Cancer patients may experience brain injury due to primary brain tumors, metastatic brain tumors, radiation related effects, and leptomeningeal disease. This chapter focuses on the factors unique to the rehabilitation of patients with brain tumors. Metastatic brain tumors are the most common intracranial tumors in adults. The most common primary cancers to metastasize to the brain include lung cancer, breast cancer, melanoma, and renal cell carcinoma. As the management of these cancers has evolved (including the use of immunotherapy), their systemic manifestations have shown more response to treatment. Brain cancer patients benefit from rehabilitation and improve at similar rates to noncancer brain injury patients. Cancer treatments including radiation and chemotherapy can contribute to functional impairments. The Stupp Regimen is the most commonly used initial treatment, which includes radiation and temozolomide chemotherapy. Many glioma patients are receiving the Stupp Regimen while receiving rehabilitation.

Cancer patients with symptoms referable to the spine present a unique imaging challenge. Metastatic disease can involve any portion of the spine, with the osseous spine most commonly involved, often with concomitant epidural disease. The purpose of this chapter is to impart an understanding of fundamental spine imaging anatomy to clinicians as well as to advance their knowledge of the most common lesions involving the spine in cancer patients. It discusses the choice of optimal imaging modalities for evaluation of such lesions. The chapter then reviews lesions that occur directly or indirectly from cancer treatment and that may mimic recurrent or metastatic disease. The diagnosis and treatment of spine metastasis and related processes in the cancer patient require a multidisciplinary approach and with the proper use of imaging will lead to earlier diagnosis, better management options, and ultimately improved neurological, functional, and potentially oncologic outcomes.

This chapter addresses nonpharmacologic pain approaches in cancer survivors. It is important to note that effective pain management usually involves a multipronged approach that may include over-the-counter or prescription medications, injections, and potentially more invasive procedures such as radiation therapy and surgery. It describes those therapies that are commonly prescribed and have some evidence to suggest that they may be useful in reducing pain symptoms in cancer survivors. Most physical modalities have not been studied extensively in cancer patients due to the concern of exacerbating an underlying malignancy. Those that are generally believed to be safe include cryotherapy (e.g., the use of cold packs), biofeedback, iontophoresis, and transcutaneous electrical nerve stimulation, and massage. Pharmacologic management certainly has an important role, as do nonpharmacologic measures. While there is certainly some evidence to suggest that the nonpharmacologic interventions, especially therapeutic exercise can be quite helpful to cancer survivors.

This chapter provides a brief description on the principles of neurosurgery in cancer. Metastatic spinal tumors are a major source of morbidity in cancer patients. The overriding goals for treatment are palliative in order to improve or maintain neurological status, provide spinal stability, and achieve local, durable tumor control. The principle treatments for spinal tumors are radiation and/or surgery. Recent advances in surgical and radiation techniques, such as image-guided intensity modulated radiation therapy, have made treatment of spine metastases safer and more effective. Additionally, the development of newer chemotherapy, hormonal, and immunotherapy treatments has led to improved systemic control of many types of cancers. Rehabilitative medicine plays a large role in achieving meaningful palliation and improved quality of life for patients with spinal tumors. A fundamental understanding of treatment decisions and outcomes will help in the assessment of cancer patients.

Genitourinary cancers include cancers of the urinary tract (prostate, bladder, urethra, and kidney) and the male genital tract (testis and penis). This chapter briefly discusses the epidemiology, diagnosis, treatment, and the rehab perspective of prostate cancer, carcinoma of the bladder and the upper urogenital tract, testis cancer, renal cell carcinoma, and penile cancer. Patients with prostate cancer now live longer with their metastatic disease and pose greater challenges for rehabilitation physicians. Bladder cancer most commonly presents with total (present throughout the length of micturition) gross painless hematuria. Radical orchiectomy through the inguinal approach is required for diagnosis and staging of testis cancer. Carcinoma of the penis comprises less than 1% of all malignancies in men. Predisposing factors include the presence of foreskin, and human papillomavirus exposure. The treatment recommendation for this rare disease is by stage. Penile conservation surgical techniques can include laser, Mohs surgery, and partial penectomy when feasible.

Head and neck cancer is a group of cancers that are linked by a shared anatomical space. The anatomical space includes structures that are critical for speech, swallowing, breathing, vision, and hearing. It has long been recognized that head and neck cancer and its therapy adversely impact function. Rehabilitation in the head and neck cancer population is often challenging: it requires the coordinated care of experienced clinicians spanning a wide array of specialties. This chapter begins with a discussion of the socioeconomic considerations that are paramount in treating head and neck cancer patients. This is followed by a broad overview of the epidemiology, etiology, pathology, and staging of head and neck cancers. The chapter then discusses the specific modalities of therapy used in the treatment of head and neck cancer with an emphasis on the associated toxicities. Finally, it discusses site-specific considerations that impact functional outcomes.

Breast cancer is the most common cause of cancer among women in the United States, with approximately 260,000 new cases of breast cancer and more than 40,000 breast cancer related deaths anticipated in 2018. Fortunately, an improved understanding of the importance of tumor biology has led to significant advances in the management of breast cancer in both the adjuvant and metastatic settings, as well as an improvement in patient morbidity and breast cancer specific survival. When an abnormality is detected on screening, breast cancer diagnosis and management typically require a multidisciplinary approach that incorporates some combination of radiology, surgery, pathology, medical oncology, radiation oncology, and/or specialists in rehabilitation. This chapter provides an overview of the principles of using systemic therapy (i.e., medications that are absorbed and carried throughout the bloodstream, such as chemotherapy and endocrine therapy) for the management of breast cancer.

Renal function impairment can affect a cancer patient’s functional capacity and mobility and thus limit participation in a rehabilitation program. This chapter discusses how acute or chronic declines in renal function can affect cancer patients’ ability to participate in rehabilitation programs and to provide information on how to optimize this very important aspect of their care. Acute and chronic kidney disease (CKD) can hinder a patient’s mental status and functional status due to electrolyte derangements. Additionally, CKD can result in anemia and mineral bone disease, which can affect a patient’s capacity to exercise and increase the risk of fractures. Patients on dialysis benefit from rehabilitation, and additional research should be fueled into structuring home exercise programs. Careful selection of pain medications that are renally dosed can provide temporary relief for patients with kidney disease and allow them to participate in rehabilitation.

Sarcomas constitute less than 1% of all cancers diagnosed annually, with ~15,000 people estimated to develop a sarcoma in 2018 in the United States. Approximately half of the patients with newly diagnosed sarcoma will die of this disease. This chapter provides a brief description on evaluation and management of sarcomas. The principles of sarcoma management are consistent between patients, and are highlighted in this chapter. New and advancing modalities of care are improving survival for patients with sarcomas of all forms. Surgical approaches have benefitted from improvements in tumor imaging, which now make limb-sparing surgeries routine. Improved techniques in tissue transfer make reconstruction of very large tissue defects feasible. Intensity modulated radiation therapy and proton irradiation are improving local control of tumors. With advances in local and systemic therapy the burden of disease becomes smaller over time, making the rehabilitation for such patients easier as well.