Cancer &physiotherapy

OBJECTIVES Etiology, stages and types of cancer

developments; Clinical manifestations, Diagnosis of cancer;

Physiotherapy examination and treatment of specific representative cancers: Breast and lung cancer.

ETIOLOGY OF CANCER

CANCER

Cancer – a large group of diseases characterized by the uncontrolled growth and spread of abnormal cells

Neoplasm – new growth of tissue that serves no physiological function

Tumor – clumping of neo plasmic cells Malignant - cancerous Benign - noncancerous Biopsy – microscopic examination of cell development Metastasis – malignant tumors that are not enclosed in a protective

capsule have the ability to spread to other organs Mutant cells – disruption of RNA and DNA within normal cells may

produce cells that differ in form, quality and function from the normal cell

CAUSES OF CANCER?

External Factors – chemicals, radiation, viruses, and lifestyle

Internal Factors – hormones, immune conditions, and inherited mutations

Cellular change/mutation theoriesCarcinogensOncogenes / proto oncogenes

FACTORS BELIEVED TO CONTRIBUTE TO GLOBAL CAUSES OF CANCER

Lifetime risk – the probability that an individual, over the course of a lifetime, will develop cancer or die from it

Relative risk – measure of the strength of the relationship between risk factors and a particular cancer

Smoking – 30% of all cancer deaths, 87% of lung cancer deaths

Obesity – 50% higher risk for breast cancer in postmenopausal women, 40% higher risk in colon cancer for men

Biological FactorsSome cancers such as breast,

stomach, colon, prostate, uterus, ovaries and lung appear to run in families

Hodgkin’s disease and certain leukemia's show similar patterns

University of Utah research suggests that a gene for breast cancer exists

A rare form of eye cancer appears to be transmitted genetically from mother to child

Reproductive And Hormonal Risks For Cancer

Pregnancy and oral contraceptives increase a woman’s chances of breast cancer

Late menarche, early menopause, early first childbirth, having many children have been shown to reduce risk of breast cancer

Occupational And Environmental Factors

Asbestos

Nickel

Chromate

Benzene

Arsenic

Radioactive substances

Cool tars

Herbicides/pesticides

Sodium nitrate when ingested forms a potential carcinogen, nitrosamine

Sodium nitrate is still used because it is effective in preventing botulism

Pesticide and herbicide residues

Social And Psychological Factors

Stress has been implicated in increased susceptibility to several types of cancers

Sleep disturbances, diet, or a combination of factors may weaken the body’s immune system

Viral Factors

Herpes-related viruses may be involved in the development of leukemia, Hodgkin’s disease, cervical cancer, and Burkitt’s lymphoma

Epstein-Barr virus, associated with mononucleosis, may contribute to cancer

Human papillomavirus (HPV), virus that causes genital warts, has been linked to cervical cancer

Helicobacter pylori causes ulcers which are a major factor in the development of stomach cancer

PATHOPHYSIOLOGY

TYPES OF CANCER

TYPES OF CANCERS

Classification of cancers Carcinomas Sarcomas Lymphomas Leukemia's

cancers are classified by the type of cell that the tumor cells resemble and is therefore presumed to be the origin of the tumor.

Carcinoma : Cancers derived from epithelial cells. This group includes many of the most common cancers, particularly in the aged, and include nearly all those developing in the breast, prostate, lung pancreas and colon.

Sarcoma: Cancers arising from connective tissue (i.e. bone, cartilage, fat, nerve), each of which develop from cells originating in mesenchymal cells outside the bone marrow.

Lymphoma and leukemia: These two classes of cancer arise from hematopoietic (blood-forming) cells that leave the marrow and tend to mature in the lymph nodes and blood, respectively. Leukemia is the most common type of cancer in children accounting for about 30%.

Germ cell tumor: Cancers derived from pluripotent cells, most often presenting in the testicle or the ovary (seminoma and dysgerminoma respectively).

Blastoma Cancers derived from immature "precursor" cells or embryonic tissue. Blastomas are more common in children than in older adults

Cancers are usually named using -carcinoma, -sarcoma or -blastoma as a suffix, with the Latin or Greek word for the organ or tissue of origin as the root.

For example, cancers of the liverparenchyma arising from malignant epithelial cells is called hepatocarcinoma while a malignancy arising from primitive liver precursor cells is called a hepatoblastoma, and a cancer arising from fat cells is called a liposarcoma. For some common cancers, the English organ name is used. For example, the most common type of breast canceris called ductal carcinoma of the breast Here, the adjective ductal refers to the appearance of the cancer under the microscope, which suggests that it has originated in the milk ducts.

Benign tumors(which are not cancers) are named using -oma as a suffix with the organ name as the root. For example, a benign tumor of smooth muscle cells is called a leiomyoma(the common name of this frequently occurring benign tumor in the uterus is fibroid). Confusingly, some types of cancer use the -noma suffix, examples including melanoma and seminoma

Some types of cancer are named for the size and shape of the cells under a microscope, such as giant cell carcinoma spindle cell carcinoma, and small-cell carcinoma

CLINICAL MANIFESTATIONS

SIX CHARACTERISTICS OF MALIGNANCIES

Sustaining proliferative signaling Evading growth suppressors Resisting cell death Enabling replicative immortality Inducing angiogenesis Activating invasion and metastasis

SYMPTOMSLocal effects Local symptoms may occur due to the

mass of the tumor or its ulceration. For example, mass effects from lung cancer can cause blockage of the bronchus resulting in cough or pneumonia; esophageal cancer can cause narrowing of the esophagus, making it difficult or painful to swallow; and colorectal cancer may lead to narrowing or blockages in the bowel, resulting in changes in bowel habits. Masses in breasts or testicles may be easily felt. Ulceration can cause bleeding which, if it occurs in the lung, will lead to coughing up blood, in the bowels to anemia or rectal bleeding, in the bladder to blood in the urine, and in the uterus to vaginal bleeding. Although localized pain may occur in advanced cancer, the initial swelling is usually painless. Some cancers can cause build up of fluid within the chest or abdomen.

Systemic symptoms unintentional weight loss, fever,

being excessively tired, and changes to the skin. Hodgkin disease, leukemias, and cancers of the liver or kidney can cause a persistent fever of unknown origin.

Specific constellations of systemic symptoms, termed paraneoplast phenomena, may occur with some cancers. Examples include the appearance of myasthenia gravis in thymoma and clubbing in lung cancer[

GRADING/STAGING OF CANCER

GRADING• Degree of maturity or differentiation under the microscope

1.Histologic grade – resemblance between tumor and normal cells2.Nuclear grade – size and shape of nucleus, dividing cells

Biopsy – benign or malignant - pathologist – level of differentiation

TUMOR GRADES

Microscopic apperance of cancer cells 4 degrees of severity

Grade: GX Grade cannot be assessed (Undetermined

grade) G1 Well-differentiated (Low grade) G2 Moderately differentiated

(Intermediate grade) G3 Poorly differentiated (High grade) G4 Undifferentiated (High grade)

GRADING SYSTEMS

• Different for different types of cancers

Gleason – prostate cancerBloom-Richardson – breast cancerFuhrman – kidney cancer

Gleason system

Fuhrman system

GRADING – TREATMENT

For treatment and prognosis

Lower grade better prognosis (outcome of diease) Higher grade worse prognosis

Important in treatment of prim. brain tumors (astrocytomas)

lymphomas breast cancer prostate

STAGING Extent of the prim. tumor and extent of spread in the

body

Important - helps planning treatment - helps estimating prognosis - helps identifying clinical trials

STAGING SYSTEMS

No unique staging system

Common elements : - Location of the primary tumor - Tumor size and number of tumors - Lymph node involvement (spread of cancer

into lymph nodes) - Cell type and tumor grade (how closely the

cancer cells resemble normal tissue) - Presence or absence of metastasis

TNM - SYSTEM

Most common (accepted by UICC, AICC)

Based on : T extent of the tumor N extent of spread to the lymph nodes M presence of metastasis

Number indicates size or extent of the prim. tumor and the extent of spread of metastasis

Primary Tumor (T) TX Primary tumor cannot be evaluated T0 No evidence of primary tumor Tis Carcinoma in situ (has not spread) T1, T2, T3, T4 Size and/or extent of the primary tumor

Regional Lymph Nodes (N) NX Regional lymph nodes cannot be evaluated N0 No regional lymph node involvement N1, N2, N3 Involvement of regional lymph nodes (number and/or extent of spread)

Distant Metastasis (M) MX Distant metastasis cannot be evaluated M0 No distant metastasis M1 Distant metastasis (cancer has spread to distant parts of the body)

OTHER CLASSIFICATION

Ann Arbour lymphomas

Duke’s classification colon cancer

Breslow scale and Clark’s level melanoma

DETERMINATION OF STAGES

Physical exams examination, looking, listening

Imaging studies X-ray, US, CT, MRI, PET

Laboratory tests blood, urine, AST/ALT, tumor markers (CA19-9,CA19-5….)

Pathology reports biopsy, cytology

Surgical reports

Lung cancer,PET scan

PREVENTING CANCER THROUGH DIET AND LIFESTYLE

Table 16.2

DIAGNOSIS OF CANCER

CANCER’S SEVEN WARNING SIGNALS

Table 16.5

DETECTING CANCER

Blood tests Urineanalysis Tumour markers Diagnostic imaging Endoscopic examination Genetic testing Tumour biopsy

TUMOUR MARKERSprostate-specific antigen (PSA)

Prostate-specific antigen is always present in low concentrations in the blood of adult males. An elevated PSA level in the blood may indicate prostate cancer, but other conditions such as benign prostatic hyperplasia (BPH) and prostatitis can also raise PSA levels. PSA levels are used to evaluate how a patient has responded to treatment and to check for tumor recurrence.

prostatic acid phosphatase (PAP)PAP originates in the prostate and is normally present in small amounts in the blood. In addition to prostate cancer, elevated levels of PAP may indicate testicular cancer,leukemia, and non-Hodgkin’s lymphoma, as well as some noncancerous conditions.

CA 125Ovarian cancer is the most common cause of elevated CA 125, but cancers of the uterus, cervix, pancreas, liver, colon, breast, lung, and digestive tract can also raise CA 125 levels. Several noncancerous conditions can also elevate CA 125. CA 125 is mainly used to monitor the treatment of ovarian cancer.

carcinoembryonic antigen (CEA)CEA is normally found in small amounts in the blood. Colorectal cancer is the most common cancer that raises this tumor marker. Several other cancers can also raise levels of carcinoembryonic antigen.

alpha-fetoprotein (AFP)Alpha-fetoprotein is normally elevated in pregnant women since it is produced by the fetus. However, AFP is not usually found in the blood of adults. In men, and in women who are not pregnant, an elevated level of AFP may indicate liver cancer or cancer of the ovary or testicle. Noncancerous conditions may also cause elevated AFP levels.

human chorionic gonadotropin (HCG)HCG is another substance that appears normally in pregnancy and is produced by the placenta. If pregnancy is ruled out, HCG may indicate cancer in the testis, ovary, liver, stomach, pancreas, and lung. Marijuana use can also raise HCG levels.

CA 19-9This marker is associated with cancers in the colon, stomach, and bile duct. Elevated levels of CA 19-9 may indicate advanced cancer in the pancreas, but it is also associated with noncancerous conditions, including gallstones, pancreatitis, cirrhosis of the liver, and cholecystitis.

CA 15-3This marker is most useful in evaluating the effect of treatment for women with advancedbreast cancer. Elevated levels of CA 15-3 are also associated with cancers of the ovary, lung, and prostate, as well as noncancerous conditions such as benign breast or ovarian disease, endometriosis, pelvic inflammatory disease, and hepatitis. Pregnancy and lactation also can raise CA 15-3 levels.

CA 27-29This marker, like CA 15-3, is used to follow the course of treatment in women with advanced breast cancer. Cancers of the colon, stomach, kidney, lung, ovary, pancreas, uterus, and liver may also raise CA 27-29 levels. Noncancerous conditions associated with this substance are first trimester pregnancy, endometriosis, ovarian cysts, benign breast disease, kidney disease, and liver disease.

lactate dehydrogenase (LDH)LDH is a protein that normally appears throughout the body in small amounts. Many cancers can raise LDH levels, so it is not useful in identifying a specific kind of cancer. Measuring LDH levels can be helpful in monitoring treatment for cancer. Noncancerous conditions that can raise LDH levels include heart failure, hypothyroidism, anemia, andlung or liver disease.

neuron-specific enolase (NSE)NSE is associated with several cancers, but it is used most often to monitor treatment in patients with neuroblastoma or small cell lung cancer.

IMAGING TECHNIQUES transmission imaging

X-rays, computed tomography scans (CT scans), and fluoroscopy are radiological examinations whose images are produced by transmission. In transmission imaging, a beam of high-energy photons is produced and passed through the body structure being examined. The beam passes very quickly through less dense types of tissue such as watery secretions, blood, and fat, leaving a darkened area on the x-ray film. Muscle and connective tissues (ligaments, tendons, and cartilage) appear gray. Bones will appear white.

x-rayX-rays are diagnostic tests that use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film. X-rays may be taken of any part of the body to detect tumor (or cancer) cells.

computed tomography scan (Also called a CT scan or computed axial tomography or CAT scan.)A CT scan is a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

bone scanBone scans are pictures or x-rays taken of the bone after a dye has been injected that is absorbed by bone tissue. These scans are used to detect tumors and bone abnormalities.

lymphangiogram (LAG)Lymphangiogram is an imaging study that can detect cancer cells or abnormalities in the lymphatic system and structures. It involves a dye being injected into the lymph system.

mammogramA mammogram is an x-ray examination of the breast. It is used to detect and diagnose breast disease in women who either have breast problems such as a lump, pain, or nipple discharge, as well as for women who have no breast complaints. Mammography cannot prove that an abnormal area is cancerous, but if it raises a significant suspicion of cancer, a biopsy may be performed. Tissue may be removed by needle or open surgical biopsy and examined under a microscope to determine if it is cancer. Mammography has been used for about 30 years, and in the past 15 years technical advancements have greatly improved both the technique and results. Today, dedicated equipment, used only for breast x-rays, produces studies that are high in quality but low in radiation dose. Radiation risks are considered to be negligible.

reflection imaging

Reflection imaging refers to the type of imaging produced by sending high-frequency sounds to the body part or organ being studied. These sound waves "bounce" off of the various types of body tissues and structures at varying speeds, depending on the density of the tissues present. The bounced sound waves are sent to a computer that analyzes the sound waves and produces a visual image of the body part or structure.

ultrasoundUltrasound, or sonography, is the most commonly used type of reflection imaging. This technique uses high-frequency sound waves and a computer to create images, called sonograms, of blood vessels, tissues, and organs. Sonograms are used to view internal organs as they function and to assess blood flow through various vessels. Tumors in the abdomen, liver, and kidneys can often be seen with an ultrasound.

emission imagingEmission imaging occurs when tiny nuclear particles or magnetic energy are detected by a scanner and analyzed by computer to produce an image of the body structure or organ being examined. Nuclear medicine uses emission of nuclear particles from nuclear substances introduced into the body specifically for the examination. Magnetic resonance imaging (MRI) uses radio waves with a machine that creates a strong magnetic field that in turn causes cells to emit their own radio frequencies.

magnetic resonance imaging (MRI)MRI is a diagnostic procedure that uses a combination of a large magnet, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. An MRI is often used to examine the heart, brain, liver, pancreas, male and female reproductive organs, and other soft tissues. It can assess blood flow, detect tumors and diagnose many forms of cancer, evaluate infections, and assess injuries to bones and joints.

ENDOSCOPIC EXAMINATION

colonoscopyColonoscopy is a procedure that allows the physician to view the entire length of the large intestine, and can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon. The colonoscope allows the physician to see the lining of the colon, remove tissue for further examination, and possibly treat some problems that are discovered.

endoscopic retrograde cholangiopancreatography (ERCP)ERCP is a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope - a long, flexible, lighted tube. The scope is guided through the person's mouth and throat, then through the esophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope and a dye is injected, which will allow the internal organs to appear on an x-ray.

esophagogastroduodenoscopy (Also called EGD or upper endoscopy.)An EGD (upper endoscopy) is a procedure that allows the physician to examine the inside of the esophagus, stomach, and duodenum. A thin, flexible, lighted tube, called an endoscope, is guided into the mouth and throat, then into the esophagus, stomach, and duodenum. The endoscope allows the physician to view the inside of this area of the body, as well as to insert instruments through a scope for the removal of a sample of tissue for biopsy (if necessary).

sigmoidoscopyA sigmoidoscopy is a diagnostic procedure that allows the physician to examine the inside of a portion of the large intestine, and is helpful in identifying the causes of diarrhea, abdominal pain, constipation, abnormal growths, and bleeding. A short, flexible, lighted tube, called a sigmoidoscope, is inserted into the intestine through the rectum. The scope blows air into the intestine to inflate it and make viewing the inside easier.

cystoscopy (Also called cystourethroscopy.)An examination in which a scope, a flexible tube and viewing device, is inserted through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones. Samples of the bladder tissue may be removed through the cystoscope for examination under a microscope in the laboratory.

GENETIC STUDIES chromosome studies- "Cytogenetics" . The chromosomes need to be stained in order to see them with a

microscope. When stained, the chromosomes look like strings with light and dark "bands." A picture (an actual photograph from one cell) of all 46 chromosomes, in their pairs, is called a "karyotype." A normal female karyotype is written 46, XX, and a normal male karyotype is written 46, XY. The standard analysis of the chromosomal material evaluates both the number and structure of the chromosomes, with an accuracy of over 99.9 percent. Chromosome analyses are usually performed using a blood sample (white blood cells), prenatal specimen, skin biopsy, or other tissue sample. Chromosomes are analyzed by specially trained healthcare personnel that have advanced degrees in cytogenetic technology and genetics. Chromosome studies may be performed when a child is born with multiple birth defects. Chromosome studies may also be performed when people have certain types of leukemias and lymphomas, to look for specific chromosome rearrangements (changes in the order of the chromosome material) associated with these types of cancers.

Biochemical genetic studiesBiochemical genetic testing involves the study of enzymes in the body that may be abnormal in some way. There are hundreds of enzyme defects that can be studied in humans. Sometimes, rather than studying the gene mutation which is causing the enzyme to be defective in the first place, it is easier to study the enzyme itself (the gene product). The approach depends on the disorder. Biochemical genetic studies may be done from a blood sample, urine sample, spinal fluid, or other tissue sample, depending on the disorder.

protein truncation studiesAnother way to look at gene products, rather than the gene itself, is through protein truncation studies. Testing involves looking at the protein a gene makes to see if it is shorter than normal. Sometimes a mutation in a gene causes it to make a protein that is truncated (shortened). With the protein truncation test, it is possible to "measure" the length of the protein the gene is making to see if it is the right size or shortened. Protein truncation studies can be performed on a blood sample. These types of studies are often performed for disorders in which the known mutations predominantly lead to shortened proteins.

DNA studies

Direct DNA studiesDirect DNA studies simply look directly at the gene in question for an error. Errors in the DNA may include a replication of the gene's DNA (duplication), a loss of a piece of the gene's DNA (deletion), an alteration in a single unit (called a base pair) of the gene's DNA (point mutation), or the repeated replication of a small sequence (for instance, 3 base pairs) of the gene's DNA (trinucleotide repeat). Different types of errors or "mutations" are found in different disorders. It is usually very important to find the mutation that is present in a family, by studying the family member with the disorder in question (in this case, cancer), before testing relatives without the cancer. When a particular mutation is found in a relative with cancer, other family members can choose to have testing for the mutation to determine if they have an increased risk to develop certain cancers and to pass the mutation on to the next generation. The DNA needed for direct DNA studies is usually obtained by taking a blood sample.

indirect DNA studiesSometimes, the gene that (when mutated) causes a condition has not yet been identified,. Indirect DNA studies involve using "markers" to find out whether a person has inherited the crucial region of the genetic code that is passing through the family with the disease. Markers are DNA sequences located close to or even within the gene of interest. Because the markers are so close, they are almost always inherited together with the disease. When markers are this close to a gene, they are said to be "linked." If someone in a family has the same set of linked markers as the relative with the disease, this person often also has the disease-causing gene mutation. Because indirect DNA studies involve using linked markers, these types of studies are also called "linkage studies."

Indirect studies usually involve blood samples from several family members, including those with and without the disorder in question. This is to establish what pattern of markers appear to be associated with the disease. Once the disease-associated pattern of markers is identified, it is possible to offer testing to relatives to determine who inherited this pattern, and as such, is at increased risk of cancer.

The accuracy of linkage studies depends on how close the markers are to the faulty gene. In some cases, a reliable marker is not available and the test, therefore, cannot give any useful information to the healthy family members. In many cases, several family members are needed to establish the most accurate set of markers to determine who is at risk for the disease in the family. Linkage studies may take many weeks to complete because of the complexity of these studies.

endoscopic biopsyThis type of biopsy is performed through a fiberoptic endoscope (a long, thin tube that has a close-focusing telescope on the end for viewing) through a natural body orifice (i.e., rectum) or a small incision (i.e., arthroscopy). The endoscope is used to view the organ in question for abnormal or suspicious areas, in order to obtain a small amount of tissue for study. Endoscopic procedures are named for the organ or body area to be visualized and/or treated. The physician can insert the endoscope into the gastrointestinal tract (alimentary tract endoscopy), bladder (cystoscopy), abdominal cavity (laparoscopy), joint cavity (arthroscopy), mid-portion of the chest (mediastinoscopy), or trachea and bronchial system (laryngoscopy and bronchoscopy).

bone marrow biopsyThis type of biopsy is performed either from the sternum (breastbone) or the iliac crest hipbone (the bone area on either side of the pelvis on the lower back area). The skin is cleansed and a local anesthetic is given to numb the area. A long, rigid needle is inserted into the marrow, and cells are aspirated for study; this step is occasionally uncomfortable. A core biopsy (removing a small bone 'chip' from the marrow) may follow the aspiration.

excisional or incisional biopsyThis type of biopsy is often used when a wider or deeper portion of the skin is needed. Using a scalpel (surgical knife), a full thickness of skin is removed for further examination, and the wound is sutured (sewed shut with surgical thread). When the entire tumor is removed, it is called excisional biopsy technique. If only a portion of the tumor is removed, it is called incisional biopsy technique. Excisional biopsy is often the method usually preferred when melanoma (a type of skin cancer) is suspected.

fine needle aspiration (FNA) biopsyThis type of biopsy involves using a thin needle to remove very small pieces from a tumor. Local anesthetic is sometimes used to numb the area, but the test rarely causes much discomfort and leaves no scar. FNA is not used for diagnosis of a suspicious mole, but may be used to biopsy large lymph nodes near a melanoma to see if the melanoma has metastasized (spread). A computed tomography scan (CT or CAT scan) - an x-ray procedure that produces cross-sectional images of the body - may be used to guide a needle into a tumor in an internal organ such as the lung or liver.

punch biopsyPunch biopsies involve taking a deeper sample of skin with a biopsy instrument that removes a short cylinder, or "apple core," of tissue. After a local anesthetic is administered, the instrument is rotated on the surface of the skin until it cuts through all the layers, including the dermis, epidermis, and the most superficial parts of the subcutis (fat).click image to enlarge

shave biopsyThis type of biopsy involves removing the top layers of skin by shaving it off. Shave biopsies are also performed with a local anesthetic.

skin biopsySkin biopsies involve removing a sample of skin for examination under the microscope to determine if melanoma is present. The biopsy is performed under local anesthesia. The patient usually just feels a small needle stick and a little burning for about a minute, with a little pressure, but no pain.

CANCER TREATMENTS Surgery Combine surgery with radiation or

chemotherapy Immunotherapy Cancer-fighting vaccines Gene therapy Neo adjuvant chemotherapy Stem cell therapy

LUNG CANCER

LUNG CANCER

Cancer develops following genetic damage to DNAand epigenetic changes. These changes affect the normal functions of the cell, including cell proliferation, programmed cell death (apoptosis) and DNA repair. As more damage accumulates, the risk of cancer increases.

LUNG CANCER SYMPTOMS 

Chronic, hacking, raspy coughing, sometimes with blood-streaked mucus

Recurring respiratory infections, including bronchitis or pneumonia

Increasing shortness of breath, wheezing, persistent chest pain

Hoarseness Swelling of the neck and face Pain and weakness in the shoulder, arm, or hand Fatigue, weakness, loss of weightand appetite,

intermittent fever, severeheadaches and body pain Difficulty swallowing

TYPES OF LUNG CANCER

Two major types of lung cancers, small cell and non-small cell lung cancers. Non-small cell lung cancers account for about 90% of all lung cancers and are less aggressive (spread to other tissues and organs slowly) than small cell cancers.NSLC

•Adenocarcinoma•Squamous-cell carcinoma•Large-cell carcinoma

SCLC

STAGING-CLASSIFICATIONNSCLC are assigned a stage from I to IV in order of

severity -TNM classification In stage I, the cancer is confined to the lung. In stages II and III, the cancer is confined to the chest

(with larger and more invasive tumors classified as stage III).

Stage IV cancer has spread from the chest to other parts of the body.

SCLC are staged using a two-tiered system: Limited-stage (LS) SCLC refers to cancer that is

confined to its area of origin in the chest. In extensive-stage (ES) SCLC, the cancer has spread

beyond the chest to other parts of the body.

Breast cancer

BREAST SELF-EXAMINATION

Figure 16.5

04/08/2023

51

Benign breast masses Noninvasive breast tumors Invasive breast tumors (malignant )

MASTECTOMY

SURGICAL PROCEDURES FOR DIAGNOSED BREAST CANCER

Figure 16.6

04/08/2023

53

TYPES

Lumpectomy or wedge resection or tylectomy or tumourectomy

Radical halsted’s operation(axillary lymphnodes+PM)

Simple mastectomy Extended simple mastectomy (patey’s)

no PM involvement Quadrantectomy (tumour segment+

axillary nodes)

04/08/2023

54

COMPLICATIONS Bleeding from the surgical site Seroma - collection of fluid (lymph or serum) at the

operative site Wound infection Possible skin slough at wound edges Thrombophlebitis of the axillary vein Numbness of the back of the upper arm usually due to

sacrifice of a nerve to the skin (intercostal brachial cutaneous nerve)

Weakness of the latissimus dorsi or serratus anterior muscles due to compromise of the thoracodorsal or long thoracic nerves, rare

Arm edema (swelling) is common but usually mild Limited range of motion of the shoulder. This occurs

early after surgery, is limited and totally recoverable

04/08/2023

55

TREATMENT

HRT Tamoxifen Chemotherapy cyclophosphamide, methotrextate and

5 fluorouracil Breast reconstruction Silicone prosthesis Musculocutaneos flaps LD or TRAM flap

04/08/2023

56

PHYSIOTHERAPYAvoid early shoulder mobilizationAdduction for 48 hrs then 60*

abductionRedivac drain usedEdema management (elevation,

compression, FUP & STM) If any brachial plexus injury, treat

as LMN lesionUsual PT protocol

REHABILITATION

REHABILITATION

‘To minimise some of the effects which the disease, or it’s treatment has on them. It is often possible to improve the quality of life regardless of their prognosis by helping them to achieve their maximum potential of functional ability and independence or gain relief from distressing symptoms’

ACPOPC 1993

‘With in the context of palliative care, realistic joint goal setting gives the patient a measure of control, often at a time when they are experiencing helplessness and loss of independence’

Robinson 2000

PHYSIOTHERAPY Physiotherapy in palliative care is

orientated to achieve the optimum quality of life as perceived by the patient.

Holistic & problem solving approach to therapy

Achieve maximum physical, psychological, social, vocational function

PalliativePrimarily directed at promoting maximum comfort Maintaining the highest level of function possible in the face of disease progression and impending death

Preventive Aims at restricting or

inhibiting the development of disability in the course of the disease or treatment before disability occurs.

Education for patient and families commencing immediately after diagnosis.

Mobility and exercise programs. Availability of therapist as a

resource for patients and families.

Restorative Rehabilitation is the objective

when no or little residual disability is anticipated for some time and patients are expected to return to normal living styles

Encouragement, education and treatment in achieving physical, work and lifestyle goals

Specific treatments as required

Supportive

Enhance independent functioning when residual cancer is present and progressive disability is probable.

Encouragement, education and treatment in achieving physical, work and lifestyle goals.

Availability of therapist as a resource(Kuchler T., Wood-Dauphinee, S. Working with people who

have cancer: Guidelines for Physical Therapists)

Role

MAJOR ISSUES OF THE PATIENT

Fatigue, Nausea,

Pain, Weakness,

Lack Of Confidence, Drug Reactions,Cachexia - Weight Loss),

Progressive Decline In Ability,Muscle Wasting,

Disease Progression,Ascities,

Grief Reactions.

AIM OF PHYSIOTHERAPY Assess and optimise the patient’s level of physical function Take into consideration the interplay between the physical, psychological, social and vocational

aspects of function Understand the patients underlying emotional, pathological and psychological condition, Focus is the physical and functional consequences of the disease and/or its treatment, on the

patient.

Restore the patient’s sense of self Facilitate and optimise the patient's ability to function with safety and independence in the face

of diminishing resources. Maintain optimum respiratory & circulatory function Listen to patient Set realistic goals with the patient

Prevent muscle shortening & joint contractures Influence pain control Educate in all aspects of physical function Education and participation of the carer Treat the patient with dignity – allowing them to “live until they die” Build a relationship of confidence and trust

Fulton and Else, 1997; p817 Chartered Society of Physiotherapy

Multidisciplinary Teams: The way forward in Cancer Care

Aim: To look at the evolving cancer care model

team.”

Consultant

Nurse

Physiotherapist

Speech and Language therapist

Dietician

Occupational Therapist

Radiographer

Social Worker

THE ROLE OF THE PHYSIOTHERAPIST IN PALLIATIVE CARE

Physiotherapists work with respiratory, neurological, lymphatic, orthopaedic, musculoskeletal, pain and haemotalogical conditions.

Education and training of multi disciplinary team as well as patients and carers.

Communication and collaboration.

PHYSIOTHERAPY INTERVENTIONS

Positioning – prevention of pressure sores TENS – pain and nausea control Respiratory care Neurological rehabilitation Mobility – Exercise tolerance, maintenance

and independence Prevention of contractures/joint-muscle

integrity Individual exercise programmes Oedema management Counselling

PRINCIPLES OF ASSESSMENT

SOAP format should be usedFunctional aspects of assessment should

be given with more weight age.Guidelines from different countries could

be used.

THE ICF FUNCTION CLASSIFICATION FRAMEWORK

MEASUREMENT OF BODY FUNCTION AND STRUCTURE

Mental Functions

Sensory Functions and Pain

Neuromusculoskeletal and Movement-Related Functions and Structures

Functions of the Cardiovascular, Hematologic, Immunologic, and Respiratory Systems

MEASUREMENT OF BODY FUNCTION AND STRUCTURE

MEASUREMENT OF BODY FUNCTION AND STRUCTURE

DIAGNOSTIC MEASURES OF BODY FUNCTION AND STRUCTURE INDICATING “RED FLAGS” OR “YELLOW FLAGS” FOR PHYSICAL THERAPISTS

MEASUREMENT OF ACTIVITY AND PARTICIPATION

Mobility Self-care Domestic

Life, Interpersonal Relations, and Major Life Areas

MEASUREMENT OF ACTIVITY AND PARTICIPATION

REFERENCE

Phys Ther. 2009 March; 89(3): 286–306.

doi: 10.2522/ptj.20070309

PMCID: PMC2967778

Laura S Gilchrist, Mary Lou Galantino, Meredith Wampler, Victoria G Marchese, G Stephen Morris, Kirsten K Ness

LS Gilchrist, PT, PhD, is Associate Professor, Doctor of Physical Therapy Program, College of St Catherine,

601 25th Ave S, Minneapolis, MN 55454 (USA), and Clinical Research Scientist, Children's Hospitals and

Clinics of Minnesota, Minneapolis, Minnesota.

ML Galantino, PT, PhD, is Professor of Physical Therapy, Richard Stockton College of New Jersey,

Pomona, NJ, and Adjunct Research Scholar, University of Pennsylvania, Philadelphia, Pennsylvania.

M Wampler, PT, DPTSc, is Physical Therapist, Harrison Medical Center, Bremerton, Washington.

VG Marchese, PT, PhD, is Assistant Professor, Department of Physical Therapy, Lebanon Valley College,

Annville, Pennsylvania, and Assistant Professor of Pediatrics, Penn State Hershey College of Medicine,

The Pennsylvania State University, Hershey, Pennsylvania.

GS Morris, PT, PhD, is Director of Clinical Research in Rehabilitation Sciences, The University of Texas MD

Anderson Cancer Center, Houston, Texas.

KK Ness, PT, PhD, is Assistant Member, Department of Epidemiology and Cancer Control, St Jude

Children's Research Hospital, Memphis, Tennessee.

Address all correspondence to Dr Gilchrist at: Email: [email protected]

Received October 10, 2007; Accepted November 26, 2008.

Copyright © 2009, American Physical Therapy Association

Abstract Cancer has a high incidence in the United States, where 46% of all males and 41% of all females can expect to develop either an invasive or in situ cancer.1 An estimated 1.4 million new cases of cancer are diagnosed each year, with nearly 13,500 of these cases occurring in individuals younger than 20 years of age.2 In years past, survival following a diagnosis of cancer was problematic; however, dramatic progress in the ability to diagnose cancers earlier and to provide more-effective and targeted treatments has led to substantial increases in survival. The National Cancer Institutes Surveillance, Epidemiology, and End Results Program estimates that 65.3% of adults diagnosed with cancer between the years 2001 and

THANK YOUThank you