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Understanding OT’s Unique Role in the Oncology Population Sarah J. Weber, MOTR/L Vinnie Quan, MOTR/L Overview • Introduction • Cancer overview • Cancer symptoms and treatments • OT interventions for people with cancer Work setting Our Cancer Care • Initial diagnosis/Prevention through end of life care • Interdisciplinary approach • Client Centered and Holistic • Goals may change across continuum • Affiliated care • Fred Hutchinson Research • Seattle Cancer Care Alliance • Children’s Hospital Cancer Diagnosis • Disease in which abnormal cells divide without control and are able to invade other tissues • Can spread through blood, and lymph systems • Benign vs. malignant • Metastasis- spread of cancer from one part of body to another • Reference: National Cancer Institute: cancer.gov http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer (Image from Understanding Cancer Series: Cancer.) Cancer Facts • > 100 types of cancer (mostly named for organ/type of cell where it started) • Main Categories: • Carcinoma- skin or tissue that lines/ covers internal organs • Sarcoma- bone, cartilage, fat, muscle, or other connective/ supportive tissue • Leukemia- blood forming tissue (e.g. bone marrow) • Lymphoma and myeloma- cells of immune system • Central nervous system cancers- tissues of brain and spinal cord • Reference: National Cancer Institute Cancer Statistics • Estimated new cases and deaths from cancer in the US in 2014: • 1,665,540 • Deaths: 585,720 • Risk increases with age (55+) • 1 in 2 men • 1 in 3 women Reference: American Cancer Society Cancer Type Estimated New Cases Estimated Deaths Bladder 74,690 15,580 Breast (female-male) 232,670-2,360 40,000-430 Colon/Rectal 136,830 50,310 Edometrial 52,630 8,590 Kidney Cancer 63,920 13,860 Leukemia 52,380 24,090 Lung 224,210 159,260 Melanoma 76,100 9,710 Non-Hodgkin Lymphoma 70,800 18,990 Pancreatic 46,420 39,590 Prostate 233,000 29,480 Thyroid 62,980 1,890 American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American Cancer Society, 2014. Also available online (PDF - 1.76 MB). Last accessed March 20, 2014 . TMN Staging: International Notation • TNM (stages 1-4) • Primary tumor size (T1-T4) • To= no evidence of tumor • Lymph node involvement (N0-N3) • Extent of mets (M0-M1) • Curative vs. palliative treatment • OT approach: restorative vs. compensatory • http://www.bioscience.org/atlases/tumpath/index.htm (Tumor Atlas with TNM Staging for all Cancers) Stages of Tumors • Stage 0 (To)–Pre-invasive • Stage 1 (T1)- Limited to organ of origin • Stage 2 (T2)- same anatomical region (may spread) • Stage 3 (T3)- Spread to area around primary organ (metastatic spread) • Stage 4 (T4)- Metastasis to distant sites Tumor Classification “Grading” • “Based on histological properties, microscopic appearance, how FAST the tumor is growing” • Labs looks at tumor markers: protein in blood that is released by cancer cells which predict trends • 4 Tiers: Grade I, II, III, IV Surgical Treatment for Cancer • Goal: Debulking- remove part of malignant tumor to enhance effectiveness of chemo/radiation treatment • TAH/BSO (total abdominal hysterectomy/ bilateral salpingo-oophorectomy) for ovarian/uterine cancer • Removal of uterus, ovaries, and fallopian tubes • Cystectomy and creation of ilieal conduit for diversion of urine to urostomy • Nephrectomy • Prostatectomy • Mastectomy/lumpectomy Surgical Precautions • Abdominal Incision- log roll, no lifting > 5-10lbs, avoid strain, check for binder, no soaking incision, avoid bending (use taylor sit for LB dress), back protection/ good body mechanics • Total pelvic exenteration: no sitting precautions Considerations for Treatment • Drains and Lines- be aware prior to mobilizing and secure appropriately, use lanyard around neck to secure drains in shower, cover entry to body with glad press n seal • Check orthostatics first time OOB, especially with epidural in place! • Lower body strength for transfers • Urostomy care during showers Cancer Treatments • Radiation • Chemotherapy • Hormone Therapy • Trials: new drugs • Gamma ray treatment (brain tumor) • Various transfusion (for myelosuppression) • Platelets (thrombocytopaenia) • Blood (anemia) CHEMOTHERAPY Stem Cell/Bone Marrow Transplant • Procedure to weaken/destroy tissues or cells that cause blood or immune diseases and then reset or replace those tissues or cells to restore healthy function • • • • • Collect Process to purify Freeze Thaw Re-infuse after treatment • Side effect: Graph vs. Host Disease (GVHD)- closer the match, the less likely to get it Types of stem cell transplants • Autologous- own cells • Syngeneic- identical twin • Allogeneic- close match General Precautions • Infection Control (neutropenia) • Sign in (clear of airborne/infectious illness) • Patients can’t go off floor if immunosuppressed unless cleared by medical team and need N95 mask General Precautions •Multiple Myeloma •Check radiology (plain films, bone scans, and MRI’s for lytic lesions and pathologic fractures) •Verify weight bearing status or consult ortho General Precautions Pancytopenia (Blood count) • Check platelets (thrombocytopenia) , HCT, and Hb daily • Avoid MMT if platelets below 20k Exercise and Blood Value Precautions • Platelet Count 50,000-100,000: cardiovascular exercise and strength training w/ weights are allowed, no exercise if signs of bleeding • Platelet Count 20,000-49,000: strength and cardio exercise are ok if no signs of bleeding, but w/out strain, massage may be contraindicated • Platelet Count 10,000-19,000: AROM and cardio without strain are ok if you are steady on feet and have no signs of bleeding (No PROM) • Less than 10,000: no exercise, walking in room or to bathroom is ok as long as you are steady and have no signs of bleeding • Less than 5,000: May be bedrest Exercise and Blood Values (continued) • Hematocrit (Hct): must be greater than 25% for any form of exercise • > 25 light exercise, shower • 30-32 resistive exercise as tolerated • Hemoglobin (Hb): greater than 8.5 for any form of exercise • 8-10 light exercise • > 10 resistive exercise Neutropenic Precautions • Bathe daily • Frequent gentle oral care with soft toothbrush • Avoid anything with dirt (bacteria), live plants/ flowers • Avoid garden work • Don’t clean kitty litter, bird cages, or fish tanks • Caution with dental work • Do not use hot tubs, swim in lakes, ponds, rivers • Neutropenic diet- fresh fruits/ veggies- raw or uncooked/ unpasteurized • Reference: Hope Cancer Clinic Patient Education Precautions (continued) • Mucositis- reddening and soreness of tongue, lips, mouth, throat, and GI tract from chemo or XRT • Keep HOB > 30* • Aspiration risk • Oral care • Steroid Myopathy- progressive weakening of proximal > distal musculature from high dose of corticosteroids • Hand to foot syndrome Soft tissue fibrosis Use caution with gait belt placement Other considerations • Pain • Fatigue • Nausea/vomiting • Edema/ lymphedema • Deep Vein Thrombosis (DVT) • Tremors (caused by transplant meds) • Avascular necrosis • Fever (> 100.5) • Deconditoning • Psychosocial implications • Peripheral neuropathy- chemo induced (CIPN) • Heart Damage: Cardiotoxicity • Paraplegia/quadreplegia • “Chemo brain” • • Assess cognition in context May resolve in 6-9 mo. (Anies & Saykin, 2002) OT’s Role • Role of OT in oncology is “to facilitate and enable an individual patient to achieve maximum functional performance, both physically and psychologically, in everyday living skills regardless of his or her life expectancy” • Health is supported and maintained by participation in desired roles and activities • “87% of oncology patients have rehab needs” • Penfold, S. (1996). The role of the occupational therapist in oncology. Cancer Treatment Reviews, 22, 75-81. Cancer Rehab Paradigms • Preventative: preoperative education and training, improve general health and function • Restorative: Return to PLOF, change client variables, restore skills • Supportive: modify, prevent, maintain in natural setting, accommodate training for existing disabilities, minimize potential debilitating changes • Palliative: best QOL for pt and family, balance between function and comfort, maintain and modify Assessments • Pain Scale/ Visual Analogue • McGill Pain Short Form, DASH Questionnaire, Shoulder Pain and Disability Index • MOCA • KELs • COPM Considerations for Treatment • Functional status may fluctuate!! • • • • Treatment continuum Progression of disease Relapse vs. remission Modify treatment plan • Energy Conservation/ Scheduling Strategies for Intervention • Education for precautions • Involve patient in treatment to give sense of control and develop meaningful goals • Individualized treatment plan • Consider family/caregivers’ needs • Look at restoring meaningful life roles Interventions • Therapeutic Exercise • Caregiver Training • Establish routines (written schedules) • Therapeutic Activities • Engage in meaningful activities (typing, crafts) • Energy Conservation and Work simplification training • Make interactive and individualized for carryover Interventions • Fall prevention education • Peripheral Neuropathy- review strategies for body awareness and use of visual feedback for body positioning • Sensory retraining/ desensitization • Safety (ie. Gloves in kitchen) • Relaxation Strategies • Diaphragmatic breathing • Guided imagery • Adapted yoga Interventions • Cognitive Retraining • Compensatory approach • Lymphedema Treatment (certification) • Equipment coordination and discharge planning • Adaptive Equipment Training • Modified Body Techniques/ Body Mechanics and Transfer Training Pain Interventions (physical) • Therapeutic Exercise • Graded and purposeful activity • Postural reeducation • Massage and tissue mobilization • TENS, heat, and cold* Pain Interventions (psychosocial) • Distraction, engaging in activities • Anxiety mangt/ guided imagery • Lifestyle adjustment • Environmental adaptation • Educational approaches • Identify triggers (ie. Noise, lights, temp, position, smell) ADL Interventions • Shower training • Check if cleared/ hemodynamically stable • Coordinate with nursing and PT • Adaptive equipment • Bath seat, long sponge, grab bars • Energy Conservation/ work simplification • Caution with shaving (electric razor) • Care of lines/ drains ADL Interventions • Dressing • Energy conservation/ work simplification • Positioning (bed level vs. chair or edge of bed) • Assess for AE • Shoe horn, reacher, elastic laces, sock aide • Be creative and make adaptations as needed! • Toileting • • • • Assess toilet height to avoid strain May need padding AE: Toilet aide *may have chemo precautions Transitions • Hospice • Inpatient Rehab • Home with family support • Home Health • Outpatient • Pete Gross or SCCA House Other considerations • Therapist self care to prevent “burnout” • “Tea for the Soul” for staff • “Light the Candle” (virtual candle +message) • “It gave him the confidence that he could do more for himself” – pt’s wife of his experience in inpatient rehab • “It’s so overwhelming. I’ve lost my strength, I feel like I’ve abandoned my daughter. I wasn’t expecting this at 39. You’ve been a blessing.”woman with AML in rehab • “I always look forward to OT and PT because it gave me hope. I aim to be able to do things for myself again.”-Man who had relapsed after stem cell transplant was in acute care. Question and Answers OT glasses References Arnadottir, G. (1990). The brain and behavior: Assessing cortical dysfunction through activities of daily living. Philadelphia: Mosby. Ahles T. A. and Saykin A. J. (2002). Breast cancer chemotherapy-related cognitive dysfunction. Clin. Breast Cancer 3, 84-90. Ballard-Barbash, R., George, S. M., Alfano, C. M. , & Schmitz, K. (2013, June 15). Survivorship, Integrative Oncology from http://www.cancernetwork.com/survivorship/physical-activity-across-cancercontinuum#sthash.dYERHZdK.dpuf Brown, C. G. (2010) A guide to oncology symptom management. 11, 215-217. Cambell, C., Hughes, J., & Munoz, L (2012) Occupational Therapy’s Unique Contributions to Cancer Rehabilitation . AOTA course continuing education. Cooper, J., and Littlechild, B., (2004, July). A study of occupational therapy intervention in oncology and palliative care. Journal of Therapy & Rehabilitation. 11(7) 329-333 . References Crannell, C. and Stone, E. (2008) Bedside Physical Therapy Project to prevent deconditionning in hospitalized patients with Cancer. OCN Oncology Nursing Forum. 35(3), 344-345. Health condition tube (2014, April) https://www.youtube.com/watch?v=izQk051qg8M Naik, H (2007). Some helpful hints during chemo therapy. PDF retrieved on October 1, 2014, from http://www.hopecancerclinic.net/patient_education. National Cancer Institute [http://cancer.gov]. Penfold, S. L. (1996) The role of the occupational therapist in ocology. Cancer Treatment Reviews , 22, 7581. Scott Hamilton Care Initiative. Low blood counts http://chemocare.com/chemotherapy/side-effects/lowblood-counts.aspx#.VDY5nlLn_ug Seattle Cancer Care Alliance. Exercise precautions for low blood values. http://www.seattlecca.org/diseases/thrombocytosis.cfm Serra, D., Parris C. R., Carper, E., Homel, P., Fleishman, S. B., Harrison, L. B., et al. (2012, December). Outcomes of guided imagery in patients receiving radiation therapy for breast cancer. Clinical Journal of Oncology Nursing,16 (6), 617-623.