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 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.