Cancer Screening DD-handout (003).pdf

Differential Diagnosis Cancer Screening Kathryn Ryans PT, DPT, CLT-LANA Mercy College DPT Program Clinical Implications related to cancer and cancer treatment • The role of the PT/ in oncology care: • Addressing physical and functional impairments related to cancer treatments • Providing optimal e...

Differential Diagnosis Cancer Screening Kathryn Ryans PT, DPT, CLT-LANA Mercy College DPT Program Clinical Implications related to cancer and cancer treatment • The role of the PT/ in oncology care: • Addressing physical and functional impairments related to cancer treatments • Providing optimal exercise program/energy conservation • Differential diagnosis – screen for red and yellow flags • Behavior of MS tumors – symptoms are shared with wide range of non-tumorous ortho disorders • Education and risk factor modification/cancer prevention 2 Case • Pt is a 67 y/o male with PMHx of prostate cancer referred to PT with LBP. Patient has been treated for 8 visits over 4 weeks and not seeing any improvements in pain or function. • What follow up questions will you ask this patient? • Are there any red flags? • Would you continue to treat this patient? • Where is Prostate Cancer most likely to metastasize? 3 4 • Lung cancer is the most common cause of cancer mortality in both men and women BUT Prostate in males and breast in females are the most prevalent forms of cancer. Predisposing Factors ???? Incidence • Some cancer with an increase incidence in older adults – Prostate; Colon; Ovarian; Chronic leukemias • Incidence doubles after the age of 25 • Some cancers occur in a very narrow range – Adult – Childhood Role of PT in Cancer Rehabilitation • Cancer is a common yet chronic disease • Survivorship is close to 70% – More people living with adverse effects of cancer treatment • The need to screen and identify conditions outside the scope of PT practice – Pain not proportional to the reported diagnosis or injury Differential Diagnosis Signs and symptoms first appearing as a mechanical problem…. • Primary cancer • Recurrence • Metastasis 15 Evaluation Checklist • Subjective statement • This may be the MOST important portion of the evaluation section: • What is the patient coming to PT/OT for? • What are their goals for therapy? • Is their condition acute/chronic? • Is there a specific date of onset? If not, did anything happen leading up to their sxs? • Be sure to ask the “usual questions” • Social, working and living environment (etc.) 16 Evaluation Checklist • PMH/PSH • Does patient have a current or past history of cancer? • If yes- ask the following questions: • Surgery? LN biopsies? – • Radiation treatments? IF so, what part of their body? – • If yes, monitor for increase limb volume » Provide patient with education on risk of lymphedema » Ask if they are interested in referral In the area being treated look for: » Soft tissue changes (decreased elasticity) » Pain » Axillary Web Syndrome/cording Chemotherapy? IF so (and if they recall) what type of agents? 17 Chemotherapy – side effects and PT implications – Cardiotoxicity – Immunosuppression – Myelosuppression – Cognitive changes – Cancer Related Fatigue (CRF) – Chemo induced peripheral neuropathy (CIPN) Side Effects -radiation • Same as chemo- affects rapidly growing tissues skin, stomach lining, bone marrow • Erythema - red, tender skin , tissue tightness • Obstruction of lymphatics • Mouth sores –bleeding; painful inflammation • Nausea, diarrhea and vomiting. • Late side effects - osteoporosis, fractures, growth disturbances, fibrosis, plexopathies • Leg length discrepancy so try to shield the epiphyseal plate. Side Effects -radiation • Radiation to the chest – Cardiac toxicity – Pulmonary fibrosis • • • • • RADIATION RECALL Grade 1 (mild): Faint erythema or dry desquamation Grade 2 (moderate): Moderate to brisk erythema; patchy moist desquamation, mostly confined to skin folds and creases; moderate edema Grade 3 (severe): Moist desquamation other than skin folds and creases; bleeding induced by minor trauma or abrasion Grade 4 (life-threatening/disabling): Skin necrosis or ulceration of full thickness dermis; spontaneous bleeding from involved site Grade 5: Death Early Warning Signs Changes in bathroom habits A sore that does not heal Unusual discharge and bleeding Thickness or lumps in the breast or other places Indigestion and difficulty in swallowing Obvious changes in moles or warts Nagging cough and hoarseness Metastasis • Benign tumors do not spread • Malignant tumors spread or metastasize – move to areas away from original tumor site • Occurs when cells break away and travel via the blood or lymphatic systems • Infiltrate new organ/site • There are differing patterns of metastasis that are unpredictable • Most common – lymph nodes, lungs, bone, liver, brain – • *Why important to PT? Process of metastasis – Metastasis cascade • Primary tumor – blood vessels from surrounding tissue grow into the solid tumor – Angiogenesis • Tumor facilitates growth of blood vessels for nutrition and oxidation • Contact with circulatory system allows spread • Lymph system – lymph drains into veins so Ca cells can enter bloodstream Common Sites for Metastasis Bone Lung Liver Brain Nodes Breast X X X X X Prostate X X X Lung X X X Colorectal Esophagus X X X X X X X X Bladder Melanoma Skin X Uterus X Ovary X Sarcoma X X X X Marrow Bowel X X Pelvic organs X X X X X X X Adrenal glands X X X Kidney X Most Common Sites of Bone Metastases (in order of frequency) • Vertebrae (thoracic 60%/lumbosacral 30%) • Pelvis • Ribs (posterior) • Skull • Femur (proximal) • Others: sternum, cervical spine Data from Smuckler A, Govindan R: Management of bone metastasis, Contemp Oncol 1(13):1-10, 2002. Clinical Manifestations of Malignancy • Integumentary – Can be the first sign of malignancy - case • Pulmonary – First organ to filter malignant cells • Neurologic – Spinal cord/CNS compression – MET’s • Musculoskeletal – – – – Bone pain Fractures Back pain hypercalcemia • Hepatic A 42-year-old woman with a previous history of breast cancer and breast lumpectomy asked a fellow clinician to examine her scar for any sign of cancer recurrence. She had just had her 6-month cancer check-up and was not scheduled to see her oncologist for another 6 months. In the meantime, she had developed a skin rash over the upper chest wall and axilla of the involved side (upper back and left thigh). When asked if there were any other symptoms present, she reported feeling feverish and a bit nauseous, and noted slight muscle aching. On examination, the client's vital signs were taken. All vital signs were within normal limits for the client's age, except body temperature, which was 102.2°F. The client reported that her normal body temperature was usually 98° F. She was not aware of an elevated body temperature, although she stated she had awakened in the night feeling feverish and took some Tylenol. Upper quadrant examination was unremarkable, except for skin rash and the presence of bilateral anterior cervical adenopathy. There was a fullness of lymph node tissue without firmness or distinct nodes palpated in the axilla on the involved side. The clinician was unable to palpate as far into the Zone II space as would be expected. Results: This client had three red flags: recent • history of cancer, skin rash, and a constitutional symptom (fever). Even though there was no external sign of local cancer recurrence, and even though she was just seen by her oncologist, these new findings warranted a return visit to her physician. The skin rash turned out to be Sweet's syndrome, a disorder usually associated with significant constitutional symptoms and involvement of the lungs and joints. Most cases are idiopathic, but some have been associated with malignancies. In this case, no further findings were made despite laboratory and medical tests performed. The use of systemic corticosteroids is usually recommended for Sweet's syndrome, but the client declined and opted to use vitamin supplements, as her symptoms were resolving by that time. She was followed more closely for any cancer recurrence with more frequent testing thereafter. Multiple Myeloma • Recurrent bacterial infections • Anemia, weakness, fatigue • Bone destruction – Bone pain, spontaneous fracture – Osteoporosis – Hypercalcemia • Renal involvement • Neurologic abnormalities – Spinal cord compression – Back pain with radicular sx – Carpal tunnel Breast Cancer Signs and symptoms • Change in appearance of breast tissue – Puckering of skin • Detection of a lump or thickening of breast tissue (including axilla) • Nipple discharge • Unusual soreness of breast tissue • • • • • • Metastases Mass supraclavicular region, chest, or axillary region Unilateral UE numbness, pain, tingling Back or shoulder pain Pain on weight bearing Leg weakness/paresis Bowel and bladder symptoms Uterine Cancer • Vaginal bleeding after menopause • Persistent irregular bleeding in premenopausal women • Abdominal or pelvic pain • Weight loss, fatigue Prostate Cancer • Difficulty with and/or frequent urination • Bloody urine or semen • Erectile dysfunction • Swelling of the legs • Pelvic discomfort Skin Cancer • Assymetry – Uneven edges • Border – Poorly/undefined • Color – variable • Diameter – Larger than a pencil eraser Lung Cancer • • • • Persistent cough Bloody Sputum Recurrent Pneumonia MET’s first to the brain • Pancoast tumors Sarcomas • Soft Tissue Sarcomas • Bony tumors – Osteosarcomas – Chondrosarcomas – Osteoid Osteomas Soft Tissue Sarcoma • • • • Persistent swelling or lump in a muscle Pain Pathologic fracture Local swelling and warmth of overlying skin Osteosarcoma • Most common form of bone cancer • Occurs typically in 10-25yo age group (boys>girls) • Usually occurs in the epiphyses of long bones – Axial skeleton rarely affected • Metastasizes through blood • • • • • • Pain and swelling Loss of motion Tender lump Pathologic fracture Malaise Fatigue Chondrosarcoma • Pelvic or shoulder girdle or long bones • Most common malignant tumor of the sternum and scapula • Occurs most often in adults >40 – Higher grade of malignancy in younger age groups • • • • Back or thigh pain Sciatica Bladder sx Unilateral edema Brain Tumors • • • • • • • • • Increased intracranial pressure Headache, especially retroorbital; sometimes worse upon awakening, improves during the day Vomiting (with or without nausea) Visual changes (blurring, blind spots, diplopia, abnormal eye movements) Changes in mentation (impaired thinking, difficulty concentrating or reading, memory, or speech) Personality change, irritability Unusual drowsiness, increased sleeping Seizures (without previous history) Sensory changes • • • • • • • Muscle weakness or hemiparesis Bladder dysfunction Increased lower extremity reflexes compared with upper extremity reflexes Decreased coordination, gait changes, ataxia Positive Babinski reflex Clonus (ankle or wrist) Vertigo, head tilt Spinal Cord Tumors • • • • • • • • • • Pain Decreased sensation Spastic muscle weakness Progressive muscle weakness Muscle atrophy Paraplegia or quadriplegia Thoracolumbar pain Unilateral groin or leg pain Pain at rest and/or night pain Bowel/bladder dysfunction (late finding) Cancer as a cause of LBP • Age >50 or <20 yo • Constant pain, no relief with bed rest • Night pain, disturbed sleep • Prior history of cancer • Severe pain unchanged with position or posture • Unexplained weight loss Indications for Medical Referral • Combination of red or yellow flags • Symptoms seem out of proportion to injury • Symptoms persist beyond expected prognosis for healing or recovery • Pain does not seem to be effected by activity or rest • Symptoms just don’t fit the expected presentation Case • Pt is a 67 y/o male with PMHx of prostate cancer referred to PT with LBP. Patient has been treated for 8 visits over 4 weeks and not seeing any improvements in pain or function. • What follow up questions will you ask this patient? • Are there any red flags? • Would you continue to treat this patient? • Where is Prostate Cancer most likely to metastasize? 42