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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.
The peripheral nervous system plexuses include the cervical, brachial, lumbar, sacral, and coccygeal plexuses; of these, the lumbar and sacral plexuses typically are discussed as a single entity, the lumbosacral (LS) plexus. Through the brachial and LS plexuses, nerve fibers pass to all four extremities and the shoulder and pelvic girdles. Consequently, patients with neoplastic plexopathies have significantly impaired quality of life. This chapter begins with a review of plexus anatomy and lesion classification, followed by the various types of tumor classification utilized. The World Health Organization categorizes peripheral nerve tumors into four groups: neurofibromas, schwannomas, perineuriomas, and malignant neural sheath tumors. The remainder of the chapter focuses on clinically relevant information, including the differential diagnosis of neoplastic plexopathies, their evaluation and management, and prognostication. Throughout these sections, specific neoplastic disorders and treatment complication (e.g., radiation plexopathy) will be discussed. The chapter ends with prognostication and future perspectives.
In order to discuss sexual dysfunction, a primer on human sexuality is essential. Human sexuality is not a static concept, but one that is dynamic and multidimensional. It is a product of interpersonal, biological, psychological, and cultural mechanisms that help formulate an individual’s personal view of sexuality, something Andersen and colleagues have termed a sexual self schema, a way to understand and identify an individual’s personal view of his or her own sexuality. This chapter reviews the issue of sexual dysfunction and discusses evaluation strategies, therapeutic options, and sexual rehabilitation. Since the etiology of sexual complaints in both men and women is a complex phenomenon and situational issues are a fundamental part of the diagnosis, a comprehensive treatment regimen would not be complete without appropriate sexual counseling and therapy. Consultants may include oncologists, social service providers, nutritionists, exercise therapists, and psychiatrists.
Nutrition is an integral component in the management of patients with cancer. A nutrition screening is essential to identify risk of malnutrition. Screening is followed by a nutrition assessment, which is the first step of the nutritional care process, and is used to make a nutrition diagnosis, determine appropriate intervention, and monitor and evaluate nutritional care outcomes. Nutritional management of the patient with cancer includes oral dietary therapy, enteral nutrition, and parenteral nutrition. The concurrent use of supplements, especially highdose antioxidants or complex botanical agents, during chemotherapy or radiation therapy can be problematic due to drug supplement interaction. Symptoms that interfere with eating include anorexia, nausea, vomiting, diarrhea, constipation, mouth sores, trouble with swallowing, and pain. Poor nutritional status can result in a decreased quality of life, functional status, and response to therapy. Nutrition screening and assessment of cancer patients can identify those at risk for malnutrition.
This book provides a state-of-the-art overview of the principles of cancer care and best practices for restoring function and quality of life to cancer survivors. Cancer rehabilitation interventions including physical, occupational, or speech therapy; exercise training; psychosocial and cognitive interventions; and physician-directed diagnostic imaging, injections, and pharmacologic symptom management have the potential to treat many impairments from cancer treatment, thereby improving functioning and quality of life. Multimodal rehabilitation interventions have also been shown to improve return to work compared to usual care. The chapters of the book review the latest evidence about which interventions should be used to treat specific impairments thereby constituting the most comprehensive and up-to-date reference on this topic. The book is organized into nine parts comprising 90 chapters. Part one presents history of cancer rehabilitation, cancer statistics, and principles of cancer care. Part two discusses various cancer types, which includes breast cancer, gastrointestinal malignancies, head and neck cancer, pediatric cancers, and primary bone tumors and their assessment and management. Parts three through six describe cancer pain, medical complications, neurological and neuromuscular complications, and musculoskeletal complications of cancer such as radiculopathy, plexopathy, autonomic dysfunction, and bone metastases and their management. Part seven discusses general topics related to cancer rehabilitation, which includes physical and occupational therapy, therapeutic modalities in cancer, therapeutic exercise in cancer, nutritional care of the cancer patient, sexuality issues, and distress and other psychiatric considerations in cancer rehabilitation. Part eight thoroughly explores the identification, evaluation, and treatment of specific impairments and disabilities that result from cancer and the treatment of cancer such as balance and gait dysfunction, cancer related fatigue, radiation fibrosis syndrome, and bowel dysfunction. Part nine discusses functional measurement in patients with cancer, health maintenance and screening in cancer survivors, research issues, barriers to accessing cancer rehabilitation, and building a cancer rehabilitation program.
This chapter discusses dermatological toxicities of anticancer therapies and mainly focuses on two adverse events: hand–foot syndrome (HFS) and paronychia. HFS is a well-documented reversible adverse effect of many chemotherapeutic therapies, causing a wide variety of cutaneous symptoms ranging from erythema, dysesthesia, pain, and desquamation of the palms and soles to impairing daily activities of living. The standard approach used in the management of HFS is treatment interruption or dose modification, with symptom improvement reported within 1 to 2 weeks. Paronychia is the inflammation of the nail folds, jeopardizing the nail fold barrier and potentially exposing the nail matrix to damage. Paronychia is also an adverse effect of chemotherapeutic agents. The known causes of acute paronychia prior to the introduction of epidermal growth factor receptor (EGFR) inhibitors included staphylococci, streptococci, and pseudomonas, whereas, Candida albicans was frequently associated with chronic paronychia, with diabetes mellitus being a predisposing factor.
Patients with head and neck malignancy may present with a palpable mass or nonspecific symptoms to their physician. This chapter provides a brief description on principles of head and neck imaging in cancer. The high metabolic uptake of head and neck tumors makes positron emission tomography essential in the staging and surveillance of disease. Cross-sectional imaging with computerized tomography (CT) or magnetic resonance imaging (MRI) should be performed with contrast. When performing CT, attention to detail in the oral cavity to minimize metal artifact and delineate mucosal surfaces with puff cheek maneuver should routinely be done. Para-axial thin sections of the larynx with thin sections should be routine for laryngeal imaging to assess the anterior commissure and paraglottic spaces. As MRI exams are lengthy and less well tolerated by patients, protocols should be designed to tailor sequences to address the clinical query.
This chapter briefly discusses the principles of orthopedic surgery in cancer. The musculoskeletal manifestations of cancer are far reaching, and have broad implications for the patient’s prognosis and function. Primary tumors are typically managed with curative surgical intent, in the form of limb salvage surgery or amputation. Secondary tumors of bone are treated with palliative intent, which most often requires stabilization of the bone without removing the entirety of the tumor. The role of the orthopedic oncologist is primarily twofold: surgically eradicate cancer from soft tissue and/or bone, and to stabilize or reconstruct the resulting defects, optimizing function and quality of life. The orthopedic oncologist is often called upon to biopsy to establish a diagnosis and oversee the patient’s musculoskeletal care such as directing the timing of radiation plans or providing activity guidelines. The chapter reviews the surgical principles of treating both primary and secondary musculoskeletal malignancies in the extremities.
This chapter provides a brief description on principles of breast reconstruction in cancer. Breast cancer will impact one in eight women over the course of their lifetime. While breast conserving therapy is a mainstay of surgical treatment with outcomes equivalent to mastectomy in many cases, some women require or elect to have mastectomy to treat their cancer or high-risk state. Breast reconstruction is an essential aspect of the overall postmastectomy treatment, with important psychosocial impacts on patient well-being, as the reconstruction is an attempt to improve their outward appearance, their sense of femininity, and ultimately, their self-esteem. Postmastectomy reconstruction can be categorized into three modalities: implant-based reconstruction, autologous tissue-based reconstruction utilizing the patient’s own tissue, or a combination of implant and autologous-based reconstruction. Immediate postmastectomy reconstruction is currently considered the standard of care in breast reconstruction. Breast reconstruction has a positive impact on postmastectomy physical and mental quality of life.
Neuropathic pain is defined by the International Association for the Study of Pain as “pain initiated or caused by a primary lesion or dysfunction of the nervous system”. Neuropathic pain is initiated or caused by a primary lesion or dysfunction of the nervous system. Its pathophysiology is explained through various immune, cell receptor, and cell signaling modalities. The medications commonly used in the treatment of neuropathic pain include tricyclic antidepressants, anticonvulsants, antiarrhythmics, opioid analgesics, N-methyl-D-aspartate antagonists, topical medications, and certain drugs that mimic the γ-aminobutyric acid receptor. Many patients with neuropathic pain do not achieve satisfactory pain relief with medications alone. Neuromodulation therapy is an expanding field; it is used to treat these various neuropathic conditions refractory to pharmacologic interventions, such as Parkinson’s disease, dystonia, obsessive compulsive disorder, refractory pain, and complex regional pain syndrome.
Melanoma has traditionally been a challenging disease to manage due to a lack of effective therapies for advanced disease. Fortunately, recent advances in our understanding of the molecular pathways underlying melanoma pathogenesis and of tumor immunology have led to unprecedented advances in targeted and immunological therapies that have dramatically improved patient outcomes. This chapter serves as a practical guide for the nononcologist and provides updated information on the epidemiology, prevention, staging, biology, and management of melanoma. The introduction of immune checkpoint inhibitors and targeted agents has dramatically improved survival for patients with advanced melanoma. Novel immune checkpoint molecules such as CD40, CD137, OX40, and LAG-3, are already under investigation in early phase I studies. With a growing number of treatment options, continued efforts to find the optimal combination and sequence of therapies will be important.
This chapter provides a brief description on the principles of neoplasia. The ability to study cancer genomics has been enhanced exponentially as a result of innovative technologies used to sequence DNA and ribonucleic acid (RNA). The chapter reviews current models and mechanisms of oncogenesis and the basic principles of next-generation sequencing technology, highlights the classic mutations and syndromes, and reviews newer therapeutic tools, namely in the field of adoptive T-cell immunotherapy. Due to limitations in space and the complexity of the subject matter and the many excellent textbooks and review articles that are available for each topic, the chapter highlights the most important principles and their impact on clinical medicine while referring the interested reader to comprehensive reviews of the pioneering work. The chapter highlights the basic principles of the next-generation sequencing and illustrates their application as it relates to our understanding of current models of oncogenesis.
This chapter provides a brief description on the principles of breast surgery. Modern breast surgery practice began in the late 1890s with the work of Dr. William S. Halsted. In the years since, the art of breast surgery has been a process in evolution, searching for a balance between the safest oncologic procedures with the least morbid results. And while multimodality therapy is increasingly being utilized, breast cancer remains largely a surgical disease. The chapter covers the basic principles of breast surgery, focusing on the current concepts of screening, preoperative diagnosis, staging, and modern surgical management of the breast and axilla. The goal of breast cancer screening is to facilitate early diagnosis and decrease breast cancer mortality. Individual screening recommendations are tailored according to a woman’s risk and breast density. The backbone of routine breast cancer screening includes clinical breast exam and mammography.
Radiation fibrosis (RF) is the term used to describe the progressive tissue sclerosis and dysfunction that occurs in response to radiation. Radiation fibrosis syndrome (RFS) defines the myriad clinical manifestations of progressive fibrotic sclerosis that can result from radiation therapy (RT). This chapter discusses the neuromuscular and musculoskeletal impairments that result from RT. It primarily concerns the late effects of radiation, the reader should note that patients treated for cancer rarely receive radiation in isolation and that surgery, chemotherapy, and degenerative disorders associated with aging and other processes may significantly contribute to morbidity in a patient. While the various complications of RFS are usually treatable, they require vigilance on part of the clinician and patient. An understanding of the basic pathophysiology of progressive fibrotic tissue sclerosis that results from radiation treatment, and how RF manifests clinically, will allow clinician to effectively evaluate and treat the various disorders that comprise RFS.
Gastrointestinal cancers, defined as those occurring in the esophagus, stomach, colon, or rectum, are among the most common forms of cancers occurring worldwide. The incidence of these cancers amounts to millions of individuals each year. When considered as a whole, these cancers have a higher prevalence than breast and lung cancers combined. Although these cancers are often group together, their risk factors, incidence, prevalence, and prognosis vary considerably. This chapter provides an overview of the more common types of gastrointestinal malignancies, focusing on their risk factors, diagnostic workup, and treatment options. Gastrointestinal cancers are treated by utilizing a multidisciplinary approach often including surgery, chemotherapy, and radiation depending upon stage and location. Screening programs in colorectal cancer have resulted in earlier detection of disease while advances in surgical techniques and medical and radiation therapies have resulted in improved outcomes in all gastrointestinal cancers.
Cancer pain can be classified into two broad categories: nociceptive pain or pain caused by damage or injury to body tissues and neuropathic pain or pain caused by damage or injury to nerves. Nociceptive pain can be further subdivided into somatic, which is usually well localized to the area of tissue damage, and visceral, which arises from the stretching or irritation of the hollow organs and is poorly localized. This chapter elucidates the pathophysiology and clinical presentation of visceral pain as it relates to the cancer patient. For those patients suffering from cancer related visceral pain, treatment options include pharmacologic, manual, interventional, and complementary/alternative medicine techniques. Psychosocial support should also be an integral part of any treatment program. The ultimate outcome of pain management in individuals with cancer is to relieve suffering and enable such individuals the best possible quality of life.
Neuromuscular complications in patients with cancer are common and they meaningfully affect function and quality of life. Recognition of specific processes is necessary for appropriate diagnosis and intervention. Complications can occur as a direct result of the underlying malignancy, complications of therapy, paraneoplastic effects, indirect effects of chronic illness, infection, or unrelated underlying medical conditions. Careful clinical examination and electrodiagnostic studies are central to accurate diagnosis and characterization of neuropathy. Mononeuropathy affects a single named nerve, most commonly by nerve compression or entrapment. Polyneuropathy, typically refers to a more generalized or systemic process. Mononeuropathy (mononeuritis) multiplex is a distinct pattern of multiple evolving mononeuropathies and is produced by several processes. The chapter discusses chemotherapy-induced peripheral neuropathy, neuropathy associated with monoclonal gammopathies and lymphoproliferative disorders, neuropathies associated with monoclonal gammopathies or lymphoproliferative syndromes, neuropathies associated with myeloma and nonmalignant immunoglobulin G or immunoglobulin A monoclonal gammopathies, and amyloid neuropathy.
Pulmonary disease and its complications are prevalent in the general population and are the third leading cause of death in the United States. Primary lung cancer is the leading cause of cancer death in men and women in the United States. Since the lungs are one of the primary sites of metastatic disease, morbidity caused by the secondary metastases to the lungs is also common. Further injury to the lungs may stem from the effects of treatment, including surgery, radiation therapy, chemotherapy, and from complications such as pneumonia and pulmonary embolism. Maintaining good pulmonary toilet practices, preserving overall conditioning, and focusing on strengthening and compensatory exercises will allow patients to maintain their capacity despite their condition and its complications. This chapter provides a brief description on metastatic disease, restrictive lung conditions, radiation pneumonitis, chemotherapy-induced lung injury, obstructive lung disease in cancer patients, pulmonary vascular disease, and rehabilitation treatment options.
Aromatase inhibitors are a class of medications that are now commonly used as adjuvant endocrine therapy for estrogen receptor positive (ER+) breast cancer. Both endogenous and exogenous estrogens stimulate breast epithelial cell mitosis. Thus, increased exposure leads to a higher number of cell divisions and consequently increased chance of random genetic errors. Currently, there are three aromatase inhibitors being used in the United States: anastrozole (Arimidex, AstraZeneca), exemestane (Aromasin, Pfizer), and letrozole (Femara, Novartis). Endocrine therapy has proved to be significant in reducing relapses in ER+ breast cancer patients. ER+ breast cancer patients are at risk for recurrences for more than 5 years after diagnosis. The incidence of aromatase inhibitor induced musculoskeletal symptoms (AIMSS) is likely quite common. While earlier studies pointed to a lower incidence, more recent studies point to a frequency as high as 50% to 82%. It may be a common reason for cessation of aromatase inhibitors.
Cancer can affect the autonomic nervous system in a variety of ways: direct tumor compression or infiltration, treatment effects (irradiation, chemotherapy), indirect effects (e.g., malabsorption, malnutrition, organ failure, and metabolic abnormalities), and paraneoplastic/autoimmune effects. This chapter focuses on a diagnostic approach and treatment of cancer patients with dysautonomia, with an emphasis on immune-mediated autonomic dysfunction, a rare but potentially highly treatable cause of dysautonomia. Autonomic dysfunction can be divided into nonneurogenic (medical) and neurogenic (primary or secondary) causes. Orthostatic hypotension is a cardinal symptom of dysautonomia. The autonomic testing battery includes sudomotor, vasomotor, and cardiovagal function testing and defines the severity and extent of dysautonomia. Conditions encountered in the cancer setting that are associated with autonomic dysfunction include Lambert-Eaton Myasthenic Syndrome, anti-Hu antibody syndrome, collapsin response-mediator protein 5, subacute autonomic neuropathy, neuromyotonia (Isaacs’ syndrome), and intestinal pseudo-obstruction. The chapter describes various pharmacologic and nonpharmacologic therapies for treatment of orthostatic hypotension.
While the entire discipline was founded on the management of serious toxicity associated with chemotherapy, medical oncology now encompasses newer treatment paradigms, including molecularly targeted agents and immunotherapy, which are widely used in clinical practice. The longer survival of patients with cancer has led to an increase in the chronic long-term toxicities associated with treatment. The entire field is increasingly focused on the problems of “cancer survivors” and we are likely to see an expanding role for rehabilitation medicine. This chapter describes common antineoplastic agents and their major toxicities, focusing primarily on the subacute and chronic toxicities associated with treatment. Acute common toxicities of chemotherapy often include acute infusion reactions, myelosuppression, which increases the risk of neutropenia, infection, and need for transfusion due to anemia or thrombocytopenia, alopecia, fatigue, and nausea to varying degrees. The chapter focuses only on currently Food and Drug Administration (FDA) approved therapies.
Gastrointestinal (GI) complications of cancer are significant and can be challenging to manage. Dysphagia, nausea, vomiting, diarrhea, constipation, fecal impaction, bowel obstruction, and infections are just a few of the adverse effects experienced by the cancer patient. This chapter discusses the current strategies for diagnosis and treatment. The treatment of cancer with chemotherapy agents, immunotherapy, and radiotherapy has dramatically improved the prognosis and survival of many patients diagnosed with cancer. However, these interventions may cause significant GI side effects that can limit tolerability of treatment. The prevention and treatment strategies often utilize a combined pharmacological approach and target the receptors located in the chemoreceptor trigger zone and periphery. Cancer rehabilitation includes vigilant monitoring for GI complications of cancer. GI complications resulting from cancer treatment are variable in presentation and often multifactorial. Proper diagnosis of treatment related symptoms and more serious sequelae are imperative.
The evaluation of pain in the cancer setting is one of the most important and challenging tasks faced by the rehabilitation clinician. This chapter intends to provide a concise conceptual framework for the evaluation of pain. Failure to accurately and specifically determine the cause of pain will lead the clinician to pursue treatment strategies that may be ineffective, inappropriate, and potentially dangerous. Pain in the cancer population is divided into that which is (a) caused by disease, (b) caused by treatment, and (c) unrelated to disease or treatment. An accurate diagnosis of pain begins with a thorough history; the clinician should strive to fully understand all components of the patient’s cancer diagnosis. Physical examination is often the most important diagnostic modality the clinician has in arriving at a correct diagnosis it includes inspection, palpation, range of motion (ROM) assessment, neurologic assessment, and special tests.
Cancer incidence increases with age, and in a little more than 10 years, 70% of cancer survivors will be over the age of 65. Many older adults have comorbid conditions and complex healthcare needs, such as physical health decline, falling, and decreased independence in activities of daily living, putting them at risk for rehabilitation needs as they prepare for or recover from various cancer treatment protocols. This chapter highlights some of the common problems that may impact upon the rehabilitation of the older adult with cancer and discusses a population specific approach to addressing these issues. The common problems are frailty, dementia, delirium, pain management, depression, sleep, polypharmacy, nutrition, comorbidities, mobility and falls. The goals of rehabilitation in the management of the older adult with cancer include providing older adult sensitive care, symptom management, maximizing functional ability and comfort to enhance quality of life while providing patient and caregiver safety.
Rehabilitation oncology is a growing and expanding discipline today. There is likely no area of cancer treatment that is more dependent upon the patient’s motivation and cooperation. Psychiatric disorders and psychological and social problems are common reasons for patients not meeting the full rehabilitation goals to get “back to normal”. The physiatrist today must be aware of the prevalence of anxiety and depression, how to manage them, and when to refer for more specialized help. This chapter describes clinical practice guidelines established by the National Comprehensive Cancer Network (NCCN), which have been developed to better integrate psychosocial care into routine clinical oncology treatment. The chapter also outlines the clinical practice guidelines for management of anxiety, depression, and psychosocial dysfunction related to personality disorders and traits that complicate all aspects of cancer care, but particularly rehabilitation. Severe and acute forms of distress and personality disorders interfere with cancer treatment and rehabilitation.
Neurologic paraneoplastic disorders are nonmetastatic syndromes that are not attributable to toxicity of cancer therapy, cerebrovascular disease, coagulopathy, infection, or toxic/metabolic causes. Paraneoplastic disorders can affect any part of the central or peripheral nervous systems. Several syndromes should always raise the possibility of a paraneoplastic etiology, including limbic encephalopathy, subacute cerebellar degeneration, opsoclonus–myoclonus, severe sensory neuronopathy, Lambert–Eaton myasthenic syndrome, and dermatomyositis. Most types of tumor can be associated with paraneoplastic disorders, but the most common and best known are thymoma with myasthenia gravis and small cell lung carcinoma with Lambert–Eaton myasthenic syndrome. Paraneoplastic encephalomyelitis is characterized clinically and pathologically by patchy, multifocal involvement of any or all areas of the cerebral hemispheres, limbic system, cerebellum, brainstem, spinal cord, dorsal root ganglia, and autonomic ganglia. The most common clinical manifestation of paraneoplastic encephalomyelitis is subacute sensory neuronopathy reflecting involvement of the dorsal root ganglia.
Pharmacologic cancer pain management requires the following skills: (a) making a pain diagnosis; (b) choosing and titrating an analgesic agent; (c) recognizing and addressing side effects of the analgesics; (d) learning about alternative analgesics including opioid rotation; (e) accessing the institutional resources and algorithm for escalation of care and recruiting additional resources. The effective use of analgesic medications should be a major part of every physician’s armamentarium in managing cancer pain. The World Health Organization (WHO) cancer pain and palliative care program advocates the three step approach incorporating the use of nonopioid, opioid, and adjuvant analgesics alone, and in combination, titrated to the needs of the individual patient. Nausea, vomiting, sedation, and constipation are the most common opioid-induced side effects, while sedation, respiratory depression, and addiction being the most dangerous. Patients should be screened for opioid-misuse risk factors and educated about safe drug use and disposal.
As survival from cancer improves, the long-term management of survivors is becoming increasingly important. Inpatient rehabilitation should be considered for cancer patients throughout the spectrum of care. Treatment often includes anticonvulsants such as gabapentin, carbamazepine, oxcarbazepine, lamotrigine, and topiramate. Antidepressants such as amitriptyline, nortriptyline, venlafaxine, and duloxetine have also been shown to be effective. Therapy interventions can be used to address balance, sensory, and strength deficits that may impair function. With an interdisciplinary team, inpatient rehabilitation can offer these services in one setting of care, thus providing a comprehensive and unified approach. Several oncological diagnoses are amenable to rehabilitation care for both short and long term needs, but special considerations may be necessary to adapt rehabilitation treatment to cancer related impairments. The ability to provide medically complex care at a lower cost may support the value proposition of inpatient rehabilitation, when compared to settings with higher cost.
Radiculopathy is a pathological process affecting the spinal nerve root(s). Epidural compression can occur in 5% to 10% of people with malignancies. Metastatic disease is the most frequent cause of spinal cord cancers and associated nerve root compression. Epidural metastases occur in up to 14% of cancer cases. Metastatic epidural tumors damage the spinal cord and nerve roots by direct compression and by secondary vascular compromise. Intradural metastases compromise spinal cord and nerve roots by compression or direct invasion. Causes of noncompressive radiculopathy include radiation treatment, chemotherapy, paraneoplastic neurological syndromes, and acute polyradiculoneuritis. MRI is the most sensitive and specific diagnostic test to evaluate spinal lesions caused by cancer and gadolinium contrast enhancement MRI is the preferred imaging technique when intramedullary tumors or leptomeningeal metastases are suspected. Needle electromyography and nerve conduction studies are valuable diagnostic tools in evaluating suspected nerve root compression from either benign or malignant processes.
Function is highly valued by patients with cancer irrespective of type, stage, or treatment phase. The importance of function has become increasingly appreciated by diverse stakeholder groups, and function has been singled out by the Institute of Medicine, third-party payers, and federal funding agencies as a principal clinical outcome. This chapter aims to clarify some of the significant difficulties inherent in measuring function, particularly as it pertains to patients with cancer, so that readers will be better equipped to make educated and conscious trade-offs, and to appreciate the trade-offs that others have made. The goals of measurement should help prioritize the attributes of available metrics. There are four basic approaches to functional measurement, each with unique characteristics. They include self-report, clinician report, objective testing, and activity monitoring. Each approach has strengths and weaknesses that should be carefully considered along with cost and patient centricity of the approach.
The two common syndromes that affect the neuromuscular junction are myasthenia gravis (MG) and Lambert–Eaton myasthenic syndrome (LEMS). MG affects 15% to 30% of patients with thymoma or more, while LEMS affects 3% of patients with small cell lung cancer. Myasthenia gravis is caused by autoantibodies directed against epitopes on or around the acetylcholine receptor in the postsynaptic membrane of the neuromuscular junction. The antibody assays available for the diagnosis of MG include the acetylcholine receptor binding, modulating, and blocking antibodies. MG can be confirmed by electrophysiologic testing, the edrophonium test, or by clinical criteria. Antibodies directed at the P/Q type of voltage-gated calcium channel in the presynaptic neuronal membrane are seen in 85% to 95% of patients with LEMS. Nerve conduction studies in LEMS show low motor amplitudes due to neuromuscular blockade. Paraneoplastic LEMS typically responds to successful treatment of the underlying cancer.
This chapter focuses mainly on delineating the barriers to outpatient physical or occupational therapy and exercise. Exercise is defined as being inclusive of all forms of physical activity, including all modes (e.g., aerobic, resistance, balance, flexibility, sports), intensities (low to high), and settings (home based and facility based, supervised and unsupervised, individual and group). In conclusion, there is ample evidence that cancer patients and survivors experience functional deficits that could be effectively addressed by medical rehabilitation services and/or exercise programming. Unfortunately, there are multiple barriers to accessing cancer rehabilitation in the United States. The current landscape is a patchwork quilt in which luck plays a leading role in determining the likelihood that a patient who would benefit from rehabilitation is referred to and receives effective services at a reasonable cost, within an acceptable distance from home.
Back pain is a common symptom in both the cancer and noncancer patient. About 1% of patients who present to their primary care providers with back pain have a malignant cause of their pain. In approximately 10% of patients with cancer, symptomatic spinal metastases may be the initial presentation. Back pain is the presenting symptom in 90% of patients with spinal tumors or metastatic disease, as well as spine infection. Spinal metastases and associated nerve root and spinal cord compression is a well-recognized complication of cancer, and can occur in 5% to 10% of patients with systemic disease. A comprehensive patient history and physical examination are extremely important to identify “red flags”, or the need for further workup. MRI is considered the gold-standard imaging modality to evaluate the spine, and should be considered in the patient with a history of malignancy and back pain.
Therapeutic modalities are important adjuncts to therapy techniques, used in a variety of rehabilitation settings and indicated for a range of medical conditions. The application of physical agents has been a traditional treatment in medicine and is performed widely across different cultures. Therapeutic modalities may be safely applied to the patient throughout the continuum of cancer care provided the clinician performs a thorough patient assessment that rules out the presence of treatment contraindications. Physical agents may include cryotherapy, thermotherapy (dry heat, hot packs, paraffin), hydrotherapy (whirlpool, contrast baths), light agents (infrared, laser, ultraviolet), and sound agents (ultrasound, phonophoresis). Therapeutic modalities are indicated in a variety of conditions in cancer but the lack of consensus on the efficacy of certain modalities and the lack of appropriate guidance and instructions on indications and contraindications have often led to avoidance even when use is appropriate.
Cancer-related cognitive impairment (CRCI) is now widely recognized and accepted as a potential consequence of cancer and cancer treatment. This chapter focuses on CRCI in adult cancer patients with gliomas, and in those with non central nervous system cancers. It also discusses treatment related changes. CRCI can also arise from a variety of neurologic complications associated with brain cancers, including seizures, increased intracranial pressure, hydrocephalus, and stroke. Neurocognitive changes are also not uncommon in patients with cancers that do not invade the brain due to the remote or indirect neurologic effects of cancer. Collectively, cognitive rehabilitation programs have the potential to improve cognitive functioning abilities in cerebral and extracerebral patients by teaching them cognitive compensatory and retraining strategies. Medications have also been found to have some utility in improving cognition in brain tumor patients and they include memantine, methylphenidate, and modafinil.
The hematologic and thromboembolic complications of cancer and its treatments are common. This chapter discusses the etiology and management of each of the hematologic and thromboembolic complications of cancer. Anemia, erythrocytosis, thrombocytopenia, leukocytosis, leukopenia, thrombocytosis, and thrombocytopenia are frequently seen in cancer patients. Chemotherapy remains the major treatment modality, and because of its myelosuppressive properties, anemia, leukopenia, thrombocytopenia, and pancytopenia are common and should be expected. All chemotherapy treated patients are at risk for neutropenic complications. The degree and the duration of neutropenia also increase the infection risk. In cancer populations, anemia can be due to bone marrow underproduction such as chronic disease, myelophthisis, renal failure, endocrine dysfunction, nutritional deficiencies, myelosuppressive therapy; blood loss anemia such as acute blood loss, chronic blood loss, and chronic occult blood loss; and hemolysis such as immune and nonimmune hemolytic anemia.
Surgery is a major component of oncology directed therapies and, despite technological advances in minimally invasive approaches, it is still associated with high morbidity rates and functional impairments. Prehabilitation, particularly but not exclusively, in the surgical setting has emerged as a promising component of oncology care. Prehabilitation is defined as process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and severity of future impairments”. In surgical populations, prehabilitation protocols may be linked to Enhanced recovery pathways (ERPs) plans of care as well as postoperative rehabilitation. Finally, with all advances in rehabilitation medicine, prehabilitation protocols should also consider not only physical and functional outcomes but patient satisfaction and the cost of care.
This chapter aims to provide clinically relevant information and discusses diagnostic evaluation and management of the cancer patient with osteoporosis. Osteoporosis is a disease characterized by compromised bone strength, leading to bone fragility and an increased risk for fractures, especially of the hip, spine, and wrist. Currently, noninvasive tools to measure bone quality are limited but some newer techniques are being used. Dual-energy x-ray absorptiometry (DXA) is the gold-standard technique to measure bone mineral density (BMD). BMD is determined by peak bone mass minus net amount of bone loss over that time. Osteoporosis has no clinical manifestations or symptoms until there is a fracture, analogous to asymptomatic hypertension increasing risk for a subsequent myocardial infarction or stroke. The chapter discusses the clinical manifestations, psychological issues, epidemiology and importance, evaluation and treatment of osteoporosis in cancer.
Heart disease is the most common cause of death in the United States. Although the primary focus of this chapter is the rehabilitation of patients with cancer, it is important to remember that cardiac disease is as prevalent in cancer patients as it is in the general population and accounts for a significant share of morbidity and mortality. This chapter focuses primarily on the additional cardiac sequelae from cancer and its treatment. However, the impact of the underlying cardiac disease must always be considered. Long-term cancer survivors are likely to have treatment-related heart disease, necessitating cardiac revascularization or other procedures. Dilated cardiomyopathy in the setting of oncologic disease is usually associated with chemotherapy, specifically doxorubicin, other anthracycline agents, or trastuzumab. The approaches to rehabilitative treatment of cancer patients with heart disease follow basic cardiac rehabilitation guidelines.
Thyroid cancer accounts for 3.4% of all new cancer cases diagnosed in the United States, but it constitutes more than 90% of all endocrine malignancies. While the 30-year disease-specific survival in thyroid cancer in most patients exceeds 90%, the risk of recurrent disease is as high as 30% over the same period of time. Over the past 20 years, the combination of highly sensitive thyroglobulin with high-resolution neck ultrasonography has resulted in earlier detection of locally recurrent disease allowing for more effective treatment of these recurrences. Recent discoveries in molecular medicine have led to enormous progress in the diagnosis and treatment of patients with thyroid cancer. The development of new compounds with greater specificity for oncogenic targets and combinatorial regimens that overcome resistance to single agents promises a bright future for the treatment of radioactive iodine-resistant and advanced forms of thyroid cancer.
This chapter purpose is twofold. The first is to review various strategies that may help in bladder management in those with cancer or cancer treatment who may have a resulting voiding disorder. The second is to give a brief overview of bladder cancer and review surgical treatments and postoperative care for individuals with bladder cancer who have a urinary diversion. Voiding dysfunctions lead to medical problems, such as skin irritation or breakdowns, embarrassment, or general decrease in quality of life. Therefore it is important to accurately diagnose and treat a person’s voiding dysfunction. In those with cancer, the disease itself or side effects of the treatment may cause severe bladder damage that significantly worsens the quality of life of the patient. In these cases, removal of the damaged bladder (simple cystectomy supravesical urinary diversion) may be necessary. Pre and postoperative education and follow-up are essential in urinary diversion.
Intracranial imaging is vital to the initial evaluation, staging and treatment planning, and posttreatment follow-up of brain tumor patients. The modalities used to evaluate the brain are CT and MRI. A familiarity with basic radiologic concepts can enable a provider to better translate the intracranial process to clinical care. This chapter is intended to give the clinician a baseline for interpreting images independently in either the acute or chronic setting. Imaging of the brain using CT and MRI techniques is essential to the evaluation of patients with intracranial malignancy, both in the acute and chronic setting. Knowledge of basic imaging principles related to the presence of an intracranial mass and familiarity with findings unique to certain malignancies are useful tools for the clinician. These skills can be built over time by reviewing patient images independently, utilizing the kinds of fundamentals discussed in this chapter.
Activities of daily living (ADL) include tasks that an individual engages on a daily basis to fulfill personal, social, and work-related roles. Self-care activities are a significant performance area that occupational therapists address when treating patients with cancer. Additionally, occupational therapists address instrumental activities of daily living (IADL), which consist of activities that require the individual to interact with the physical and social environment. It describes how each component of self-care can be addressed and/or modified when working with patients in all settings, including: acute hospital, inpatient acute rehabilitation, outpatient or home setting to maintain engagement. In all stages of cancer rehabilitation, a patient’s independence in performing ADL/IADL may be compromised by weakness, fatigue, or loss of function. The occupational therapists role in cancer rehabilitation is to enhance the patient’s performance of ADL/IADL, to provide education to maintain or increase daily living skills, to improve overall quality of life.
This chapter focuses on the rehabilitation implications for occupational therapy and physical therapy practitioners when working with patients with cancer who have undergone a surgical procedure. There are a variety of surgical procedures that have different effects on function and quality of life. It discusses breast surgery, head and neck surgeries, orthopedic surgeries, and pediatric surgeries. Physical therapy and occupational therapy interventions with these complex patients require a high level of clinical reasoning. The collaborative goal for both physical and occupational therapy is to return patients to a maximum level of independence in daily activity and mobility to improve quality of life. The chapter’s main objective is to describe the complexity of postsurgical rehabilitation with the oncology population. It provides references and resources to guide therapy practitioners and healthcare professionals on the various surgeries and activity restrictions that limit patient engagement in activities of daily living (ADL).
Muscle weakness in cancer patients, especially those receiving aggressive life-sustaining therapies, can be due to multiple factors. While muscle is rarely a primary organ affected by adult neoplasms, direct invasion of muscle from a tumor or metastasis to muscle is not uncommon. A generalized myopathy can also occur due to a paraneoplastic process, unintended side effects of therapy, or cachexia. Sarcomas can present in any connective tissue, including muscle. Primary muscle tumors are often diagnostic conundrums. Paraneoplastic myopathies tend to be necrotizing myopathy, dermatomyositis, polymyositis, and inclusion body myositis. Amyloid myopathy is a rare complication of multiple myeloma. Chronic glucocorticoid use may cause a proximal myopathy (steroid myopathy) in up to 60% of cancer patients. Treatments always include therapy directed at the underlying neoplasm and should include any needed supportive therapies, including nutritional, cancer rehabilitation, physical therapy, occupational therapy, and psychological care to improve quality of life.
This chapter describes the inverse planning basics. An ideal plan would have the prescribed isodose conform to the planning target volume (PTV) while having a minimal dose to the nearby organs at risk (OAR). To obtain an optimal plan, inverse planning includes the following three key components: planning objectives; cost function that measures goodness of a plan; and optimizer to minimize the cost function. The use of the gradient search algorithm and dose-volume-based cost function, optimization for a complex case with numerous sensitive structures requires multiple, manual iterations, also termed staged planning or warm starts. On the first stage planners start with planning objectives for the PTVs, critical structures, and the ring structure. On the second round optimization, without resetting intensity modulated radiation therapy, the planners add more planning objectives for additional OARs. Modern treatment planning systems are implementing advanced planning tools such as auto-planning, multi-criteria optimization, and knowledge-based planning.
Interventional pain procedures are an adjunct to pharmacologic therapy for cancer pain. While pain at the location of the tumor might be the primary cause of pain, cancer patients may also have non-cancer related pain as a result of altered anatomy or biomechanics, for example, myofascial pain. Myofascial pain is pain or autonomic phenomena referred from active trigger points in the muscles, fascia, and tendons. This chapter discusses about the therapies for muscular pain which includes the trigger point, botulinum toxin, acupuncture, therapies for peripheral nerve mediated pain, local blockade, ultrasound guided procedures, sympathetic blocks, complex regional pain syndrome, spinal procedures, epidural steroid injections, neuromodulation, vertebral procedures and facet arthropathy. Kyphoplasty and vertebroplasty not only have been studied most extensively in stabilizing compression fractures from osteoporosis, but have also been used to treat fractures resulting from osteolytic metastasis, myeloma, vertebral osteonecrosis, and hemangioma.
Cancer patients experience a range of symptoms that often span the course of the diagnosis, treatment, and survivorship it includes problem such as pain, fatigue, mood disturbance, insomnia, and more. This chapter focuses on complementary health approaches that are used as adjuncts to conventional cancer care and rehabilitation. It follows an overview and brief description of major complementary health approaches. The chapter notes appropriate use of these approaches according to health goals and common symptoms experienced by cancer patients. Individuals with a current or past history of cancer face a range of physical and psychological symptoms that can be relieved through the use of complementary health approaches. Working with providers trained in the safe and evidence-informed use of complementary health approaches can help patients support their health during and after cancer care.
The chapter discusses strategies for radiation therapy treatment planning for lymphoma. It explains clinical application, patient setup and immobilization. Treatment planning describes dose specification, extended field radiation therapy, involved/regional field radiation therapy, and involved site radiation therapy. Radiation therapy is used as monotherapy, or as an adjunct to chemotherapy to treat Hodgkin’s and Non-Hodgkin’s lymphoma. The chapter provides clinical application, patient setup, and treatment planning with dose specification, and treatment techniques for total skin electron irradiation. The clinical application for total skin electron irradiation is definitive treatment of cutaneous T-cell lymphoma, also called mycosis fungoides. The chapter also presents clinical application, patient setup, and treatment planning for total body irradiation. Total body irradiation is used on its own, or as an adjunct to chemotherapy as part of a myeloablative regimen, to condition the host prior to receiving a hematopoietic transplantation.
The chapter discusses strategies for radiation therapy treatment planning for gynecologic cancer. It presents patient simulation and localization, planning targets and goals, critical structure objectives, 3D conformal planning, and intensity modulated planning for whole pelvis radiation therapy. Intensity modulated therapy is used for extended field treatment including para-aortic lymph nodes. The chapter gives examples of intensity modulated planning for endometrial cancer, cervical cancer, vulvar cancer, vaginal cancer. It describes patient simulation and localization, planning targets and goals, critical structure objectives and high dose rate (HDR) planning for HDR brachytherapy. The chapter also presents five examples of HDR planning for vaginal cuff brachytherapy, tandem and ring applicator for cervical cancer, tandem and ring applicator for uterine cancer, and interstitial implant for large gynecological tumors.
The cancer rehabilitation needs of survivors span all ages, with the full spectrum of rehabilitation fields including musculoskeletal, neurological, cardiopulmonary, and chronic pain. Effective cancer rehabilitation involves an interdisciplinary team of healthcare professionals, including physical and occupational therapists. Rehabilitative interventions deal with physical and cognitive impairments that may interfere with survivor’s cancer treatment and may negatively impact on function and quality of life. Physical therapists promote individual health and wellness through physical and physiological therapeutic interventions, such as manual therapy, electrophysical modalities, muscle lengthening and strengthening techniques, therapeutic exercise, and balance and coordination retraining. Occupational therapists are involved in all aspects of rehabilitation care, from acute to community to palliative, and including return-to-work programs, school education, senior support, and environmental adaptations and building projects. Physical and occupational therapists are highly skilled healthcare professionals, uniquely positioned within the healthcare system to support survivors in bridging the gap between illness and wellness.
This chapter defines the problem of balance and gait dysfunction in adult cancer survivors, reviews normal balance and gait functions, identifies common causes of balance and gait disorders in the cancer population, highlights methods for assessing and diagnosing dysfunction, and provides a basic overview of general rehabilitation management. Balance and gait are interrelated, and it is challenging to isolate the independent contributions of each to the performance of functional mobility and activities of daily living. These problems are multifactorial and the result of cancer and treatment on postural control and movement systems. Functional limitations and rehabilitation needs of a patient with cancer are directly related to the extent of disease at the time of diagnosis and concomitant cancer treatment. Clinicians can integrate knowledge of health conditions, findings from the comprehensive clinical assessment and principles of oncology rehabilitation to determine the most appropriate rehabilitation strategies and guide successful rehabilitation management.
Tumors arising from the musculoskeletal system include benign and malignant neoplasms. Benign etiologies include posttraumatic, infectious, and inflammatory conditions. Malignant neoplasms include primary tumors of soft tissue and bone. Metastatic disease to the musculoskeletal system may present as soft tissue masses, bone destruction, or marrow replacement. The choice of a radiologic diagnostic imaging test takes into account the sensitivity of each modality as it pertains to the patient’s cancer history, presentation, and clinical query. The entire skeletal system is evaluated with a whole body nuclear medicine bone scan. Musculoskeletal imaging in evaluating cancer patients requires complementary exams to diagnose patients and evaluate treatment response. Most important are the availability of prior scans for comparison and a detailed history of treatment and current medication to allow the interpreting radiologist the ability to provide a thorough comprehensive detailed consultation.
This chapter provides a brief description on evaluation and treatment of lung and bronchus cancer. An estimated 234,030 cases of lung cancer will occur in 2018, accompanied by an estimated 155,870 deaths from the disease. Lung cancer is the second most common cancer in men and women but is the leading cause of cancer mortality in both. This chapter discusses epidemiology, pathology, screening, diagnosis, and prevention of lung cancer. Paraneoplastic syndromes are a combination of symptoms produced by substances formed by the tumor or produced by the body in response to the tumor. Lung carcinoma is a pathologically heterogeneous tumor. The most important distinction is between small cell carcinoma and non-small cell carcinoma. Treatment for early-stage disease usually involves one or more modalities of treatment, which include surgery, chemotherapy, and radiation therapy. Patients with advanced disease are treated with chemotherapy, immunotherapy, or targeted therapy.
Primary central nervous system (CNS) tumors encompass a heterogeneous mix of histologies and sites of origin. The 2016 World Health Organization (WHO) classification introduces molecular parameters in addition to histology to define many tumor types with the goal to facilitate clinical, experimental, and epidemiological studies in the molecular era. This chapter reviews epidemiology, symptoms, and signs, as well as diagnosis and treatment of CNS tumors. It also provides an overview of specific brain and spine tumor types followed by a brief discussion of long-term sequelae of CNS tumors and their treatments. Long-term CNS sequelae of treatment include neurocognitive dysfunction, stroke, radiation therapy necrosis, and secondary cancers, among others. Radiation is also a risk factor for secondary tumors including meningiomas, malignant gliomas, and nerve sheath tumors. The incidence of CNS neoplasm is 8.1 to 52.3 times higher in survivors of childhood cancer who received cranial irradiation compared with the general population.
This chapter describes common upper extremity pain disorders frequently seen in the cancer population. A systemic approach will provide a construct for thorough assessment and accurate diagnosis so that comprehensive and effective treatment geared toward functional restoration can be initiated. The evaluation of upper extremity pain disorders includes cancer history, pain history, and functional assessment. The cancer history is imperative in patients with a history of malignancy. An understanding of the underlying malignancy and cancer treatment can clarify common etiologies of cancer pain. For those with an unclear etiology, a systematic approach is required to exclude recurrent malignancy and establish a clear diagnosis. Management of upper extremity pain disorders includes diagnosis, pain control, functional restoration, and return to prior activity. An established diagnosis can be a great relief to the patient and may avoid unnecessary delays in cancer treatment and pain treatment.
Cancer and its treatment can result in various lower extremity musculoskeletal complications that may negatively influence a patient’s function. This chapter discusses the causes, evaluation, and treatment of common lower extremity musculoskeletal complications and conditions likely to occur in patients with cancer. The causes of lower extremity pain in patients with cancer are numerous. The pain may be from muscle, joint, or bone disorders. In addition, there are neurologic, vascular, and systemic causes that should be considered. The chapter describes some of the musculoskeletal causes such as bone metastases, insufficiency fracture, soft tissue tumors, bursitis, myofascial pain, arthritis, plantar fasciitis, and sprains. Goals should be determined based on an aggregate of factors, including a patient’s age, type and stage of cancer, and comorbidities, and should be established with the patient and family, as their “buy in” is vital.
Much consideration and discussion should take place between physicians, dosimetry, physics, and therapists before a patient is brought into the simulator and scheduled on a treatment machine. One should try to anticipate factors such as how the patient will be immobilized, target and organ at risk dose goals, and beam angles. Whenever possible, patient’s care should be referred to a high-volume pediatric oncology center, and clinical trial enrolment should be considered. Patients should be in a tolerable, reproducible position. Patients under anesthesia are often very limp, so immobilization should be maximized to limit movement. The treatment time for a pediatric patient is an important factor. Treatment can affect the growth of developing organs, particularly growth plates in the bone. The chapter provides a brief description on patient setup, immobilization, and treatment planning for Wilms’ tumor, Ewing’s sarcoma, rhabdomyosarcoma, craniopharyngioma, craniospinal irradiation of embryonal tumors, and total body irradiation.
The comprehensive rehabilitation of children with cancer requires an interdisciplinary team approach across the continuum of care. Childhood cancers account for approximately 1% of all cancers diagnosed in the United States each year. The type of treatment for childhood cancer can include any combination of chemotherapy, surgery, radiation, and biologic therapies depending upon many factors including tumor pathology, genetics, and staging. Pediatric rehabilitation is an important component in minimizing the adverse effects and maximizing the return of independence and function in these children and young adults. In pediatric rehabilitation, prescriptions for therapy programs, adaptive equipment, orthoses, and prostheses must be appropriate to the age and the developmental level of the child and include considerations related to ongoing growth and development. The chapter discusses specific childhood cancers like leukemia, central nervous system tumors, bone sarcomas its and rehabilitation issues.
Body imaging utilizes multiple modalities such as ultrasound, conventional radiographs, CT, and MRI, in the care of the cancer patient. Advances in CT technology to allow faster scanning at lower dose and postprocessing imaging ensure that imaging is constantly developing to meet the needs of patients with cancer. Newly developed hybrid imaging techniques such as PET–CT and PET–magnetic resonance (MR) provide metabolic and functional information that helps improve staging and treatment planning. This chapter broadly discusses the modalities used in body imaging and imaging recommendations for diagnosis, staging, follow-up, and detection of complications. Imaging is an essential element of the management of patients with cancer. Imaging aids with many facets of the cancer treatment, including conditions requiring immediate attention, diagnosis, staging, therapy decisions, and response assessment. A basic overview of imaging is provided for evaluation of some of the more common malignancies and conditions seen in adults.
Graft-versus-host disease (GVHD) is a complication of allogeneic hematopoietic stem cell transplantation that affects many organ systems. There are both acute and chronic forms. It is an inflammatory process thought to be T-cell-mediated in which transplanted immune cells attack host tissues. Immunomodulation is the mainstay of both acute and chronic GVHD management. Acute GVHD is generally treated initially in the inpatient setting with high-dose glucocorticoid therapy. Symptoms are often related to a skin rash and/or crampy, watery diarrhea with nausea. The impact of chronic GVHD and its treatments is a challenge to the rehabilitation team because it presents a chronic, complex, and ever-changing series of impairments, functional limitations, and disabilities across a number of organ systems with varying impacts on function and quality of life. Patients with GVHD can benefit greatly from rehabilitation services. Involvement of a physiatrist is warranted given the high risk of medical complications in these patients.
Cancer is a complex group of hundreds of distinct diseases, with occurrence that varies by cancer type, age, sex, race/ethnicity, socioeconomic status, geographic location, and time. This chapter describes cancer occurrence patterns in the United States for all cancers combined and for seven select cancer sites (prostate, lung and bronchus, and colorectum in men and breast, lung and bronchus, and colorectum in women). These cancers account for 42% and 50% of new diagnoses in men and women, respectively. Lung and bronchus cancer is the leading cause of cancer death in both men and women, followed by prostate and colorectal cancers in men and breast and colorectal cancers in women. The chapter focuses on these four cancer types, as well as three additional cancers (liver and intrahepatic bile duct, esophagus, and pancreas) that are unique with respect to risk factors, distribution and trends by histologic subtype, and low survival.
Treatment planning consists of clinical treatment planning and technical treatment planning. Clinical treatment planning refers to the treatment intent, treatment modality, and treatment dose scheme. Technical treatment planning refers to the details of patient positioning, placement of radiation beams, and the aperture shapes of radiation beams designed to achieve highly conformal radiation dose distributions to the treatment target volumes while protecting the critical organs. Treatment plan quality depends on the radiation beam orientation in combination with the treatment couch angles; the number of beams; radiation beam energies; and beam shapes or number of sub shapes. The chapter provides a brief description on: source-to-skin (patient) distance versus source-to-axis (isocenter) distance treatment planning; treatment target volumes and planning margins; treatment plan types; prescription and normalization methods; open field, wedged field, and field-in-field; forward planning versus inverse planning; boost: sequential versus integrated; intensity modulated radiation therapy and volumetric modulated arc therapy delivery methods.
This book details the technical aspects of how to achieve requirements for clinical treatment planning aspects, including patient positioning, creation of patient specific bolus, beam angle configurations, and inverse planning optimization approaches. It is written for everyone involved in treatment planning including dosimetrists, physicists, and physicians. The book comprises of 14 chapters. The first three chapters are introductory chapters. Chapter one describes the types of treatment plans and the general process of treatment planning. The second chapter explains the principles and limitations of current inverse planning optimization algorithms, and discusses the application of auto-planning, knowledge-based planning, and multi-criteria optimization to overcome these limitations. The third chapter covers the available immobilization equipment and general principles of simulation, including patient safety procedures. Chapters four through eleven are organized by body site or system and covers central nervous system, head and neck, breast cancer, thoracic cancer, gastrointestinal radiotherapy, genitourinary cancer, gynecologic cancer, lymphoma, and soft tissue sarcoma. For each site, there is a description of patient simulation, including immobilization, setup, isocenter placement, and any special considerations such as motion management. The plan goals for each treatment site are tabulated, followed by recipes to achieve them from the simplest planning technique to the most advanced planning technique. For simple 3D conformal plans, the recipes include the field arrangement and portal shape design (both with many figures), beam weighting, and selection of dose normalization point. For advanced techniques such as intensity-modulated radiation therapy, volumetric modulated radiation therapy, and stereotactic body radiation therapy, the recipes provide details of creation of optimization structures and multiple stage optimizations. Each chapter concludes with plan evaluation, comparing achieved doses to the clinical planning goals. Chapter thirteen describes treatment planning for pediatric cancers. Chapter fourteen discusses treatment planning for palliative treatment.
According to the National Institutes of Health Surveillance, Epidemiology, and End Results (SEER) program database, there are estimated to be 3,200 patients diagnosed with primary bone cancer in 2017. The staging system helps guide surgical management. The primary aim of surgical intervention is to resect the tumor in a manner that will prevent local recurrence. Conventional bone radiography is the mainstay for imaging techniques for the primary evaluation of bone. Biopsy is often the most important procedure performed in patient management. With the exception of the Ewing family of tumors, radiation therapy has a limited role in the management of primary bone sarcomas. When surgery is not possible, radiotherapy has been used to help provide local control, although with results that are not comparable to the combination of chemotherapy and surgery. The primary surgical objective for the management of primary malignant bone tumors is resection with wide surgical margins.
This chapter covers the common leukemias (acute myeloid leukemia, acute lymphoblastic leukemia, and chronic lymphocytic leukemia), myelodysplastic syndromes, and multiple myeloma. It describes the key features of these disorders and discusses how the various treatments affect the disease as well as the function of other organs, at times leading to acute or chronic organ dysfunction. With the advent of imatinib, dasatinib, and nilotinib, tyrosine kinase inhibitor therapy has dramatically changed the treatment of chronic myeloid leukemia. Many excellent reviews have described the optimal approach for using these agents in chronic myeloid leukemia and addressed how to best manage their side effects and monitor the response to treatment. Remarkable progress has been made in the treatment of multiple myeloma in the past decade, yet it remains a fatal disease. Moving forward, strategies are aiming toward deeper responses, achieving long-term disease control and perhaps cure.
This chapter explores recent insights from preclinical and clinical studies of cancer induced bone pain (CIBP). There are various neuropathic, nociceptive, and inflammatory pain mechanisms that contribute to CIBP. Neuropathic pain can be induced as tumor cell growth injures distal nerve fibers that innervate bone and pathological sprouting of both sensory and sympathetic nerve fibers. These changes in the peripheral sensory neurons result in the generation and maintenance of tumor induced pain. CIBP is usually described as dull in character, constant in presentation, and gradually increasing in intensity with time. A component of bone cancer pain appears to be neuropathic in origin as tumor cells induce injury or remodeling of the primary afferent nerve fibers that normally innervate the tumor bearing bone. The treatment of pain from bone metastases involves the use of multiple complementary approaches including radiotherapy, chemotherapy, surgery, bisphosphonates, and analgesics.
Communication and swallowing are activities that not only serve vital physical functions but also contribute to an individual’s emotional health. This chapter describes the changes in swallowing and communication that may occur with cancer and cancer treatment, and current approaches to evaluating and rehabilitating these functions. Tumors of the oral cavity and oropharynx can be very small and create minimal impact or can become quite disruptive as they grow. Brain tumors in the cortex, subcortical regions, cerebellum, and brainstem can all cause dysarthria, aphasia, and dysphagia, as well as cognitive deficits, disruption of balance and coordination, vision loss or change, or apraxia. Seizures associated with brain tumors may exacerbate speech, language, or swallowing deficits. Surgical management of cancers of the head and neck, lung, mediastinum, esophagus, trachea, cervical spine, base of skull, and brain can all affect speech, language, hearing, voice, and swallowing.
The development of bone metastases is complex and requires a series of coordinated steps. Bone metastases are frequently asymptomatic. Yet, the majority of patients will develop symptoms during the course of their disease. Clinical features include pain, loss of function, hypercalcemia, and depression. Assessing the general condition as well as using tools to predict the survival is important once a treatment decision has to be made. After a clinical history is taken and the physical examination is performed further investigations should include chest x-ray; CT scan of chest, abdomen, and pelvis; bone scan; serum protein electrophoresis; serum and urine immunofixation; and prostate-specific antigen in men. The most important treatment the patient will receive is the systemic treatment and it can be in the form of either chemotherapy, targeted therapy, or immunotherapy. Bone metastases from breast cancer and lymphoma are sensitive to systemic treatment and may be treated with just chemotherapy.
Cancer remains a leading cause of functional impairment and disability worldwide. There has been a rapid acceleration in cancer rehabilitation research and publication over the past decade. This growth has yielded important improvements in clinical interventions, enabled targeted and effective therapeutic intervention, and enhanced function and quality of life across the life span of individuals touched by cancer. Rehabilitation researchers will need to think differently about research design, extend their focus beyond traditional interventional trials and seek to enhance the understanding of models of care delivery, comparative effectiveness of rehabilitative interventions, and the economics of rehabilitation services. The challenges can be overcome through a concerted effort to identify a research agenda that will alleviate critical gaps in the field, collaborative partnerships across disciplines that research important questions in the varied domains of cancer rehabilitation, and expanded funding for cancer rehabilitation research.
This chapter provides a brief description on simulation and general planning principles for head and neck cases. It describes specific case planning for T2 N0 M0 squamous cell carcinoma of the glottis; T2, N2b, M0 squamous cell carcinoma of the base of tongue; T4b N0 M0 esthesioneuroblastoma of the nasal cavity; T2 N0 M0 squamous cell carcinoma of the scalp; and T2b N1 M0 malignant neoplasm of connective tissue of head, face, and neck. The chapter describes planning for T3 N0 M0 squamous cell carcinoma of the tonsil, re-irradiation and T4b N2b M0 P16+ malignant neoplasm of the right tonsil re-irradiation. It describes planning for special cases such as two isocenter treatment plan for a T4b N0 M0 teratocarcinoma of the ethmoidal sinus and cases involved with pacemaker.
This chapter presents radiation therapy treatment planning for breast cancer. Patient is immobilized with arms supported, wedge sponge under the knees for comfort, and feet bound with rubber band to ensure the patient is straight. In supine position, physician places Radio-opaque wires to delineate the superior, inferior, medial, and lateral field borders after the patient is properly positioned. Patient is set up prone on a specially designed immobilization device with both arms above the head, the ipsilateral breast falling anteriorly, and the contralateral breast displaced posteriorly away from the treatment fields. The chapter discusses opposed tangents, regional nodal irradiation, intensity modulated radiation therapy and volumetric modulated arc therapy. It also lists treatment plan goals for unilateral breast plan prescribed with 40.05 Gy in 15 fractions and planning goals for breast plan including regional nodes prescribed 50 Gy in 25 fractions.
Physical activity significantly improves cancer specific mortality, survival, fatigue, pain, lymphedema, muscular strength, aerobic capacity, physical function, psychosocial distress, depression, anxiety, and quality of life. This chapter explains the effects of physical activity according to the cancer continuum, starting with prehabilitation, neoadjuvant treatment, during adjuvant treatment, posttreatment, long-term survivorship, and palliative and end of life. Prehabilitation is defined as “a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and psychological health to reduce the incidence and/or severity of future impairments”. Neoadjuvant therapy is used to shrink tumor size and improve surgical outcomes. Adjuvant therapy is often used to prevent cancer recurrence following primary surgery, including radiation therapy, chemotherapy, immunotherapy, and hormone therapy.
Lymphedema is edema that is specifically caused by an abnormality of the lymphatic system. Primary lymphedema results from anomalous development of the lymphatic system. Secondary lymphedema occurs as a result of trauma, damage or disruption of a previously normal lymphatic system. The patient undergoing cancer treatment has many potential causes of edema that can mimic lymphedema that must be evaluated before assigning a diagnosis of lymphedema. The clinician treating cancer patients must do a thorough evaluation of all of the potential causes of enlargement of a body part, always maintaining a high index of suspicion for the possibility of tumor as a primary source of enlargement and treating all serious and life-threatening edemas before assuming lymphedema is the only cause or one of the causes of swelling. Clinicians should provide patients with personalized recommendations regarding risk reduction measures according to the patient’s status and available research on these measures.
A cancer diagnosis and treatment for cancer can result in physiologic and emotional changes that impact the health and quality of life of patients long after the completion of initial cancer therapy. The field of cancer survivorship care was established to identify and meet the diverse needs of patients surviving after a cancer diagnosis. In recent years, much has changed regarding our understanding of late effects and methods to maintain or improve the health of cancer survivors. In particular, the potential late effects following treatment of cancer in children and adolescents are reasonably well characterized and we are now studying interventions intended to lower risk. Understanding the unique challenges that can emerge following the completion of initial cancer therapy can result in improved identification of issues impacting our patients, and early intervention to improve health outcomes.
This chapter provides a brief description on: simulation and immobilization; 3D conformal planning; intensity modulated radiation therapy/volumetric modulated arc therapy planning principles; planning objectives and evaluation for external beam treatment involving central nervous system. It discusses simultaneous integrated boost (SIB), and gamma knife (GK) and linear accelerator-based stereotactic radiosurgery. SIB is delivered with intensity modulated radiation therapy or volumetric modulated arc therapy and is an efficient technique to incorporate the boost into a single treatment plan. GK requires 3D imaging, a high degree of dose conformity, sleep dose gradient, and accuracy of beam delivery less than 1 mm. GK is for cranial irradiation, and has typically used a frame attached to the patient’s head for immobilization. Treatment time depends on source strength, number of targets, shape, size, and prescription, and can vary between 10 minutes to several hours.
This chapter discusses palliative treatment. It provides a brief description on simulation, target and organ at risk (OAR) delineation and planning for spine stereotactic body radiation therapy (SBRT). The chapter presents simulation, target and OAR delineation, and planning for hippocampal-sparing whole brain radiotherapy (WBRT). It discusses simulation and planning for WBRT and spine metastases. The chapter describes simulation for bone metastases. It discusses simulation and planning for malignant pulmonary obstruction, other malignant obstructions and bleeding. The chapter presents simulation and planning process for soft tissue metastases. It lists treatment planning objectives for spine SBRT, treatment planning objectives for hippocampal sparing WBRT.
This chapter discusses treatment planning for gastrointestinal radiotherapy. It describes patient setup, immobilization, and planning technique for esophageal cancer external beam radiation therapy (EBRT). The chapter provides patient setup and immobilization, motion management techniques, target delineation, and planning technique for pancreas fractionated EBRT. It explains patient setup and immobilization, motion management techniques, and planning technique for pancreas stereotactic body radiation therapy (SBRT). The chapter presents patient setup and immobilization, motion management techniques and planning technique for rectal cancer EBRT. It describes patient setup and immobilization, and planning technique for anal cancer EBRT. Finally the chapter explores patient setup and immobilization, motion management techniques and planning technique for liver SBRT.
Patients with cancer are susceptible to a variety of infections. Common infections include sepsis, cellulitis, pneumonia, urinary tract infections, and colitis. Infections can result in a decline in functional status, with subsequent debility, fatigue, and reduced oral intake. The cancer patient will also have a broader differential diagnosis for the cause of an infection, which can include bacterial, fungal, viral, and parasitic etiologies. This chapter tabulates common infections seen in the rehabilitation setting like bladder infections, cellulitis, sepsis and pneumonia. Pneumonia is common in patients with primary lung cancer or metastasis, due to partial obstruction of the air ways with subsequent atelectasis and postobstructive pneumonia. This may cause lung abscess formation with polymicrobial organisms. If this occurs, treatment in addition to antibiotics is needed to ensure eradication of the infection, such as chemotherapy, radiation, stent placement, or endobronchial brachytherapy.
This chapter examines clinical aspects of cancer and motor neuron disease (MND), in particular sporadic amyotrophic lateral sclerosis (ALS) that is relevant to practitioners involved in cancer rehabilitation. ALS is a distinct clinical and neuropathological condition. The clinical lower motor neuron manifestations of weakness, wasting, and fasciculation are due to anterior horn cell degeneration and loss; those of the upper motor neuron recognized by hyperreflexia, spasticity, clonus, and Hoffmann and Babinski signs are due to corticospinal tract degeneration. The World Federation of Neurology El Escorial diagnostic criteria provide a useful clinical classification of ALS. Although there is no cure for ALS, the quality of life can be favorably altered by symptomatic therapy. Rilutek is the only approved medication for the treatment of patients with ALS. The diagnosis of ALS is usually established while the patient is ambulatory, allowing for the institution of physical and occupational therapy programs and orthotics.
Electrodiagnostic tools, such as nerve conduction studies (NCS) and needle electromyography (EMG) are invaluable in assessing the function of the peripheral nervous system and evaluation of neuromuscular disorders in cancer patients. Nerve conduction studies are typically divided into sensory NCS and motor NCS. Needle EMG can be used to distinguish between lower motor neuron, peripheral nerve, neuromuscular junction, and muscle disease. The indications for performing electrodiagnostic studies include confirming a suspected neuropathic lesion, ruling out other likely possibilities, localizing lesions, determining chronicity and severity, and detecting subclinical neuropathic/myopathic processes. Information regarding pathophysiology and assessing prognosis for neurologic recovery can be achieved with electrodiagnosis. Information obtained with NCS and needle EMG in the cancer patient can often assist in chemotherapy or radiation therapy decision making. This chapter describes electrodiagnostic findings in cancer, indirect neuromuscular effects of cancer, and electrodiagnosis of neuromuscular complications of cancer treatments.
Precautions comprise a defining area of cancer rehabilitation, and are at the very essence of the field’s knowledge base. Precautions historically have served as a major component of the intellectual framework specific to cancer rehabilitation. This chapter discusses precautions in rehabilitation of breast cancer and lymphedema patients. Concerns about therapeutic modalities such as ultrasound and other heat modalities, electricity, laser, and massage, generally pertain to use directly over tumor, due to local blood flow or cytoactive effects. The concern with therapeutic ultrasound lies in the potential for increased tumor size or propagation due to increased blood flow effects. Massage has generally been deemed to be safe, and there is no evidence that massage therapy can spread cancer. In patients receiving tamoxifen, reduced concentrations of its active metabolite endoxifen have been found in patients also taking certain serotonin reuptake inhibitors (SSRIs), such as paroxetine or fluoxetine which inhibit CYP2D6 enzymatic activity.
Palliative care is interdisciplinary care that anticipates and relieves suffering in order to ensure maximal quality of life. Palliative care does this by focusing on expert management of physical symptoms, functionality, psychosocial concerns, and spiritual health. This chapter follows the case discussion about a patient and his transitions through the various phases of his cancer in order to illustrate how the palliative care team can work in conjunction with rehabilitation services to provide optimal care to a patient. Major national guidelines, including those from the American Society of Clinical Oncology have recommended palliative care early in the course of illness for any patient with metastatic cancer or a high symptom burden, rather than waiting until the end of life. Rehabilitation, with its overarching goals of maximizing function and improving quality of life, is philosophically and pragmatically harmonious with the art of palliative care.
The National Comprehensive Cancer Network (NCCN) has defined cancer-related fatigue (CRF) as “an unusual, persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning”. The diagnosis of CRF includes four agreed upon criteria: a period of 2 weeks or longer within the preceding month during which significant CRF or diminished energy was experienced each day or almost every day along with additional CRF-related symptoms; the experience results in significant distress or impairment of function; there is clinical evidence suggesting that CRF is a consequence of cancer or cancer therapy; and CRF is not primarily a consequence of a concurrent psychiatric condition, such as major depression. Contributors to CRF include chemotherapy, radiation, and comorbidities such as heart failure, metabolic syndrome, obesity, anemia, and endocrine dysfunction.
This chapter provides a brief description on the history of cancer rehabilitation. The early history of cancer rehabilitation certainly would not be complete without a review of some of the pioneer rehabilitation programs. Although the political legislation of the 1960s and 1970s was lofty and admirable, seemingly very little tangible benefit accrued to cancer patients and indeed most cancer rehabilitation programs. At present, the efficacy and worth of rehabilitation efforts are proven and undoubted. Recent works have documented the very positive effects of exercise and other rehabilitation therapies on functional improvement, independence, a feeling of well-being, and fatigue problems in the cancer patient. Clearly, the cancer population needs, and should demand, the services of rehabilitation professionals. Supported by the convincing pioneer works of their predecessors, the modern-day cancer rehabilitation specialist is empowered by evidence, inspiration, and experience to march forward and provide the expertise and support for this deserving population.
Involvement of neural plexus structures in a patient with cancer may result from direct invasion by tumors originating within nerve tissue, local metastatic extension or distant spread from diseased organs, or compression by adjacent tumor masses. The function of the neural components may also be severely affected by sequelae or complications of surgical intervention or radiation therapy. Clinical history may suggest a possible etiology; however, physical examination may be of limited value in evaluation of plexopathy depending on the structure affected. Conventional radiologic methods are usually nonrevealing, although they may be helpful in advanced disease. As new techniques are introduced, improved resolution and ability to analyze chemical composition of tissues advanced MRI to the method of choice in diagnosis and assessment of treatment response in patients with plexopathy. This chapter discusses the role of conventional and new modalities in evaluation of plexus disease, including indications, current techniques, advantages, and pitfalls.
Cancer treatment is becoming increasingly complicated and a multidisciplinary approach to treatment is often indicated. For example, radiation therapy can have adverse effects on wound healing, and if the patient is to undergo surgery after radiation, radiation treatment should be planning in such a way as to minimize the effects on the surgical bed. Chemotherapy can also potentiate the effects of radiation on both normal tissue and tumor. As a result, determination of the optimal treatment approach often results from evaluation of a patient from surgical, medical oncology, as well as radiation oncology perspectives, and with the help of input from other allied specialties such as pathology, radiology, neurology, and physiatry. Radiation therapy can be broadly defined as the use of ionizing radiation for the treatment of neoplasms. The most commonly utilized form of radiation is photon radiation, commonly known as x-rays or gamma rays.
This chapter briefly discusses the evaluation and management of lymphoma. It provides a brief description on introduction, epidemiology and etiology, signs and symptoms, diagnosis and staging, prognostic factors of non-Hodgkin lymphoma and Hodgkin lymphoma. Non-Hodgkin lymphoma refers to all malignancies of the lymphoid system, with the exception of Hodgkin disease. The treatment of non-Hodgkin lymphoma’s can vary greatly depending on several factors including tumor stage, lymphoma-related symptoms, patient’s age and comorbidities but it is mostly driven by the histology of the disease and its biologic characteristics (e.g., indolent vs. aggressive lymphoma). Hodgkin disease is typically considered a chemotherapy and radiation sensitive disease. Clearly, advances in the treatment of lymphoma have been significant, and may be among the most successful of any malignancy. As new drugs and new treatment paradigms emerge, the probability of curing or managing these patients will improve still further.
This chapter delves into some of the frequently encountered cancers in childhood, their incidence, and common presenting features from a rehabilitation practitioner’s point of view. It highlights the multimodality approach in treatment for various types of pediatric cancer. Pediatric cancer is fairly rare compared to cancer in adults. There has been a remarkable progress in the outcomes for cancer in childhood overall, over the past half-century. One of the key determinants for this success has been a collaborative effort by pediatric oncologists all over the world in enrolling majority of the patients in cooperative group studies. With improved survival, there have been efforts to decrease the intensity of treatment to curtail some of the long-term effects in low-risk cancers. Recently, there has been explosive growth in genomic information that led to a better understanding of various subtypes, revised classifications, and therapeutic strategies for various cancers.
Gynecologic cancers have the potential to originate from anywhere in the reproductive tract, which includes the uterus, ovaries, cervix, vulva, vagina, fallopian tubes, or peritoneum. This chapter focuses on three gynecologic cancers, namely endometrial, ovarian, and cervical carcinomas. The interested reader is referred elsewhere for a more detailed description of these cancers and for information on the other less common gynecologic malignancies. The initial treatment of endometrial cancer involves surgical staging if the patient is medically fit. Adjuvant therapy is based on several key factors, namely stage, grade, and age, with the goal of adjuvant therapy to decrease the risk of cancer recurrence. Surgery followed by postoperative chemotherapy is the standard treatment for all patients with advanced-stage epithelial ovarian cancer and for many patients with early-stage disease. Postoperative chemotherapy is known to significantly prolong survival, and the current data support the use of platinum- and taxane-based regimens.
This chapter discusses about immobilization using reusable devices such as prone belly board; supine thoracic immobilization; prone breast system; and conformal bag systems. It also describes immobilization with single use devices including thermoplastic masks; custom head pads; and alpha cradle device. The chapter also presents immobilization using special devices such as bite block or mouthpiece and bolus material. It describes patient setup, motion management, scan acquisition and virtual simulation, patient marking, and quality assurance and charting. The patient should be placed in a reproducible and comfortable position so he or she is able to hold the position for the entire treatment using immobilization devices as an aid. Sites including lung, liver, breast, and pancreas are affected by respiratory motion. This motion may be accounted for via margins that represent the extent of motion as determined by fluoroscopy or 4D-CT imaging, reducing the motion, and adapting the treatment.