Cancer Treatment Effects and Patient Care

Cancer Fundamentals Part 2

• Topics covered include treatments, comorbidities, exercise in the oncology setting, and cancer's impact on the heart.
• Immunotherapy's use in cancer treatment was pioneered by William Coley in 1891, using bacterial toxins to stimulate the body's defenses against cancer.

Cancer Treatment: Surgery

• Surgery typically involves removing the tumor and surrounding tissue (margins).
• Tumors spreading through lymphatics often require resection of regional lymphatics, potentially using sentinel node biopsy to reduce the number of removed lymph nodes.
• Common impairments due to surgery depend on location and extent of resection, and include compromised tissues, wound complications, and complications from post-surgical treatments. Dehiscence (wound separation) and infection are secondary issues.
• Lymphedema is a chronic condition where lymph fluid builds up, causing localized swelling. It's distinct from edema.

Goals of Surgery

• Diagnosis/staging (biopsy)
• Cure
• Debulking (reducing tumor size to aid other treatments)
• Removing metastases
• Reconstruction
• Palliation (improving quality of life)

Rehabilitation Goals for Surgery

• Restoring/regaining function
• Retraining lost function
• Pain control
• Managing swelling/lymphedema
• Addressing foreseeable problems

Common Postsurgical Impairments

• Limited motion
• Joint issues
• Soft tissue problems
• Decreased depth of respiration
• Pain
• Sensory loss
• Weakness
• Altered posture and gait

Survivor Interview/History

• Gathering information on tumor site and stage
• Reviewing surgical reports
• Specifics on when surgery occurred, the procedure, tissues damaged, post-operative course, and any remaining symptoms.

Head and Neck Dissection

• Potential consequences (sequelae) include spinal accessory nerve damage (affecting SCM and trapezius muscles), cervical range of motion (ROM) deficits, altered posture, lymphedema, pain, and temporomandibular joint (TMJ) dysfunction.

Radiation Therapy XRT

• Employs ionizing radiation to kill cancer cells, shrinking tumors and killing cancer cells.
• Examples include sunlight, microwaves, X-rays, and gamma rays.

Radiation Therapy: The Goals of XRT

• Curative
• Adjunctive
• Control
• Prophylactic
• Palliative

Radiation Fields

• The targeted areas on the body where radiation beams are aimed during XRT.
• XRT damages healthy and cancerous tissue. Different patterns exist including Mantle, Para-aortic, Inverted "Y", and Total nodal.

Radiation Dose

• Radiation dose is the absorbed energy in human tissue.
• Measured in rads (old terminology) or grays (Gy).
• 1 Gy = 100 rads

Fractionation

• Treatment by splitting a total radiation dose into smaller fractional doses delivered over several sessions for better tolerance vs delivering the total amount up front.
• Factors considered in determining dose include cancer type, tumor size and location, patient health, treatment response.
• Three fractionation schedules exist: standard, hyperfractionation and hypofractionation.

XRT Side Effects (Visible)

• Radiation dermatitis/desquamation

XRT Side Effects (Invisible)

• Mucositis (inflammation/ulceration of mucous membranes, including GI tract)
• Fibrotic injury (scar-like tissue issues)
• Pain
• Cardiovascular and pulmonary pathologies
• Bone injury (e.g., osteoporosis)
• Fatigue (often starting 3 weeks into treatment).

Physiopathology of Heart Damage Induced by Radiation

• Radiation exposure damages the heart by increasing risk of:
  • Myocardial damage
  • Valvular disease
  • Pericardial damage
  • Micro/macrovascular issues
  • Conduction issues
  • DNA disruption
  • Oxidative stress
  • Lipid peroxidation
  • Inflammation
  • Vasoconstriction
  • Prothrombosis
  • Ventricular remodeling
  • Fibrosis

Sequelae of XRT for Breast Cancer

• Muscle impairments (e.g., intercostals, pectorals major/minor, serratus anterior, latissimus dorsi, subclavius).
• Decreased neck and shoulder ROM
• Compromised posture

Chemotherapy:

•  Uses chemicals to eliminate cancer, reduce symptoms, or prolong life, often used alongside surgery and/or radiology.
•  KILLS mostly fast-growing cells but damages healthy cells.

Chemotherapy: Types of Drugs

• Cytotoxic Chemotherapy: disrupts cell division, damages DNA, or prevents normal cell division.
• Hormonal therapies: modify or reduce the production/influence of sex hormones, slowing tumor growth.

Hormonal Therapies - Chemotherapy

• Anti-estrogens
• Anti-androgens
• Aromatase inhibitors
• LH-RH antagonists

Chemotherapy: Targeted Therapies

• Targeted therapies target specific receptors, ligands, or intracellular molecules in cancer cells (e.g., imatinib, gefitinib).

Chemotherapy: Delivery Methods

• Injection
• Intra-arterial
• Intravenous (IV)
• Topically
• Orally
• Ports/Central lines
• Pumps

Chemotherapy: Acute Adverse Effects

• Immune suppression
• Fatigue
• Pain
• Skin and Nail changes
• Swelling
• Peripheral neuropathy
• Cognitive impairments
• Organ damage

Chemotherapy: Long-Term Adverse Effects

• Myelosuppression
• pain/neuropathy
• Fatigue
• Appetite changes
• Diabetes
• Memory changes
• Infertility
• Peripheral neuropathy

Chemotherapy: Late Adverse Effects

• Cardiopulmonary changes
• Impaired balance
• Sexual and fertility changes (men & women)
• Premature frailty
• Lymphedema

Chemotherapy- Classes: Immunomodulatory drugs

• Cytokines are involved in cell signaling associated with inflammation, infection, and trauma
• Vaccine therapy (BCG, HPV)
• Immunomodulatory drugs (IMIDs) - influence tumor cells, NK and NK T Cells, and inhibition of angiogensis
• Monoclonal antibodies

Chemotherapy Apps

• Drugs.com Mobile
• Pocket Pharmacist
• Physician's Cancer Chemotherapy Drug Manual

Survivor Interviews: History of Chemotherapy

• Gather Information on Chemotherapy (Yes/No)
• Details about start and end dates.
• Chemotherapy dosage.
• Details on any dose reductions
• Names of drugs and anticipated side effects
• Patient's response to chemotherapy and residual symptoms.

History of Chemotherapy: Why Ask?

• Evaluation: screening for acute/chronic adverse effects.
• Adjusting Interventions: Identifying non-chemo treatments, e.g. cervical and head and neck cancer.
• Outcomes: Assessing impact on rehab outcomes, e.g. musculoskeletal disorders and modifying side effects.

Persistent Changes Resulting From Cancer Therapies

• Effects of surgery, chemotherapy and radiation on various body systems, like the musculoskeletal, cardio-vascular, pulmonary systems. Other conditions are also included such as fatigue, pain and immune/anemia issues.

Cancer Comorbidities

• Discussing chronic conditions common in/with cancer survivors, and/or connected in nature or treatment related.

Cancer-Related Fatigue (CRF)

• A distressing, persistent fatigue not proportionate to recent activity that interferes with usual functioning, experienced by many cancer patients, including those undergoing chemo,
• CRF often continues after treatment concludes, and can significantly impact recovery.
• Presence of pain, anemia, nutritional deficiencies, electrolyte imbalances, and sleep disturbances can cause or exacerbate CRF.
• Assess CRF in survivors.

CRF: Signs & Symptoms

• The symptoms of CRF include difficulty concentrating, remembering, issues with personal appearance, more difficulty with daily tasks, issues improving with rest, and less participation in normal daily activities.

Treatable Causes of CRF

• pain, anemia, inadequate nutrition, electrolyte imbalances, sleep disorders, emotional distress (anxiety, depression), inactivity, comorbidities, side effects of treatment like medications.

Assessment of CRF (Screening)

• Screening for CRF varies based on patient age (7 years old - "tired/not tired", 7-12 years old -0 to 5 scale, 12 years or older -0 to 10 Likert scale).

Brief Fatigue Inventory (BFI)

• A 5-minute screening tool for evaluating CRF, available across many languages.
• Fatigue is classified as severe, moderate, or mild.

Exercise & CRF

• Exercise is beneficial to cancer survivors experiencing CRF.
• Research is needed in determining optimal type, intensity and/or timing of exercise.

Survivor Fall Risk

• factors to consider include age, CIPN, pain, depression, incontinence, impaired cognition, vestibular dysfunction, impaired vision, use of assistive devices, physical/performance, and environmental factors.

Fall Risk Assessment

• History of falls
• Timed Up and Go (TUG) test
• 30-second sit-to-stand test
• Four-stage balance test
• Mini-Best Test
• Clinical Test Sensory Interaction and Balance Test (CTSIB)

Chemotherapy-Induced Peripheral Neuropathy (CIPN)

• A set of symptoms arising from chemotherapy/radiation associated with damage to peripheral nerves.
• Often involves sensory deficits but may also impact autonomic/muscular function.
• Symptoms often include pain, numbness, burning, tingling, impaired thermal sensitivity, and possible falling related to inner ear damage.

CIPN: Clinical Presentation

• Sensory symptoms and difficulties with daily activities.
• Diminished quality of deep tendon reflexes.
• Reduced muscle strength.
• Decreased nerve sensibility to pain and vibration.
• Reduced nerve conduction velocity.

CIPN: Recovery

• Complete resolution is not always achieved.
• Nerves can regenerate after the cause of CIPN is removed.
• Regeneration speed is influenced by factors such as optimal healing conditions and is typically at the rate of 1 inch per month.
• CIPN differs from diabetic peripheral neuropathy.

CIPN: Treatment

• Supportive measures include muscle strengthening, fall prevention, training, orthotics, desensitization, proper nutrition/hydration, sleep, pain management, energy conservation for CRF, and adaptive aids.

Assess Balance

• Clinical Test of Sensory Organization and Balance (CTSB).
• Single-leg stance (<5 sec).
• Tandem stance (<10 sec).
• Head movements, dual-task activities.
• 5XSTS (>12 sec or loss of balance.).

Assess Gait

• Timed Up and Go (TUG).
• 4-meter and 10-meter walk tests.
• Clinically significant values (1.2 m/s to 0.6 m/s).
• Dynamic Gait Index (DGI)/Functional Gait Assessment (FGA).

Neutrophils/Neutropenia

• Neutrophils are the most abundant leukocytes (WBC).
• They are the initial responders in the immune response, defending against bacteria and fungi.
• Neutropenia is a condition with a low absolute neutrophil count (ANC) (<500 neutrophils).

Neutropenic Fever

• Neutropenia increases the risk of infection, a leading cause of morbidity and mortality in oncology patients.
• Prophylactic antibiotics were introduced to mitigate this risk, significantly lowering the mortality rate.
• Myelosuppressive chemotherapy is often associated with febrile neutropenia.
• Myelosuppression can be long-lasting.

Neutropenic Fever - Signs & Symptoms

• Symptoms of infection.
• Precautions to avoid infections / febrile neutropenia: diligent handwashing, avoiding crowds, avoiding public environments, and maintaining personal hygiene.

Chemobrain

• Chemobrain is a real phenomenon impacting higher order mental functions, which may be dependent on the patient's age and extent of chemotherapy.
• Temporary and may improve as time passes, however, and varies among all patients.

Inactivity

• The bed should not be the patient's only friend/activity.
• Encourage daily movement.

Osteoporosis

• WHO: Occurs at a T-score of 2.5 or below.
• Associated with surgical oophorectomy, chemotherapy-induced ovarian failure, cyclophosphamides, platinum agents; anthracyclines, taxanes, androgen deprivation therapy, aromatase inhibitors, glucocorticoid therapy, and bone irradiation.

Thrombocytopenia

• A low platelet count caused by myelosuppressive XRT/drugs.
• Bleeding symptoms should be closely monitored/investigated in the patient.

Cardio-Oncology

• New practice area for cardiopulmonary physical therapists.
• Focus on the intersection between cardiovascular and cancer issues.
• Includes a review of the various cardiovascular diseases and risk factors for survivors, common risk factors, and treatments.

This quiz focuses on the side effects of radiation therapy and chemotherapy, including their impacts on blood cells and tissues. It also covers important dietary advice for patients with myelosuppression and considerations for those recovering from lymphedema. Prepare to enhance your understanding of patient management in cancer care.