Danielle G.

Devilleres, PTRP
Definition
Pathologic process characterized by
dysregulated cell growth and spread
All tissue types have neoplastic potential
and can become cancerous. The ff. have
higher rates of malignancy:
Tissues distinguished by rapid cell turnover (GI
mucosa)
Tissues with high hormone sensitivity (breast,
prostate)
Tissues with regular exposure to environmental
mutagens (lung, skin)
Definition
Differentiation
Process by which normal cells undergo physical
and structural changes as they develop to form
different tissues of the body
In malignant cells, differentiation is altered and
may be lost completely so that the malignant cell
may not be recognizable in relationship to its
parent cell
When tumor has completely lost identity, it is
considered to be undifferentiated (aplastic)
The less differentiated a tumor becomes, the
faster the metastasis
Definition
Dysplasia
General category which indicates a
disorganization of cells in which an adult cell
varies from its normal size, shape or
organization
Definition
Metaplasia
First level of dysplasia (early dysplasia)
Reversible and benign but abnormal change
in which one adult cell changes from one
type to another
Definition
Anaplasia
Most advance form of metaplasia and is
characteristic of malignant cells only
Definition
Hyperplasia
Increase in the number of cells in tissue,
resulting in increased tissue mass
Can be normal
Neoplastic Hyperplasia increase in cell
mass because of tumor formation and is
abnormal
Definition
Tumors
Or neoplasms
Abnormal growths of tissue that serve no
useful purpose and may harm the host
organism by competing for vital blood supply
and nutrients
May be benign or malignant
May be primary or secondary
Definition
Tumors
Benign usually considered harmless and
does not spread to or invade other tissues
Malignant the more dangerous kind

Definition
Tumors
Primary tumor
Cells that are normally local to the given
structure
Secondary tumor
Arises from cells that have metastasized from
another part of the body
Epidemiology
Prevalent condition that becomes
increasingly common with advanced age
Over 1,300,000 new cancers were
diagnosed within the USA in 2004
Over 500,000 people died of CA
CA causes 1 in 4 deaths
2
nd
to heart disease as the leading
cause of mortality in developed
countries

Epidemiology
Roughly 76% of all CA occur in patients 55
years of age and older
Men > female (excluding basal and
squamous cell cancers of the skin)
Lifetime risk in men: 1 in 2
Lifetime risk in women: 1 in 3
In 2004, the American Cancer Society
estimated that 180,000 CA deaths are
related to obesity, physical inactivity, and
other lifestyle factors
Epidemiology
Only 5-10% of CA are hereditary and
directly related to aberrantly expressed
or regulated genes
MC CA showing familial pattern include
prostate, breast, ovarian and colon
cancer
Epidemiology
Men = MC CA are predicted to be CA of
prostate, lung and bronchus, and
colon/rectum
Women = CA of breast, lung and
bronchus, and colon/rectum
Without gender bias = lung and
bronchus
Demographic Disparities in CA
African Americans have the highest
mortality asso. c CA of lungs, breast,
prostate, and cervix among all racial
groups in the USA
When African Americans are compared
with whites, CA death rates are 40%
higher in males and 20% higher in
females
Demographic Disparities in CA
A report in 2003 by the Institute of
Medicine identified poverty as the most
critical overall factor affecting health and
longevity
The 5-year survival rate is over 10%
higher for individuals living in affluent
census tracts
Etiology
Endogenous (genetic)
Exogenous (environmental or external)
Most CA develop as a result of multiple
environmental, viral and genetic factors
working together to disrupt immune system
along with failure of an aging immune
system to recognize and scavenge cells that
have become less differentiated
Etiology
Carcinogens
Etiologic agent capable of initiating the
malignant transformation of a cell
Viruses
HIV
Chemical Agents
Tar, soot, asphalt, dyes, hydrocarbons, oils,
nickel or arsenics
Etiology
Physical agents
Radiation or asbestos
Drugs
Cancer chemotherapeutic agents are in
themselves carcinogenic
Cytotoxic drugs including steroids (decrease
antibody production and destroy circulating
lymphocytes
Etiology
Hormones
Have been linked to tumor development and
growth (estrogen = stimulating the growth of
the endometrial lining, which overtime
becomes anaplastic)
Excessive alcohol
Associated with cancer of mouth, pharynx,
larynx, esophagus, pancreas
Etiology
Diet as an influence to the risk of CA
The National Research Council
recommends a diet in total saturated fat,
a high in complex carbohydrates and
fiber, low in sugars and moderate in
protein especially animal proteins.
Etiology
High intake of fats = linked to breast, colon
and prostate CA
Low intake of fruits, vegetables, complex
carbs and fiber = colon, larynx, esophagus,
prostate, bladder, stomach and lungs
Salt-cured foods = may influence CA of
esophagus and stomach
Obesity = linked to CA of breast, colon,
uterus, and gallbladder
Psychological factors = chronic stress
Risk Factors
Pathophysiology
Metastasis = transfer of diseased cells
of one organ to another or part of
another not directly connected with it
Because cells are not encapsulated, it is
easy for CA cells to invade other tissues
and extend themselves rapidly via
lymphatic and blood circulatory systems
Pathophysiology
Lymph secondary growths of tumor cells
are often caught in the lymph filter, the
lymph node
In the blood = by invasion, tumor cells
enter the blood vessels and are carried
to organs where the venous blood
passes through the capillary bed
Classification
Classification of Neoplasm
Epithelial
Covers all external body surfaces and lines all
internal spaces and cavities
Cacinoma
From glandular epithelium Adenocarcinoma


Classification
Classification of Neoplasm
Connective Tissue
Elastic fibrous and collagenous tissues (bone,
cartilage, etc.)
Sarcomas
If from nerve tissue, CA is named for the type
of cell involved (e.g. astrocytoma = astrocytes)



Classification
Classification of Neoplasm
Lymphoid tissues
Lymphomas

Hematopoietic
Leukemia, multiple myeloma, myelodysplasia


Classification
Staging and Grading
Stage 0 Carcinoma in situ (premalignant,
pre invasive)
Stage I Early stage; local cancer
Stage II Increased risk of spread because
of tumor size
Stage III Local cancer has spread but may
not be disseminated to distant regions
Stage IV Cancer has spread and
disseminated to distant sites
Prognosis
It is clear that some tumors notably
esophagus, stomach, hepatic, pancreas,
lungs, nervous system and leukemias/
myeloma have a low five year survival
rate
Others breast, larynx, prostate, and
kidney, among others have a much
better prognosis.

Survivorship
Cancer 5 yr survival rates are
increasingly due to:
Successful early detection efforts
Improved multimodality treatments
Expansion of chemotherapeutics available
62% of adult and 77% of pediatric CA
pxs live beyond 5 yrs (needs to be
updated)
Survivorship
Prevalence will increase due to the ff
factors:
Aging of the population will produce an increase
in the incidence of age-related CA such as
colon, breast, and prostate CA
Early detection efforts are being aggressively
funded and implemented. We can expect that
more and more CA will be identified at early,
curable stages.
Clinical research continues to refine strategies
for delivering established and novel anticancer
therapies

Clinical Manifestations
Clinical manifestations
The therapist is most likely to observe
signs and symptoms affecting one of the
ff. systems:
Integumentary
Pulmonary
Neurologic
Musculoskeletal
Hepatic
Clinical manifestations
Proximal Muscle Weakness
If idiopathic may be an early sign of cancer
Known as carcinomatous neuromyopathy
May occur secondary to hypercalcemia
indirect effect on bone
Clinical manifestations
Pain
Rarely an early warning
Night pain that is constant and intense = red
flag symptom of cancer
Result of destruction of tissue or pressure
on tissue
Clinical manifestations
Change in One or More Deep Tendon
Reflexes
May be hyperreflexive or hyporeflexive,
depending on which level the tumor has
impinged the reflex arc
Clinical manifestations
Integumentary
Often present as asymmetrical, firm, skin-
colored, red, purple, or blue nodules near
the primary tumor
Scalp = alopecia neoplastica
Clinical manifestations
Pulmonary
Pleural pain and dyspnea = first 2 symptoms
Clinical manifestations
Neurologic manifestations
Headachev(30-50%; usually bioccipital or
bifrontal)
Personality change
Seizures (1/3 of persons with metastatic
brain tumor)
Papilledema (edema and hyperemia of the
optic disc) may be the first sign of
intracranial tumors
CTS
Clinical manifestations
Neurologic manifestations
Nerve and Cord compression
Clinical manifestations
Musculoskeletal
Bone pain
Fracture
Back pain

Hepatic Manifestations
Diagnosis
Tissue Biopsy
Taking of a tissue sample
An important diagnostic tool in the study of
tumors
Tumor Markers
Substances produced and secreted by tumor
cells
May be found in the blood serum
The level of tumor markers is not a diagnostic
tool itself but can signal malignancies and the
extent of the disease
Diagnosis
MRI
Procedure of choice to evaluate the epidural
space and SC
CT Scan
If there is absolute contraindication to MRI
Best for evaluation of spinal roots
Electromyography
When nerves are involved
Medical and Surgical
Management
Complementary and Alternative
Medicine
Acupunture
Hypnosis
Mind-body techinques
Massage
Music
Yoga
Meditation, etc.
Medical and Surgical
Management
Surgery
Once a mainstay in CA Tx
Now used most often in combination with
other therapies
May be used curatively for tumor biopsy, and
tumor removal
May be used palliatively to relieve pain,
correct obstruction, or alleviate pressure

Medical and Surgical
Management
Radiation Therapy
Used to destroy the dividing cancer cells by
destroying hydrogen bonds between DNA
strands within CA cells, while damaging
resting normal cells as little as possible
More useful for treatment of localized
lesions
Medical and Surgical
Management
Chemotherapy
Particularly useful in the treatment of
widespread or metastatic disease
Used in eradicating residual disease
Disadvantage: cancer cells may become
resistant to the medication (that is why a
combination of chemicals must be
administered)
Medical and Surgical
Management
Biotherapy
Immunotherapy or immune-based therapy
Relies on biologic response modifiers to
change or modify the relationship between
the tumor and host by strengthening the
hosts biological response to tumor cells
E.g. bone marrow or stem cell
transplantation
Medical and Surgical
Management
Antiangiogenic Therapy
Pathologic angiogenesis process by which
a malignant tumor develops new vessels
and is the primary means by which CA cells
spread
Blocks the general process of tumor growth
by cutting off their blood supply rather than
on the destruction of an already formed
cancerous mass
Tumor cells cannot survive without oxygen
and other nutrients transported by the blood
Medical and Surgical
Management
Hormonal Therapy
Used for certain types of CA shown to be
affected by specific hormones
E.g. tamoxifen (antiestrogen hormone
agent) is used in breast CA to block
estrogen receptors in breast tumor cells that
require estrogen to survive
Medical and Surgical
Management
Pharmacological Management
NSAIDS
Act on the peripheral neurotransmitters
Narcotic Analgesics
Bind to opiate receptors and act on the CNS
pathways
Adjuvant Analgesics
Enhance the narcotic analgesics effect or act
independently and provide analgesia
Intraspinal Opiates
Complications
Septic Shock
Spinal Cord Compression
Hypercalcemia
Superior Vena Cava Syndrome
(Obstruction)
Complications
Side effects of CA Treatment
Refer to the table found in Pathology
Implications for the Physical Therapist by
Goodman and Fuller

PT Assessment
Observation
Inspection
Auscultation
Percussion
Palpation
Special tests
PT Management
Cancer Rehabilitation
Addresses physical impairments related to
tumor effects or to cancer treatment
The fact that any tissue can develop cancer
means that cancer rehab must address all
body parts and systems
Extends far beyond efforts to decelerate the
functional decline in patients with metastatic
disease
PT Management
General Strategies
Exercise
Aerobic conditioning
Resistive exercise
Rehabilitation of cardiopulmonary dysfunction
Flexibility exercises
Lymphedema Management
PT Management
Specific CA populations
Breast CA
Head and Neck CA
For Further Reading!
Please read!
Physical Medicine and Rehabilitation by
Braddom, chapter on Cancer Rehabilitation:
Rehabilitation Strategies


For Further Reading!
Pathology Implications for the Physical
Therapist by Goodman and Fuller: Chapter
on Oncology, Special implications for the
therapist, most specifically the ff:
Table on Side effects of CA Treatment
Table on Common Physiological Effects and
uses of Physical Agents and modalities in
people with CA
Box on Risks for modality use based on stage
of medical management
Paragraph on Cancer, Physical Activity and
Exercise Training