Download The Cancer Team: Physical Therapy

Oncology Rehabilitation: Web-based Learning for Physical Therapists
Who Provide Rehabilitation to Patients with Breast Cancer
File #3
The Cancer Team
Physical Therapy
The Cancer Team : Physical Therapy
• Realize the expertise and importance of physical
•
therapy necessary to treat the breast cancer patient.
Physical Therapy should be prominent in establishing
and following a plan of treatment for the breast cancer
patient.
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MEDICAL TEAM
General Surgeon
Plastic Surgeon
Psychiatrist/psychologist
Rehabilitation Director
Physical Therapist
Nurse
Social Worker
Registered Dietician
Occupational Therapist
Vocational Counselor
Respiratory therapist
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PHYSICIANS’
ROLE IN THE
TREATMENT OF
BREAST CANCER
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• GP or Internist - diagnoses and refers to specialists
as needed.
• Oncologist – coordinates diagnostic and treatment
interventions.
• Radiologist - determines required methods and
dosage of radiation
• Pathologist - diagnoses & classifies disease
• Surgeon - determines procedure and attempts to
save surrounding structures.
• Plastic Surgeon – restores appearance leading to a
positive self image.
Who prescribes rehabilitation?
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Staging to Treatment
• Breast cancer treatment programs are
dependent upon the diagnosis rendered by the
pathologist and the collaborative treatment plan
established by the physician and the patient. All
diagnostic studies presented will make a realistic
breast cancer rehabilitation program possible.
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(Slide permitted by the American Cancer Society)
Medical Interventions:
• Chemotherapy
• Radiation
• Surgery
• Hormone Therapy
• Immunotherapy
• Bone Marrow Transplants
• Prescribed Physical Rehabilitation
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Chemotherapy
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Chemotherapy
• The use of drugs to treat cancer.
• Combination Chemo - Some drugs work
better with another drug.
• Why chemotherapy?
– Regional and systemic disease
– Designed to kill cancer cells and stop them
from growing
– Goals: cure; control; palliative; prophylactic
(Otto, 2004)
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Medical interventions can be mixed in an attempt to
reach maximal progress with chemotherapy drugs
or other treatment regimes.
Combination Chemotherapy:
Some drugs work better
With another drug,
Than when used alone
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Chemotherapy
• Schedule therapy around chemotherapy
– Medications being used
– Treatment schedule
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Chemotherapy Agents
• ALKYLATING: Damage DNA in nucleus
which has decreased ability to repair.
– Examples: nitrogen mustard & cyclophosphosphamide
• ANTIMETABOLITES: Replace
compounds needed for DNA synthesis.
– Examples: 5-fluorouracil & methotrexate
.
(Abraham, 2005)
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Agents
• INHIBITORS OF CELL: Inhibit cell mytosis, so
dividing cells cannot separate chromosomes
into daughter cells.
– Examples: vincristine, vinblastine & colchicine
• ANTI-TUMOR ANTIBIOTICS: Bind DNA and
block RNA preventing protein growth.
– Examples: doxorubicin, bleomycin, mitomycin & cisplatin
(Abraham, 2005)
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During chemotherapy notify M.D. if:
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A fever greater than ______
degrees.
Bleeding
___________
or unexpected bruising.
rash
swelling
A ________
or allergic reaction (_______)
Chills
soreness
Pain / _______
at chemo injection site.
Unusual pain
SOB
vomiting
Diarrhea or prolonged ___________.
Blood
___________
in urine.
(Otto, 2004)
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Side Effects: Chemotherapy
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Nausea
Vomiting
Loss of Appetite
Menstrual Irregularities
Low Blood Count
Hair Loss
Mouth Sores
Conjunctivitis
Ulcers
Fatigue
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Heart Problems
Headache
Pain at IV Site
Numbness
Dizziness
Bladder Liver Problem
Infertility
Depression
(Adcock, 1992)
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Specific examples of chemotherapy side effects
• Cytoxan (Oral/IV)
Nausea, vomiting, loss of appetite,
menstrual irregularity, low blood counts, hair loss. Possible
urinary bladder problems, liver problems, infertility
• Adriamycin(IV)
Hair loss, mouth sores, nausea, vomiting,
low blood counts. Possible heart problems, nail and skin
darkening, liver problems.
• Viscristine(IV) Hair loss, tingling and numbness in fingers
and toes, pain at IV site, constipation, headache. Possible
muscle and jaw pain, loss of reflexes, depression, insomnia
• 5 fluorouracil (5FU) Mouth sores, nausea, vomiting,
diarrhea, low blood counts, loss of appetite, hair loss, sore
throat. Possible rash, nail change, skin darkening
(Otto, 2004)
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Hormone Therapy
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Hormone Therapy
• Natural or Synthetic change of hormones
to treat disease.
• Three Methods of treatment
1. Medication (injected or oral)
2. Surgical removal of hormone
producing gland.
3. Radiation to destroy hormone
producing cells.
(Otto, 2004)
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HORMONE THERAPY
• Treatment plan:
• Tamoxifen - Blocks body’s use of estrogen.
• Hormones used: Adenocorticoids (Prednisone &
Cortisone), Estrogen & Progesterone (Female
hormones), Androgen (Male hormone) .
(Otto, 2004)
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Side Effects: Hormone Replacement
Therapy
• Tamoxifen - Hot flashes, nausea, vaginal
•
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discharge or itching. Possible headache, bone
pain, depression.
Progestins - Weight gain, edema, breast
tenderness. Possible carpal tunnel syndrome,
hair loss.
Prednisone - Mood changes, increased
appetite, fluid retention. Possible acne, muscle
weakness, diabetes, high blood pressure.
(Otto, 2004)
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Radiation
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RADIATION
ENERGY CARRIED BY
WAVES OR A STREAM OF
PARTICLES. DELIVERED
BY MACHINE OR FROM
RADIOACTIVE
SUBSTANCES.
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External Beam Radiation
• A machine (Linear accelerator) that directs
high energy rays or particles to the Cancer
and margins of normal tissue.
Damaging DNA (directly or indirectly)
• Best used for: ______________________
__________________________________
Mapping (Taking about an hour)
• Preparation: _______________________
Every weekday for five to six weeks + a boost (+ five)
• Amount: __________________________
Standard type of radiation
Average dose post lumpectomy 4,500 to 5,000 centigray (cGy)
Boost dose 1,000 to 1,500 cGy
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(www.mayoclinic.com, 2004)
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(Slide permitted by the American Cancer Society)
Internal Beam Radiation
• Radioactive substance is sealed in small containers,
•
•
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such as wires and tubes then placed directly into tumor
or body cavity.
Container of radioactive material placed
Intracavitary: ______________________
in a cavity of the body
__________________________________
Radioactive source placed a short
Brachytherapy: _____________________
distance from affected area
__________________________________
Problem: Radiation may cause disease that is being
treated. Donegan and Spratt (2002), report second
breast cancers can be linked to radiotherapy for primary
breast cancer for exposed women under age 45.
(Otto, 2004)
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HIGH DOSES OF RADIATION THAT
DAMAGE AND DESTROY CANCER
CELLS CAN ALSO EFFECT
NORMAL CELLS, BUT THE SIDE
EFFECTS ARE LESS THAN THE
BENEFITS
(Risks effects less than 1% of
women treated with radiation)
(Elk, 2003)
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Radiation after mastectomy recommended if:
• Tumor > 2 inches (5 centimeters) and positive
lymph nodes
• Cancer cells found in many lymph nodes
• Tumor close to rib cage or chest wall
musculature, which could lead to spreading
(METS)
• Inflammatory breast cancer, which is described
as cancer cells blocking lymph vessels in the
skin of the breast, appearing with redness and
heat of the breast.
(Altman, 1992)
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Success with radiation
• Depends on whether cells multiply between
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fractions*. To much time between fractions
increases doubling time*. Intervals should be
short to kill greatest number of Ca cells.
Schedule usually 5 days/week for 5-8 weeks or
more (Prevents to much RAD to skin and normal
tissue).
Split Course Therapy allows patient several
weeks off in middle of treatment to allow body
recovery time.
(Dollinger et al, 2002)
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Radiation after breast conserving
surgical procedures
10 years later
No radiation radiation
Recurrence rate
Mortality
31.9%
24.7%
10.5%
20.9%
(Dixon, 2006)
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Side Effects: Radiation
• Acute
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Itching / Swelling
Skin Reddening / Burn
Fatigue
Nausea / Vomiting / Loss of appetite
Decrease in lab values including blood counts
Pain in the treated regions
• Long Term
– Fibrosis (Firmness of the Breast)
– Radiation induced 2nd Malignancy
(Otto, 2004)
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Surgery
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Why Surgery?
• Preventive:
Patient known to be at high
risk.
• Diagnostic:
Biopsy to obtain tissue.
Exploratory surgery for staging.
• Cure: Removal of cancerous tissue. Best
when combined with other interventions.
(Dollinger, 2002)
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•
Palliation: Relieve pain--restore
function in terminal patients to
increase quality of life.
• Reconstruction: Correct function
and cosmetic defects.
(Dollinger, 2002)
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Diagnostic Surgery
• Sentinel lymph node biopsy
• 70% of stage 1 breast cancer have negative
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nodes.
Multiple node dissection can increase
complications.
Sentinel node is the first draining node. If this is
negative, good chance other nodes are also
negative.
Has become procedure of choice.
(Dollinger, 2002)
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Breast Surgery
Simple mastectomy Remove breast tissue only.
• ____________
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Chest wall muscles and axillary lymph intact.
Generally precancerous condition.
Lumpectomy
____________
Remove tumor and margin of
surrounding tissue. Axillary dissection to
determine need of other interventions.
Modified Radical Breast tissue removed, some
____________
axillary nodes. Spare pectoralis major pectoralis
minor may be removed, getting to axilla.
(Altman, 1992)
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Breast Surgery
Radical Mastecomy
• ____________
Remove breast tissue,
pectoralis major, pectoralis minor and all
axillary nodes, not common choice.
Axillary Dissection
• ____________
Axilla primary site of
regional metastasis needed for staging.
Estimated 27 Lymph nodes in axilla.
(Altman, 1992)
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Post-operative right side mastectomy
What’s next?
(Slide donated with permission to show by: Ronald H. Schuster, MD
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Board Certified Plastic Surgeon)
Reconstructive Prosthetics
Silicone
• Saline
• Tissue Expander (Temporary or Permanent)
•
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Reconstruction
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Know where new breast tissue originated.
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)41
Muscle tissue transfer
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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TRAM
Transverse Rectus Abdominal Myocutaneous Flap
• Breast Reconstruction method using autologous
tissue.
• Consideration for post mastectomy patients.
• Contraindicated:
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Chronic Pulmonary Disease
Cardiovascular Disease
Hypertension
Insulin Dependent Diabetes Mellitus
• Risk
• Smoker
• Obesity
• Thin
• Radiotherapy
(Grant, 1994)
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Abdominal region, where TRAM originates
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Pre-Operative markings for TRAM
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Surgical procedure shows removed breast and
preparing of abdominal tissue for transfer
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Attached tissue ready to be transferred
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Procedure completed with staples
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Tattoo of areola
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Post-surgical TRAM
• As shown in the example, the TRAM
procedure is very complicated and
requires the expertise of a surgeon and
plastic surgeon.
• Precautions are needed to avoid any
possible complications that could harm
transferred tissue, leading to necrosis.
Such things as aggressive exercise and
stretching are potential problems.
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Other less performed breast procedures:
• Skin–sparing mastectomy: surgery
removing breast tissue by making an
incision around the areola.
• Subcutaneous (nipple sparing)
mastectomy: surgery removes only breast
tissue, sparing the skin, nipple, areola,
chest wall muscles and lymph nodes.
(Altman, 1992)
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Time Out Test
• Why should physical therapy be a vital member of the cancer team?
• A tumor larger than 1cm, usually receives removal and what other
ANSWERS
Expertise in Rehabilitation; chemotherapy; half-life; damaging DNA; False;
Less tissue trauma ;Musculature in not attached, microsurgery needed to
Restore circulation.
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medical intervention?
Knowing how a medication will function in the body is called?
What is radiation best used for?
Radiation only destroys cancer cells? T / F
What is the advantage of sentinel node biopsies?
A free flap surgical procedure lets you know what?
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Side Effects: Surgery
• Cosmetic and Functional
• Infection
• Psycho-social Issues (Patient’s may have
problems dealing with their diagnosis and prognosis as
well as treatment and side effects . Proper care will be
needed, advise the referring physician).
• Pain
• Decreased function with possible
deformity
(Otto, 2004)
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Bone Marrow Transplant
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BONE MARROW TRANSPLANTS
• Bone Marrow produces 3 types of cells.
Red Blood Cells =Cells that transport oxygen
from the lungs to other parts of the body.
(Too few RBC's called Anemia)
White Blood Cells = Defense mechanism that
fights infection.
Platelets = prevention of bleeding by the
formation of clots.
• BMT = Replacement of diseased or
destroyed bone marrow with
healthy cells
(Otto, 2004)
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Types of Transplants:
• Autologous--Patient's own marrow is
removed, stored, and later returned.
• Syngeneic--Marrow from an identical twin.
• Allogeneic--Marrow donated by another
person (Often sister or brother).
• Donor match completed with a blood
sampling called an HLA
(Human Leukocyte Antigen)
(Otto, 2004)
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When BMT might be prescribed?
Solid tumors
(Cancer of brain, testes, breast & lung)
•
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Clinical trials with high dose therapy with
autologous bone marrow transplants suggest
increased response rate.
Studies appear inconclusive as far as the
benefits of BMT for breast cancer. A randomized
trial with metastatic disease showed no
difference between conventional chemotherapy
and autologous transplant.
(Dollinger, 2002)
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BMT Procedure
• Patient selection
• Allogeneic transplant: Donor matching
• Autologous transplant: BM harvest
• Treatment--Chemo and/or Radiation
• Protective Isolation
• Allogeneic/Syngeneic transplant: harvest
• Marrow transplant = Reinfusion
• Engraftment, a rise in blood counts
• Discharge and follow-up
• 4 to 6 weeks in hospital
• Cost : $75,000 - $200,000
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BMT Success
• 60-80% success
• 50% cure rate for AML; Late in disease
10%
• 30% breast Ca. cure rate
• Predictions of other Ca. cure rates not
possible
(www.healthline.com, 2005)
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BMT Problem
(1/2 BMT = GVHD)
• Graft versus Host Disease (GVHD)
16% death rate
• Symptoms: From mild skin rash to
severe diarrhea to life threatening liver
damage and hemorrhage.
(www.healthline.com, 2005)
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National Marrow
Donor
Program
100 South Robert Street
St. Paul, MN. 55107
1-800-654-1247
About 1.5 million
volunteers
registered
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Side Effects:
Bone Marrow Transplant
• Short Term
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Nausea / Vomiting
Irritation of lining of mouth and GI tract
Decreased Blood Counts
Damage to vital organs
Hair loss
Loss of appetite
• Long Term
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Infertility
Early Menopause
Cataracts
Secondary Cancers
(Otto, 2004) 62
Immunotherapy
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Immunotherapy
• Stimulates the bodies own immune system
to attack the disease.
• Many patients who have failed using other
types of interventions made positive
progress with immunotherapy.
• Alter genetic make-up:
1. By removing cells that could fight Cancer
2. Inserting fighting gene into them then
3. Infusing cell back into patient.
(Lange, 2005)
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Side Effects: Immunotherapy
• Interferon toxicity
– Fever / Chills
– Nausea / Vomiting
– Anorexia
– Fatigue
• Monoclonal Antibody Toxicity
– Fever / Chills
– Dyspnea
– Hypotension
– Nausea / Vomiting
• Interleukin 2 Toxicity
– Fluid Retention / Pulmonary Edema
(Otto, 2004)
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Treatment Options
Medical Interventions are determined by the risk of recurrence
No Surgery
Radiation
Lumpectomy
Chemotherapy
Bone Marrow Transplant
Mastectomy
Hormone Therapy
Immunotherapy
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Important to follow cancer
developments:
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Constant research
Changes in chemotherapy medications
Changes in surgical procedures
Stem cell bone marrow transplants
Best areas to obtain bone marrow
Continual rehabilitation research
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Deconditioning
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All Medical interventions can lead to
deconditioning of the total body.
Patients should complete some
exercises as tolerated during
treatments
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Complications seen with Deconditioning
•Gastrointestinal
•Acute/Chronic Pain
•Neurological
•Psychological
•Hematological effects
•Effects on bone
(Pathological Fx)
• Peripheral vascular
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and lymphatic
Compression
Cardiopulmonary
Urinary signs
Metabolism and
Endocrine
70
American Cancer Society
Clinical Trials and Research
The Need for Clinical Trials
Research studies to produce guidelines which reveal the
effects of drugs, working alone or together, to prevent,
alleviate, or cure a disease.
Clinical trials lead to strategies for drugs.
Examples: Tamoxifen and Raloxifene for breast cancer.
(Jennings-Dozier, 2002)
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(Slide permitted by the American Cancer Society)
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(Slide permitted by the American Cancer Society)
Example of Research
75
(Slide permitted by the American Cancer Society)
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(Slide permitted by the American Cancer Society)
Clinical Trials
•1-800-4-CANCER
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Tumor Markers
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Tumor Markers
Diagnostic data used in the
diagnostic and stage the process
of cancer
Example: Serum tumor markers
measure the serum level of
glycoproteins that are shed from the
tumor cells into the blood stream.
CA-27.29 used for breast cancer
This can be followed to evaluate the
activity of the tumor.
(Otto, 2004)
Method of following tumor
80
(Slide permitted by the American Cancer Society)
Time Out Test
• Autologous transplants are more beneficial than
chemotherapy, when treating metastatic disease? T / F
• What do agents like interferon's and interleukins do to
attack cancer cells?
• With immunotherapy, cells are removed, fighting cells
are inserted and then cleaned cells are returned? T / F
• All medical interventions have side effects, how does
that effect physical therapy?
ANSWERS
False; Activate white blood cells; True; Possible change in program.
81