream conventional therapies • Curative vs. palliative • More evidence for palliative

33. MAJOR MEDICAL TREATMENTS • 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)

34. CANCER, PHYSICAL ACTIVITY AND EXERCISE TRAINING • 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

35. EXERCISE GUIDLEINES (continued) • 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

36. CHILDHOOD CANCER • 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

37. LATE EFFECTS AND PROGNOSIS • **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

38. PHYSICAL THERAPIST IMPLICATIONS • *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

39. OTHER WAYS WE CAN HELP • Assisting with management of side effects of treatment • Accomodations and/or assistive devices • Physical agents/modalities • Sexual issues • QOL!

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

43. Created by • Andrea C. Mendes PT, DPT in collaboration with Sean M. Collins PT, ScD