Oncology Patient

Does Physiotherapy have a role To Play ?

Robyn SmithDepartment of Physiotherapy

UFS2011

Prevalence of cancer• Over 7 million people die from cancer, and more than

11 million new cases are diagnosed worldwide.

• Tobacco kills more than 5 million people, of whom 1.5 million die of lung cancer.

• More than 160,000 cases of childhood cancer are diagnosed and at least 90,000 children die of cancer.

• In 2020, if current trends continue, new cases of cancer will increase to 16 million per year and more than 10 million people will die.

International Union against Cancer Report

What is cancer?

• Cells are the body’s building blocks• Cancer is a condition affecting the cells of the

body• Cancer cells divide or reproduce uncontrollably

resulting in a lump (tumour), cells forget to die or in the case of leukaemia the body produces too many white blood cells

• Metastases occur when cancerous cells break down and these parts are transported to other areas of the body via the blood stream

What causes cancer? • In many cases the causes remain unknown.

• Estimated that 90% of cancers are caused by environmental and lifestyle factors (Cansa website. 2011)

• Some of the known causes include: Benzene and other chemicals Drinking excess alcohol Environmental toxins, such as certain poisonous mushrooms and a

type of poison that can grow on peanut plants Excessive sunlight exposure Genetic problems Obesity Radiation Viruses

Types of cancer

• More than 200 types of cancers

What are the most common types of cancers?

Men • Prostate • Lung• Colon

Children • Leukaemia• CNS tumours• Lymphoma• Osteosarcoma

Women• Breast• Colon • Lung

Prevalence may vary according to the geographical location e.g. Stomach cancer prevalent in Japan

Cancer statistics in South Africa

Men (1/6 chance)• Prostate 1 in 23 • Lung 1 in 69• Oesophagus 1 in 82• Colon/rectum 1 in 97• Bladder 1 in 108

Lung cancer remains a growing problem in both gender groupsThe most common cancer in South Africa is skin cancer

Female (1/8 chance)• Breast 1 in 29• Cervix 1 in 35• Uterus 1 in 144• Colorectal 1 in 162• Oesophageal 1 in 196

Signs and symptoms of cancer• Vary according to the type of cancer

• Common signs and symptoms are:

ChillsFatigueFeverLoss of appetite MalaiseLoss of weightNight sweats

Recent advances in management of cancer include:

• Improved understanding of the disease process

• Improved diagnostic testing• Improved treatments

Diagnostic tools

• A cancer diagnosis is made with the aid ofTissue biopsyBone marrow biopsyBlood testsMRICT scanCXR

• Diagnostic tools also assist in staging the cancer

How are cancers classified?• There are five broad groups that are used to classify cancer.

• Carcinomas are characterized by cells that cover internal and external parts of the body such as lung, breast, and colon cancer.

• Sarcomas are characterized by cells that are located in bone, cartilage,

fat, connective tissue, muscle, and other supportive tissues.

• Lymphomas are cancers that begin in the lymph nodes and immune system tissues.

• Leukemias are cancers that begin in the bone marrow and often accumulate in the bloodstream.

• Adenomas are cancers that arise in the thyroid, the pituitary gland, the adrenal gland, and other glandular tissues.

How are cancers staged?• For most cancers, the stage is based on 3 main factors:

• The size of the tumour's size and whether or not the tumour has grown into nearby areas

• Whether or not the cancer has spread to nearby lymph nodes• Whether or not the cancer has metastasized to distal areas • Some cancers of the blood, such as leukemia's, are not staged in this way,

because it is assumed that they are in all parts of the body. • Brain cancer brain also not staged, since these cancers can disrupt vital

brain and body functions before they even begin to spread.

How are cancers staged?• Clinical staging is done at the time of diagnosis, before any treatment is given.

It helps doctors to determine what the best treatment will be and is also used as a baseline comparison when looking at a person's response to treatment.

• Pathologic staging can only be done on patients who have had surgery to remove the cancer or to determine how much cancer is in their body. It gives the doctors more precise information that can be used to predict treatment response and the prognosis (outcome).

• Restaging is not common, but may be done to determine the extent of the cancer if it comes back after treatment. This helps to decide on the most suitable treatment option at that time.

• Cancer's stage does not change• The stage of cancer does not change over time, even if the cancer progresses. A

cancer that comes back or spreads is still referred to by the stage it was given when it was first found and diagnosed.

Prognosis• The outlook depends on the type of cancer.• Even among people with one type of cancer, the

outcome varies depending on the stage of the tumor when they are diagnosed.

• Some cancers can be cured.• Other cancers that are not curable can still be

treated well. • Some patients can live for many years with their

cancer. • Other tumors are quickly life-threatening

Medical management of cancer

Traditional • Chemotherapy• Radiotherapy • Surgery• Bone marrow transplant

Choice of treatment depends on the type and stage of cancerCombination therapy also given

Alternative therapies • Hormonal therapy

Immunotherapy • targeted therapy• steriotactic radiosurgery

• Complementary medicine ????

Bone marrow transplant• Treatment often used in case leukaemia's• Where donor marrow cells are transfused into recipient• Need higher dose of chemotherapy or radiation therapy to kill the

host bone marrow cells• Symptoms and side effects may as for chemotherapy but more

severe• Patients are treated in isolation due to their low immunity and high

risk of infection• Also at risk of graft versus host disease • Strict infection control measures must be adhered to when treating

these patients

Bone marrow transplant

Chemotherapy • Large variety of drugs

now used• Cytotoxic agent that

destroys cancer cells by halting their growth and replication

• Not specifically selective to only cancerous cells

Aims therapy:

• Curative• Prevents spreading• Kills metastases• Relieves symptoms• Slows growth of tumour

Chemotherapy

Administered:• Orally • IVI via a portovac or central catheter called a

Hickman line. • Intrathecally following the insertion portocath

Chemotherapy & radiation therapy

Side effects of chemotherapy. How does this impact on physiotherapy?

• Side effects of chemotherapy will have an effect on the timing and extent of physiotherapy treatment the child will be able to tolerate

• Physiotherapist needs to be flexible and adjust therapy goals accordingly

Short term side effects of chemotherapy

Anorexia Nausea

VommitingMucositis

• Weight loss• Muscle wasting • Loss of energy• Depression

Plan shorter more frequent PT sessionsPositive input and motivation is very NB

Short term side effects of chemotherapy

Myelosupression =

↓production wbc (neutopaenia)

↓ rbc ↓platelets(throbocytopaenia)by bone marrow

• Anaemia contributes to fatigue• Low platelet levels (< 20) restrict physical

activity and use of manual CPT techniques for respiratory conditions due to the risk of bleeding

• ↓wbc results in infection which affect the ability to start or continue with therapy

May need to focus to monitoring respiratory function and bed exercise programme

Short term side effects of chemotherapy

Neurotoxicity Well documented that certain agents induce peripheral neuropathy

• Causes sensory or sensori-motor disturbances

• Often diagnosed too late (PT crucial in the identification, and management thereof, and education other medical personnel)

• Reversible? depends on early the case is picked up

• Physiotherapy imperative including functional activities, passive mobilization and orthotics

Short term side effects of chemotherapy

Steroid induced myopathy

• Weight loss• Muscle wasting and

weakness• Loss of energy• Depression

Plan shorter more frequent activitiesPositive input

Short term side effects of radiotherapy

Radiotherapy =

Use of high energy XR rays to destroy cancer cells

• Can skin reactions• Fatigue • Weight loss• Nausea• Cranio-sacral radiation may

result in ↑ICP

Long term effects of chemotherapy and radiotherapy

• Abnormal growth and development in children• Hearing loss• Cranial radiation may have detrimental effects on CNS

myelinization and cognition in children younger 5 yrs• Endocrine dysfunction with subsequent obesity• Late effects on cognitive function includes short-term

memory loss, attention deficits, low IQ, poor verbal and non-verbal reasoning skills

Hickman line/ catheter

• Used for ling term venous access

• Subcutaneous catheter exiting midway in the anterior chest wall

• Introduced via the Sublcavian vein and the tip lies in the SVC or right atrium

Precaution whilst chemotherapy being administered:

• Make sure that the IVAC is running at all times to prevent occlusion of the line.

• If chemotherapy not being administered the line is closed and flushed weekly with heparin.

Hickman line/catheter

PICC line

• Catheter inserted into one of the large veins near the elbow, it is then slid into the vein until it sits in the vein just above the heart

• Used to give chemotherapy

What aspects need to be included in the physiotherapy

assessment

Physiotherapy addresses the following aspects:

1. Musculoskeletal system

• ROM especially above and below the affected site

• Muscle strength both specific and functional strength e.g. walking and stair climbing as indicated or determined by age

• Posture

2. Neurological system

• Especially important in children with cranial or spinal tumours

• Full neurological assessment, but also include assessment of:

• Pain• Vision• Sensation, proprioception and sensory integration• Balance and co-ordination

3. Functional and ADL assessment

• Functional positions and activities as is age appropriate

• Younger child assess neurodevelopmental status relevant to age

4. Quality of life

• Participation in sport, play, work and/ or school

5. Cardiorespiratory system• Bed rest, and cancer treatment negatively impact on

the CVS• It is therefore important to perform a comprehensive

respiratory and CVS assessment• Vitals: HR, RR, BP, SaO2• Exercise tolerance and endurance NB• Important to remember that metastases to the lungs

and ribcage may occur. One may need to auscultate and assess breathing pattern and chest expansion, shoulder girdle and thoracic mobility

6. General observations

• Important to observe for an radiation blisters or infected wounds

Is there evidence to support physiotherapy intervention in patients with cancer ?

YES

Evidence to support role of physiotherapy in improving:

• Improving functional abilities and performance of ADL

• Improved participation • Improved quality of life

Documented benefits of exercise and activity in patients with cancer:

• ↑ Hb• ↓ reduction in the

duration of neutropaenia and thrombocytopaenia

• ↓ severity of diarrhoea and pain

• ↓ length of hospitalisation

• ↓ emotional stress• ↓fatigue

• ↑ lean body weight• ↑ physical

performance• ↑functional ability• ↑ quality of life• ↑flexibility• ↑concentration• ↑ skeletal mass/bone

density

Importance of effective communication, service coordination and documentation

• Important to communicate with oncologist• Procedures are frequent, and often require

sedation –physiotherapy needs to be arranged around this.

• Important to be informed of the patient’s blood results (Hb, platelets, infection markers) as this determines timing, intensity of and aims physiotherapy treatment

• Important to have team meeting to discuss the patient’s prognosis, staging and treatment plan and outcome goals

Importance of effective communication, service coordination and documentation

• Physiotherapist plays an important role in inspiring and motivating the patient

• Important to educate patient and family as to the role of physiotherapy and exercise in the treatment plan

• Instruct the patient and family on relevant exercises and activities

How should physiotherapists approach system problems ?

Challenges …..

• Patients condition may change suddenly

• Nausea, vomiting, weakness and poor blood counts often necessitate a change in approach

Pain management

• Electrotherapy modalities as well as cold and heat therapy

• Massage• Assistive devices• Neuropathic pain – deep pressure and a

compression stocking

Strengthening

• Exercises• Functional activities• Stair climbing• Squats• 3-5 /wk

ROM & Stretching

• CPM• Passive movements and

stretches• Splinting• 3-5/wk

Aerobic exercising

• Walking• Treadmill • Cycling• Stair climbing• Swimming• Dancing

Special techniques where indicated

• Neurodevelopmental therapy

• OMT

Chest physiotherapyCheck blood results

Neutropenia Child may be unproductive, short of

breath with increases work of breathing

• Focus on positioning to assist in breathing control

Thrombocytopaenia

Need to know the platelet count – if there is active bleeding minimise intervention:

• DBE• Positioning• Avoid suctioning of platelet count is

below 20

Manual CPT can take place during or after transfusion.

• Manual techniques are to be performed over a towel to reduce the risk of bruising and improve comfort

Chest physiotherapyCheck blood results

• Low Hb

• low <8g/dL• Anaemic patient

often presents with shortness of breath and easy fatigue ability

• Physiotherapy will not benefit the patient

Disseminated intravascular coagulation (DIC)

• Bleeding disorder caused by an alteration in the clotting mechanism

• Risk of haemorrhage• NO active CPT

Chest physiotherapyCheck blood results

Bony metastatic disease

• Usually very painful • Rib metastases common in lung

cancer and spine cancers can lead to pathological fractures

• NB assess CXR• Analgelsia NB to manage pain • If no fractures very gentle one

handed percussions over towel• Gentle vibrations if nothing else

works to clear secretions

Tumour occluding airway

• Can cause obstruction, atelectasis and consolidation

• Patient may present with stridor, harsh wheezing and may sound productive.

• Secretion clearance techniques not indicated until the tumour has been shrunk.

• Positioning and O2 therapy

Chest physiotherapyCheck blood results

Pleural effusion

• Patient often present with ↑RR, ↓SaO2

• No physiotherapy intervention indicated until effusion drained.

• DBE will then be indicated to expand the deflated lung volume

The dying patient

• Managing the terminal stage of the disease process is often very difficult for a patient

• When a patient faces “his/her end” there are a sequence of reactions he goes through in the process of acceptance (Kubler- Ross, 1969.

• Healthcare professional working with patients in this phase need to allow them to ask questions and discuss this phase of their illness.

The dying patient

• In case where family asks not to tell the patient what is happening remember:

Patient right to access about his conditionHelp the patient feel more in control if he is informedWill be better able to make sense of what is happeningShared burden Allows one to say ones goodbyes

• Allow family and patient to voice their concerns, listen- be support and offer advice if you can

The dying patientCancer diagnosis

Supporting a bereaved family

• Process an individual goes through when they experience the loss or death of a loved one

• Common amongst all cultures .... Form the mourning takes on may however vary

• Acceptance is often a process... Kubler-Ross stages

• How one grieves is individual• Encourage family members to talk about their

feelings... be there...listen..provide support

Palliative care

• Terminal oncology patients often have a so called “death rattle” caused by secretions in the back of the throat.

• This is often very distressing to the patient’s family (sometimes the patient) and PT

• The value of PT at this stage is very limited, the aim is just to keep the patient as comfortable as possible

• Physiotherapist often feels helpless in this situation but one must recognise the professional limitations

Can I reduce my risk of getting cancer?YES by......

• Healthy life – Eating a healthy diet– Exercising regularly– Limiting alcohol– Maintaining a healthy weight– Not smoking

• Minimizing your exposure to radiation and toxic chemicals• Reducing sun exposure, especially if you burn easily

• Regular screening– such as mammography and breast examination for breast cancer – Colonoscopy for colon cancer, may help catch these cancers at their

early stages when they are most treatable.

• Some people at high risk for developing certain cancers can take medication to reduce their risk.

References• Poutney, T. 2007. Physiotherapy in Children.Butterworth-Heinemann• Harden, B.; Cross, J.; Broad, B.A.; Quint, M.; Ritson, R. &Thomas,S.

2004.Respiratory Physiotherapy. An on- call guide. 2 ed. Churchill Livingstone.

• Tecklin, J.S. 2007. Pediatric Physical Therapy.4ed. Lippincott Williams & Wilkins

• Smith, R. 2011. Paediatric Oncology (learning material :unpublished)• PubMed Health. 2011. Cancer. Available at:

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002267.• Medical news today. 2011. what is cancer?. Available online at:

http://www.medicalnewstoday.com/info/cancer-oncology/• CANSA website.2011. Available online at:

http://www.cansa.org.za/cgi-bin/giga.cgi?cat=820&limit=10&page=0&sort=D&cause_id=1056&cmd=cause_dir_news\

• Bryon, M & Steed.E. 2008. Psychological Aspects of Care in Physiotherapy for respiratory and Cardiac Problems. Adults and Paediatrics. 4th ed. by prior, J.A. & Ammani Prasad, S.