Management of the Cancer Patient: Rehab · – Secondhand smoke – Radon – Personal or family history of lung cancer – Radiation to the chest – Diet 7 Lung Cancer 50, 51 •

“Managing the Cancer Patient in the Acute Care Setting”

Property of Kathryn E. Tasillo, PT, DPT, not to be

copied without permission 1

Management of

the Cancer

Patient: Rehab Kathryn E. Tasillo, PT, DPT

The information contained in this presentation is the property of Kathryn E. Tasillo, PT, DPT, and

should not be copied or otherwise used without express written permission of the author.

Provider Disclaimer

•Allied Health Education and the presenter of this webinar do not

have any financial or other associations with the manufacturers of

any products or suppliers of commercial services that may be

discussed or displayed in this presentation.

•There was no commercial support for this presentation.

•The views expressed in this presentation are the views and opinions

of the presenter.

•Participants must use discretion when using the information

contained in this presentation.

Learning Objectives

• Types of Cancers

• Special Patient Populations

• Goals of Therapy, Fatigue, Pain

• Rehab Considerations

3




TYPES OF CANCER 8,9,10

4

Different types of Cancer8,9,10

5

Lung Cancer 8,9,10

• Small Cell Lung CA – most rapid, responds well to chemo

• Non-Small Cell Lung CA – does not respond well to chemo, radiation curative for stage I or II or as an adjunct to sx

• Smoking is directly related to this CA

6




Lung Cancer 50

• Symptoms – Cough that doesn’t go away and

gets worse over time

– Constant chest pain

– Coughing up blood

– SOB, wheezing, or hoarseness

– Repeated problems with

pneumonia or bronchitis

– Swelling of the neck and face

– Loss of appetite or weight loss

– Fatigue

• Risk Factors– Smoking

– Secondhand smoke

– Radon

– Personal or family history of

lung cancer

– Radiation to the chest

– Diet

7

Lung Cancer 50, 51

• Diagnosingo Chest CT

o Needle Biopsy with

Endoscopic Ultrasound

o Chest X-ray

o Bronchoscopy

o MRI

o PET

o Radionuclide bone scan

o Pulmonary function test (PFT)

• Staging of NSCLCo Occult

o Stage 0

o Stage I – in lung

o Stage II – in lymph nodes

o Stage IIIA – beginning spread

out of lung

o Stage IIIB – above collarbone

and to opposite side of chest

o Stage IV – both lungs, in fluid

around the heart, and to the

rest of the body

8

Lung Cancer 52

9




Colorectal Cancer 8,9,10,45

• Symptoms – Diarrhea, constipation or

consistency lasting >4 wks

– Rectal bleeding

– Persistent gas, pain, or cramps

– Don’t feel like emptied completely

– Weakness/fatigue

– Unexplained weight loss

• Risk Factors– Older age >50 yrs

– African American race

– Family history

– H/o Crohn’s or ulcerative colitis

– Genetic syndromes

– Low fiber, high fat diet

– Sedentary lifestyle

– Diabetes

– Obesity

– Smoking/Alcohol

– Radiation therapy from previous

cancers

10

Colorectal Cancer 45

• Diagnosing– Should begin at age 50

with colonoscopy

• Biopsies can be taken if needed

– Blood tests

• Staging– Stage I – grown through

mucosa of colon or rectum but not beyond

– Stage II – grown into wall or through wall of color or rectum but NO lymph nodes

– Stage III – invaded nearby lymph nodes but no other parts of the body

– Stage IV – spread to distant sites like liver or lung

11

Colorectal Cancer Treatment 45

• Surgery is primary treatment for 75% of cancers, radiation can be pre or postop

• Early Stage– Remove polyps during colonoscopy

– Endoscopic mucosal resection

– Minimally invasive surgery laparoscopically

• Invasive– Partial colectomy

• Placement of a colostomy bag (temporary or permanent)

• Careful when mobilizing these patients!

– Lymph node removal

• Chemo/Radiation/Targeted drug therapies

12




Malignant Pleural Effusions and PleurX

Catheters 39

• Used to treat malignant ascites

– Ascites – collection of fluid in

the peritoneal cavity – in 50%

of cancer patients

• Fluid obstructs lymph system and

blocks flow to circulatory system

• Patients often require multiple

paracenteses

• Increased ascites = abdominal

pain, dyspnea, nausea, vomiting,

and anorexia

Cervical Cancer 35

• One of the most preventable types of cancer

• Continues to decline in prevalence every year due to use of Pap smears to detect abnormalities and patients to get earlier treatment

• Most women diagnosed between 35-55, rarely those under 20

• 90% are squamous cell cancers, adenocarcinomas account for the remaining 10-20%

• HPV is found in 99% of cervical cancers

Cervical Cancer cont’d 35

• Signs and Symptoms

– Abnormal or Irregular Bleeding

– Bleeding AFTER menopause

– Pelvic pain not related to menstrual cycle

– Heavy or unusual discharge that may be watery, thick, and possibly have a foul odor

– Increased urinary frequency

– Pain during urination

– Pain during sex

15




Cervical Cancer Stages 35

– Stage 0: Carcinoma in situ. Abnormal cells in the innermost lining of the cervix.

– Stage I: Invasive carcinoma that is strictly confined to the cervix.

– Stage II: Locoregional spread of the cancer beyond the uterus but not to the pelvic sidewall or the lower third of the vagina.

– Stage III: Cancerous spread to the pelvic sidewall or the lower third of the vagina, and/or hydronephrosis or a nonfunctioning kidney that is incident to invasion of the ureter.

– Stage IV: Cancerous spread beyond the true pelvis or into the mucosa of the bladder or rectum.

16

Cervical Cancer Treatments 35

• Total hysterectomy - Surgery to remove the uterus, including the cervix.

• Hysterectomy - The uterus is surgically removed with or without other organs or tissues.

• Radical Hysterectomy - Surgery to remove the uterus, cervix, part of the vagina, and a wide area of

ligaments and tissues around these organs. The ovaries, fallopian tubes, or nearby lymph nodes

may also be removed.

• Modified Radical Hysterectomy - Surgery to remove the uterus, cervix, upper part of the vagina,

and ligaments and tissues that closely surround these organs. Nearby lymph nodes may also be

removed. In this type of surgery, not as many tissues and/or organs are removed as in a radical

hysterectomy.

• Pelvic Exenteration - Surgery to remove the lower colon, rectum, and bladder. In women, the

cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are

made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed

to make an artificial vagina after this operation.

• Cryosurgery - A treatment that uses an instrument to freeze and destroy abnormal tissue, such as

carcinoma in situ.

• Laser surgery - A surgical procedure that uses a laser beam (a narrow beam of intense light) as a

knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.

• Loop electrosurgical excision procedure (LEEP) - A treatment that uses electrical current passed

through a thin wire loop as a knife to remove abnormal tissue or cancer.

• Radiation

• Chemotherapy

Endometrial Cancer 42

• 95% of cases

• Most common type of uterine cancer

• Develops in the lining of the uterus (endometrium)

• Uterine sarcoma is more rare

• Symptoms:

– Abnormal, non-bloody vaginal discharge

– Pelvic pain or cramping

– Unexplained weight loss

– A tumor or mass

• Differential Diagnosis – GI bleed




Ovarian Cancer 8,9,10,44

• Back pain

• Bloating/swelling/discomfort in pelvis area

• Feeling of fullness

• Urinary urgency or incontinence

• Constipation

• Weight loss• “silent killer”• Usually history of breast, endometrial or colon CA in

family• Sx, TAH, chemo – intraperitoneal chemo

Ovarian Cancer 44

• Types– Epithelial tumors

• 90% of ovarian cancers

– Stromal tumors• 7% of ovarian cancers

– Germ cell tumors • Rare and occur in younger

women

• Risk Factors – Most common in women ages 50-

60

– Inherited gene mutation BRCA1 and BRCA2

– Estrogen hormone replacement therapy

– Early menstruation or late menopause

– Never being pregnant

– Fertility treatment

– Smoking

– IUD

– Polycystic ovary syndrome

20

Ovarian Cancer 44

• Staging

– Stage I – in one or

both ovaries

– Stage II – spread to

other parts of pelvis

– Stage III – spread to

the abdomen

– Stage IV – outside

the abdomen

• Treatment

– Usually a

combination of

surgery and

chemotherapy

21




Breast Cancer 8,9,10

• Breast – personal or family history

• Early menarche, late menopause – increase in estrogen

• Late first pregnancy, no pregnancy – increase in estrogen

• Exogenous estrogen – after removal of ovaries

• Sentinel node biopsy – 1st node blue dye drains to for breast CA and melanoma

22

Prostate Cancer 49

• Most common cancer among men in the U.S. with 1 in 7 men getting diagnosed

• Often has no early symptoms

• Most do not die from it with more than 2.9 million men still alive today after diagnosis

• Detected by Prostate specific antigen (PSA) in bloodstream – if levels are high, either prostate cancer or some kind of condition

• Many men have died and then been found during autopsy to have had prostate cancer – roughly 80% of men in their 80s

23

Prostate Cancer 49

• Symptoms – Frequent urination

– Nocturia

– Hard to start urinating

– Hard to keep urinating once started

– Hematuria

– Painful urination

– Ejaculation may be painful

– Difficulty achieving or maintaining erection

– Bone pain (pelvis, spine, ribs, femur)

– Leg weakness

– Urinary and fecal incontinence

• Causes– Much more common after 50

– Genetics – BRCA2

– Diet – low vitamin D

– Medication

– Obesity

– STDs - gonorrhea

– Agent Orange – 48% higher risk

– Enzyme PRSS3 – changes environment of prostate cancer cells – more likely to metastasize

24




Prostate Cancer 49

• Staging

– Clinical T1 and T2 – only in prostate

– Clinical T3 and T4 are outside the prostate

• Gleason Score

– Grades tumor after biopsy sample examined microscopically

• Two numbers

– Number 1-5 for most common pattern observed more than 51% of sample

– Number 1-5 for second most common pattern more than 5% but less than 50%

• Example

– Predominant grade is 3 and secondary grade is 4, Gleason score is 7

– Predominant grade is 4 and secondary grade is 3, Gleason score is 7

– First example has a less aggressive cancer than the second example with a lower predominant score

25

Prostate Cancer 49

• Possible complications– Metastasis – through blood or lymph to other organs or

bones

– Incontinence

– Erectile dysfunction

– Metabolic factors – much higher risk of death with HTN, DM, high BMI and high blood lipid levels

• Treatments– Radical prostatectomy

– Brachytherapy – radioactive seeds are implanted

– Conformal radiotherapy – conformed to area to minimize healthy tissue exposure

– Intensity modulated radiotherapy - beams with variable intensity

26

Liver Cancer 47

• Symptoms– Unexplained weight loss

– Loss of appetite

– Upper abdominal pain

– N/V

– General weakness and fatigue

– Abdominal swelling

– Jaundice

– White, chalky stools

• Risk Factors – Chronic infection with HBV

or HCV (Hep B or Hep C)

– Cirrhosis

– Inherited liver diseases

– Diabetes

– Nonalcoholic fatty liver disease

– Exposure to aflatoxins(molds on crops that are stored poorly)

– Excessive alcohol consumption

27




Liver Cancer 47

• Surgery– To remove the tumor

– Liver transplant surgery

• Treatments – Radiofrequency ablation –

electric current is used to heat and destroy cancer cells

– Cryoablation - Freezing cancer cells

– Injecting pure alcohol into tumor

– Chemoembolization –supplies strong anti-cancer drugs directly to liver

– Placing beads filled with radiation in the liver

28

Kidney Cancer 48

• Case Study Example

29

Kidney Cancer 48

• Signs/Symptoms

– Hematuria

– Constant side/flank pain

– Lump/mass in abdomen

or side

– Intermittent Fever

– Weight loss

– Fatigue

– Anemia

• Risk Factors

– Smoking

– Obesity

– HTN

– Long-term dialysis

– Male gender

– Von Hippel-Lindau (VHL)

Syndrome

– Occupational exposure

(asbestos)

30




Kidney Cancer 48

• Types

– Clear Cell

– Papillary renal cell

– Chromophobe renal cell

• Stages

–Measuring size of tumor

– Location of the cancer cells either confined to the kidney, locally spread, or widespread beyond the fibrous tissue surrounding the kidney (stages I-IV)

31

Kidney Cancer 48

• Treatments

–Chemotherapy

–Radiation Therapy

–Embolization

–Biological Therapy

– Surgery

32

Pancreatic Cancer

• Signs/Symptoms

– Upper abdominal pain

that radiates to your

back

– Jaundice

– Loss of appetite

– Weight loss

– Depression

– Blood clots

• Risk Factors

– African American Race

– Obesity

– Pancreatitis

– Diabetes

– Genetic syndromes

– Personal/family h/o

pancreatic cancer

– Smoking

33




Diagnosing Pancreatic Cancer

• US

• CT

• MRI

• Endoscopic Ultrasound

(EUS) – makes images

of pancreas and can

collect cell samples

• Endoscopic Retrograde

Cholangiopancreatography

(ERCP) – uses a dye to

highlight the bile ducts in

your pancreas

34

Pancreatic Cancer

• Staging

– Stage I- confined to pancreas

– Stage II – beyond pancreas to nearby tissues/organs and possibly lymph nodes

– Stage III – beyond pancreas to major blood vessels around pancreas, maybe to lymph nodes

– Stage IV – spread to distant sites beyond the pancreas, such as the liver, lung, and peritoneum

• Surgery

– Whipple (pancreatoduodenectomy) – sx for tumors in the pancreatic head

– Distal Pancreatectomy –sx for tumors in the pancreatic tail and body, might also remove spleen

35

Brain Tumors 69

• Primary brain malignancies comprises 1.4% of all cancer

• However, the incidence of a brain tumor is higher considering that a metastatic brain tumor is estimated as being at least 10 times more common than primary brain malignancy

• Primary brain tumors most common solid tumor in children

• Can cover the entire spectrum from benign lesions to metastatic lesions and glioblastomas

• Brain is the most common site for central nervous system (CNS) malignancy; cranial nerves, spinal cord, cauda equinaaccount for 10% of tumors, and pituitary and pineal tumors account for 16%

36




Brain Tumors cont’d 69

• Meningiomas and glioblastomas most

common in adulthood

• Survival varies greatly on these facts:

– Type of tumor

–Molecular markers

– Age (older less favorable)

37

Brain Tumors 69

Treatment

• Surgical resection

– When not totally resectable:

• Stereotactic biopsy

• Open biopsy/debulking

• Adjuvant therapy

• Chemotherapy implants

• Radiation therapy

• Chemotherapy

• Corticosteroids

Supportive Care

• Acute rehab

• Patient and Caregiver

psychological and supportive

needs

• Cognition

• Communication

• Depression and Anxiety

• Stress Management

• Seizures

• Fatigue and Sleep

• Headaches 38

Leukemia8,9,10

39




Invasive Fungal Infections (IFI) in AML37

• Among the leading causes for morbidity, mortality (35%), and economic burden ( LOS, healthcare expenditures)

• Incidence has increased dramatically by 200% from 1979-2000

• Management complicated by increasing frequency of infection by non-Asperigillus molds (zygomycosis) and emergence of drug-resistant fungal pathogens

• Aspergillus and Candidemia account for majority of cases

• Infection of blood stream, lungs, and sinuses is most common

IFI in AML cont’d 37

• Risk factors:

– colonization of yeast in the GI mucosa with acute mucosal damage caused by cytotoxic drugs (e.g. high-dose cytarabine)

– Neutropenia

– Use of broad-spectrum antibacterial therapy

– Bacteremia

– Renal insufficiency

– Prolonged stay in an ICU

– Receipt of TPN

– Recent GI surgical procedure

41

IFI in AML cont’d 37

• Management:

– Early initiation of antifungal therapy with various medications based on the fungus being treated

• Prognosis:

– Achievement of remission of AL can also lead to the recovery of neutropenia and positively affect the outcome of fungal infection

– Invasive candidiasis

– Invasive aspergillosis

– Zygomycosis42




Multiple Myeloma 4

• Malignancy of plasma cells

• Slow progression

• Pathological compression fractures especially

in vertebral bodies

– Often how they present to the hospital where no

trauma occurred but a fracture has been found

• Dehydration is common

• No treatment is curative

43

MM Cont’d

• Associated with a number of complications:

– Hematological (anemia, bone marrow failure, bleeding disorders)

– Bone (pathological fractures, lytic lesions, hypercalcemia d/t excessive bone turnover)

– Kidney insufficency

– Compromised Immune function

– Neurological (SC and nerve root compression, cranial nerve compression)

• Almost all patient will have had the the precursor smouldering multiple myeloma (SMM) – which means the present of MM in the bone marrow and M-proteins in the blood but without evidence of organ damage.

44

MM Survivors

• Persistent deformities

• Chronic pain

• Reduced mobility and physical

functioning

45




Multiple Myeloma Patient Examples

• Mrs. Purple

• Mr. Yellow

46

Lymphoma 57

• Lymph system affected includes: lymph,

lymph vessels and nodes, spleen,

thymus, tonsils and bone marrow

• Lymph tissue is also found in brain,

stomach, thyroid gland and skin

• Hodgkin and Non-Hodgkin

47

Hodgkin’s and Non-Hodgkin’s Lymphoma4

48

Ann Arbor Classification

A = means without symptoms

B = with symptoms like night sweats,

unexplained weight loss and fevers

Ex: Stage IIIS A




Follicular Lymphoma 38

• A B-cell lymphoma

• Most common, slow-growing form – 20-30% of all NHLs

• Common signs/symptoms:– Enlarged lymph nodes in neck, underarm, stomach,

groin

– Fatigue

– SOB

– Night sweats

– Weight loss

– Usually no symptoms of disease at time of diagnosis

Follicular Lymphoma 38

• Treatment:

– Very responsive to radiation and chemotherapy

– If no symptoms, often not treated right away

–Many achieve remission but disease often returns later

– Common chemotherapy combos:

• R-Bendamustine (rituximab and bendamustine)

• R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)

• R-CVP (rituximab, cyclophosphamide, vincristine, prednisone)

50

Follicular Lymphoma Case Study

– Mr. Red

51




AIDS-Related Lymphoma 57

• Malignant cells form in the lymph system of patients who already have AIDS

• However, sometimes this can be the first diagnosis for both AIDS and the AIDS-related lymphoma

• Sometimes this type of cancer can occur outside lymph nodes in bone marrow, liver, meninges, and GI tract

• Non-Hodgkin Lymphoma more common and called AIDS-related lymphoma

• When occurs in the CNS: AIDS-related primary CNS lymphoma

52

AIDS-related NHL 57

• These lymphomas are the aggressive type

• Diffuse Large B-cell lymphoma (including B-cell immunoblastic lymphoma)

• Burkitt or Burkitt-like lymphoma

• Signs and symptoms:– Weight loss

– Fever

– Night sweats

– Painless, swollen lymph nodes in the chest, neck, underarm or groin

– A feeling of fullness below the ribs

53

Stages of AIDS-related Lymphoma 57

• E: "E" stands for extranodal and means

the cancer is found in an area or organ

other than the lymph nodes or has

spread to tissues beyond, but near, the

major lymphatic areas.

• S: "S" stands for spleen and means the

cancer is found in the spleen.

54




• Stage I – one lymphatic area

– Stage IE – one organ or area outside of the lymph nodes

• Stage II – two or more lymph nodes either above/below the diaphragm

– Stage IIE – Also found outside the lymph nodes in one organ or area on the same side of the diaphragm as the affected lymph nodes

• Stage III – one or more lymph node groups above AND below diaphragm

– Stage IIIE – AND outside the lymph nodes in a nearby organ or area

– Stage IIIS – AND in the spleen

– Stage IIIE plus S - the three stages above combined

55

• Stage IV

– is found throughout one or more organs that are

not part of a lymphatic area (lymph node group,

tonsils and nearby tissue, thymus, or spleen) and

may be in lymph nodes near those organs; or

– is found in one organ that is not part of a lymphatic

area and has spread to organs or lymph nodes far

away from that organ; or

– is found in the liver, bone marrow, cerebrospinal

fluid (CSF), or lungs (other than cancer that has

spread to the lungs from nearby areas).

56

Treatment 57

• For treatment, AIDS-related

lymphomas are grouped based

on where they started in the

body

– Peripheral/systemic

lymphoma

– Primary CNS lymphoma

• cART (combined antiretroviral

therapy)

• Clinical trials

• Chemotherapy

– Intrathecal

– Ommaya reservoir

– Regional

– Combination

• Radiation

– External

– Internal

• Stem cell transplant

• Targeted therapy

– Monoclonal antibody therapy

57




58

SPECIAL PATIENT POPULATIONS

59

Neck Dissections 3,4,7

• Tobacco use is closely associated with this cancer type

• Underlying lung disease could be present if tobacco was involved prior

• New prevalence of head and neck cancer associated with the HPV virus

• Three flaps: pectoralis, fibular, radial forearm, and sometimes a scapular flap

• Focusing on posture and positioning, cervical, shoulder, and scapular ROM and movement during recovery is vital

• Multiple lines and tubes can make this patient population appear difficult from the beginning

60





• “Head, neck, and facial cancers involve the paranasal sinuses, nasal and oral cavities, salivary glands, pharynx, and larynx.”

• Radical neck dissection, laryngectomy, and reconstructive surgery are common surgical interventions

• We see a lot of these patients on our surgical unit and in the acute care setting, managing the lines and tubes that are associated with this patient population is quite the challenge. They can typically have (trach, trach collar, pulse ox, multiple JP drains that are bifurcated and secured to wall suction, DHT for feedings, PCA, IV – if a flap was done to the face a doppler is usually present initially to ensure graft is taking, if a mandibulectomy is performed, this is usually fixed with a fibular graft. Venturi mask can be used for moblizing the patient out of the room while still requiring oxygen. Initially, a second person is helpful to mobilize the patient due to managing all of the equipment. Often times these patients can be frustrated with their current state of inability to communicate whether temporary or newly permanent so asking ‘yes’ and ‘no’ questions helps ease that frustration.

• With all of this equipment, positioning of the patient can be tricky as they might be more prone to stay in one position depending on how the trach collar is set up as well as other lines that are attached to the wall. These patients have a lot of secretions and if not positioned properly, it could be harder for them to clear the secretions. A towel roll vertically is commonly used to help with a slow, easy stretch as well as opening up upper lungs.

• If a mandibulectomy has been performed as well, they will usually be in a walker boot for 7 days 61


• Radical vs. modified radical neck – Radical = removal of all 5 levels of lymph

nodes, sacrifice of spinal accessory nerve, IJ vein, SCM, platysma, and omohyoid musculature – large met tumors and large palpable nodes

– Modified=possible removal of SCM and nodes, preservation of SAN and IJ vein

• “Radical neck dissections (RND) may include removal or partial removal of the larynx, tonsils, lip, tongue, thyroid gland, parotid gland, cervical musculature (including the sternocleidomastoid, platysma, omohyoid, and floor of the mouth), internal and external jugular veins, and lymph nodes. Reconstructive surgery may include a skin flap, muscle flap, or both to cover resected areas of the neck and face. The pectoralis or trapezius muscle is used during muscle flap reconstructive procedures.”

• Pec flap – need for muscle bulk, large resection– Usually compensated by lat dorsi and

subscapularis

• Fibular flap – reconstruct mandible, usually up to 10cm of bone is resected, preserving peroneal nerve however; usually NWB for 4-7 days

• Radial forearm flap used to replace skin lost on face or in reconstructing the oral pharynx. Avoid weightbearing through donor site.

• Acute care should focus on postural training and cervical ROM

62


• Type of Procedure/Patient Population– s/p any head and neck

surgery

– Mandibulectomy

– Neck dissection

• Rehab Implications– HOB elevated typically >

30°

– Keep head in neutral

– No pressure to graft sites

– No constriction around neck

– No pillows

– Check diet orders

– Dental clearance

– Bone donor graft site: WB status

63




BMT4,15

• Types – Allogeneic vs. Autologous

• Body is immunosuppressed prior to transplant

– period called cytoreduction (usually 2-4

days) of chemo, radiation, or both

• Aspiration from posterior/anterior iliac crest

• 1-3 days after last dose of chemo/radiation –transplant is administered either through

central venous access device or a Hickman

right atrial catheter

• BMT vs. PBSCT64

BMT4,15

• Allogeneic – “bone marrow is harvested from an HLA-matched donor and immediately infused into the recipient after cytoreduction therapy. The donor may be related or unrelated.”

• Autologous – “is one in which the donor and recipient are the same. Bone marrow is harvested from the patient when he or she is healthy or in complete remission. The marrow is then frozen and stored for future reinfusion.”

• Recovery is faster after a PBSC transplant by 10-12 days, a week earlier than in BMT

• Peripheral blood stem cells (PBSCs) can be used in either type– harvested by leukapheresis– 3-7 harvests may need to occur to get desired number– Reinfusion occurs after lethal doses of chemo, radiation or both

• PRO - “PBSC transplant is becoming more common with faster immune recovery after allogeneic transplant and faster blood count recover with autologous transplant when compared to bone marrow transplantation.”

• CON - “Some disadvantages include longer process for donors and increased fluid to recipients during transplantation with possible fluid overload to lungs.” 65

66




Can be used to treat patients with: 4,15

67

Afterward4…• Bone marrow failure begins within 10 days after

transplant and can last up to 3 weeks

• Neutrophil count less than 1,000/mm3 = reverse protective isolation

• Platelets less than 50,000/mm3 = thrombocytopenic precautions

• Stem cells begin functioning 10-28 days after transplant

• A successful engraftment = increase in platelet and WBC count (again 10-28 days afterward)

68

Complications4

• Infection

• Pneumonia

• Hemorrhage

• Marrow failure

• Veno-occlusive disease of the liver

• Interstitial pneumonitis

• Graft versus host disease

69




GVHD 36

• The older the person, the higher the risk

• Donor’s immune cells attack patient’s good cells• Can be mild, moderate or severe

• Symptoms can be:– Rashes – palms and soles, then to trunk, then to entire

body

– Blistering – exposed skin flaking off in severe cases

– Nausea/vomiting/abdominal cramps, diarrhea, loss of appetite

– Jaundice

– Excessive dryness of mouth and throat, leading to ulcers

– Dryness of the lungs, vagina and other surfaces

GVHD 36

• Acute vs. Chronic – Acute – soon after transplant cells begin to appear in

recipient

– Chronic – usually at 3 months post transplant but can be a year or more later• Usually starts with a rash/itching

• Skin, GI tract and liver are mainly targeted

• Less commonly – involvement of the hematopoietic system, eyes, and kidneys

• Many deaths occur due to infection with patients with suppressed immune systems

71

GVHD 40

STAGE SKIN GI TRACT LIVER

1 Maculopapular rash

over <25% of body

area

Diarrhea 500-1000

mL/day

Bilirubin 2-3 mg/dL

2 Maculopapular rash

25-50% of body

area

Diarrhea

1000-1500 mL/day

Bilirubin 3-6 mg/dL

3 Generalized

erythroderma

Diarrhea

1500-2000 mL/day

Bilirubin 6-15

mg/dL

4 Generalized

erythroderma with

bullous formation,

often with

desquamation

Diarrhea

>2000 mL/day or

pain or ileus

Bilirubin >15 mg/dL

72




Prevention Drugs for GVHD 36

• Prevention

– Cyclosporine and methotrexate

– Tacrolimus (Prograf) and methotrexate

– Tacrolimus and mycophenolate mofetil (CellCept)

– Prograf and sirolimus (Rapamune)

• Treatment

– Glucocorticoids (prednisone or methylprednisone)

combined with cyclosporine – acute GVHD

– Corticosteroids – chronic GVHD

73

Extracorporeal Photophoresis 41

• Cell-based immunomodulatory therapy that involves collecting leukocytes from peripheral blood

• Exposed to a photosensitizing agent, then treated with UV radiation, and then reinfused

• Produces mass apoptosis of the treated cells

• Reduced risk of infections with ECP as compared to other immunosuppressive agents

• Usually done as a steroid-sparing maneuver or as a last ditch effort

• Many complications are related to vascular access

– Infection, clotting in catheters, DVTs, and vessel stenosis

GVHD Case Study

75




Donor Lymphocyte Infusions (DLI) 53, 54

• Uses the immune system to fight the tumor

• T cells, a leukocyte, can cause GVHD as well as initiate an attack on the malignant

cells that remain after high doses of chemotherapy and radiation

• Used for patients when they present with relapse after an allogenic bone marrow

transplant

• Receives a boost of immune cells from the donor's original blood

• Especially helpful in those with CML but can be used in other leukemias or

lymphoproliferative disorders

• Can cause GVHD or marrow toxicity however (mild or moderate)– Toxicity can be less severe than a second transplant

• Also experience a marked drop in blood counts as bone marrow switches back to

donor cells

• In some cases, patients can receive multiple infusions until remission is achieved or

side effects are lessened

• Those at high risk for relapse after BMT are sometimes offered this treatment while

still in remission76

Mastectomy

• Initial Mastectomy procedure

• DIEP flap

• This population is now solely under the

OT umbrella unless a major mobility

deficit requires PT involvement

77

Sarcoma17,18

- Most common

type of cancer

that STARTS in

the bone

- Limb sparing

surgery

78




Sarcoma17,18

• “Limb-sparing surgery (limb-salvage surgery): Most patients with tumors in the arms or legs can have limb-sparing surgery, but this depends on where the tumor is and how big it is. This type of surgery is very complex and should be done by a doctor with special skill and experience. The challenge for the surgeon is to remove all of the tumor while saving the nearby tendons, nerves, and blood vessels. But if the cancer has grown into these structures, they will need to be removed along with the tumor. In such cases, amputation may sometimes be the best option.

• The part of the bone that is removed is replaced with a bone graft (piece of bone from a different part of the body or from another person), or with a device made of metal or other materials. Some metal rods are designed to grow with the child and can be made longer without any extra surgery. They have tiny devices in them that can lengthen the “bone” whenever needed to make room for a child’s growth. But even these may need to be replaced with something stronger once the child’s body stops growing.

• More surgery may be needed during the years after the first operation, and some patients might still need an amputation later on. There can be a danger of infection, and grafts or rods can become loose or break. It takes about a year, on average, for patients to learn to walk again after this surgery on a leg. If the person does not keep up with rehabilitation, the arm or leg may become useless.” 79

Goals of Therapy – Dietz20,21

80

Karnofsky Criteria of Performance

Status21

81




Eastern Co-operative Oncology Group

(ECOG)22

0 Fully active, able to carry on all predisease performance without

restriction

1 Restricted in physically strenuous activity, but ambulatory and

able to carry out work of a light and sedentary nature (e.g. light house

work, office work)

2 Ambulatory and capable of all self-care but unable to carry out

any work activities. Up and about more than 50% of waking hours

3 Capable of only limited self-care, confined to bed or chair more

than 50% of waking hours

4 Completely disabled. Cannot carry on any self-care. Totally

confined to bed or chair.

5 Dead82

Battling Cancer Related Fatigue4,7

• Bedrest will only make it worse!

• Defined by the National Comprehensive Cancer Network as a “persistent, subjective since of tiredness related to cancer or cancer treatment that interferes with usual functioning.”

• According to Vogelzang et al. patients indicated that fatigue affected their daily lives more than pain

83

Types of Fatigue 63

• Peripheral

• Central

• Central exhaustion syndrome

84




Fatigue continued 63

• Aggressive cancers are more likely to result in fatigue because the treatments are harder on the body.

• Brain cancers more likely than any other area in the body

• Fatigue usually peaks 2-3 weeks after beginning radiation

• Having both chemo and radiation treatments can worsen fatigue

85

Risk Factors and Causes of Fatigue 63

• Older age

• Having fatigue before cancer diagnosis

• Depressoin

• Poor sleep habits or OSA

• Thyroid problems

• Anemia

• Poor nutrition

86

So how do we fight fatigue?7,63

• Fatigue scale• Eating well • Exercise to address decreased biologic

resources• Incorporate rest breaks• Plan treatment session when patient has the

most energy to maximize treatment quality• Energy conservation techniques/ergonomics• Sleep and wake schedule• Psychological Health

87




88(23)

(23)

Exercise! 63

• Physical activity is the ONLY treatment

consistently proven to reduce fatigue

• Walking or using a stationary bike are

good options

• 20 minutes of exercise 4-5x/wk or 60 min

3x/wk

90




Move!74

• Mobility and exercise participation in the

acute postoperative stage of treatment

may reduce:

–Risk of adverse events

–Affect overall length of stay

–Reduce admissions and complications in

various cancer populations

91

Emphasis on Exercise4,7

• Goals:

–Optimize functional mobility

–Minimize cancer-related fatigue

–Prevent joint contracture/skin breakdown

–Prevent/reduce limb edema

–Prevent post-op pulmonary complications

92

How hard do I push them though?4

•Exercise intensity

should be between 1

and 4

•Aerobic

•Progressive, building

duration over time

•An exercise log is

important for

monitoring progress as

well as adherence

93




General Exercise Considerations 74

• Walking, stationary cycling, resistance training

appear safe for those with leukemia

• May be limited by complications such as

infection, thromboembolic disease, hemorrhage

• Aerobic and strength training exercises can be

safely performed by persons with stem cell

transplant

• Exercise should be less intense, progress slowly,

and avoid overtraining

94

Hematologic Considerations 74

• Anemia– Low-intensity exercise may be beneficial

to promoting improvements in blood counts

– Monitor for chest pain, lightheadedness, and inappropriate dyspnea

• Thrombocytopenia– <10,000 are at risk for spontaneous

hemorrhage

– <20,000 – generally restricted to walking and ADLs

– <30,000 – moderate exercise and light resistive exercise with tolerance

– Maintain BP below 170/100

• Chemotherapy-induced neutropenia – No real restrictions other than use

appropriate barrier protection • Hand hygiene

• Masks

– Take into consideration they will be more fatigued, dizzy, and possibly lethargic

• If on the fence as the patient has been chronically low, it is always better to speak with your provider before cancelling the session as many providers find the benefit of moving in light of low blood values outweigh the risks of low blood counts – every facility is different on this matter

• As a result of antineoplastic therapies:– Neurotoxicities affecting peripheral

nerve function

– Myopathy due to chronic corticosteroid use

– Prolonged immobility

– Nutrition deficits

– Cognitive dysfunction

95

Hematologic Considerations 74

• Dimeo et all suggest that exercise not

only mediates better physical

performance at discharge in this

population, but a shorter duration of

anemia, neutropenia, thrombocytopenia,

and length of hospitalization

96




Cardiopulmonary Toxicity 74

• Cardiac Cachexia – advanced cancer patients have cachexia with severe muscle wasting that can affect cardiac function

• Radiation therapy to chest wall can affect cardiac and pulmonary function

• Anthracyclines (one of most common chemos) – may have a significant and irreversible impact on cardiac function specifically reduced L ventricular function reduces overall EF compromises long term cardiac function

• Trastuzumab (frequently used in breast cancers) – cardiac toxicity potential – systemic edema, SOB, dyspnea, lung congestion

• Bleomycin and methotrexate pulmonary compromise, pulmonary inflammation, and fibrosis

97

Cardiopulmonary Toxicity 74

• Radiation to the chest wall (lung, breast, and Hodgkin lymphomas) – structural damage to myocardium, coronary arteries, valves and the conduction system– Can manifest 6-12 months after radiation

• Vital sign monitoring– Low-intensity exercise administered during chemotherapy may

be protective against anthracycline-induced cardiotoxicity

• Routine to get a baseline echocardiogram

• Nearly 50% demonstrate cardiac-related comorbidity that compromises function 20-30 years after completion of treatment

• Use of the BORG scale is a good self-reported tool

• Look for excessive fatigue, sweating or pallor changes with exercise or activity, and severe SOB

98

General Oncological Surgical

Considerations7

• Precautions/restrictions: WB, ROM, surgery specific

• Reconstruction: skin grafts, nerve grafts, tendon transfers, flap coverage

• Bone graft donor sites• Real & phantom pain• Leg length discrepancy• Cosmetic deformity• Lymphedema• Edema: post-surgical vs venous

insufficiency• Pulmonary status• Early mobility

99




Surgical Interventions(24,25)

• Total Pelvic Exenteration

• Abdominoperineal Resection

• Radical Prostatectomy

• Radical Cystectomy

• Sacrectomy

• Hemipelvectomy

"Managing the Cancer Patient in the Acute Care Setting," 6/4/2019."This

information is the property of Kathryn E. Tasillo, PT, DPT, and should not be

copied or otherwise used without express written permission of the author."

100

Rehab Implications7

• Type of Procedure/Patient

• Surgeon/pt specific restrictions

• No sitting (typically x6 weeks)

• Getting OOB is more difficult with prone exit

• Sidelying<->Stand transfer

• Monitor orthostatics

• HOB typically <30 degrees

• When scooting towards HOB using chuck, pt in side-lying to limit pressure on surgical site

• Possible ROM restrictions

• Requires clearance for toilet/commode

• High risk for DVT• Clear stair negotiation

w/Plastics

101

ORTHOPEDIC CONSIDERATIONS

102




Bony Mets7,26

• Primary cancer site of breast, prostate,

lung, kidney, thyroid commonly

metastasize to bone

• Common locations: axial skeleton,

humerus, femur, skull, pelvic girdle, ribs

103

Osteolytic lesions26,27,28

• A.K.A. lytic lesion or osteoclastic

lesion

• “punched out” look• This particular picture is a result of

myeloma that has invaded the bone

and caused the weak areas

• Myeloma also releases chemicals

into the body that lead to this

breakdown

• Most commonly in spine, skull,

pelvis, and ribs

104

Osteoblastic lesions26,29

• Induce bone formation

and can produce

sclerotic vertebral

bodies

• Growth typically

stimulated by tumor

105




MRS. GREEN CASE STUDY

106

BONY METASTASIS >50% cortex involved No exercise; touch down:not weight bearing, usecrutches, walker; activeROM exercise (no twisting)

Plain x-ray findings: high risk indicated by following:cortical lesions >2.5–3.0 cm;>cortical involvement;painful lesions;unresponsive to radiation

25–50% cortex involved No stretching, light aerobicactivity; partial weightbearing; avoidlifting/straining activity

0–25% cortex involved Full weight bearing

(7)

Modifications of evaluation and

treatment7:

–Modify MMT

–Modify PROM or AROM

–Avoid resistive exercises

–Avoid spinal loading with spine mets

108




Pain characteristics that may indicate

fracture or impending fracture3

109

NEUROLOGICAL CONSIDERATIONS

110

Spinal Cord Compression

• Associated cancers/conditions: metastasis to spine, breast, lung, kidney, prostate, lymphoma, myeloma

• Onset: local back pain, escalates while supine

• Progression: paralysis, numbness

• Late: loss of bowel/bladder control

Rehab Considerations

• Spinal precautions

• Monitor changes in bowel/bladder control

• Assess and monitor sensations to light touch, proprioception, balance, coordination

111(7)




112(7)

Rehab considerations7:

113

• Monitor sensation, proprioception, balance, coordination

• Safety awareness

• Following commands

• Avoid Valsalva maneuvers and keep HOB elevated to at least 30 degrees (to prevent ↑ ICP)

• Monitor for headaches, nausea, dizziness, ↑ BP

Rehab Implications7

• Log rolling

• BLT (No bending, lifting, twisting)

• May need adaptive equipment for ADLs

• Room set-up

• No Chest PT over spine

• Mets/surgical site

114




Questions

115

[email protected]

Documents

Management of the Cancer Patient: Rehab · – Secondhand smoke – Radon – Personal or family history of lung cancer – Radiation to the chest – Diet 7 Lung Cancer 50, 51 •