ACUTE CARE IN ONCOLOGY Meredith Wampler-Kuhn, PT, DPTSc October 22, 2011

Objectives

¨  Understand how cancer and cancer treatment impacts systems involved with mobility

¨  Create a SAFE treatment plan for patients with cancer

¨  Identify and understand how to handle red flags in oncology acute care

Cancer Trajectory

• Prevention • Screening/detection

Pre dx

Pre-treatment

Post dx

•  Palliation •  End of

life •  Coping

Post dx

Tx Post Tx Survivorship and health-promotion

(adapted from Cournyea and Friedenreich, 2001)

Time                        

   

 106  

 1012    

Log

Num

ber

of c

ance

r ce

lls

 1010    

 108    

Death

Symptoms

Detectable

Cure Treatment Model

Adapted  from  UCSF  medical  school  lecture  2004  

Treatment

Time                        

   

 106  

 1012    

Log

Num

ber

of c

ance

r ce

lls

 1010    

 108    

Death

Symptoms

Detectable

Palliative Treatment Model

Adapted  from  UCSF  medical  school  lecture  2004  

Treatment

Acute Care Oncology Rehabilitation

Complex medical issues

PLUS

• psychosocial

• financial

• emotional

¨  Survivor Trajectory ¤  Post-surgical care

n  chemo and radiation often completed in outpatient setting ¤  Post-bone marrow transplant ¤  Metastatic disease? ¤  PT GOALS– RESTORATIVE, PATIENT EDUCATION

¨  End of Life Trajectory ¤  Metastatic disease ¤  Multi-system treatment side-effects ¤  PT GOALS– COMFORT (SYMPTOM MANAGEMENT),

COMPENSATORY, CAREGIVER EDUCATION, DME NEEDS

Disease and Treatment Impairments by System

Gastrointestinal

Oncology patients are complex

¨  Disease ¨  Impairments can be related to

primary or metastatic disease ¨  Surgery

¤  Acute impairments ¨  Radiation

¤  Acute impairments ¤  Late or persistent impairments

¨  Chemotherapy ¤  General impairments ¤  Drug specific impairments

Gastrointestinal impairments

¨  Disease ¨  Colorectal cancer

¨  Surgery ¤  Adhesions/scar tissue ¤  Colostomy vs.

reanastamosis ¨  Radiation

¤  Rarely used colon CA ¤  More common in rectal or

esophageal CA ¤  Fibrosis

¨  Chemotherapy ¤  Nausea/vomiting ¤  Mucositis

PT treatment

¨  Patient Education ¤  Return to basic ADLs early to promote ROM and strength ¤  Reinforce post-op lifting or ROM restrictions (if any)

¨  Seating Assessment ¨  Rectal cancer

¨  Stretches/Strengthening/Scar massage ¤ GOAL—increase ROM, strength, mobility of soft tissues in

abdomen, trunk, or pelvic floor ¤ Caveats

n  MD post-op restrictions n  Lifting too much/too soon may cause hernia

Disease and Treatment Impairments by System

Integumentary

Integumentary impairments

¨  Disease ¤ Melanoma

¨  Surgery ¤ Myofascial adhesions

that limit ROM ¤  Seroma

¨  Radiation ¤  Fibrosis ¤ Decreased gland

secretion ¨  Chemotherapy

¤ Alopecia

PT treatment

¨  Patient Education ¤  Return to basic ADLs early to promote ROM and strength ¤  Reinforce post-op lifting or ROM restrictions (if any)

¨  Stretches ¤ GOAL—increase ROM ¤ Caveats

n  MD post-op restrictions n  Early aggressive mobilization may cause seroma n  Be aware of port or Hickman lines (for chemo)

n  Takes 4-6 weeks for them to ‘scar’ in place

PT treatment

¨  Myofascial mobilization ¤  GOAL—increase ROM and

myofascial mobility ¤  Caveats

n  Can start gentle techniques 4-6 weeks post-op

n  Do not work on areas where there is open skin OR infection

n  Must have ‘clean margins’ (becomes gray area in palliative stage)

Disease and Treatment Impairments by System

Hemopoietic

Hemopoietic impairments

¨  Disease ¤ Leukemia

¨  Surgery ¤ Post-op anemia?

¨  Radiation ¤ Minimal pancytopenia

¨  Chemotherapy ¤ Pancytopenia is

common

Pancytopenia from chemotherapy

¨  Nadir—time point that RBC, WBC, and platelets drop to their lowest number ¤ Drug specific (www.chemocare.com)

¨  Acute problem that will resolve in days to weeks ¨  Medical treatment

¤ Anemia (↓ RBC)—erythropoietin (‘EPO’) or transfusion ¤ Neutropenia (↓WBC)—filgrastim (ex. Neupogen) ¤ Thrombocytopenia (↓  platelets)-- transfusion

Pancytopenia from chemotherapy

¨  PT treatment considerations ¤  Anemia (Hgb <8g/dL, or Hct <25% = no exercise)

n  If anemic, monitor HR, BP, and O2 sats n  If also volume depleted, could have orthostatic symptoms n  Hgb 8-10, light exercise permitted

¤  Neutropenia (<5,000 = no exercise) n  Higher risk for infection n  Don’t treat a patient if you are ill n  Avoid exercise in gyms or community places n  Handwashing!

¤  Thrombocytopenia (<20,000 = no exercise) n  Higher risk for bruising and bleeding n  Avoid high impact activities and closed pack joint activities n  20,000-50,000 light exercise permitted n  >50,000 resistance training permitted

(http://acutept.affiniscape.com/associations/11622/files/labvalues2.pdf)

Disease and Treatment Impairments by System

Neurologic

Neurologic impairments

¨  Disease ¤  Brain cancer ¤  Common location of metastases

or disease recurrence ¨  Surgery

¤  Stretched or cut nerves ¨  Radiation

¤  Changes to electrophysiology ¤  Fibrosis

¨  Chemotherapy ¤  Chemotherapy induced

peripheral neuropathy (CIPN) ¤  Vestibular toxicity

Neurologic-- Disease Related

¨  Metastases ¤  Brain ¤  Spinal Cord

¨  Locally advanced disease ¤  Peripheral Nerve

Cancer Type Common Neurologic Mets

Breast Brain Spinal fluid Brachial plexus

Prostate Brain Spinal fluid Sacral plexus

Lymphoma Spinal fluid Brain (rare)

Lung Brain Spinal fluid

Leukemia Spinal fluid Melanoma Brain (common)

(h;p://neurosurgery.mgh.harvard.edu/abta/mets.htm#PRIMARY_6)    

Ototoxicity and Vestibular Toxicity q Ototoxicity is associated with platinum compounds:

q cisplatin (Platinol®) q carboplatin (Paraplatin®) q oxaliplatin (Eloxatin®)

q Cisplatin q  loss  of hair cells in auditory > loss of hair cells in  

vestibular system (Sergi, 2003) q  Limited clinical or basic science research examining

vestibular toxicity

Who should be screened for CIPN? TAXANE CLASS: Paclitaxel (Taxol®) Docetaxel (Taxotere®) Abraxane™

INCIDENCE 60%* 50%* 71%*

USED TO TREAT Breast Lung Ovarian

VINCA ALKALOID CLASS:

Vincristine (Onkovin®) Vinorelbine (Navelbine®)

Not listed* 25%*

Leukemia Lymphoma Sarcoma (CHOP, MOPP)

PLATINUM COMPOUNDS:

Cisplatin (Platinol®) Carboplatin (Paraplatin®) Oxaliplatin (Eloxatin®)

Not listed* 4%* 74%*

Colon Lung Ovarian Sarcoma

*From  drug  prescribing  informaNon  sheets.  

Clinical Presentation of CIPN

Common impairments: q  paresthesias and/or dysaesthesias q  ↓ strength q  ↑vibration q  ↑ touch thresholds q  ↓or absent deep tendon reflexes q ↓ amplitude of nerve conduction studies q ↓ number of epidermal nerve fibers q  ↓ balance  

Clinical Presentation of CIPN

¨  Symptoms and impairments ¤ worse in patients with pre-existing peripheral neuropathy or

receiving combo of several neurotoxic drugs (Chauhdry, 1994)

¤  progress from distal to proximal ¤  variability of onset (ex. after 1st cycle?, 4th cycle?)

¨  Resolution of symptoms and impairments ¤  ‘Most patients symptoms improve, if not resolve completely

after chemotherapy is completed’ (lack evidence of this) ¤  1”/month, seems to be a good rule of thumb

Useful Clinical Screening Tools

q  CIPN q  “Do you have any numbness or tingling of your hands or

feet?” q  Look for special issue of Cancer that will focus on breast

cancer rehabilitation (CIPN guidelines) q  Balance

q  Romberg (document amount of sway or failure) q  Supported by force plate data (Wampler et al, 2007)

q  Single limb stance (Richardson, JK et al, 2001)

q  Gait observation q  Wide base of support, trendellenberg type pattern

Standardized Evaluation Tools

¨  CIPN ¤  Modified Total Neuropathy Scale (mTNS) (Gilchrist et al, 2009)

¤  Chemotherapy Induced Peripheral Neuropathy Assessment Tool (CIPNAT) (Tofthagen et al, 2011)

¤  Balance ¤  Fullerton Advanced Balance Scale (Rose, 2003; Wampler et al. 2007) ¤  Berg Balance Scale ¤  Tinetti ¤  Functional Reach

¨  Physical Performance ¤  Timed Up and Go (TUG) test (Wampler et al., 2007)

¤  Purdue Pegboard Test (Dougherty et al., 2004)

Medical Treatment/Prevention

¨  Efficacious treatments or preventative agents are limited ¤ Neuropathic pain

medications (ex. gabapentin) ¤ Nutraceuticals

n vitamin E n glutamine n glutathione

Physical Therapy Treatment

¨  Patient education ¨  Integrative balance

training ¨  Fine motor retraining ¨  Sensory reeducation ¨  Aerobic exercise?

Disease and Treatment Impairments by System

Musculoskeletal

Musculoskeletal impairments

¨  Disease ¤  Ex. osteosarcoma,

multiple myeloma ¤  Bone metastases

¨  Surgery ¤ Common part of tx with

osteosarcoma n  AMP vs. limb sparing

¨  Radiation and chemotherapy ¤ Minimal direct impact

Musculoskeletal impairments

¨  Arthralgias/myalgias ¤  Aromatase inhibitors (AIs)

¤  Examestane (Aromasin®) ¤  Anastrozole (Arimidex®) ¤  letrozole (Femara®)

¤  Selective Estrogen Receptor Modulators (SERMs) ¤  tamoxifen (Nolvadex®)

¨  Osteoporosis ¤  Premature menopause

¤  Chemotherapy ¤  Bioagents (AIs)

Musculoskeletal impairments

¨  Osteonecrosis—yellow flag ¤ Can occur with high dose steroids or with

biphosphonates (ex. Fosamax®) ¤ Post bone marrow transplant ¤ No pain à pain with weight-bearing à pain at rest ¤ Most commonly occurs near diaphysis of long bones

¨  Myopathies ¤ High dose prednisone (CHOP) ¤ Bioagents

n prostate canceràtestosterone blockers/inhibitors

Physical Therapy Treatment

¨  Post-surgical rehabilitation in primary bone cancers (often LE cancers) ¨  ROM and strengthening to improve gait ¨  Prosthesis training

¨  Post-surgical or post-radiation in vertebral body mets ¨  Body mechanics and spine protection education

¨  Myopathies ¨  Strengthening

¨  Osteoporosis ¨  Bone strengthening exercises

Yellow Flag--Strengthening

¨  Bone metastases in weight bearing bone ¤ >50% of cortex,

recommend avoid strengthening exercises

¤ 25-50% AROM, but avoid twisting and stretching

¤ 1-25% avoid lifting/straining

(Gerber L, Hicks J, Klaiman M, et al. Rehabilitation of the cancer patient In: Rosenberg S, ed. Cancer : Principles and Practice of Oncology. Philadelphia, Pa: Lippincott; 1997:2925-2956.)

Yellow Flag--Gait Training

¨  Bone metastases in a weight bearing bone ¤ > 50% of cortex

involved = TDWB, NWB

¤ 25-50%, PWB ¤ 0-25%, FWB

(Gerber L, Hicks J, Klaiman M, et al. Rehabilitation of the cancer patient In: Rosenberg S, ed. Cancer : Principles and Practice of Oncology. Philadelphia, Pa: Lippincott; 1997:2925-2956.)

Disease and Treatment Impairments by System

Lymphatic

Lymphatic impairments

¨  Disease ¤ Lymphoma

¨  Surgery ¤ SLN biopsy or lymph

node dissection

¨  Radiation ¤ Fibrosis

¨  Chemotherapy ¤ Minimal

Lymphatic System

¨  Lymphdema can affect UE, LE, chest wall, or head and neck

¨  Risk factors ¤ More invasive surgery ¤ Lymph node dissection vs. sentinel

node dissection vs. no nodes removed ¤ Radiation therapy ¤ Obesity ¤  Infection

Lymphatic System

¨  Incidence ¤ Wide range (5%-45%) ¤ Likely depends on how many risk factors are present ¤ Life-time risk of lymphedema for those patients who

have had lymph nodes removed

J Clin Oncol. 2010 Apr 1;28(10):1808 J Clin Oncol. 2009 Jan 20;27(3):390-7.

Lymphatic System

¨  Assessment ¤ Limb volume

n Water displacement –gold standard n Circumference with truncated cone

formula--estimates volume n Bioimpedence—reliability??

¤ Pitting edema àFibrosis n Stemmer’s sign

¤ Subjective complaints n  ‘heavy’, ‘tight’ n  ‘tingling’, ‘prickling’

General Strength Training

•  Those with STABLE lymphedema can safely strength train

–  PAL trial—breast cancer –  supervised àindependent

–  Should be cleared by MD for exercise AND receive lymphedema education

EXERCISE GUIDELINES ¤  Wear compressions sleeve and

glove during exercise ¤  Start with lowest weight and

progress SLOWLY (1#/week), only if no onset of signs or symptoms

¤  3 sets of 10, twice/week ¤  If miss more than 2 sessions,

then go back in weight and restart process

(Schmitz et al, 2009)

General Strength Training

¨  Those AT RISK for lymphedema can also strength train safely

¨  Same guidelines as the women with stable lymphedema (except no sleeve)

¨  PAL trial continuation (Schmitz, 2010)

•  For all women at risk for lymphedema n  BCRL onset was 11% (8 of 72) in weight lifting group and 17% (13 of

75) in the control group

•  Among women with 5 or more lymph nodes removed n  BCRL onset was 7% (3 of 45) in the weight lifting intervention group

and 22% (11 of 49) in the control group.

General Strength Training

¨  Precautions ¤ Monitor for signs/symptoms of lymphedema in patients

with > 1 lymph node removed and/or radiation therapy to lymph nodes

SIGNS AND SYMPTOMS OF LYMPHEDEMA Heaviness in the limb Jewelry, sleeves are fitting too tight Tightness of the skin Less mobility in joints Greater than 2 cm difference in circumference between affected and unaffected limb or 5-10% difference in volume (early lymphedema may not have measurable edema)

Physical Therapy Treatment

¨  Patient education

¤  prevention ¤  signs and symptoms of ¤ management of

symptoms

Physical Therapy Treatment

¤  Manual lymph drainage

¤  Compression n Wrapping n Custom fit

compression sleeves

Disease and Treatment Impairments by System

Cardiopulmonary

Cardiopulmonary impairments

¨  Disease ¤  Cardiac not common ¤  Pulmonary—Lung cancer #2 most common CA ¤  Pulmonary mets common

¨  Surgery ¤  Lobectomy common tx for lung CA

¨  Radiation ¤  Fibrosis of arteries ¤  Fibrosis of lungs

¨  Chemotherapy ¤  Cardiotoxicity ¤  Pulmonary toxicity

Pulmonary—chemotherapy related

Chemotherapeutic agents toxic to the lungs → Pulmonary Fibrosis:

¤ Bleomycin ¤ Mitomycin-C ¤ Cyclophosphomide ¤ Busulfan ¤ Nitrosurea

¤  Ginsberg & Comis. Semin. Oncol. 1982;9:34-51

Pulmonary--radiation related

Miller  et  al.    IJROBP.    2003:56:611  

RadiaNon  therapy  to  lungs    (for  primary  or  metastaNc  tumor)  

Who should be screened for cardiac toxicity?

Yeh & Bickford. JACC 53;2009:2231.

PT treatment—aerobic exercise

¨  Cardiac impairments ¤ Ejection fraction ¤ Monitor for symptoms of

CHF ¤ Monitor BP and HR

¨  Pulmonary impairments ¤ Pulmonary function tests

(PFT) ¤ Monitor O2 sats and for

shortness of breath

Red Flags in Acute Care

Red Flags

In patients with metastatic disease, these may be signs of spinal cord or nerve root compression and patients should seek immediate care from their oncologist

¨  Back pain that is accompanied by ¤ Acute change in strength or sensation that are symmetrical

and follow a dermatome/myotome pattern ¤ New onset of incontinence

¨  70% of SCC—thoracic (breast and lung) ¨  20% of SCC—lumbar (prostate, melanoma, GI)

Red Flags

These may be signs of cancer or cancer recurrence and patient should seek follow up with their oncologist

¨  Pain that is non-relenting ¤ Often worse at night ¤ Doesn’t seem to fit a musculoskeletal pattern ¤ Doesn’t respond to treatment

¨  Non-healing wounds over body part that had cancer

Red Flags www.topicsingeriatricrehabilitation.com

¨  Superior Vena Cava Syndrome (Morris, 2011)

¤ Caused by either tumor pressing against the vessel or blood clot

¤ ↓ cardiac output ¤ Slow onset ¤ Signs/symptoms

n Swelling in the face neck and upper thorax n  Jugular vein distention n  If not resolved can lead to severe cardiovascular

(tachycardia, hypotension), pulmonary (cough, dyspnea), or CNS impairments (HA, confusion, vision changes)

Red Flags www.topicsingeriatricrehabilitation.com

¨  Venothrombolic events (VTE) ¤ DVT or PE ¤ Cancer patients 4-7 times more likely to develop blood

clot ¤  Symptoms for LE DVT

n Swelling one or both legs n Pain n Warmth/redness

¤ Medical tests n Ultrasound n D-dimer n Chest CT

Red Flags www.topicsingeriatricrehabilitation.com

¨  PT implications (Morris, 2011)

¤  Increased risk for VTE IS NOT sufficient reason to withhold PT treatment n PTs should be aware of ↑ risk n Be vigilant for signs and symptoms n Carefully review medical records

¤ Educate patient/caregiver in proper use of compression stockings/compression pumps

¤ Ambulation is recommended as a treatment for VTE n AMB does not increase risk of progression or migration of

clot