Cancer

pediatric cancers

• Leukemias

• Lymphomas

• Sarcomas

• Brain Tumors

• Neuroblastoma

leukemia

cancer of the blood

• where bone marrow produces cancer cells

• bigger real estate

types of leukemia

 Acute Lymphoblastic Leukemia (ALL)
 Acute Myeloid Leukemia (AML)

acute leukemia

blast cells

chronic leukemia

mature/abnormal cell

clinicsl presentation of leukemia

 Fatigue and generalized weakness
 Bruising and bleeding (petichiae)
 Fever and unexplained infection
 Bone and/or joint pain
 Abdominal pain
 Decreased appetite/weight loss

lymphoma

• liquid cancer

• cancer in the lyymphatic y=sytsem

• can be a solid mass of lymph nodes

types of lymphoma

 Hodgkin’s Disease - easy to predict and treat
 Non-Hodgkin’s Lymphoma - more prevelant

clinical presentation of lymphoma

 Swelling of lymph nodes
 Mediastinal mass
 Difficulty breathing
 Weight loss
 Night sweats
 Fatigue
 Fever

diagnosis of leukemia and lymphoma

 CBC
 Lumbar Puncture
 CXR
 Bone Marrow Aspiration and Biopsy
 Biopsy of lymph nodes or mass
 CT Scan, PET Scan and Bone Scan

sarcoma

cancer of bone

• more common in older kids

types of sarcoma

 Osteosarcoma - within long bones
 Ewing’s Sarcoma - outside of long bones

clinical presenation of sarcoma

 Localized pain
 Swelling and/or redness at tumor site
 Increase pain with activity
 Limp
 Pathologic fracture

diagnosis of sarcoma

 X-ray
 MRI
 Chest CT and Bone Scan
 Biopsy

important considerations for brain tumor

 Location
 Rate of growth and if malignant
 Areas of the brain impacted

low grade

not malignant

hif=gh grade

highly malignant

neuroblastoma

 Tumor arises from tissues of the sympathetic nervous system
 Mostly in abdomen

risk level (COG)

• low

• internmediate

• high

clinical presentation of neuroblastoma

 Increased abdominal girth
 Abdominal pain
 Swelling of the legs, upper chest, neck, and face
 Weight loss
 Limp
 Pain
 Hypertension

diagnosis of brain tumor and neuroblastoma

 MRI of brain and spinal cord - b
 MRS (Magnetic Resonance Spectroscopy) - b
 CT of brain, chest, abdomen and pelvis
 Biopsy
 Lumbar Puncture
 Bone Scan
 MIBG Scan - n
 PET Scan

treatment

 Chemotherapy
 Radiation
 Transplants
 Bone Marrow
 Stem Cell
 Umbilical Cord Blood
 Surgery
 Tumor Resection, Excision, and/or Debulking
 Shunt Placement
 Amputation and Limb Salvage Procedures
 Chimeric Antigen Receptor Therapy (CAR-T)

chemotherapy

• Cytotoxic medications used to kill cancerous cells

• Attacks and kills cells that rapidly divide including cancerous and noncancerous.

• administered
   Orally
   Intravenously
   PICC line, CVL, or Port
   CNS-Directed Therapy

stages of chemo

• Induction
   First phase of treatment
   Goal is remission

• Consolidation/Intensification
   Intensified therapy
   Goal is to consolidate remission

• Maintenance/Continuation
   Less intense therapy
   Goal is to maintain remission

chemo side effects

slide 30

radiation

• Radioactive dose of energy directed at tumor

• Damages DNA of the cells

• Causes cell death and stops cell reproduction and division

side effects of radiation

 Nausea/Vomiting
 Myelosuppression
 Alopecia/Hair Loss
 Neurologic
 Inflammation
 Swelling
 Dry skin
 Skin reddening or burns
 Hearing loss

transplants

 Healthy marrow or stem cells are infused into pt’s blood stream
 Goal of transplant is engraftment

types of transplants

 Bone Marrow
 Stem Cells
 Umbilical Cord Blood

what is the process for transplants

• Pre-transplant conditioning
   High doses of chemo and or radiation

• Transplant
   Cells are administered

• Post-transplant
   Await engraftment
   Typically 12-17 days

transplant side effects

 Graft vs. Host Disease (GVHD)
 Mucositis
 Nausea/Vomiting
 Venous Occlusive Disease (VOD)
 Steroid induced myopathy
 Sterility
 Cardiac and pulmonary disease

Surgical interventions for brain and bone tumors

 Tumor excision
 Tumor resection or debulking

surgical interventions fro bone tumors

 Amputation
 Limb Salvage

shunt placement

 Management of Intracranial Pressure (ICP)
 Used to treat hydrocephaly as a result of surgical intervention (brain tumor resection).
 Shunts CSF from a ventricle of the brain to a different space.
 Externalized – CSF is collected in container external to the body.
 Internalized – CSF is routed into a body cavity for re-absorption.

risks and side effects of limb salvage

 Fracture
 Infection
 Aseptic loosening
 Dislocation
 Mechanical failure
 NO high impact activities or sports

chimeric antigen receptor therapy (CAR-T)

 Use the body’s own immune system to kill cancer cells.
 Goal is proliferation and persistence of engineered T cells.

ICF for ped oncology

slide 51

eval and diagnosis

slide 53

important considerations for PT diagnosis and prognosis

 Stage of the patient’s disease
 Stage of treatment
 Medical prognosis

cancer rehab continuum

• diagnosis

• inpatient admission

• outpatient follow up

• readmissions

• clinic visits

• end of treatment

• survovorship

what influences frequency of transfers between settings of care

 Indications for full re-assessment
 Use of developmentally appropriate outcome measures

important considerations for interventions

• Medical stability
   Lines
   Isolation
   Side effects

• Counts
   Blood count is significantly altered due to medical treatement and disease process.
   Those which affect treatment are Hgb, ANC, and platelets

counts slides 59-60

cancer

disease characterized by abnormal cells that divide without control

hyperplasia

cells are multiplying but still connected to the membrane

dysplasia

cells are changing in characteristics

in situ cancer

cancer with changed characteristics but connected to membrane

invasive cancer

cancer outside the membrane

carcinoma

skin or tissues that line or cover internal organs

sarcoma

Bone, cartilage, fat, muscle, blood vessels, or connective or supportive tissue

how is cancer categorized?

by origin

leukemia

Blood-forming tissue such as bone marrow

Lymphoma and myeloma

cells of immune system

Central nervous system cancers

Tissues of the brain and spinal cord

how are cancers typicallly named?

by where it started

what is the leading cancer for men?

prostate

what is the leading cancer for women?

breast cancer

what is the implication of cancer statistics in PT?

May present for physical therapy with side effects of their cancer or musculoskeletal conditions of any kind

who is at risk of developing cancer?

• 88% are 50 years of age or older
• 57% are 65 years of age or older
• 41 out of 100 men
• 39 out of 100 women

variables on who develops risk of cancer?

• Exposures
• Family history
• Genetic susceptibility

trends in cancer survival rate?

• changed due to advantages in treatment and earlier diagnosis

• Varies greatly
  • Cancer type
  • Stage
  • Age at diagnosis

In What Ways Have Statistics on Cancer Not Changed Dramatically?

• rate per 100,000

• survival from pancreatic, ovarian, and lung cancers

• non-hispanic black patients of both sexes continue to die at a higher rate

leading causes of death due to cancer

• lung and bronchus

• colorectum

• breast

• prostate

cancer etiology

• Personal factors
• Lifestyle factors
• Environmental factors

personal risk factors

• age

• genetics

• hormones

• height

lifestyle risk factors

• Diet and physical activity
  • Body weight

• Tobacco use

• Alcohol use

environmental risk factors of cancer

• sun and ultraviolet (UV) exposure

• Radiation exposure

• Carcinogens
  • Radon, lead, asbestos
  • Chemicals (benzene, arsenic)
  • Pollution

• Infectious agents
  • Viruses (HPV)
  • Bacteria
  • Parasites

what is the cause of change in head and neck cancers?

HPV

modifiable cancer risk

• Tobacco use
• Alcohol
• Obesity
• Physical activity level
• Diet/nutrition
• Unsafe sex
• Sun exposure
• Pollution

non-modifiable cancer risk

• Age
• Height
• Ethnicity
• Gender
• Genetics
• Hormones

Cancer Prevention

• Stop smoking
• Avoid excessive sun exposure
• Eat a healthy diet
• Exercise most days of the week
• Maintain healthy weight
• Drink alcohol in moderation if you choose to drink
• Schedule cancer screening exams
• Ask doctor about immunizations

Cancer Screening

• During any evaluation, keep risk factors in mind
• Thorough review of medical history to elicit previous cancer diagnoses/treatment
• Keep red flags in mind
• Consider anomalous findings carefully
• Consider lack of progress during treatment

cancer red flags

• Unexplained weight loss
• Fever, chills, night sweats
• Rest/night pain
• Fatigue
• Skin changes

skin inspection

ABCDE

Signs and Symptoms of Cancer

• Change in bowel habits or bladder function
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening or lump
• Indigestion or trouble swallowing
• Obvious change in wart/mole
• Nagging cough or hoarseness

Horner’s syndrome

• Eyelid Ptosis
• Pupil Dilation
• Anhydrosis of same side of the face
• Tumor Invasion of the sympathetic innervation of the eye

Pancoast Tumor

• Rare non-small cell lung CA in lung apex
• Silent until nearby structures are affected
• Often presents as musculoskeletal dysfunction when chest wall or thoracic outlet region affected.
• One study found that 69% of patients had arm/shoulder pain and delayed or inadequate imaging

cancer staging

• in situ

• localized

• regional

• distant

• unknown

in situ

Abnormal cells are present only in the layer of cells in which they developed

localized

Cancer is limited to the organ in which it began, without evidence of spread

regional

Cancer has spread beyond the primary site to nearby lymph nodes or tissues and organs

distant

Cancer has spread from the primary site to distant tissues or organs or to distant lymph nodes

unknown

There is not enough information to determine the stage

TNM systen

• T = size or extent of primary tumor

• N = amount of spread to regional lymph nodes

• M = presence of distant metastasis

cancer staging

• stage 0 = carinoma in situ

• stage I-III = higher numbers indicate more extensive disease

• stage IV = cancer has spread to distant tissues or organs

Tests used for staging

• Physical examination
• Imaging studies
• Laboratory tests
• Pathology reports
• Surgical reports

cancer staging

• Cure rate differs by cancers given specific stage
• Stage IV cancers are considered not “curable” generally
• But many stage IV cancers these days are treated as chronic diseases with more effective treatments to suppress the cancer long-term

cancer treatment

• Surgery
• Radiation therapy
• Chemotherapy
• Targeted therapy
• Transplantation
• Other

surgery

• Prophylactic
• Diagnostic
• Staging
• Curative
• Debulking
• Palliative
• Supportive
• Reconstructive

Radiation Therapy

• High-energy particles such as photons or proton

• “Once and done” modality

• Curative
  • Post-surgery
  • Instead of surgery for unresectable tumors

• Palliative

dose sculpting

look at area and highlight where they will deliver

acute side effects of radiation therapy

• Skin irritation
• Damage in regions exposed to radiation
• Cancer-related fatigue
• Nausea/vomiting

late side effects of radiation therapy

• Bone health
  • Fracture
  • Osteoporosis
  • Avascular necrosis

• Lymphedema

• Secondary cancer

• Fibrosis
  • Neuromuscular complications
  • Musculoskeletal complications

chemotherapy

• goal is to kill cells by targeting a specific aspect of the growth cycle

Neoadjuvant chemotherapy

before surgery

Adjuvant chemotherapy

after surgery

mestatic disease

long-term supression

side effects of chemo

• Cells of skin and hair follicles
  • Mouth sores, hand-foot syndrome, hair loss, long-term alopecia

• Cells lining digestive tract
  • Nausea, vomiting, diarrhea, constipation, loss of appetite

• Cells lining reproductive tract
  • Vaginal dryness

• Bone marrow/blood cells
  • Neutropenia, anemia, thrombocytopenia

• Effects on wound healing

• Organ damage
  • Heart, kidney, liver

• Electrolyte abnormalities

• Hearing loss

• Peripheral neuropathy

• Cancer-related fatigue

targeted therapy

• hormone therapies

• monoclonal antibodies

• Signal transduction inhibitors

• Gene expression modulator

• Apoptosis inducer

• Angiogenesis inhibitor

• Immunotherapies

Transplantation

• Bone marrow transplantation (BMT)

• Peripheral blood stem cell transplantation (PBSCT)

• Treatment requires eliminating the cancerous bone marrow, then replacing it with engrafted cells