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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