advanced neuro - oncology

cancer - dysplasia vs differentiation

- dysplasia: precursor to cancer; abnormal organization and appearance of cells

- differentiation: grades established cancer; how specialized a cell is (cancer cells are less differentiated)

cancer stages 0-IV

- 0: carcinoma in situ

- 1: local to primary tissue

- 2: high risk of regional spread

- 3: regional spread

- 4: distant metastasis

malignant neoplasms

carcinoma, sarcoma, leukemia

causes of cancer

- genetic factors

- tobacco use

- environmental exposures (sun, chemicals, pollution)

- lifestyle factors (poor diet, inactivity, excess alcohol)

- infections (HPV, hep B or c)

- age (older)

oncogenesis requires both

- activation of oncogenes

- loss of tumor suppressor function

[removes the normal controls on cell growth and survival]

what tumor characteristics allow them to grow, survive, and spread?

1. uncontrolled proliferation (tumors grow)

2. evading cell death (tumors can continue to grow and survive)

3. angiogenesis/new blood vessels (tumors get the oxygen and nutrients they need to keep growing)

4. invasion and metastasis (metastatic disease can form in distant organs)

cancer progresses only when

it escapes the immune surveillance

what are common sites of metastasis

lungs, liver, bones, brain, lymph nodes

sxs/red flags of brain metastasis

- headaches

- seizures

- neurologic changes

- cognitive changes

sxs/red flags of lung metastasis

- cough

- SOB

- chest pain

- reduced endurance

sxs/red flags of liver metastasis

- abdominal pain

- jaundice

- fatigue

- nausea

sxs/red flags of bone metastasis

- pain

- pathologic fx

- spinal instability

- hypercalcemia

sxs/red flags of lymph nodes metastasis

- swelling

- discomfort

- enlarged lymph nodes

curative cancer treatment

- eliminate the cancer

- intent is cure

palliative cancer treatment

- not intended to cure

- reduce sxs

- prolong life

adjuvant cancer treatment

- given after surgery

- eliminate microscopic residual disease

neoadjuvant cancer treatment

- given before surgery

- shrink the primary tumor

why are cancer treatments given in repeated cycles?

- cells that are not currently replicating are not susceptible to chemotherapy or radiation

- allows recovery of normal tissues between treatments

what are the two types of chemotherapy?

- systemic (travels throughout; affects rapidly dividing cells wherever they are found)

- non-specific (can't distinguish healthy vs cancer; SE occur in normal cells)

side effects of chemotherapy

- immunosuppression

- nausea and vomiting

- alopecia

- diarrhea

- mucositis

- neuropathy

- organ damage

- sterility

how does radiation therapy work?

kills cells by destroying their DNA during replication

what are the types of radiation therapy?

- non-specific (can't distinguish healthy vs cancer)

- localized (effects tissues within area of radiation; SE more localized)

- proton beam therapy (highly targeted; reduces exposure of surrounding tissues)

side effects of radiation therapy

- immunosuppression

- nausea and vomiting

- fibrosis

- diarrhea

- dermatitis

- avascular necrosis

- organ damage

- myelitis

- lymphedema

radiation fibrosis can affect which tissues within the radiation field?

- skin

- muscles

- tendons, ligaments, fascia

what tissue changes occur with radiation induced fibrosis?

- poor vascularization

- impaired sensation

- loss of elasticity

t/f: soft tissue therapy is encouraged in areas with active inflammation

false - contraindicated

*gentle progressive stretching and mobility

**avoid thermal modalities over irradiated areas

if a pt receives radiation to the chest for breast cancer, which movements or joints may become limited?

- shoulder jt

- chest wall/rib cage

why might RT increase the risk of avascular necrosis?

- vascular damage

- osteoblast and osteocyte damage

- bone marrow fibrosis

goals of surgery for cancer

- prevention

- diagnosis

- curative

- palliative

stem cell transplant/bone marrow transplant is used primarily for ___ cancer

hematologic (leukemia, lymphoma, multiple myeloma)

t/f: someone with stem cell/bone marrow transplant requires prolonged hospitalization

true - monitoring and infection prevention

autologous vs allogenic transplants

- autologous (pts own stem cells)

- allogenic (donor stem cells; high risk of graft-versus-host disease)

how does immunotherapy work?

it helps the immune system recognize and attack cancer cells again

because immunotherapies activate the immune system, side effects often resemble

autoimmune inflammation and can affect many organ systems

how does hormone therapy work?

removes the hormone signal that the cancer depends on to grow

common side effects of hormone therapy

- hot flashes

- fatigue

- bone loss

- joint pain

- sexual dysfunction

CIPN risk factors

- high dose

- longer duration

CIPN mitigation strategies

- cryotherapy

- compression

CIPN related impairments

- sensory:

- motor:

- autonomic:

- sensory: hypersensitivity, pain, decreased protective sensation, impaired balance

- motor: weakness

- autonomic: orthostatic hypotension

CIPN OM

- functional assessment of cancer therapy/gynecologic oncology group neurotoxicity subscale (FACT/GOC Ntx)

- fullerton advanced balance scale (FABS)

- TUG

CIPN PT management

- skin checks, fall prevention

- targeted strengthening

- balance exercises

- AD

- orthotics

ototoxicity is damage to the inner ear caused by

- RT

- surgery

- chemotherapy (cisplatin)

ototoxicity causes impairments in

hearing and vestibular functions

cancer-related cognitive impairment (CRCI) includes impairments to

- memory

- concentration

- multi-tasking

- word-finding

cancer related skeletal complications

- primary bone cancer

- metastasis

- osteopenia/osteoporosis

- avascular necrosis

red flags for metastatic bone disease

- pain w/ wt bearing

- pain worse at night

- constant pain

- pain not relieved by change in position

- empty end feel

- non-capsular pattern of motion restriction

- hx of cancer

common locations of metastatic bone disease

- vertebrae

- pelvic

- ribs

- femur

- humerus

PT considerations for those with metastatic bone disease

- weight bearing status

- pain with WB indicates high risk for fracture

- progressive strengthening and endurance of supporting muscles

- avoid high-impact and torsional activities

vertebral metastasis can cause

compression fractures

what should you consider implementing if there is known spinal metastasis?

- spinal precautions

- focus on extensor strengthening

- limit concentrate abdominal strengthening

signs and sxs of spinal cord compression

- pain that increases in supine

- pain with valsalva

- increasing back pain

- sensory deficits

- bladder or bowel dysfunction

- hyperreactive reflexes

during radiation, healthy tissues are damaged causing a local inflammatory response:

cell damage --> inflammation --> fibrosis

what is cancer related fatigue (CRF)?

- persistent, distressing fatigue

- can be physical, emotional or cognitivr

CRF screening tool

One-Item Fatigue Scale

- "how would you rate your worst fatigue on a scale of 0 to 10 with 0 being no fatigue and 10 being worst fatigue?"

CRF OM

- piper fatigue scale - revised (PFS-R)

- functional assessment of chronic illness therapy - fatigue (FACIT-F)

- patient-reported outcomes measurement information system - short form fatigue (PROMIS fatigue SF)

what is the gold standard for managing CRF?

Supervised moderate-intensity aerobic exercise

- borg 12-14

- >/= 10 mins

how should you educate pts with CRF on energy conservation?

- encourage pts to plan activities to maximize participation in meaningful tasks (like sitting down when meal prepping)

- planned breaks

what psychological factors may amplify the experience of cancer related pain?

- anxiety

- depression

- poor coping skills

what are the 4 general causes of cancer pain?

- tumor-related sources (mechanical compression, bone pain/destruction, nerve infiltration, ischemic pain)

- treatment-related sources (surgery, CIPN, RT)

- biological and physiological mechanisms (immune system, hormones, peripheral/central sensitization)

- psychosocial (emotional, coping skills)

how can PT manage tumor related pain

- education

- activity modification

- positioning

- mobility training

how can PT manage treatment-related pain

- desensitization

- mobility

- aerobic exercise

- progressive loading

how can PT manage pain sensitization

- pain neuroscience education

- skilled touch

- graded motor imagery

- graded exposure

how can PT manage psychosocial contributors to pain

- motivational interviewing

- mindfulness

- relaxation

- goal setting

what factors may contribute to people with cancer being undernourished or malnourished?

- increased metabolic demand

- malabsorption

- reduced intake (fatigue, reduced appetite, nausea/vomit, oral pain, constipation, depression)

t/f: some medications affect the GI tract and they interfere w/ digestion and absorption of nutrients

true

what should you consider safety-wise if a pt has prolonged vomitting?

- electrolyte levels (sodium, potassium)

- monitor for signs of dehydration (dizziness, orthostatic hypotension)

what may contribute to sarcopenia (loss of muscle mass/strength) in cancer pts?

- reduced activity

- cachexia

- impaired nutrition

what is cachexia

metabolic syndrome associated with serious illness that results in ongoing loss of skeletal muscle

*increased nutritional intake cannot fully reverse underlying metabolic changes

chemotherapy and RT can suppress bone marrow, leading to impaired production of: ____________. These effects are more pronounced in people with ________ cancers.

- RBC, WBC, thrombocytes

- hematologic (lymphoma, leukemia, multiple myeloma)

what are the associated effects of anemia?

orthostatic hypotension and falls --> consider pacing strategies and RPE

what are the associated effects of thrombocytopenia?

spontaneous bleeding --> consider fall risk and monitoring fatigue

what are the associated effects of neutropenia?

increased risk of infection

neutropenic fever --> when to contact the physician

>/= 100.9 deg or >/=100.4 deg for >1hr

what are the phases of Dietz's model of cancer rehabilitation?

- preventative (minimize future impairments)

- restorative (treat exisiting impairments)

- supportive (reduce decline & support QoL)

- palliative (symptom relief & QoL)

what is the prospective surveillance system for cancer rehabilitation?

when someone is diagnosed with cancer, an IE is scheduled ASAP to get baseline measures

- measures are redone every 3 months

what are potential barriers to prospective surveillance?

- patient: cost/insurance, transportation/access, competing appointments, symptom/treatment burden, lack of awareness of rehab

- provider: lack of awareness of cancer rehab, failure to identify rehab needs, uncertainty about referring

- healthcare: lack of referral pathways, limited access to oncology rehab, reimbursement constraints

criteria to qualify for hospice

- prognosis of 6 months or less if the illness follows its usual course

- elect to end curative interventions

what is the role of PT when approaching end of life?

- balance preserving meaningful participation and function with symptom management

- anticipate future needs of pt --> DME, environmental adaptations, caregiver training

which cancers have strong evidence that physical activity reduces the risk for cancer?

- colon

- breast

- kidney

- endometrium

- bladder

- stomach

- esophageal

- lung

what are the physical activity recommendations for cancer prevention?

150-300 mins/week of moderate-intensity exercise

OR

75-150 mins/week of vigorous-intensity exercise

(or equivalent mix)

physical activity improves cancer-related symptoms such as

- decreased fatigue, anxiety, and depression

- improved physical function, health-related QoL, sleep

what are the AEROBIC physical activity guidelines for cancer survivors?

- frequency: 3-5 days/week

- intensity: moderate (RPE 12-13) or vigorous (14-17)

- time: 75 mins/week for vigorous or 150 mins/week for moderte (or combo)

- type: prolongef rhythmic activities using large muscle groups (walk,cycle,swim)

what are the RESISTANCE physical activity guidelines for cancer survivors?

- frequency: 2-3 days/week

- intensity: start with low resistance (

what should you consider when individualizing exercise for cancer survivors?

- cancer type and stage

- active vs post treatment

- current treatment effects/sxs

- medical considerations (comorbidities and risk factors)

- baseline function

- response to exercise

breast cancer specific exercise considerations

- shoulder dysfunction

- lymphedema

- bone health

- bone metastasis

prostate cancer specific exercise considerations

- bone health/fx risk

- bone metastasis

colorectal cancer specific exercise considerations

- ostomy considerations --> avoid excessive abdominal pressure

- bone metastasis

hematologic cancer specific exercise considerations

- infection risk

- immune status

- anemia

- thrombocytopenia

- bone metastasis

gynecolic cancer specific exercise considerations

- LE lymphedema

- pelvic/abdominal sxs

- bone metastasis