Transcript Paediatric Oncology The Role of Physiotherapy

Oncology Patient
Does Physiotherapy have a role To Play ?
Robyn Smith
Department of Physiotherapy
UFS
2011
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 groups
The 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:
Chills
Fatigue
Fever
Loss of appetite
Malaise
Loss of weight
Night 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 of
Tissue biopsy
Bone marrow biopsy
Blood tests
MRI
CT scan
CXR
• 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 cancer
Combination 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:
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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
Vommiting
Mucositis
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Weight loss
Muscle wasting
Loss of energy
Depression
Plan shorter more frequent PT
sessions
Positive 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 activities
Positive input
Short term side effects of radiotherapy
Radiotherapy =
Use of high energy XR
rays to destroy cancer
cells
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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:
Musculoskeletal
Neurological
Cardiovascular
Pain
Respiratory
QOL
Function
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:
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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
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↑ 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
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Exercises
Functional activities
Stair climbing
Squats
3-5 /wk
ROM & Stretching
• CPM
• Passive movements and
stretches
• Splinting
• 3-5/wk
Aerobic exercising
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Walking
Treadmill
Cycling
Stair climbing
Swimming
Dancing
Special techniques where indicated
• Neurodevelopmental
therapy
• OMT
Chest physiotherapy
Check 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 physiotherapy
Check 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 physiotherapy
Check 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 physiotherapy
Check 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 condition
Help the patient feel more in control if he is informed
Will be better able to make sense of what is happening
Shared 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 patient
Cancer diagnosis
Denial
Acceptance
Anger
Bargaining
Depression
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
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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/cgibin/giga.cgi?cat=820&limit=10&page=0&sort=D&cause_id=1056&cm
d=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.