Download Dr. Gutierrez

Improving
“Cancer Rehabilitation:
Function and Quality of Life.”
Carolina Gutierrez, MD
Clinical Assistant Professor
Cancer Rehabilitation
Department of Physical Medicine and Rehabilitation, UTHealth
TIRR Memorial Hermann
September 15, 2016
“Cancer Rehabilitation: Improving
Function and Quality of Life.”
Outline
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Cancer rehabilitation – definition
“Chemo brain”
Neuropathy
Recommendations for cancer survivors
What is Cancer Rehabilitation?
• Is medical care that should be integrated
throughout the oncology care continuum
… delivered by trained rehabilitation professionals
who have it within their scope of practice to
diagnose and treat patients’ physical, psychological
and cognitive impairments
… in an effort to maintain or restore function,
reduce symptom burden, maximize independence
and improve quality of life in this medically complex
population.
Cancer Survivor
• A cancer survivor is defined as anyone who
has been diagnosed with cancer, from the
time of diagnosis through the balance of his or
her life.
CDC (Centers for Disease Control and
Prevention)
“Chemo Brain"
• Chemo brain is a common term used by
cancer survivors to describe thinking and
memory problems that can occur after cancer
treatment. Chemo brain can also be called
chemo fog, chemotherapy-related cognitive
impairment or cognitive dysfunction.
http://www.mayoclinic.org/diseases-conditions/chemobrain/home/ovc-20170224
“Chemo Brain"
• Forgetting things that they usually have no
trouble recalling
• Trouble concentrating
• Trouble remembering details like names,
dates, and sometimes larger events
American Cancer Society
“Chemo Brain"
• Trouble multi-tasking, like answering the
phone while cooking, without losing track of
one task
• Taking longer to finish things (disorganized,
slower thinking and processing)
• Trouble remembering common words
American Cancer Society
Is it Really Chemo Brain?
• Can occur after
– Cancer
– Chemotherapy
– Hormone therapy
– Surgery
Cognitive Function
• Patients who report cognitive impairment
should be screened for potentially reversible
factors that may contribute to cognitive
impairment such as depression, sleep
disturbance and fatigue
NCCN Guidelines Cognitive Function
Cognitive Function
• Assessment
– Focused history
– Contributing factors
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Medication
Hormonal status
Depression/anxiety
Pain
Fatigue
Comorbidities
Use of alcohol/other agents
NCCN Guidelines Cognitive Function
Cognitive Function
• Evaluation
– Imaging
– Neuropsychologic testing
NCCN Guidelines Cognitive Function 1.2016
Cognitive Function
• Interventions
– Education and counseling
– Occupational therapy
– Speech therapy
– Management
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Depression/emotional distress
Sleep disturbances
Fatigue
Symptoms as pain
Medical comorbidities
NCCN Guidelines Cognitive Function 1.2016
What you can tell your patients
• Use a daily planner
• Get enough rest and sleep
• Exercise your brain
– Take a class, learn a new language
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Regular physical activity
Have routines
Do not multitask
Ask for help
http://www.cancer.org/treatment/treatmentsandsideeffects/physicalside
effects/chemotherapyeffects/chemo-brain
What you can tell your patients
• Keep a record of your memory problems
– Time of the day
– Things that can make it better / worse
– Since when
• Try not to dwell on how much these problems
bother you
http://www.cancer.org/treatment/treatmentsandsideeffects/physicalside
effects/chemotherapyeffects/chemo-brain
Tips for patients
• Encourage them to talk to their doctors
• Have a list of all the medications including
supplements with them
• Have a family member or a close friend
coming to the appointments with them
– Can help with the information disclosed in the
consult
– Can describe changes
• Write down the questions for your doctor
http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsidee
ffects/chemotherapyeffects/chemo-brain
Neuropathy
• Other names
– Peripheral neuropathy
– CIPN – Chemotherapy-Induced peripheral
neuropathy
• Damage to the peripheral nerves
• Affects quality of life, survivorship, and
modifications in oncological treatments
Peripheral Neuropathy
• Can also be also caused by
– Surgery
– Radiation
– Tumor compressing directly on nerves
– Chemicals released by tumors
– Infections
https://www.nccn.org/patients/resources/life_with_cancer/managing_s
ymptoms/neuropathy.aspx
Incidence of Peripheral Neuropathy
• 30 – 40% of patients treated with
chemotherapy will develop some degree of
peripheral neuropathy
• Not predictable
https://www.nccn.org/patients/resources/life_with_cancer/managing_sympt
oms/neuropathy.aspx
Chemotherapy-Induced Peripheral Neuropathy
CIPN
• May change depending on:
– Chemotherapy agent
– Dose
– Duration of exposure (cumulative)
• Usually sensory symptoms
• Rare motor symptoms (Thalidomide and
Paclitaxel)
• Autonomic symptoms - rare
• Sensory
Symptoms
– Pain
– Tingling
– Numbness
• Motor
– Weakness
– Decreased balance
• Autonomic
– Constipation
– Dizziness
https://www.nccn.org/patients/resources/life_with_cancer/managin
g_symptoms/neuropathy.aspx
Other Symptoms
• Cramping
• Burning
• Pain – shooting, stabbing
– Constant
– Intermittent
• Decrease sensation to light touch
• Decrease sensation to temperature
• Sensitivity to heat or cold or touch
https://www.nccn.org/patients/resources/life_with_cancer/managing_sympt
oms/neuropathy.aspx
Other Symptoms
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Feeling off balance
Difficulty walking
Constipation
Difficulty with fine motor skills
– Buttoning
– Picking up objects
– Holding objects
https://www.nccn.org/patients/resources/life_with_cancer/managing_sympt
oms/neuropathy.aspx
Course of Neuropathy
• Start in fingers and toes  Progress to hand
and feet  Followed by arms and legs
• Can begin
– Any time after initiation of treatment
– Can be sudden
– Usually are mild and slowly worsen
• Get better slowly – months
• Sometimes permanent
https://www.nccn.org/patients/resources/life_with_cancer/managing_sympt
oms/neuropathy.aspx
Risk for Neuropathy
• Having had chemotherapy, surgery or
radiation before
• High dose or long course of chemotherapy
• Taking more than one agent than can cause
neuropathy
• Multiple myeloma, lymphoma, lung or breast
cancer
• Nerve damage from prior injury or illness
https://www.nccn.org/patients/resources/life_with_cancer/managing_sympt
oms/neuropathy.aspx
Risk for Neuropathy
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History of alcohol abuse
Diabetes
HIV or AIDS
Malnutrition
– Vitamin B 12, B6, folic acid deficiency
• Hypothyroidism
https://www.nccn.org/patients/resources/life_with_cancer/managing_sympt
oms/neuropathy.aspx
Diagnosis
• History
• Physical exam
– Strength
– Reflexes
– Sensation to light touch
• NCS-EMG – nerve conduction
study/electromyography
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Treatment
Symptoms & Side effects
Pain management
Education
Skin protection
– Sharp objects
– Cold / Heat
• Skin inspection
• Fall prevention
• Appropriate foot wear
Preventive Agents
• No established agents recommended for the
prevention of chemotherapy-induced
peripheral neuropathy
• Preliminary data may suggest potential
protective effect of exercise in CIPN
Uptodate
Cytotoxic Chemotherapy Agents
• Platinum drugs, such as cisplatin (Platinol), oxaliplatin (Eloxatin),
carboplatin (Paraplatin)
• Taxanes, such as paclitaxel (Taxol, Abraxane), docetaxel (Taxotere)
• Vinca alkaloids, such as vincristine (Oncovin, Vincasar), vinorelbine
(Navelbine), and vinblastine (Velban)
• Podophyllotoxins, such as etoposide (Etopophos, VePesid, Toposar,
VP-16) and teniposide (Vumon)
• Epothilones, such as ixabepilone (Ixempra)
• Thalidomide (Thalomid) and lenalidomide (Revlimid)
• Bortezomib (Velcade)
• Interferon
• Methotrexate (Rheumatrex, Trexall, Amethopterin, MTX)
• Fluorouracil (5-FU, Adrucil)
• Cytarabine (Cytosar-U)
Acute Neurotoxicity Syndrome
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Not always peripheral
Non cumulative
Improves within days of each dose
Recurring with subsequent doses
Oxaliplatin
Paclitaxel
Uptodate, Prevention and treatment of chemotherapy-induced peripheral
neuropathy
Additional Recommendations
For Survivorship
• American Cancer Society (ACS)
• American Institute for Cancer Research (AICR)
• American College of Sports Medicine (ACSM)
ACS Recommendations
• Achieve and maintain a healthy weight
throughout life
• Adopt a physically active lifestyle
• Consume a healthy diet, with an emphasis on
plant foods
• If you drink alcoholic beverages, limit
consumption
ACS – American Cancer Society
ACSM Guidelines
• Cancer patients and survivors should adhere to the 2008
federal Physical Activity Guidelines for Americans
– 150 minutes per week of moderate intensity aerobic activity
• Avoid inactivity
– For those with disease or undergoing treatment
• Exercise recommendations should be tailored to
– Exercise tolerance and specific diagnosis
• Close attention to cancer survivors response to physical
activity
– Safely progress exercise programs & avoid injury
ACSM – American College of Sports Medicine 2011
AICR’S Guidelines For Cancer Survivors
Recommendations to Reduce Your Cancer Risk
• Be as lean as possible without becoming underweight.
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Be physically active for at least 30 minutes every day.
Avoid sugary drinks, and limit consumption of energy-dense foods
Eat more of a variety of vegetables, fruits, whole grains and legumes.
Limit consumption of red meats and avoid processed meats.
Limit alcoholic drinks to two for men and one for women a day.
Limit consumption of salty foods and foods processed with salt.
Do not rely on supplements to protect against cancer.
Do not smoke or chew tobacco.
AICR – American Institute for Cancer Research
AICR – American Institute for Cancer Research
AICR’S Guidelines For Cancer Survivors
Recommendation for new mothers
• Best for mothers in the general population to
breastfeed exclusively for up to six months
and then add other liquids and foods.
• Note: new mothers receiving chemotherapy
should not breastfeed.
AICR – American Institute for Cancer Research
• http://www.cancer.org/treatment/treatments
andsideeffects/physicalsideeffects/chemother
apyeffects/chemo-brain
• https://www.nccn.org/patients/resources/life
_with_cancer/managing_symptoms/neuropat
hy.aspx