Muscular and Cutaneous Disorders Associated With Malignancy and Medical Management of Cancer Prevention

Muscular and Cutaneous Disorders

  • Muscular Disorders:
    • Muscular Amyloidosis
    • Amyotrophic lateral sclerosis
    • Polymyositis
    • Lambert–Eaton myasthenic syndrome (LEMS)
    • Myasthenia gravis
    • Metabolic myopathies
    • Primary neuropathic diseases
    • Type II muscle atrophy
  • Cutaneous Disorders:
    • Acanthosis (diffuse thickening)
    • Dermatomyositis
    • Extramammary Paget's disease
    • Nigricans (blackish discoloration; changes in skin pigmentation)
    • Pemphigus vulgaris (water blisters)
    • Pruritus (itching)
    • Pyoderma gangrenosum (eruption of skin ulcers)
    • Reactive erythemas (skin redness)
  • Gradual, progressive muscle weakness may develop over weeks to months.
  • Proximal muscles (especially of the pelvic girdle) are most likely to be involved.
  • Reflexes of the involved extremities are present but diminished.
  • Proximal leg weakness is often associated with small cell carcinoma of the lung.

Medical Management of Cancer Prevention

  • Goal of Healthy People 2030: Reduce new cancer cases, illness, disability, and death.
  • Evidence suggests several cancers can be prevented，and survival prospects continue to improve.
  • ACS estimates half of all cancer deaths in the U.S. could be prevented with healthier lifestyles and better screening.
  • Key resources for reducing cancer death rates:
    • Culturally and linguistically appropriate information on prevention, early detection, and treatment.
    • Mechanisms for providing access to state-of-the-art preventive services and treatment.
    • Mechanism for maintaining continued research progress and fostering new research.
  • Combining genetic screening for cancer predisposition with individualized targeted chemoprevention may dramatically reduce cancer rates in the future.
  • Studying older adults who do not develop cancer may help identify age-resistant protective mechanisms.
  • Genetic information is emerging for many cancers and may improve clinical and preventive medicine services.

Primary Prevention

  • Primary prevention includes screening to identify high-risk people and reducing/eliminating modifiable risk factors.
  • Physical activity and weight control can contribute to cancer prevention.
  • Chemoprevention: Using agents to inhibit and reverse cancer, focusing on diet-derived agents.
  • More than 40 promising agents and agent combinations are being evaluated clinically for major cancer targets (breast, prostate, colon, lung).
  • Low-dose aspirin and nonsteroidal antiinflammatory drug intake have shown promising results in gastrointestinal cancer prevention.
  • Research is focusing on cancer vaccines to stimulate the immune system.
  • The most promising vaccines are for malignant melanoma and prostate cancer; vaccines for cancer viruses are already in use.
  • A person's own tumor cells can be obtained, radiated to inactivate them, and then reinfused to stimulate the immune system to react and make antibodies against these specific cells.
  • The vaccine specifically evokes the activity of killer T cells to directly target and destroy tumors in all vaccine recipients.
  • A vaccine given on an outpatient basis would be less dangerous than surgery and less toxic than other cancer treatments such as chemotherapy and RT.

Secondary Prevention

  • Secondary prevention aims at preventing morbidity and mortality through early detection and prompt treatment.
  • Drugs like tamoxifen (Nolvadex) are used in both primary and secondary prevention of breast cancer.
  • Tamoxifen has been approved by the FDA as a preventive agent in women at high risk for breast cancer.
  • Preliminary results suggest that tamoxifen can decrease the risk of breast cancer by approximately 50% in high-risk women.
  • Multifactor risk reduction is important for secondary prevention, especially given the cumulative and interrelated nature of risk factors.

Tertiary Prevention

  • Tertiary prevention focuses on managing symptoms, limiting complications, and preventing disability associated with cancer or its treatment.

Diagnosis

  • Diagnosis includes:
    • Medical history
    • Physical examination
    • Specific diagnostic procedures
  • Useful tests:
    • Laboratory values
    • Radiography
    • Endoscopy
    • Isotope scan
    • CT scan
    • Mammography
    • Magnetic resonance imaging (MRI)
    • Biopsy
  • Advances in nuclear medicine allow for examining images of organs, structures, and physiologic or pathologic processes and detect the distribution of radiopharmaceuticals according to their uptake and metabolism.

Table 6.5 Early Detection of Cancer

  • Breast
    • Women age >20 years
      • BSE (Breast Self-Examination)
      • Clinical breast examination
        • For women in their 20s and 30s, CBE should be part of a periodic health examination, preferably at least every 3 years.
        • Asymptomatic women aged 40 years old or older should continue to receive a CBE as part of a periodic health examination, preferably annually.
      • Mammography
        • Begin annual mammography at age 40; CBE should be performed first
  • Colorectal
    • Men and women age >50years
      • Fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
        • Annual, starting at age 50
      • Flexible sigmoidoscopy
        • Every 5 years, starting at age 50 years
      • FOBT and flexible sigmoidoscopy:
        • Annual FOBT (or FIT) and flexible sigmoidoscopy every 5 years, starting at age 50
      • Double contrast barium enema (DCBE)
        • DCBE every 5 years, starting at age 50
      • Colonoscopy
        • Colonoscopy every 10 years, starting at age 50
  • Prostate
    • Men age >5
      • Digital rectal examination (DRE) and prostate-specific antigen (PSA) test
        • PSA test and DRE should be offered annually, starting at age 50, for men who have a life expectancy of at least 10 more years
  • Cervix
    • Women age >18
      • Pap test
        • Cervical cancer screening should begin approximately 3 years after a woman begins having vaginal intercourse, but no later than 21 years of age; screening should be done every year with conventional Pap tests or every 2 years using liquid-based Pap tests; at or after age 30 years, women who have had three normal test results in a row may get screened every 2–3 years with cervical cytology alone, or every 3 years with a human papillomavirus DNA test plus cervical cytology; women aged >70 years who have had three or more normal Pap test results and no abnormal Pap test results in the last 10 years and women who have had a total hysterectomy may choose to stop cervical cancer screening
  • Endometrial
    • Women, at menopause
      • At the time of menopause, women at average risk should be informed about risks and symptoms of endometrial cancer and should be strongly encouraged to report any unexpected bleeding or spotting to their physicians
  • Cancer-related checkup
    • Men and women age >20
      • On the occasion of a periodic health examination, the cancer-related checkup should include examination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin, as well as health counseling about tobacco, sun exposure, diet and nutrition, risk factors, sexual practices, and environmental and occupational exposures
Tissue Biopsy
  • Biopsy of tissue samples is an important diagnostic tool in the study of tumors.
  • Tissue for biopsy may be taken by curettage (Pap smear), fluid aspiration (pleural effusion, lumbar puncture, or spinal tap), fine needle aspiration (breast or thyroid), dermal punch (skin or mouth), endoscopy (rectal polyps), or surgical excision (visceral tumors and nodes).
  • Types of Biopsies:
    • Open Biopsy: Incision and removal of a portion of abnormal tissue.
    • Needle Biopsy: Uses a large-diameter needle to take a core or plug of tissue.
    • Incisional Biopsy: Takes a slice or wedge of the lesion but does not remove the entire pathologic structure.
    • Excisional Biopsy (Lumpectomy): Removes the tumor and a perimeter of normal tissue to get negative margins.
    • Stereotactic Mammotome Biopsy: Uses digital X-ray studies to locate the abnormality and a computer to calculate the needle insertion.
    • Sentinel Lymph Node (SLN) Biopsy: A blue dye is injected around the cancerous tumor; the dye flows through the ducts, and the first node or nodes it reaches is identified as the sentinel or sentinels.
      • An incision is made over the nodes, and the blue-stained sentinel node or nodes (one to three) are removed and analyzed.
      • Information regarding the lymphatic drainage from the cancer can directly impact on surgery.
      • SLN biopsy has reduced the number of unnecessary axillary dissections in breast cancer.
      • The status of axillary nodes is the most important prognostic factor in breast cancer and in determining the medical management.
Tumor Markers
  • Tumor markers are substances produced and secreted by tumor cells that may be found in the blood serum.
  • The level of tumor marker seems to correlate with the extent of disease.
  • A tumor marker is not diagnostic itself but can signal malignancies.
  • Carcinoembryonic antigen (CEA) is one tumor marker that may indicate malignancy of the large bowel, stomach, pancreas, lungs, and breasts.
  • CEA and other serum titers, such as cancer antigen (CA) 125 (ovarian), CA 27-29 (breast), and prostate-specific antigen, may be valuable during chemotherapy to evaluate the extent of response and detect tumor recurrence.

Treatment

  • Changes in the health care system have shifted much of cancer care to ambulatory and home settings.
  • The medical management of cancer may be curative or palliative (care that provides symptomatic relief but does not cure).
  • Major therapies include surgery, radiation, chemotherapy, biotherapy, angiogenesis therapy, and hormonal therapy.
  • Gene-profiling assays are now available that can predict fairly accurately what certain tumors will do and how best to treat them.
  • Two gene-profiling tests are already available for breast cancer; others are being evaluated for non-Hodgkin's lymphoma, head and neck cancer, prostate cancer, kidney cancer, melanoma, and ovarian cancer.
  • The future of oncologic care may rest on the model of individualized (tailored) therapy based on a pretreatment assessment of each individual's organ reserves, physical condition, and cognitive function.
  • Identifying predictive factors of successful outcome will help assess who could benefit from more aggressive treatment and have the greatest chance for successful outcomes.
  • When curative measures are no longer possible or available, palliative treatment may include radiation, chemotherapy, physical therapy, medications, acupuncture, chiropractic care, alternative medicine, and hospice care.

Complementary and Alternative Medicine

  • Many people are seeking help in the cure and palliation of cancer through complementary and alternative medicine (CAM) therapies, such as acupuncture, hypnosis, mind–body techniques, massage, music, yoga, meditation, and other methods, to improve physical and mental well- being.
  • Conventional treatments do not always relieve symptoms of pain, fatigue, anxiety, and mood disturbance. Some people cannot tolerate the side effects of conventional treatment.
  • The ACS has published a guide to help consumers make these kinds of treatment decisions and has provided some direction for health care professionals.
  • Major research institutions and universities are beginning to investigate the effectiveness of these types of interventions for cancer.
  • A new movement toward integrative medicine combining the best of complementary modalities with mainstream conventional therapies has been launched.

Major Treatment Modalities

  • Cancer treatment depends on an understanding of the biology of metastasis and how tumor cells interact with the microenvironment of different organs for effective therapies to be designed.
  • Each of the curative therapies described here may be used alone or in combination, depending on the type, stage, localization, and responsiveness of the tumor and on limitations imposed by the person's clinical status.
  • Surgery may be used curatively for tumor biopsy and tumor removal or palliatively to relieve pain, correct obstruction, or alleviate pressure.
  • Surgery can be curative in persons with localized cancer, but 70% of clients have evidence of micrometastases at the time of diagnosis, requiring surgery in combination with other treatment modalities to achieve better response rates.
  • Adjuvant therapy used after surgery eradicates any residual cells.
Radiation Therapy
  • RT (or XRT), also known as radiotherapy, plays a vital role in the treatment of cancer.
  • It is used to destroy the dividing cancer cells by destroying hydrogen bonds between DNA strands within the cancer cells while damaging resting normal cells as little as possible.
  • Recent advances in RT have primarily involved improvements in dose delivery.
  • Radiation consists of two types: ionizing radiation and particle radiation.
  • Both types have the cellular DNA as their target; however, particle radiation produces less skin damage.
  • The goal is to ablate as many cancer cells as possible while sparing surrounding normal tissues.
  • Radiation is given over a period of weeks to capture cells at each stage of the cell cycle.
  • Radiation treatment approaches include external beam radiation and intracavitary and interstitial implants.
  • Radiation may be used preoperatively to shrink a tumor, making it operable while preventing further spread of the disease during surgery.
  • After the surgical wound heals, postoperative doses prevent residual cancer cells from multiplying or metastasizing.
  • Modern radiology has advanced to include site-specific techniques that take into account complex tissue contours and irregular shapes, visceral movement, digestion, and the effect of respiration on the lungs when the lungs are the target organ.
  • Intensity-modulated RT now allows for sculpting the radiation field and dose to match the area being irradiated.
  • Normal and malignant cells respond to radiation differently, depending on blood supply, oxygen saturation, previous irradiation, and immune status.
  • Cells most affected by chemotherapy and radiation have the greatest oxygenation and are the fast-producing cells (e.g., hair, skin).
  • Generally, normal cells recover from radiation faster than malignant cells; damaged cancer cells cannot self-repair.
  • Success of the treatment and damage to normal tissue also vary with the intensity of the radiation.
  • Although a large single dose of radiation has greater cellular effects than fractions of the same amount delivered sequentially, a protracted schedule allows time for normal tissue to recover in the intervals between individual sublethal doses.
  • Challenges with radiation treatment still remain because of the inability to identify microscopic disease with accuracy.
  • Immobilizing patients and keeping them completely still for the duration of treatment are also difficult.
  • Weight loss associated with treatment alters body geometry, requiring further corrections in dosimetry.
Chemotherapy
  • Chemotherapy includes a wide array of chemical agents to destroy cancer cells.
  • It is particularly useful in the treatment of widespread or metastatic disease, whereas radiation is more useful for treatment of localized lesions.
  • Chemotherapy is used in eradicating residual disease, as well as inducing long remissions and cures, especially in children with childhood leukemia and adults with Hodgkin's disease or testicular cancer.
  • Chemotherapy (and RT) kills most of the billion or more cells in each cubic centimeter of tumor tissue.
  • Cytotoxic therapies do not always eradicate every tumor cell for several reasons.
  • Unlike normal cells, cancer cells are genetically unstable and replicate inaccurately.
  • As the tumor grows, multiple subpopulations of cells with different biologic characteristics develop.
  • Almost all chemotherapy agents kill cancer cells by affecting DNA synthesis or function, a process that occurs through the cell cycle.
  • Chemotherapy interferes with the synthesis or function of nucleic acid, targeting cells in the growth phase, and therefore does not kill all cells.
  • Chemotherapeutic drugs can be given orally, subcutaneously, intramuscularly, intravenously, intracavitarily (into a body cavity such as the thoracic, abdominal, or pelvic cavity), or intrathecally (through the sheath of a structure, such as through the sheath of the spinal cord into the subarachnoid space) or by arterial infusion, depending on the drug and its pharmacologic action and on tumor location.
  • Administration in any form is usually intermittent to allow for bone marrow recovery between doses.
  • “Chemobrain,” sometimes called “chemo fog” or “brain fog,” refers to problems with memory, attention, and concentration reported by many people who have been treated with chemotherapy.
  • MRIs of brain structures have shown temporary shrinkage in the brain structures that are responsible for cognition and awareness.
  • Shrinkage may be a possible physiologic explanation for chemotherapy-related cognitive difficulties.
Biotherapy
  • Biotherapy, sometimes referred to as immunotherapy or immune-based therapy, relies on BRMs to change or modify the relationship between the tumor and host by strengthening the host's biologic response to tumor cells.
  • Much of the work related to BRMs is still experimental, so the availability of this type of treatment varies regionally within the United States.
  • Other forms of biotherapy include bone marrow or stem cell transplantation, monoclonal antibodies, colony-stimulating factors, and hormonal therapy.
  • BMT or peripheral stem cell transplantation is used for cancers that are responsive to high doses of chemotherapy or radiation.
  • These high doses kill cancer cells but are also toxic to bone marrow; BMT provides a method for rescuing people from bone marrow destruction while allowing higher doses of chemotherapy for a better antitumor result.
  • BMT was a technique developed to restore the marrow in people who had sustained lethal injury to that site because of bone marrow failure, destruction of bone marrow by disease, or intensive chemical or radiation exposure.
  • These cells occur in the bone marrow and also circulate in the blood and can be harvested from the blood of a donor by treating the donor with an agent or agents (e.g., granulocyte colony-stimulating factor) that cause a release of larger numbers of stem cells into the blood and collecting them by hemapheresis.
  • Because blood (peripheral site), as well as marrow, is a good source of cells for transplantation, the term stem cell transplantation has replaced the general term for these procedures.
Antiangiogenic Therapy
  • Antiangiogenic therapy shows promise as a strategy for cancer treatment.
  • Research has shown that the one common area of vulnerability of all cells in any phase of growth is the nonnegotiable need for oxygen.
  • Tumor cells cannot survive without oxygen and other nutrients transported by the blood.
  • Antiangiogenic therapy may be able to put a stop to pathologic angiogenesis, the process by which a malignant tumor develops new vessels and the primary means by which cancer cells spread.
  • Treatment with antiangiogenesis factors (approved for use in the United States) focuses on blocking the general process of tumor growth by cutting off the tumor's blood supply rather than on the destruction of an already formed cancerous mass.
  • In the future, antiangiogenic agents may be used as maintenance therapy to control cancer much the same way that medications are used to control hypertension or hyperlipidemia.
  • It is expected that different mutations in cancer will require individualized therapy based on current knowledge of specific tumors, their patterns of resistance, and response to angiogenesis inhibitors.
Hormonal Therapy
  • Hormonal therapy is used for certain types of cancer shown to be affected by specific hormones.
  • For example, tamoxifen, an antiestrogen hormonal agent, is used in breast cancer to block estrogen receptors in breast tumor cells that require estrogen to thrive.
  • The luteinizing-releasing hormone leuprolide is now used to treat prostate cancer. With long- term use, this hormone inhibits testosterone release and tumor growth.

BOX 6.3: Definitions of Cancer Treatment Outcomes

  • CR, complete remission; PR, partial remission.
Cure
  • The disease is gone and there is no sign of it reappearing; individual must have been in complete remission for at least 5 years (or more) from the time of treatment to be considered “cured.”
  • Cancer recurrence or the onset of a new type of cancer is still possible; in theory, the chances of cancer recurrence or new cancer for a person who has been cured are no higher than in someone who has not had cancer.
Complete Remission
  • All signs of disease have disappeared after treatment, although this does not mean there are no cancer cells present and it does not mean the person is cured. CR may be referred to as no evidence of disease. After several years, this state may be referred to as durable remission until 5 years have passed, at which point the individual is considered cured.
Partial Remission
  • Primary tumor has been reduced to half its original size after treatment; also known as partial response.
Improvement
  • Size of primary tumor has been reduced, but tumor remains more than half its original size.
Advanced Disease
  • Disease has spread to more than one location; staging is used to describe the extent of disease.
Stable Disease
  • No change with treatment; the cancer is not increasing or decreasing in size, extent, severity, or symptoms.
Refractory
  • Cancer is resistant, does not respond to treatment, and continues to progress; also referred to as treatment failure, resistant cancer, or disease progression.
Relapse
  • Cancer returns after treatment or a period of improvement either in the first place it started or in another place.
Survival Rate
  • The percentage of people in a study or treatment group who are alive for a given period of time after diagnosis. This is commonly expressed as 1-year, 5-year, or 10-year survival rate, referring to the chances of being alive in 1 year, 5 years, or 10 years compared with the chances of someone who has not been diagnosed with cancer.
Prognostic Index
  • Used as a measure of risk for relapse, the prognostic index is not a predictor for death.

Effects of Cancer Treatment

  • Long-term effects of cancer treatment are problems that affect multiple systems.
  • The physical therapist assistant (PTA) must take this into consideration when planning intervention and offering patient/client education.
  • With improved survival rates, we expect to see more delayed reactions and long-term sequelae to today's cancer treatment modalities.
  • With improved survival and longevity, we also may see an increased prevalence of cancer recurrence in the future. This may mean worsening of symptoms such as peripheral neuropathy or lymphedema from second and third rounds of treatment.
  • In time, with the identification of genetic traits of cancer, treatment may become more specific to the cancer cells and less toxic to healthy cells and tissue, eventually reducing and maybe even eliminating side effects experienced by many of today's cancer survivors.

Prognosis

  • Previously, a cancer diagnosis was often a death sentence; survivors referred to themselves as “victims.”
  • Cancer is no longer considered a death sentence, and many survivors return to the mainstream of family life, community activities, and work.
  • Medical treatment is often provided in outpatient settings, making it possible to work during treatment.
  • Increased survival rates occur with screening and early detection, especially for cancers that do not have a highly effective treatment such as melanoma.
  • Prognosis is influenced by the type of cancer, the stage and grade of disease at diagnosis, the availability of effective treatment, the response to treatment, and other factors related to lifestyle such as smoking, alcohol consumption, diet, and nutrition.
  • Despite advances in early diagnosis, surgical techniques, systemic therapies, and patient care, the major cause of death from cancer is metastases that are resistant to therapy.
  • The prognosis is poor for anyone with advanced, disseminated cancer.
  • Researchers continue to search for the mechanisms responsible for cancer metastases and chemotherapeutic failure and develop new strategies to circumvent drug resistance.
  • Generally, the earlier cancers are found, the simpler treatment may be and the greater likelihood there is of a cure.
  • The term no evidence of disease may be used when all signs of the disease have disappeared after treatment but before 5 years have elapsed. There are no signs of the disease using current tests.
  • If the response is maintained for a long period, the term durable remission may be used (Box 6.3).
  • The person who is alive and without evidence of disease for at least 5 years after diagnosis is considered cured.
  • The terms survival and cure do not always portray the functional status of a cancer survivor. Many people considered cured are left with physical limitations and movement dysfunctions that interfere with their daily lives.
  • Even without complete remission, cancer can be controlled to provide longer survival time and improved quality of life (QOL), but these factors are not reflected in survival rates.
  • Survival rates for many cancers have increased from 1960 to the present, but not all cancers have been characterized by this increase.
  • For example, whereas survival rates for Hodgkin's disease and prostate, testicular, and bladder cancers have increased by at least 25%, the survival rates for cancers of the oral cavity and pharynx, liver, pancreas, esophagus, and colon have decreased or increased less than 5% during the same period.

6.1 Special Implications for the PTA

Oncology and Cancer Role of the Physical Therapist Assistant in Cancer Treatment

  • Treatment for cancer has improved over the past 20 years but often results in functional deficits caused by tissue resection or segmental bone, joint, or limb amputation.
  • Treatment can result in severe disfigurement; cancer is the major cause of amputation in children.
  • Site-specific cancer issues and side effects of radiotherapy, chemotherapy, and bone marrow or stem cell transplantation often require physical therapy intervention and education.
  • At the present time, standard protocols do not exist for problems associated with cancer and cancer treatment encountered by the rehabilitation team including the physical therapist assistant (PTA).
  • Indications and precautions for oncology patients are wide ranging, varied, or nonexistent regarding cardiovascular training, stretching, weight training, other exercise, or intervention by the PTA for any of the problems associated with this condition and its treatment.
  • Weakness, inflexibility, osteoporosis, risk of falls, altered or diminished breathing patterns, and lymphedema are just a few of the challenges faced by many of our cancer clients.
  • Many experts in the field of cancer treatment suggest automatic referral to a physical therapy team once the diagnosis of cancer has been made instead of waiting until radiation-induced fibrosis causes disabling contractures, for example.
  • Psychosocial-spiritual issues (e.g., loss, grief, and anger) require consideration during planning of an effective therapeutic approach.
  • The psychosocial-spiritual status and cultural beliefs can be a driving factor in successful outcomes. Engaging the individual in honest discussion, listening to concerns or feelings, and sharing rehabilitation needs to set mutually achievable goals will enhance outcomes.
  • As medical innovations help people with cancer live longer, there has been a shift in the way we approach cancer treatment. Shifting from the search for a cure to managing the disease as a chronic condition necessitates a more comprehensive and integrated management approach.
  • There is greater emphasis on maximizing function and improving quality of life (QOL) with a more holistic approach throughout the various phases of intervention and management.
  • The PTA will be involved in all phases of care, including prevention, restoration, support, and palliative care. Prevention lessens the impact of anticipated disability through education and training. Restorative care focuses on restoring physical function as much as possible. Supportive care assists clients in coping with the condition while maintaining maximal functional capacity. Palliative care provides comfort during function and activities of daily living to minimize dependence while offering emotional support.

Benign Tumors

  • The PTA may be asked by clients to observe unusual skin lesions or aberrant tissue such as unusual moles, ganglion, fibromas, or lipomas.
  • A general screening examination is required with history, age, and risk factors taken into consideration. The asymmetry, border, color, diameter skin cancer screening examination can be used with documentation of findings for any skin changes.
  • Benign fatty (lipoma) or fibrous tumors (fibroma) commonly located in the subcutaneous tissues can be located anywhere in the body.
  • Lipomas are found most often in locations where fat accumulates, such as the abdomen, thighs, upper arms, back, and breast. These masses are usually round or oval, soft, lumpy, and easily moveable. They may be small (pea size) or as large as 3–4 inches across. Palpation reveals defined borders and a mass that is not fixed but moves readily with pressure along the edge. These benign tumors are usually painless but can be tender when palpated.
  • Many people who discover the lump are understandably concerned about cancer. Any suspicious integumentary or soft tissue mass must be evaluated medically, especially in the client with any additional risk factors.
  • Only a pathologist can diagnose or rule out cancer in these types of lesions.

Side Effects of Cancer Treatment

  • Side Effects of Cancer Treatment Compared in Table 6.6.
  • The ACS provides an online guide to drugs used in the treatment of cancer with common side effects listed.
  • The National Comprehensive Cancer Network offers a number of clinical practice guidelines for cancer in general and for specific types of cancer.
  • The ACS offers suggestions for optimizing the preservation of fertility for men and women after cancer therapy.
  • Each individual will experience and report discomfort in a slightly different way. The occurrence of symptoms is a stressor of its own, sometimes initiating a response of fear behaviors and distress.
  • Individual perception of symptoms includes whether the person notices a change in how he or she usually feels or behaves, intensity of the symptoms, and the impact of both the presence and intensity of symptoms on daily activities, function, and QOL.
  • Response to symptom distress includes physiologic, psychologic, sociocultural, and behavioral components.
  • The most common and often distressing side effect of cancer and cancer-related treatment is fatigue. The PTA can be very instrumental in offering information and ideas about energy conservation and can help the client set priorities, pace himself or herself, and delegate activities and responsibilities as well as provide labor-saving devices and ideas.
  • Scheduling activities at times of peak energy is important, as is a structured daily routine that focuses on one activity at a time.
  • The importance of socializing, relaxing, and finding quiet moments of pleasure cannot be emphasized enough.
  • Exercise to improve functional capacity, increase activity tolerance, manage stress, and improve mood is an integral part of fatigue management.

Physical Therapy Ongoing Assessment

  • In a physical therapy practice, anyone with a previous history of cancer, with known cancer risk factors, and/or over the age of 40 should be screened for red flags suggestive of cancer.
  • The physical therapist (PT) and PTA are key professionals in offering education for risk factor modification and cancer prevention.
  • For the individual with a current diagnosis of cancer, an ongoing health assessment is important in providing the optimal exercise program.
  • Recommended rehabilitation protocols during medical intervention with consideration for the specific cancer treatment are available for PTs and PTAs to consider.
  • Cardiovascular and pulmonary tests and measures—including heart rate; breath sounds and respiratory rate, pattern, and quality; blood pressure; aerobic capacity test; and pulse oximetry—establish a baseline for reference in developing an exercise program.
  • This is especially important with the aging demographics of cancer survivors. The older the people are when diagnosed with cancer, the greater the likelihood of other problems being present, such as heart disease, hypertension, stroke, diabetes, osteoporosis, and so on.
  • Observe for and document any cluster of signs and symptoms of accompanying health conditions or comorbidities from cancer or cancer treatment such as hypoxia, decreased peripheral vascular supply, deep vein thrombosis, hypercalcemia, fluid or electrolyte imbalances, anemia, hypertension, integumentary changes, infection, and so on.
  • Integumentary, neuromuscular, musculoskeletal, and neurologic assessment should include but is not limited to observation of skin characteristics and condition (including lymph node palpation); anthropometrics; functional strength testing; assessment of range of motion and flexibility; arousal, attention, and orientation tests; evaluation of cranial and peripheral nerve integrity; tests of motor function; assessment of deep tendon and postural reflexes; and evaluation of sensory condition.
  • The risk of falling is one of the most serious sequelae of both the local effects of cancer and the systemic consequences of cancer treatment. Weakness, pain, fatigue, orthostatic hypotension, peripheral neuropathy, decreased bone density (osteoporosis), and diminished flexibility, in various combinations, may result in falls.
  • Higher incidences of osteoporosis and osteopenia are found in individuals with cancer. Management of long-term bone health is an important aspect of comprehensive cancer care.
  • Fall prevention and education about falls are important aspects of the rehabilitation or exercise program.
  • Assessment of the home environment is essential in providing a fall-prevention program.
  • In addition, the PTA must observe each client individually, possibly selecting an assistive device in appropriate cases. A wheelchair may be necessary for someone who experiences dizziness, weakness, fatigue, or signs of disorientation.

Precautions

  • The PTA must practice standard precautions carefully to help the individual undergoing cancer treatment avoid infection.
  • Closely monitoring blood and vital signs and observing for signs of infection, bleeding, or arrhythmias are important.
  • The PTA should contact the PT and physician when the client exhibits fever or a cluster of constitutional symptoms, unusual fatigue or tiredness, irregular heartbeat or palpitations, chest pain, unusual bleeding, or night pain.
  • Radiated tissue must be treated with care to avoid local trauma; extreme temperatures must be avoided, management of lymphedema may be required, and specific guidelines for the use of physical agents must be followed.
  • Many people undergoing cancer treatment are using complementary and alternative herbs or supplements that can have an adverse effect when combined with radiation or chemotherapy.
  • By being open and nonjudgmental and inviting more discussion about the use of these techniques, the PTA may be able to bring to light potential risks involved.
  • The client should be advised that most herbal or natural supplements and complementary interventions are designed to support, not replace, traditional medical interventions that have been proved effective.

Oncologic Emergencies

  • Oncology patients/clients can present complex challenges for the PT and PTA.
  • Early recognition of potential emergencies, such as superior vena cava syndrome (SVCS), tumor lysis syndrome (TLS), emergent spinal cord compression, severe thrombocytosis, and other conditions, is extremely important in reducing morbidity and mortality.
  • Most of these conditions are uncommon or rare, making knowledge of them even more important so the PTA does not miss early clinical manifestations.
  • Each one is typically associated with a particular type of cancer; knowing the patterns of potentially serious problems linked with individual cancers can help the PTA conduct surveillance with appropriate clients.
    • SVCS
      • Associated with small cell lung cancer and lymphoma, is caused by mediastinal metastasis and central lung lesions compressing the superior vena cava.
      • Presentation of SVCS is insidious, with dilated neck veins and facial and arm lymphedema.
      • Treatment may be palliative if the malignancy causing the compressive force is not curable; curative chemotherapy for lymphoma is the exception.
    • TLS
      • Occurs often in high-grade non-Hodgkin's lymphoma but may become clinically apparent in only a small number of affected individuals.
      • Occurs in people with myeloproliferative disorders, such as leukemia and lymphoma, when chemotherapy causes lysis of a massive number of cells in a short period of time.
      • Acute renal failure may occur from the deposition of potassium, phosphate, and uric acid from the cell lysis.
      • Symptoms of TLS are most common 6–72 hours after chemotherapy begins.The PTA may hear reports of and observe muscle weakness and cramping from TLS. In addition, the PTA must monitor for arrhythmias, decreased blood pressure, and tachycardia during activity.
    • Spinal cord compression
      • affects up to 30% of individuals with disseminated cancer from lung, breast, prostate, multiple myeloma, and colon. The thoracic spine is targeted most often, followed by the lumbosacral region.