CANCER

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
2nd 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

END