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Chemotherapy
The overall purpose of chemotherapy is to treat or prevent metasratic disease and reduce the size of the tumor for surgical resection or palliative care. Patients may receive single agents or a combination of agents. Chemotherapy can be performed preoperatively and postoperatively. Chemotherapy is usually delivered systemically, via
intravenous or cenrral lines, bll[ may be directly injected in or near a
tumor. Patients may receive a single or multiple rounds of chemotherapy over time to treat their cancer and to possibly minimize side effects. Side effects of chemotherapy include nausea, vomiting,
342 ACtrrE CARE HANDBOOK FOR I'HYSICAL THERAI'ISTS
"cancer pain," and loss of hair and other fast-growing cells, including platelets and red and white blood cells.
Different types of chemotherapeutic agents have different mechanisms
of action. Alkylating agents and nitrosoureas inhibit cell growth and division by reacting with DNA. Antimetabolites prevent cell growth by competing with metabolites in production of nucleic acid. Plant alkaloids prevent cellular reproduction by disrupting cell mitosis.12
Chemotherapeuric agents are listed in Appendix IV, Tables rV-IS.A-H.
Clinical Tip
• Some chemotherapeuric agents are so toxic to humans
that patients may have to remain in their rooms while the
agents are being delivered to avoid risk to other patients
and health care workers. Physical therapists should check
with the patient'S physician if unsure.
•
Nausea and vomiting after chemotherapy vary on a
patient-to-patient basis. The severity of these side effects
may be due to the disease stage, chemotherapeutic dose, or
number of rounds. Some side effects may be so severe as to
limit physical therapy, whereas others can tolerate activity.
Rehabilitation should be delayed or modified until the side
effects from chemotherapy are minimized or alleviated.
•
Patients may be taking antiemetics, which help to control
nausea and vomiting after chemotherapy. The physical therapisr should alert the physician when nausea and vomiting
limit the patient'S ability to participate in physical therapy so
that the antiemetic regimen may be modified or enhanced.
Antiemetics are listed in Appendix lV, Table lV-6.
• Chemotherapy agents affect the patient's apperite and
ability to consume and absorb nutrients. This decline in
nutritional status can inhibit the patient's progression in
strength and conditioning programs. Proper nutritional
support should be provided and directed by a nutritionist.
Consulting with the nutritionist may be beneficial when
planning the appropriate activity level that is based on a
patient's caloric intake.
•
Patients should be aware of the possible side effects
and understand the need for modification or delay of
rehabilitation effortS. Patients should be given emotional
ONCOLOGY 343
supporr and encouragement when rhey are unable to
achieve the goals that they have initially set. Intervention
may be coordinated around rhe patient's medication
schedule.
• Vital signs should always be monitored, especially when
patients are taking the more toxic chemotherapy agents that
affect the hearr, lungs, and central nervous system.
• Platelet and red and white blood cell counts should be
monitored with a patient on chemotherapy. The Bone
Marrow Transplant section in Chapter 12 suggests therapelitic activities with altered blood cell counts.
• Patients receiving chemotherapy can become neutropenic.
They can be at risk for infections and sepsis.' (A neutrophil is
a type of leukocyte or white blood cell that is often the first
immunologic cell at the site of infection; neutropenia is an
abnormally low neutrophil count. Refer to Bone Marrow
Transplantation in Chapter L2 for reference value of neurropenia.) Therefore, patients undergoing chemotherapy may be
on neutropenic precautions, stich as being in isolation. Follow the institution's guidelines for precautions when treating these patients to help reduce the risk of infections. Examples
of these guidelines can be found in the Bone Marrow Transplantation section of Chapter 12.
Biotherapy
Hormonal therapy and immunotherapy also play an important role in
managing cancer. Hormonal therapy includes medically or surgically
eliminating the hormonal source of cancer (e.g., orchiectomy,
oophorectomy, or adrenalectomy) or pharmacologically changing
hormone levels.'·' Immunotherapy includes enhancing the patient'S
immune system and changing the immune system's response to the
cancer, most commonly with recombinant growth factors, such as
interferon-alpha or interleukin.
Hormonal therapy is most commonly used to treat breast and
prostate cancer. Some breast tumor cells contain estrogen in their
cytoplasm (estrogen-receptor positive). Use of antiestrogens, such as
tamoxifen, may keep the tumor from enlarging or metastasizing.
344 AClffE CARE HANDBOOK FOR PHYSICAL THERAPISTS
Elimination of the source of androgens in prostate cancer via orchiectomy may also reduce the cancer's spread.
Colony-stimulating factors may be used to sustain the patient
with low blood counts during cancer treatment. Colony-stimulating
factors, such as erythropoietin, may be given to reduce anemia.7
MO/lOclona/ alltibodies are antibodies of a single type produced by a
single line of B lymphocytes. The antibodies are produced specifically
to attach themselves to specific types of tumor cells. These antibodies
can be used alone to anack cancer cells or may have radioactive material bound to them.
Cancers in the Body Systems
Cancers can invade or affect any organ or tissue in the body. The following is a description of various cancers in each body system.
Pulmonary Cancers
Cancer can affect any structure of the pulmonaty sysrem. The cOlTlmon
types of lung cancer are squamous cell carcinoma, adenocarci1loma,
small cell carcinoma, and large cell carcinoma.6.7 Symptoms associated
with these include chronic cough, dyspnea, adventitious breath sounds
(e.g., wheezing, crackles), chest pain, and hemoptysis.'
Nonsurgical techniques, such as x-ray, computerized axial
romography, and positron emission tomography, can be lIsed to
stage lung cancer." Table 5-7 describes pulmonary cancer sites and
Table 5-7. Surgical lmerventions for Pulmonary Cancers
Area Involved
Surgical Procedure
Excision of
Pleura
Pleurecromy
Portion of pleura
Rib
Rib resection
Portion of rib
Trachea n.nd
Tracheal repair and
Trachea
bronchi
reconstcuction
Sleeve resection
Portion of main stem bronchus
Lung
Pneumonectomy
Entire single lung
lobec(Qmy
Single oc mulriple lobes of the lung
Wedge cesection
\Vedge-shaped segmenr of lung