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    PTPM008B PTM of Oncology and Palliative Care-related Medic… - Presentation Transcript

    1. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 1 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS SPEC. BY: Abdulrehman S. Mulla DATE: 04/09/2009 REVISION HISTORY REV. DESCRIPTION CN No. BY DATE 01 Initial Release PT0008 ASM 04/09/2009 Medicine: it’s a noble profession, it serves humanity 1/122
    2. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 2 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. TABLE OF CONTENTS PAGE 5.0 BREAST CANCER: 7 5.1 NONINVASIVE BREAST CANCER: 8 5.2 INVASIVE BREAST CANCER: 8 5.3 RISK FACTORS: 8 5.3.1 RISK FACTORS FOR BREAST CANCER INCLUDE: 9 A. AGE: 9 B. RACE AND ETHNICITY: 9 C. FAMILY AND PERSONAL HISTORY: 10 D. GENETIC FACTORS: 10 E. EXPOSURE TO ESTROGEN: 10 F. BREAST ABNORMALITIES: 11 5.3.3 PHYSICAL CHARACTERISTICS: 13 A. ENVIRONMENTAL FACTORS: 13 I. EXPOSURE TO ESTROGEN-LIKE INDUSTRIAL CHEMICALS. 13 II. EXPOSURE TO DIETHYLSTILBESTROL. 13 III. RADIATION EXPOSURE. 13 IV. DISPROVEN RISK FACTORS: 13 5.4 SYMPTOMS: 13 5.5 DIAGNOSIS: 14 5.5.1 MONTHLY SELF-EXAMINATION: 14 5.6 MAMMOGRAMS: 15 5.6.1 CURRENT RECOMMENDATIONS FOR SCREENING: 15 5.6.2 OTHER IMAGING TECHNIQUES: 16 A. MAGNETIC RESONANCE IMAGING AND ULTRASOUND: 16 B. SCINTIMAMMOGRAPHY: 18 5.6.3 BIOPSY: 18 5.7 LYMPHADENECTOMY: 20 5.7.1 SENTINEL NODE BIOPSY: 20 5.8 PROGNOSIS: 21 5.8.1 LOCATION OF THE TUMOR: 21 5.8.2 HORMONE RECEPTOR-POSITIVE OR –NEGATIVE: 22 5.8.3 TUMOR MARKERS: 22 5.8.4 GENE EXPRESSION PROFILING: 23 5.8.5 OTHER FACTORS FOR PREDICTING OUTLOOK: 23 A. TUMOR SIZE AND SHAPE: 23 B. RATE OF CELL DIVISION: 23 5.9 EFFECT OF EMOTIONS AND PSYCHOLOGICAL SUPPORT: 23 5.9.1 TREATMENT: 23 A. LOCAL TREATMENT: 24 B. SYSTEMIC TREATMENT: 24 C. CANCER STAGE AND TREATMENT OPTIONS: 24 D. TREATMENT OPTIONS FOR DCIS INCLUDE: 25 E. TREATMENT OPTIONS FOR LCIS INCLUDE: 25 I. STAGE I AND II (EARLY-STAGE INVASIVE): 26 II. STAGE II CANCER IS CLASSIFIED AS EITHER STAGE IIA OR STAGE IIB: 26 1. Treatment options for stage i and stage ii breast cancer may include: 26 2. Stage iii (locally advanced): 26 a. In stage iiia breast cancer, the tumor is either: 26 3. Treatment options for stage iiia breast cancer are the same as those for stages i and ii. 26 a. Stage iiib: 26 b. Stage iiic: 27 c. Treatment options for operable stage iii breast cancer: 27 5. Stage iv (advanced cancer): 27 a. Treatment options for stage iv cancer include: 28 5.10 POST-TREATMENT CARE: 28 5.10.1 GENETIC COUNSELING MAY BE HELPFUL IF YOU HAVE: 29 5.10.2 PREGNANCY AFTER BREAST CANCER TREATMENT: 29 Medicine: it’s a noble profession, it serves humanity 2/122
    3. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 3 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.11 RECURRENT BREAST CANCER: 29 5.12 SURGERY: 30 5.12.1 BREAST-CONSERVING PROCEDURES: 30 A. LUMPECTOMY: 30 B. BREAST-CONSERVING SURGERY: 30 5.12.2 MASTECTOMY: 30 5.12.3 COMPLICATIONS AND SIDE EFFECTS OF SURGERY: 31 5.13 RADIATION: 32 5.13.1 ADMINISTRATION OF RADIATION THERAPY: 32 A. EXTERNAL BEAM RADIATION: 32 B. BRACHYTHERAPY: 32 C. SIDE EFFECTS OF RADIATION THERAPY: 33 D. LONG-TERM COMPLICATIONS: 33 5.14 CHEMOTHERAPY: 33 5.14.1 SIDE EFFECTS OF CHEMOTHERAPY: 34 5.14.2 HIGH-DOSE CHEMOTHERAPY WITH BONE MARROW OR PERIPHERAL-BLOOD STEM CELL TRANSPLANTATION: 35 A. HORMONE THERAPY: 35 B. TAMOXIFEN AND SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS): 35 5.15 AROMATASE INHIBITORS: 36 5.16 OVARIAN ABLATION: 36 5.16.1 CHEMICAL OVARIAN ABLATION: 36 5.16.2 BILATERAL OOPHORECTOMY: 37 5.17 AFTER IMPLANT SURGERY: 37 5.18 AFTER YOU LEAVE: 38 5.19 CALL YOUR DOCTOR IF: 39 5.20 CANCER REHABILITATION: 39 5.20.1 LYMPHEDEMA REHABILITATION: 40 5.20.2 EXERCISES AFTER BREAST SURGERY: 40 6.0 LUNG CANCER: 43 6.1 SYMPTOMS: 43 6.2 CAUSES: 43 6.2.1 SMOKING CAUSES LUNG CANCER: 44 6.3 TYPES OF LUNG CANCER: 44 6.4 RISK FACTORS 44 6.5 TESTS AND DIAGNOSIS: 45 6.5.1 SCREENING: 45 6.5.2 DIAGNOSIS: 45 6.5.3 STAGING: 47 A. STAGES OF NON-SMALL CELL LUNG CANCER: 47 I. Stage I. 47 II. Stage II. 47 III. Stage IIIA. 47 IV. Stage IIIB. 47 V. Stage IV. 48 B. STAGES OF SMALL CELL LUNG CANCER: 49 6.6 COMPLICATIONS: 49 6.7 TREATMENTS AND DRUGS: 50 6.7.1 SURGERY: 51 6.7.2 CHEMOTHERAPY: 51 6.7.3 RADIATION THERAPY: 52 6.7.4 TARGETED DRUG THERAPY: 52 6.7.5 CLINICAL TRIALS: 53 6.7.6 SUPPORTIVE (PALLIATIVE) CARE: 53 6.8 PREVENTION: 53 6.9 ALTERNATIVE MEDICINE: 54 6.10 PHYSICAL THERAPY AFTER LUNG CANCER: 55 6.10.1 AEROBIC EXERCISE AS THERAPY FOR CANCER FATIGUE: 55 A. TRAINING PROGRAM: 56 7.0 PROSTATE CANCER: 58 7.1 SYMPTOMS: 59 Medicine: it’s a noble profession, it serves humanity 3/122
    4. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 4 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.2 CAUSES: 60 7.3 RISK FACTORS: 60 7.4 WHEN TO SEEK MEDICAL ADVICE: 61 7.5 TESTS AND DIAGNOSIS: 61 7.5.1 DETERMINING HOW FAR THE CANCER HAS SPREAD: 61 7.5.2 GRADING: 63 7.5.3 STAGING: 63 A. STAGE I. 63 B. STAGE II. 63 C. STAGE III. 63 D. STAGE IV. 63 7.6 COMPLICATIONS: 64 7.6.1 THE TYPICAL COMPLICATIONS OF PROSTATE CANCER AND ITS TREATMENTS INCLUDE: 64 A. SPREAD OF CANCER: 64 B. PAIN: 64 C. DIFFICULTY URINATING (URINARY INCONTINENCE): 64 D. ERECTILE DYSFUNCTION (ED) OR IMPOTENCE: 64 E. DEPRESSION: 64 7.7 TREATMENTS AND DRUGS: 65 7.6.1 EXTERNAL BEAM RADIATION THERAPY (EBRT): 65 A. SIDE EFFECTS OF EBRT: 65 7.6.2 RADIOACTIVE SEED IMPLANTS: 66 A. SIDE EFFECTS OF RADIOACTIVE SEED IMPLANTS: 66 7.6.3 HORMONE THERAPY: 68 A. SIDE EFFECTS OF HORMONE THERAPY: 68 B. CERTAIN HORMONE THERAPY MEDICATIONS CAN ALSO CAUSE: 68 7.6.4 RADICAL PROSTATECTOMY: 69 A. SIDE EFFECTS OF RADICAL PROSTATECTOMY: 70 7.6.5 ROBOT-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (RALRP): 70 7.6.6 WATCHFUL WAITING: 70 7.6.7 CHEMOTHERAPY: 71 7.6.8 CRYOTHERAPY: 71 7.6.9 GENE THERAPY AND IMMUNE THERAPY: 72 7.7 PREVENTION: 72 7.8 COPING AND SUPPORT: 73 7.9 ALTERNATIVE MEDICINE: 73 7.10 PHYSICAL THERAPY AND EXERCISE BEFORE AND AFTER PROSTATE CANCER: 75 7.10.1 PHYSICAL THERAPY / EXERCISE PROGRAM: 75 7.10.2 MANUAL THERAPY: 76 7.10.3 SEVEN BENEFITS OF REGULAR PHYSICAL ACTIVITY: 77 7.10.4 BLADDER CANCER REHABILITATION: 79 A. PHYSICAL THERAPY / EXERCISE PROGRAM: 79 I. BORG RATING OF PERCEIVED EXERTION (RPE): 79 II. FLEXIBILITY PROGRAM: 80 III. THE BENEFITS OF STRETCHING: 80 IV. PELVIC FLOOR EXERCISES FOR WOMEN: 80 1. PELVIC FLOOR EXERCISE ONE: 80 2. PELVIC FLOOR EXERCISE TWO: 80 V. PELVIC FLOOR EXERCISES FOR MEN: 81 1. HOW TO DO THE EXERCISES: 81 2. HOW LONG TO CONTINUE WITH THE EXERCISES: 82 8.0 LEUKEMIA: 84 8.1 TYPES OF LEUKEMIA: 84 8.1.1 COMMON TYPES OF LEUKEMIA: 85 8.2 LEUKEMIA RISKS 86 8.2.1 RISK FACTORS FOR LEUKEMIA: 86 8.3 SYMPTOMS OF LEUKEMIA: 86 8.3.1 COMMON SYMPTOMS OF LEUKEMIA: 86 8.4 LEUKEMIA DIAGNOSES? 87 8.4.1 DIFFERENTIAL DIAGNOSIS 88 Medicine: it’s a noble profession, it serves humanity 4/122
    5. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 5 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 8.5 LEUKEMIA TREATMENT: 89 8.5.1 GETTING A SECOND OPINION: 89 8.5.2 PREPARING FOR TREATMENT: 89 8.5.3 METHODS OF TREATMENT: 90 A. CHEMOTHERAPY: 90 B. BIOLOGICAL THERAPY: 92 C. RADIATION THERAPY: 93 D. STEM CELL TRANSPLANTATION: 93 8.5.4 SIDE EFFECTS OF TREATMENT FOR LEUKEMIA: 97 A. CHEMOTHERAPY: 97 B. BIOLOGICAL THERAPY: 98 C. RADIATION THERAPY: 98 D. STEM CELL TRANSPLANTATION: 98 8.5.5 WHAT HAPPENS AFTER TREATMENT FOR LEUKEMIA? 98 A. SUPPORTIVE CARE: 98 B. NUTRITION: 99 C. FOLLOWUP CARE: 99 D. SUPPORT FOR PEOPLE WITH LEUKEMIA: 99 8.5.6 WHAT DOES THE FUTURE HOLD FOR PATIENTS WITH LEUKEMIA?: 100 8.6 LEUKEMIA AT A GLANCE: 100 8.7 PHYSICAL THERAPY INTERVENTIONS: 100 8.7.1 EVIDENCE: 100 A. MAKING THERAPY FUN: 101 I. RECOMMENDED INTERVENTION: 101 II. PHYSICAL THERAPY PRECAUTIONS: 101 III. PSYCHOSOCIAL MANIFESTATIONS: 101 IV. OTHER INFORMATION: 102 9.0 LYMPHOMA: 103 9.1 LYMPHOMA CAUSES: 106 9.2 LYMPHOMA SYMPTOMS: 107 9.2.1 SYMPTOMS OF LYMPHOMA MAY INCLUDE THE FOLLOWING: 107 9.3 WHEN TO SEEK MEDICAL CARE: 107 9.4 EXAMS AND TESTS: 107 9.4.1 BLOOD TESTS: 108 A. BIOPSY: 108 B. IMAGING STUDIES: 109 C. BONE MARROW EXAMINATION: 109 D. OTHER TESTS: 109 9.4.2 STAGING: 110 9.4.3 PROGNOSTIC FACTORS: 111 9.5 LYMPHOMA TREATMENT: 111 9.5.1 MEDICAL TREATMENT: 113 A. RADIATION THERAPY: 113 B. CHEMOTHERAPY: 113 I. CHEMOTHERAPY PILLS: 113 II. DRUG COMBINATIONS; 114 III. CHEMOTHERAPY CYCLES. 114 C. BIOLOGICAL THERAPY: 114 I. MONOCLONAL ANTIBODIES: 114 II. CYTOKINES: 114 III. VACCINES: 115 9.5.2 MEDICATIONS: 115 9.5.3 OTHER THERAPIES: 115 A. WATCHFUL WAITING: 115 B. CLINICAL TRIALS: 116 C. COMPLEMENTARY/ALTERNATIVE THERAPIES: 116 9.6 NEXT STEPS: 116 9.7 PREVENTION: 116 9.8 OUTLOOK: 117 9.9 SUPPORT GROUPS AND COUNSELLING: 117 Medicine: it’s a noble profession, it serves humanity 5/122
    6. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 6 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.10 PHYSICAL THERAPY INTERVENTIONS FOR LYMPHOMA: 117 9.10.1 PHYSICAL EVALUATION: 117 A. PHYSICAL THERAPY / EXERCISE PROGRAM: 118 B. BORG RATING OF PERCEIVED EXERTION (RPE) - 118 C. FLEXIBILITY PROGRAM: 118 D. MANUAL THERAPY: 118 10.0 PALLIATIVE CARE: 119 10.1 THE ROLE OF PHYSIOTHERAPY IN PALLIATIVE CARE: 120 10.1.1 CONDITIONS SEEN IN PALLIATIVE CARE: 120 10.1.2 AIMS OF PHYSIOTHERAPY: 121 Medicine: it’s a noble profession, it serves humanity 6/122
    7. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 7 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.0 BREAST CANCER: Breast cancers are potentially life-threatening malignancies that develop in one or both breasts. The structure of the female breast is important in understanding this cancer:  The interior of the female breast consists mostly of fatty and fibrous connective tissues.  It is divided into about 20 sections called lobes.  Each lobe is further subdivided into a collection of lobules, structures that contain small milk-producing glands.  These glands secrete milk into a complex system of tiny ducts. The ducts carry the milk through the breast and converge in a collecting chamber located just below the nipple.  Breast cancer is either noninvasive (referred to as in situ, confined to the site of origin) or invasive (spreading). Medicine: it’s a noble profession, it serves humanity 7/122
    8. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 8 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.1 NONINVASIVE BREAST CANCER: Noninvasive breast cancers include:  Ductal carcinoma in situ (also called intraductal carcinoma or DCIS). DCIS consist of cancer cells in the lining of the duct. DCIS is a non-invasive, early cancer, but if left untreated, it may sometimes progress to an invasive, infiltrating ductal breast cancer. DCIS is the most common type of noninvasive breast cancer.  Lobular carcinoma in situ, or LCIS. Although it is technically not a cancer, lobular carcinoma in situ is a marker for an increased risk of invasive cancer the same or both breasts. A diagnosis of these early cancers (DCIS and LCIS) is made when there is no evidence of invasion. 5.2 INVASIVE BREAST CANCER: Invasive cancer occurs when cancer cells spread beyond the basement membrane, which covers the underlying connective tissue in the breast. This tissue is rich in blood vessels and lymphatic channels that are capable of carrying cancer cells beyond the breast. Invasive breast cancers include the following:  Invasive (also called infiltrating) ductal carcinoma. This is invasive breast cancer that penetrates the wall of a milk-passage duct. It comprises between 70 - 80% of all breast cancer cases.  Invasive (also called infiltrating) lobular carcinoma. This invasive cancer has spread through the wall of a milk-producing lobule. It accounts for 10 - 15% of all breast cancers. It may sometimes appear in both breasts, sometimes in several separate locations. 5.3 RISK FACTORS: Breast cancer is the second leading cause of cancer deaths in women today (after lung cancer) and is the most common cancer among women, excluding nonmelanoma skin cancers. According to the American Cancer Society, about 1.3 million women will be diagnosed with breast cancer annually worldwide about 465,000 will Medicine: it’s a noble profession, it serves humanity 8/122
    9. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 9 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. die from the disease. Breast cancer death rates have been dropping steadily since 1990, according to the Society, because of earlier detection and better treatments. About 40,910 breast cancer deaths are expected in 2007. According to the American Cancer Society, in general, breast cancer rates have risen about 30% in the past 25 years in western countries, due in part to increased screening which detects the cancer in earlier stages. In the United States, though, breast cancer rates decreased by 10% between 2000-2004, due in part to a reduction in the use of hormone replacement therapy. Although breast cancer rates are rising in many western countries, deaths from the disease have decreased in some countries as a result of improved screening and treatment. The lifetime probability of developing breast cancer in developed countries is about 4.8%, according to the American Cancer Society (the probability is about 13% for any type of cancer). In developing countries, the lifetime probability of developing breast cancer is about 1.8%. Breast Cancer Worldwide Breast (All ages) Incidence Deaths China Zimbabwe India Japan Brazil Singapore Italy Switzerland Australia Canada Netherlands UK Sweden Denmark France United States 5.3.1 RISK FACTORS FOR BREAST CANCER INCLUDE: A. AGE: Most cases of breast cancer occur in women older than age 60. According to the American Cancer Society, about 1 in 8 cases of invasive breast cancer are found in women younger than age 45, while 2 in 3 cases of invasive breast cancer occur in women age 55 and older. B. RACE AND ETHNICITY: Breast cancer is slightly more common among white woman than African-American, Asian, Latina, or Native American women. However, African-American women tend to have more aggressive types of breast cancer tumors and are more likely to die from breast cancer than women of other races. It is unclear whether this is mainly due to biologic or socioeconomic reasons. Social and economic factors make it less likely that African-American women will be screened, so they are Medicine: it’s a noble profession, it serves humanity 9/122
    10. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 10 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. more likely to be diagnosed at a later stage. They are also less likely to have access to effective treatments. Breast cancer is also more prevalent among Jewish women of Eastern European (Ashkenazi) descent (see Genetic Factors). C. FAMILY AND PERSONAL HISTORY: Women who have a family history of breast cancer are at increased risk for developing breast cancer themselves. Having a first-degree relative (mother, sister, or daughter) who has been diagnosed with breast cancer doubles the risk for developing breast cancer. Women who have had ovarian cancer are at increased risk for developing breast cancer. And, a personal history of breast cancer increases the risk of developing a new cancer in the same or other breast. D. GENETIC FACTORS: About 5 - 10% of breast cancer cases are due to inherited genetic mutations. BRCA Genes. Inherited mutations in genes known as BRCA1 or BRCA2 are responsible for most cases of hereditary breast cancers, ovarian cancers, or both in families with a history of these cancers. BRCA gene mutations are present in only about 0.5% of the overall population. However, certain ethnic groups -- such as Jewish women of Eastern European (Ashkenazi) descent -- have a higher prevalence (2.5%) of BRCA gene mutations. BRCA gene mutations are also seen in some African-American and Hispanic women. Screening Guidelines for BRCA Genes. The U.S. Preventive Services Task Force (USPSTF) recommends that women at high risk should be tested for BRCA genes, but does not recommend routine genetic counseling or testing in low-risk women (no family history of BRCA 1 or 2 genetic mutations). Risk assessment is based on a womans family history of breast and ovarian cancer (on both the maternal and paternal sides). The relevance of the inherited BRCA1 or BRCA2 mutations to survival is controversial. Some studies have suggested that these mutations are linked to less lethal breast cancer. Others suggest that they do not change prognosis or may worsen it. Women with these genetic mutations do have a greater risk for a new cancer to develop. Patients with BRCA1 mutations tend to develop tumors that are hormone receptor negative, which can behave more aggressively. Other Genetic Mutations. Other genes associated with increased hereditary breast cancer risk include p53, CHEK2, ATM, and PTEN. E. EXPOSURE TO ESTROGEN: Because growth of breast tissue is highly sensitive to estrogens, the more estrogen a woman is exposed to over her lifetime, the higher her risk for breast cancer. Duration of Estrogen Exposure. Early age at menarche (first menstrual period) or later age at menopause may slightly increase a womans risk for breast cancer. Pregnancy. Women who have never had children or who had their first child after age 30 may have a slightly increased breast cancer risk. Having children at an early age, and having multiple pregnancies, reduces breast cancer risk. Evidence does not show an association between abortion and increased breast cancer risk. Studies have been mixed on whether breast-feeding decreases breast cancer risk. Breast- feeding reduces a womans total number of menstrual cycles, and thereby estrogen exposure, Medicine: it’s a noble profession, it serves humanity 10/122
    11. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 11 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. which may account for its possible protective effects. Some studies suggest that the longer a woman breast-feeds, the lower her risk. Oral Contraception. Although studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer, the most recent research indicates that current or former oral contraceptive use does not significantly increase breast cancer risk. Women who have used oral contraceptives may have slightly more risk for breast cancer than women who have never used them, but this risk declines once a woman stops using birth control pills. Hormone Replacement Therapy. Many studies have reported a higher risk for breast cancer in postmenopausal women who take combination hormone replacement therapy (HRT), which contains both estrogen and progestin. A combination of estrogen and testosterone also increases breast cancer risk. Several studies of women who had a hysterectomy indicate that estrogen alone does not increase overall breast cancer risk when the drug is used for 7 years or less. However, women who take estrogen for 10 - 15 years or more do have an increased risk, especially women who are already at higher risk for breast cancer. In addition, HRT increases breast cancer density, making mammograms more difficult to read. This can cause cancer to be diagnosed at a later stage. Women who take estrogen HRT should be aware that they need frequent mammogram screenings. The North American Menopause Society recommends that women who are at risk for breast cancer should avoid hormone therapy and try other options to manage menopausal symptoms such as hot flashes. Most doctors recommend that women use HRT only for short-term relief of menopausal symptoms. [For more information, see In-Depth Report #40: Menopause.] Infertility and Infertility Treatments. Despite some concerns that infertility treatments using the drug clomiphene may increase the risk for breast cancer, most studies do not show an association. Some studies indicate that ovulation induction with clomiphene may actually decrease breast cancer risk. (Clomphine is related to tamoxifen, a drug that is used for breast cancer prevention in high-risk women.) F. BREAST ABNORMALITIES:  Abnormalities or Breast Conditions Suggesting a Higher Risk. Certain factors and breast conditions may increase the risk for breast cancer:  Dense breast tissue is associated with a higher risk for breast cancer. Studies suggest that women with highly dense tissue have 2 - 6 times the risk of women with the least dense tissue. Genetic factors play a large role in breast density. Hormone replacement therapy also increases breast density. In addition, dense breasts make mammograms more difficult to read, which increases the likelihood of missing early signs of cancer.  Benign proliferative breast disease, or unusual cell growth known as atypical hyperplasia, is a significant risk factor for breast cancer. Some common benign breast abnormalities that pose few or no risks include the following:  Cysts. These mostly occur in women in their middle-to-late reproductive years and can be eliminated simply by aspirating fluid from them. Medicine: it’s a noble profession, it serves humanity 11/122
    12. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 12 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Fibroadenoma. These are solid benign lumps that occur in women ages 15 - 30.  Breast abscesses during breast-feeding.  Nipple discharge. Discharge from the nipple is worrisome to patients, but is unlikely to be a sign of cancer. Unexplained discharge still warrants evaluation, however.  Mastalgia. This is breast pain that occurs in association with, or independently from, the menstrual cycle. About 8 - 10% of women experience moderate-to-severe breast pain associated with their menstrual cycle. In general, breast pain does not need assessment unless it is severe and prolonged. Medicine: it’s a noble profession, it serves humanity 12/122
    13. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 13 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.3.3 PHYSICAL CHARACTERISTICS: The following physical characteristics have been associated with increased risk:  Obesity increases the risk for all types of estrogen receptor-positive breast cancers. Women who gain weight after menopause are most at risk. (On a positive note, losing weight after menopause decreases breast cancer risk.) In postmenopausal women, estrogen is produced in fat tissue. High amounts of fatty tissue increase levels of estrogen in the body, leading to faster growth of estrogen- sensitive cancers.  Estrogen is involved in building bone mass. Therefore, women with heavy, dense bones are likely to have higher estrogen levels and to be at greater risk for breast cancer.  Some studies have found a greater risk for breast cancer in taller women, possibly due to the higher estrogen levels associated with greater bone growth. A. ENVIRONMENTAL FACTORS: I. EXPOSURE TO ESTROGEN-LIKE INDUSTRIAL CHEMICALS. Chemicals with estrogen-like effects, called xenoestrogens, have been under suspicion for years. There has been particular concern with pesticides containing organochlorines (DDT and its metabolites, such as dieldrin) and pyrethroids (permethrin), but at this time evidence of any causal association is very weak. II. EXPOSURE TO DIETHYLSTILBESTROL. Women who took diethylstilbestrol (DES) to prevent miscarriage have a slightly increased risk for breast cancer. There may also be a slightly increased risk for their daughters (commonly called \"DES daughters\"), who were exposed to the drug when their mothers took it during pregnancy. III. RADIATION EXPOSURE. Heavy exposure to radiation is a significant risk factor for breast cancer. Girls who received high-dose radiation therapy for cancer face an increased risk for breast cancer in adulthood. Low-dose radiation exposure before age 20 may increase the risk for women with BRCA genetic mutations. IV. DISPROVEN RISK FACTORS: Antiperspirants or use of deodorants after shaving have not been linked with any higher risk for breast cancer. There is also no evidence that bras increase breast risk. Abortion does not increase risk. 5.4 SYMPTOMS: Breast cancers in their early stages are usually painless. Often the first symptom is the discovery of a hard lump. Fifty percent of such masses are found in the upper outer quarter of the breast. The lump may make the affected breast appear elevated or asymmetric. The nipple may be retracted or scaly. Sometimes the skin of the breast is dimpled like the skin of an orange. In some cases there is a bloody or clear discharge from the nipple. Many cancers, however, produce no symptoms and cannot be felt on examination. They can be detected only with a mammogram. Breast self-exam Medicine: it’s a noble profession, it serves humanity 13/122
    14. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 14 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.5 DIAGNOSIS: Breast Examination by a Health Professional. Women ages 20 - 49 should have a physical examination by a health professional every 1 - 2 years. Those over age 50 should be examined annually. Self-Examinations. Women have been encouraged to perform a self-examination each month, but some studies have reported no difference in mortality rates between women who do self-examination and those who do not. This does not mean women should stop attempting self-examinations, but they should not replace the annual examination done by a health professional. 5.5.1 MONTHLY SELF-EXAMINATION: 1. Pick a time of the month that is easy to remember and perform self-examination at that time each month. The breast has normal patterns of thickness and lumpiness that change within a monthly period, and a consistently scheduled examination will help differentiate between what is normal from abnormal. Many doctors recommend breast awareness rather than formal monthly self- examinations. 2. Stand in front of a mirror. Breasts should be basically the same size (one may be slightly larger than the other). Check for changes or redness in the nipple area. Look for changes in the appearance of the skin. With hands on the hips, push the pelvis forward and pull the shoulders back and observe the breasts for irregularities. Repeat the observation with hands behind the head. Move each arm and shoulder forward. 3. Lie down on the back with a rolled towel under one shoulder. Apply lotion or bath oil over the breast area. The finger action should be as follows: Using the 2nd, 3rd, and 4th finger pads (not tips) held together, make dime-sized circles. Press lightly first to feel the breast area, then press harder using a circular motion. Medicine: it’s a noble profession, it serves humanity 14/122
    15. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 15 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Using this motion, start from the collarbone and move downward to underneath the breast. Shift the fingers slightly over, slightly overlapping the previously checked region, and work upward back to the collarbone. Repeat this up-and-down examination until the entire breast area has been examined. Be sure to cover the entire area from the collarbone to the bottom of the breast area and from the middle of the chest to the armpits. Move the towel under the other shoulder and repeat the procedure. Examine the nipple area, by gently lifting and squeezing it and checking for discharge. 4. Repeat step 3 in an upright position. (The shower is the best place for this, using plenty of soap.) Note: A lump can be any size or shape and can move around or remain fixed. Of special concern are specific or unusual lumps that appear to be different from the normal varying thicknesses in the breast. 5.6 MAMMOGRAMS: 5.6.1 CURRENT RECOMMENDATIONS FOR SCREENING: Mammograms are very effective low-radiation screening methods for breast cancer. At this time, the U.S. Preventive Services Task Force recommends screening mammograms, with or without breast examination, every 1 - 2 years for all women over age 40. Guidelines from the American College of Physicians (ACP), however, debate whether women with a low risk for breast cancer should begin mammogram screening at age 40. The 2007 guidelines, instead, recommend that women in their 40s ask their doctor when they should begin having the test. In contrast, the American Cancer Society and the U.S. National Cancer Institute continue to endorse annual screening for women age 40 and older. Supporters of the ACP guidelines believe that their recommendations reflect some of the risks involved in screening younger women. These risks include radiation exposure and unnecessary biopsies. Mammographies in younger women produce a relatively high rate of false-positive results (when the test falsely indicates breast cancer). Scientists are working on new technologies to improve mammography's accuracy, but more work is needed. Medicine: it’s a noble profession, it serves humanity 15/122
    16. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 16 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Opponents of the ACP guidelines argue that mammograms help catch tumors while they are in their earliest and most treatable stages, and that the most deadly types of breast cancer tend to occur in women in their 40s. After age 50, all guidelines recommend annual screenings. As a woman ages, her risk for developing breast cancer increases. (Women over age 65 account for most new cases of breast cancer.) Women with risk factors for breast cancer, including a close family member with the disease, should consider having annual mammograms starting 10 years earlier than the age at which the relative was diagnosed. 5.6.2 OTHER IMAGING TECHNIQUES: A. MAGNETIC RESONANCE IMAGING AND ULTRASOUND: Magnetic resonance imaging (MRI) and ultrasound techniques can detect very small tumors (less than half an inch). However, they are expensive and time-consuming procedures, and ultrasound may yield more false-positive results. Nevertheless, some doctors believe they are important in identifying small tumors missed on mammography in women who are receiving lumpectomy or breast-conserving surgeries. Such findings allow surgeons to remove the optimal amount of abnormal tissue. Ultrasound may be particularly helpful for women with dense breast tissue who show signs of breast cancer. In 2007, the American Cancer Society recommended that high-risk women have an MRI of their breast with their annual mammogram, including those who have: Medicine: it’s a noble profession, it serves humanity 16/122
    17. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 17 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  A BRCA1 or BRCA2 mutation  A first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves  A lifetime risk of breast cancer that has been scored at 20 - 25% or greater based on various risk assessment tools that evaluate family history and other factors  Had radiation to the chest between ages 10 - 30  Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these genetic syndromes based on a history in a first-degree relative For women who have had cancer diagnosed in one breast, MRIs can also be very helpful for detecting hidden tumors in the other breast. An important study reported that MRI scans of women who were diagnosed with cancer in one breast detected over 90% of cancers in the other breast that had been previously missed by mammography or clinical breast exam. Currently, few women who are diagnosed with cancer in one breast are offered an MRI of the other breast. Some doctors advocate MRIs for all women newly diagnosed with breast cancer; others oppose this view. MRI Medicine: it’s a noble profession, it serves humanity 17/122
    18. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 18 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. scans may be most useful for younger women with breast cancer who have dense breast tissue that may obscure tumors from mammography readings. MRIs are less likely to be helpful for older women with early tumors in one breast and clear mammography readings in the other. It is very important that women have MRIs at qualified centers that perform many of these procedures each year. MRI is a complicated procedure and requires special equipment and experienced radiologists. MRI facilities should also be able to offer biopsies when suspicious findings are detected. B. SCINTIMAMMOGRAPHY: In scintimammography, a radioactive chemical is injected into the circulatory system, which is then selectively taken up by the tumor and revealed on mammograms. This method is used for women who have had abnormal mammograms or for women who have dense breast tissue. It is not used for regular screening or as an alternative to mammography. 5.6.3 BIOPSY: A definitive diagnosis of breast cancer can be made only by a biopsy (a microscopic examination of a tissue sample of the suspicious area).  When a lump can be felt and is suspicious for cancer on mammography, an excisional biopsy may be recommended. This biopsy is a surgical procedure for removing the suspicious tissue and typically requires general anesthetic. Medicine: it’s a noble profession, it serves humanity 18/122
    19. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 19 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  A core biopsy involves a small incision and the insertion of a spring-loaded hollow needle that removes several samples. The patient only requires local anesthetic.  A wire localization biopsy may be performed if mammography detects abnormalities but there is no lump. With this procedure, using mammography as a guide, the doctor inserts a small wire hook through a hollow needle and into the suspicious tissue. The needle is withdrawn, and the hook is used by the surgeon to locate and remove the lesion. The patient may receive local or general anesthetic.  A vacuum-assisted device may be used for some biopsies. This uses a single probe through which a vacuum is used to draw out tissue. It allows several samples to be taken without having to remove and re-insert the probe. Final analysis of the breast tissue may take several days. Medicine: it’s a noble profession, it serves humanity 19/122
    20. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 20 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.7 LYMPHADENECTOMY: If breast cancer has been determined, the next diagnostic step is to find out how far it has spread. To do this, the doctor performs a procedure called an axillary lymphadenectomy, which partially or completely removes the lymph nodes in the armpit beside the affected breast (called axillary lymph nodes). It may require a hospital stay of 1 - 2 days. Once the lymph nodes are removed, they are analyzed to determine whether subsequent treatment needs to be more or less aggressive:  If no cancer is found in the lymph nodes, the condition is referred to as node negative breast cancer. The chances are good that the cancer has not spread and is still local.  If cancer cells are present in the lymph nodes, the cancer is called node positive. Their presence increases the possibility that the cancer has spread microscopically to other areas of the body. In such cases, however, it is still not known if the cancer has metastasized beyond the lymph nodes or, if so, to what extent. The doctor may perform further tests to see if the cancer has spread to the bone (bone scan), lungs (x-ray or CT scan) or brain (MRI or CT scan). Side effects of the procedure may include increased risk for infection and pain, swelling in the arm from fluid build-up, and impaired sensation and restricted movement in the affected arm. 5.7.1 SENTINEL NODE BIOPSY: Sentinel node biopsy is a less invasive alternative to axillary lymph node dissection. This procedure can help determine if cancer has spread beyond the nodes. If the doctor finds no evidence of cancer, the patient may not need to have a complete axillary lymphadenectomy. Sentinel node biopsy involves:  The procedure uses an injection of a tiny amount of a tracer, either a radioactively-labeled substance (radioisotope) or a blue dye, into the tumor site.  The tracer or dye then flows through the lymphatic system into the sentinel node. This is the first lymph node to which any cancer would spread.  The sentinel lymph node and possibly one or two others are then removed.  If they do not show any signs of cancer, it is highly likely that the remaining lymph nodes will be cancer free, making further surgery unnecessary. Patients who have a sentinel node biopsy tend to have better arm function and a shorter hospital stay than those who have an axillary node biopsy. The American Society of Clinical Oncology's guidelines recommend sentinel node biopsy instead of axillary lymph node dissection for women with early stage breast cancer who do not have nodes that can be felt during a physical exam. It is still not known if the Medicine: it’s a noble profession, it serves humanity 20/122
    21. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 21 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. sentinel node biopsy has any survival advantages compared to standard lymph node removal procedures. 5.8 PROGNOSIS: Breast cancer is the second most lethal cancer in women. (Lung cancer is the leading cancer killer in women.) The good news is that early detection and new treatments have improved survival rates. The 5-year survival rate for women diagnosed with cancer is 80%. About 88% of women diagnosed with breast cancer will survive at least 10 years. Unfortunately, women in lower social and economic groups still have significantly lower survival rates than women in higher groups. Several factors are used to determine the risk for recurrence and the likelihood of successful treatment. They include:  Location of the tumor and how far it has spread  Whether the tumor is hormone receptor-positive or -negative  Tumor markers  Gene expression  Tumor size and shape  Rate of cell division The good news is that women are living longer with breast cancer. Due to better treatment options, breast cancer mortality rates declined by about 25% since 1990. However, survivors must live with the uncertainties of possible recurrent cancer and some risk for complications from the treatment itself. Recurrences of cancer usually develop within 5 years of treatment. About 25% of recurrences and half of new cancers in the opposite breast occur after 5 years. 5.8.1 LOCATION OF THE TUMOR: The location of the tumor is a major factor in outlook:  If the cancer is ductal carcinoma in situ (DCIS) or has not spread to the lymph nodes (node negative), the 5-year survival rates with treatment are up to 98%.  If the cancer has spread to the lymph nodes or beyond the primary site (node positive), the 5-year survival rate is about 84%. Medicine: it’s a noble profession, it serves humanity 21/122
    22. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 22 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  If the cancer has spread (metastasized) to other sites (most often the lung, liver, and bone), the average 5-year survival rate is 27%. New drug therapies, particularly aromatase inhibitors, have helped prolong survival for women with metastatic cancer. The location of the tumor within the breast is an important predictor. Tumors that develop toward the outside of the breast tend to be less serious than those that occur more toward the middle of the breast. 5.8.2 HORMONE RECEPTOR-POSITIVE OR –NEGATIVE: Breast cancer cells may contain receptors, or binding sites, for the hormones estrogen and progesterone. Cells containing these binding sites are known as hormone receptor-positive cells. If cells lack these connectors, they are called hormone receptor-negative cells. About 75% of breast cancers are estrogen receptor-positive (ER-positive, or ER+). About 65% of ER-positive breast cancers are also progesterone receptor-positive (PR-positive, or PR+). Cells that have receptors for one of these hormones, or both of them, are considered hormone receptor-positive. Hormone receptor-positive cancer is also called \"hormone sensitive\" because it responds to hormone therapy such as tamoxifen or aromatase inhibitors. Hormone receptor-negative tumors are referred to as \"hormone insensitive\" or \"hormone resistant.\" Women have a better prognosis if their tumors are hormone receptor-positive because these cells grow more slowly than receptor-negative cells. In addition, women with hormone receptor-positive cancer have more treatment options. (Hormone receptor-negative tumors can be treated only with chemotherapy.) Recent declines in breast cancer mortality rates have been most significant among women with estrogen receptor-positive tumors, due in part to the widespread use of post-surgical hormone drug therapy. 5.8.3 TUMOR MARKERS: Tumor markers are proteins found in blood or urine when cancer is present. Although they are not used to diagnose cancer, the presence of certain markers can help predict how aggressive a patients cancer may be and how well the cancer may respond to certain types of drugs. Tumor markers relevant for breast cancer prognosis include: HER2. The American Cancer Society recommends that all women newly diagnosed with breast cancer get a biopsy test for a growth-promoting protein called HER2/neu. HER2-positive cancer usually occurs in younger women and is more quickly-growing and aggressive than other types of breast cancer. The HER2 marker is present in about 20% of cases of invasive breast cancer. Two types of tests are used to detect HER2:  Immunohistochemistry (IHC)  Fluorescence in-situ hybridization (FISH) Some doctors think that FISH is a more accurate test than IHC. According to 2006 HER2 testing guidelines from the American Society of Clinical Oncology and the College of American Pathologists, either test may be used as long as it is performed by an accredited laboratory. Tests that are not clearly positive or negative should be repeated. Treatment with trastuzumab (Herceptin) or lapatinib (Tykerb) may help women who test positive for HER2. In 2008, the FDA approved a new genetic test (Spot- Light) that can help determine which patients with HER2-positive breast cancer may be good candidates for trastuzumab treatment. Other Markers. Other markers that may be evaluated include CA 15-3, CA 27.29, CEA, ER, PgR, uPA, and PAI-1. Medicine: it’s a noble profession, it serves humanity 22/122
    23. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 23 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.8.4 GENE EXPRESSION PROFILING: Gene expression profiling tests (Oncotype DX, MammaPrint) examine a set of genes in tumor tissue to determine the likelihood of breast cancer recurrence. These tests are also used to help determine whether adjuvant (following surgery) drug treatments should be given. The American Society of Clinical Oncology and the National Comprehensive Cancer Network now recommend that gene expression profiling tests be administered to newly diagnosed patients with node-negative, estrogen-receptor- positive breast cancer. Based on the results, a doctor can decide whether a patient who has had surgery may benefit from chemotherapy. 5.8.5 OTHER FACTORS FOR PREDICTING OUTLOOK: A. TUMOR SIZE AND SHAPE: Large tumors pose a higher risk than small tumors. Undifferentiated tumors, which have indistinct margins, are more dangerous than those with well-defined margins. B. RATE OF CELL DIVISION: The more rapidly a tumor grows, the more dangerous it is. Several tests measure aspects of cancer cell division and may eventually prove to predict the disease. For example, the mitotic index (MI) is a measurement of the rate at which cells divide. The higher the MI, the more aggressive the cancer. Other tests measure cells at a certain phase of their division. 5.9 EFFECT OF EMOTIONS AND PSYCHOLOGICAL SUPPORT: Recent evidence has not supported early reports of survival benefits for women with metastatic breast cancer who engage in support groups. However, some studies have suggested that psychotherapy, group support, or both may relieve pain and reduce stress, particularly in women who are suffering emotionally. Stress has been ruled out as a risk factor either for breast cancer itself or for its recurrence. 5.9.1 TREATMENT: The three major treatments of breast cancer are surgery, radiation, and drug therapy. No one treatment fits every patient, and combination therapy is usually required. The choice is determined by many factors, including the age of the patient, menopausal status, the kind of cancer (ductal verses lobular), its stage, and whether or not the tumor contains hormone-receptors. Breast cancer treatments are defined as  Local  Systemic Medicine: it’s a noble profession, it serves humanity 23/122
    24. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 24 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. A. LOCAL TREATMENT: Surgery and radiation are considered local therapies because they directly treat the tumor, breast, lymph nodes, or other specific regions. Surgery is usually the standard initial treatment. B. SYSTEMIC TREATMENT: Drug treatment is called systemic therapy, because it affects the whole body. Drugs may include either chemotherapy or hormone therapy. Drug therapy may be used as primary therapy for patients for whom surgery or radiation therapy is not appropriate, neoadjuvant therapy (before surgery or radiation) to shrink tumors to a size that can be treated with local therapy, or as adjuvant therapy (following surgery or radiation) to reduce the risk of cancer recurrence. For metastatic cancer, drugs are used not to cure but to improve quality of life and prolong survival. Any or all of these therapies may be used separately or, most often, in different combinations. For example, radiation alone or with chemotherapy or hormone therapy may be beneficial before surgery, if the tumor is large or not easily removed at prevention. Surgery followed by radiation and hormone therapy is usually recommended for women with early-stage, hormone-sensitive cancer. There are numerous clinical trials investigating new treatments and treatment combinations. Patients, especially those with advanced stages of cancer, may wish to consider enrolling in a clinical trial. C. CANCER STAGE AND TREATMENT OPTIONS: Treatment strategies depend in part on the stage of the cancer. Stage 0 (Carcinoma in Situ). Stage 0 breast cancer is considered non-invasive (in situ\"), meaning that the cancer is still confined within breast ducts or lobules and has not yet spread to surrounding tissues. Stage 0 cancer is classified as either: Ductal carcinoma in situ (DCIS). These are cancer cells in the lining of a duct that have not invaded the surrounding breast tissue. Lobular carcinoma in situ (LCIS). These are cancer cells in the lobules of the breast. LCIS rarely develops into invasive breast cancer, but having it in one breast increases the risk of developing cancer in the other breast. Medicine: it’s a noble profession, it serves humanity 24/122
    25. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 25 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. D. TREATMENT OPTIONS FOR DCIS INCLUDE:  Breast-conserving surgery and radiation therapy (followed by hormone therapy for women with hormone-sensitive cancer). Many doctors recommend this approach.  Total mastectomy (followed by hormone therapy for women with hormone-sensitive cancer)  Breast-conserving surgery without radiation therapy E. TREATMENT OPTIONS FOR LCIS INCLUDE:  Regular exams and mammograms to monitor any potential changes (observation treatment)  Hormone therapy to prevent development of breast cancer (for women with hormone-sensitive cancer)  Mastectomy of both breasts was previously used as treatment, but is now rarely recommended Medicine: it’s a noble profession, it serves humanity 25/122
    26. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 26 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. I. STAGE I AND II (EARLY-STAGE INVASIVE): In stage I cancer, cancer cells have not spread beyond the breast, and the tumor is no more than 2 cm (about 3/4 of an inch) across. II. STAGE II CANCER IS CLASSIFIED AS EITHER STAGE IIA OR STAGE IIB: In stage IIA cancer the tumor is either:  No more than 2 centimeters and has spread to the underarm lymph nodes (axillary lymph nodes)  Between 2 - 5 centimeters and has not spread to the underarm lymph nodes In stage IIB cancer the tumor is either:  Larger than 2 centimeters and less than 5 centimeters and has spread to 1 - 3 axillary lymph nodes  Larger than 5 centimeters but has now spread to lymph nodes 1. Treatment options for stage i and stage ii breast cancer may include:  Breast-conserving surgery (such as lumpectomy) followed by radiation therapy  Modified radical mastectomy with or without breast reconstruction  Post-surgical therapy (adjuvant therapy), including radiation of lymph nodes, chemotherapy, or hormone therapy  Trastuzumab (Herceptin) given along with or following adjuvant chemotherapy for women with HER2-positive cancer 2. Stage iii (locally advanced): Stage III breast cancer is classified into several sub-categories:  Stage IIIA,  Stage IIIB, and  Stage IIIC (operable or inoperable). a. In stage iiia breast cancer, the tumor is either: Not more than 5 centimeters and has spread to 4 - 9 axillary lymph nodes Larger than 5 centimeters and has spread to 1 - 9 axillary nodes or to internal mammary nodes. 3. Treatment options for stage iiia breast cancer are the same as those for stages i and ii. In stage IIIB breast cancer, the tumor has spread to either:  Tissues near the breast (including the skin or chest wall)  Lymph nodes within the breast or under the arm a. Stage iiib: Treatment options may include:  Chemotherapy, and possibly hormone therapy (sometimes in combination with chemotherapy)  Chemotherapy followed by surgery (breast-conserving surgery or total mastectomy) with lymph node dissection followed by radiation therapy and possibly more chemotherapy or hormone therapy Medicine: it’s a noble profession, it serves humanity 26/122
    27. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 27 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Clinical trials b. Stage iiic: Breast cancer is classified as either operable or inoperable. In operable stage IIIC, the cancer may be found in:  10 or more of the underarm lymph nodes  Lymph nodes beneath the collarbone and near the neck on the same side of the body as the affected breast  Lymph nodes within the breast as well as underarm lymph nodes c. Treatment options for operable stage iii breast cancer: Are the same as those for stage I and II breast cancers. In inoperable stage III breast cancer, the cancer has spread to lymph nodes above the collarbone and near the neck on the same side of the body as the affected breast. Treatment options are the same as those for stage IIIB. 5. Stage iv (advanced cancer): In stage IV, the cancer has spread (metastasized) from the breast to other parts of the body. In about 75% of cases, the cancer has spread to the bone. The cancer at this stage is considered to be chronic and incurable, and the usefulness of treatments is limited. The goals of treatment for stage IV cancer are to stabilize the disease and slow its progression, as well as to reduce pain and discomfort. Medicine: it’s a noble profession, it serves humanity 27/122
    28. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 28 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. a. Treatment options for stage iv cancer include:  Surgery or radiation for any localized tumors in the breast.  Chemotherapy, hormone therapy, or both. Targeted therapy with trastuzumab (Herceptin) or lapatinib (Tykerb) should be considered for women with HER2- positive cancer.  Cancer that has spread to the brain may require radiation and high-dose steroids.  Cancer that has spread to the bone may be helped by radiation or bisphosphonate drugs. Such treatments can relieve pain and help prevent bone fractures.  Clinical trials of new drugs or drug combinations, or experimental treatments such as high-dose chemotherapy with stem cell transplant. 5.10 POST-TREATMENT CARE: The American Society of Clinical Oncology (ASCO) recommends follow-up care for patients who have been treated for breast cancer:  Visit your doctor every 3 - 6 months for the first 3 years after your first cancer treatment, every 6 - 12 months during the fourth and fifth year, and once a year thereafter.  Have a mammogram 1 year after the mammogram that diagnosed your cancer (but no earlier than 6 months after radiation therapy), and every 6 - 12 months thereafter.  Perform a breast self-exam every month (however, this is no substitute for a mammogram).  See your gynecologist regularly (women taking tamoxifen should be sure to report any vaginal bleeding). Medicine: it’s a noble profession, it serves humanity 28/122
    29. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 29 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. A year after diagnosis, you can either continue to see your oncologist or transfer your care to your primary care physician.  If you are on hormone therapy, discuss with your oncologist how often to schedule follow-up visits for re- evaluation of your treatment. ASCO does not recommend the use of laboratory blood tests (complete blood counts, carcinoembryonic antigen) or imaging tests (bone scans, chest x-rays, liver ultrasound, FDG-PET scan, CT scan) for routine breast cancer follow-up. 5.10.1 GENETIC COUNSELING MAY BE HELPFUL IF YOU HAVE:  Ashkenazi Jewish heritage  Personal or family history of ovarian cancer  Personal or family history of cancer in both breasts  Any first-degree female relative (mother, sister, daughter) diagnosed with breast cancer before age 50  Two or more first-degree or second-degree (grandparent, aunt, uncle) diagnosed with breast cancer  History of breast cancer in a male relative 5.10.2 PREGNANCY AFTER BREAST CANCER TREATMENT: There are no definite recommendations on how long a woman should wait to become pregnant after breast cancer treatment. Because of the connection between estrogen levels and breast cancer cell growth, some doctors recommend delaying pregnancy until 2 years after treatment in order to reduce the risk of cancer recurrence and improve odds for survival. However, other studies indicate that conceiving 6 months after treatment does not negatively affect survival. Discuss with your doctor your risk for recurrence, and when it may be safe to attempt pregnancy. 5.11 RECURRENT BREAST CANCER: Recurrent breast cancer is considered to be an advanced cancer. In such cases, the disease has come back in spite of the initial treatment. Most recurrences appear within the first 2 - 3 years after treatment, but breast cancer can recur many years later. Treatment options are based on the stage at which the cancer reappears, whether or not the tumor is hormone responsive, and the age of the patient. Between 10 - 20% of recurring cancers are local. Most recurrent cancers are metastatic. All patients with recurring cancer are candidates for clinical trials. Because most breast cancer recurrences are discovered by patients in between doctor visits, it is important to notify your doctor if you experience any of the following symptoms. These symptoms may be signs of breast cancer recurrence:  New lumps in the breast  Bone pain  Chest pain  Abdominal pain  Shortness of breath or difficulty breathing  Persistent headaches or coughing  Rash on breast  Nipple discharge Medicine: it’s a noble profession, it serves humanity 29/122
    30. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 30 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.12 SURGERY: Surgery forms a part of nearly every patient's treatment for breast cancer. The initial surgical intervention is often a lumpectomy, the removal of the tumor itself. In the past, mastectomy (the removal of the breast) was the standard treatment for nearly all breast cancers. Now, many patients with early-stage cancers can choose breast-conserving treatment, or lumpectomy followed by radiation, with or without chemotherapy. For invasive breast cancer, studies indicate that lumpectomy or partial mastectomy combined with radiation therapy works as well as a modified radical mastectomy. 5.12.1 BREAST-CONSERVING PROCEDURES: Breast-conserving procedures are now appropriate and as successful as mastectomy in most women with early stage breast cancer. All women should discuss these options fully with their doctor. Recurrence rates with conservative surgery are highest in women under age 45. Some women choose mastectomy over breast-conserving treatment even if the latter is appropriate because it gives them a greater sense of security and allows them to avoid radiation therapy. A. LUMPECTOMY: Lumpectomy is the removal of the tumor, often along with lymph nodes in the armpit. It serves as an opportunity for biopsy, a diagnostic tool, and a primary treatment for small local breast tumors. If invasive cancer is found, the doctor will decide to proceed with breast radiation therapy, to remove additional tissue (should the margins of the specimen show signs of cancer), or to perform a mastectomy. Lumpectomy followed by radiation therapy is appropriate and as effective as mastectomy for most women with Stage I or II breast cancers. B. BREAST-CONSERVING SURGERY: (Quadrantectomy). Breast-conserving surgery (sometimes referred to as quadrantectomy) removes the cancer and a large area of breast tissue, occasionally including some of the lining over the chest muscles. It is less invasive than a full mastectomy, but the cosmetic results are less satisfactory than with a lumpectomy. Studies have found that breast-conserving surgeries plus postoperative radiotherapy offer the same survival rates as radical mastectomy in women with early breast cancer. 5.12.2 MASTECTOMY: Surgery to remove the breast (mastectomy) is important for women with operable breast cancer who are not candidates for breast conserving surgeries. There are different variations on the procedure:  A total mastectomy involves removal of the whole breast and sometimes lymph nodes under the armpit.  A radical mastectomy removes the breast, chest muscles, all of the lymph nodes under the arm, and some additional fat and skin. (A modified radical mastectomy removes the entire breast and armpit lymph nodes, with the underlying chest wall muscle.) For most patients, there are no survival advantages from radical mastectomy compared to less invasive mastectomies. Medicine: it’s a noble profession, it serves humanity 30/122
    31. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 31 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.12.3 COMPLICATIONS AND SIDE EFFECTS OF SURGERY:  Short-term pain and tenderness occur in the area of the procedure, and pain relievers may be necessary.  The most frequent complication of extensive lymph node removal is lymphedema, or swelling, of the arm. The likelihood of edema can be lessened by removing only some of the lymph nodes instead of all of them.  Infrequent complications include poor wound healing, bleeding, or a reaction to the anesthesia.  After mastectomy and lymph node removal, women may experience numbness, tingling, and difficulty in extending the arm fully. These effects can last for months or years afterward. 5.12.4 BREAST RECONSTRUCTION: After a mastectomy, some women choose a breast prosthesis or opt for breast reconstruction, which can be performed during the mastectomy itself, if desired. Several studies have indicated that women who take advantage of cosmetic surgery after breast cancer have a better sense of well-being and a higher quality of life than women who do not choose reconstructive surgery. The breast is reshaped Medicine: it’s a noble profession, it serves humanity 31/122
    32. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 32 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. using a saline implant or, for a more cosmetic result, a muscle flap is taken from elsewhere in the body. Muscle flap procedures are more complicated, however, and blood transfusions may be required. (It should be noted that implants, including silicone implants, do not appear to put a woman at risk for breast cancer recurrence.) If the nipple is removed, it is rebuilt from other body tissues and color is applied using tattoo techniques. It is nearly impossible to rebuild a breast that is identical to its partner, and additional operations may be necessary to achieve a desirable effect. 5.13 RADIATION: Radiation therapy uses high-energy x-rays to kill cancer cells or to shrink the size of a tumor in the breast or surrounding tissue. It is used for several weeks following lumpectomy or partial mastectomy, and sometimes after full mastectomy. Radiation therapy can help reduce the chance of breast cancer recurrence in the breast and chest wall. Radiation is also important in advanced stages of cancer for relief of symptoms and to slow progression. Research shows that radiation therapy is helpful for women of all ages, including those over age 65. 5.13.1 ADMINISTRATION OF RADIATION THERAPY: Radiation is generally administered in the following ways: A. EXTERNAL BEAM RADIATION: This type of radiation is administered 4 - 6 weeks after surgery and delivered externally by an x-ray machine that targets radiation to the whole breast. It may be delivered to the chest wall in high-risk patients (large tumors, close surgical margins, or lymph node involvement). The treatment is generally given daily (except for weekends) for about 6 weeks. Some hospitals offer a shortened course of 3 weeks of radiation for patients with early-stage breast cancer. B. BRACHYTHERAPY: Less commonly, radiation is delivered in implants (called brachytherapy). Implants are most often used as a radiation boost after whole breast radiation. Medicine: it’s a noble profession, it serves humanity 32/122
    33. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 33 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. C. SIDE EFFECTS OF RADIATION THERAPY: Side effects of radiation include:  Fatigue is very common and increases with subsequent treatments, but most women are able to continue with normal activities. Exercise may be helpful.  Nausea and lack of appetite may develop and worsen as treatment progresses.  Skin changes and burns can occur on the breast skin. Using a cream that contains a corticosteroid, such as mometasone furoate (MMF), may be helpful. After repeated sessions, the skin may become moist and \"weepy.\" Exposing the treated skin to air as much as possible helps healing. Washing the affected skin with soap and water is not harmful.  Uncommonly, the breast may change color, size, or become permanently firm.  Rarely, the nearest arm may swell and develop impaired mobility or even paralysis. D. LONG-TERM COMPLICATIONS: Future complications include:  Radiation to the left breast may increase the long-term risk for developing heart disease and heart attacks.  There is a very small risk (less than 1%) of lung irritation and scarring.  Some studies have reported a higher risk for future cancer in the opposite breast in younger women who have been given radiation to the chest wall.  Radiation therapy can increase the risk of developing other cancers, such as soft tissue malignancies known as sarcomas. Current advanced imaging techniques use precise radiation that reduces exposure. These newer techniques are likely to reduce the risks for heart disease and other serious complications. 5.14 CHEMOTHERAPY: Chemotherapy drugs are \"cytotoxic\" (cell-killing) drugs. They are given orally or by injection. They work systemically by killing cancer cells throughout the body. (Unfortunately, they also kill normal cells, which accounts for many of their side effects.) Chemotherapy is always used for advanced breast cancer, but may also be used to treat types of early-stage breast cancer. Newer biologic drugs target specific proteins involved in cancer. Because they do not work as systemically as chemotherapy or hormone therapy drugs, they tend to cause fewer widespread side effects, although they also carry risks of their own Chemotherapy needs to be tailored to the type of cancer involved. Women require different treatments depending on whether the tumor is node-negative or -positive, hormone receptor-positive or -negative, or HER2-positive or -negative. Different treatment approaches are also used for early-stage cancer and advanced cancer. In general, women with hormone receptor-negative cancers respond better to chemotherapy than women with hormone receptor-positive cancer. However, some women with hormone receptor-positive cancer do benefit from chemotherapy, as well as from hormone therapy. Adjuvant chemotherapy is administered following surgery and before radiation therapy. Delaying chemotherapy until more than 12 weeks after surgery may increase the risk for breast cancer recurrence and reduce the odds for survival. Medicine: it’s a noble profession, it serves humanity 33/122
    34. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 34 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.14.1 SIDE EFFECTS OF CHEMOTHERAPY: Side effects occur with all chemotherapeutic drugs. They are more severe with higher doses and increase over the course of treatment. Common side effects include: Nausea and vomiting. Drugs such as ondansetron (Zofran) and aprepitant (Emend) can help relieve these side effects.  Diarrhea  Temporary hair loss  Weight loss  Fatigue  Depression Serious short- and long-term complications can also occur and may vary depending on the specific drugs used. They include the following:  Anemia. Chemotherapy-induced anemia is usually treated with erythropoiesis-stimulating drugs, which include epoietin alfa (Epogen, Procrit) and darberpetin alfa (Aranesp). Erythropoiesis- stimulating drugs should not be used unless a patients hemoglobin level drops to below 10 g/dL. These drugs may pose serious health risks when they are used to achieve a hemoglobin level of 12 g/dL or greater. Doctors need to follow strict dosing guidelines when administering these drugs. Patients should discuss the risks and benefits of erythropoiesis-stimulating drugs with their oncologists. [For more information, see In-Depth Report #57: Anemia.]  Increased chance for infection from severe reduction in white blood cells (neutropenia). The addition of a drug called granulocyte colony-stimulating factor (filgrastim and lenograstim) is very helpful in reducing the risk for severe infection.  Liver and kidney damage.  Abnormal blood clotting (thrombocytopenia).  Allergic reaction, particularly to platinum-based drugs.  Menstrual abnormalities and infertility. Premature menopause occurs in about 30% of women, particularly in those over 40. A natural hormone medication called a gonadotropin-releasing hormone analogue, which puts women in a temporary pre-pubescent state during chemotherapy, may preserve fertility in some women. Women may also wish to consider embryo cryopreservation -- the harvesting of eggs, followed by in vitro fertilization and freezing of embryos for later use. The American Society of Clinical Oncology recommends that women being treated for cancer see a reproductive specialist to discuss all available fertility preservation options.  Sexual dysfunction.  Rarely, secondary cancers such as leukemia.  A quarter to a third of women report problems in concentration, motor function, and memory, which can be long-term.  Heart problems. Trastuzumab (Herceptin) may increase the risk for heart failure, particularly in women with pre-existing risk factors. Cumulative doses of anthracyclines (doxorubicin, epirubicin) can also damage heart muscles over time and increase the risk for heart failure.  Taxanes can cause a drop in white blood cells and possible problems in the heart and central nervous system. Allergic reactions can occur, more often in taxol than taxotere. Taking a steroid before taxane administration can help prevent such reactions. Taxane therapy may also cause severe joint and muscle pain in some patients, relievable with corticosteroids. Medicine: it’s a noble profession, it serves humanity 34/122
    35. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 35 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.14.2 HIGH-DOSE CHEMOTHERAPY WITH BONE MARROW OR PERIPHERAL-BLOOD STEM CELL TRANSPLANTATION: High-dose chemotherapy along with peripheral-blood stem cell rescue or bone marrow transplantation procedures have been used for cancer that has metastasized and, in some cases, for earlier stages of breast cancer in high-risk patients. The objective of this treatment is to be able to give patients very high toxic doses of cell-killing drugs. Transplantation procedures are based on stem cells, which are produced in the bone marrow. Stem cells are the early forms for all blood cells in the body (including red, white, and immune cells). Cancer treatments can harm these growing cells as well as cancer cells. Despite the initial enthusiasm over the use of transplantation therapy for treatment of high-risk breast cancer, this approach is no longer generally recommended and is rarely used outside of a clinical trial setting. A. HORMONE THERAPY: The goal of hormone therapy is to prevent estrogen from stimulating breast cancer cells. It is recommended for women whose breast cancers are hormone-receptor positive (either estrogen or progesterone), regardless of the size of the tumor and whether or not it has spread to the lymph nodes. Like chemotherapy, hormone therapy works systemically. Hormone therapy works by blocking estrogen that causes cell proliferation. It is used only for patients with hormone receptor-positive tumors. Different types of hormone therapy work in different ways by:  Blocking estrogen receptors in cancer cells (Tamoxifen)  Suppressing estrogen production in the body (Aromatase inhibitors)  Destroying ovaries, which produce estrogen (Ovarian ablation) Tamoxifen was the first widely used hormonal therapy drug, but it has been replaced by aromatase inhibitors for some women. Aromatase inhibitors are used only to treat postmenopausal women. Tamoxifen is mainly used as adjuvant therapy for premenopausal women with hormone-sensitive breast cancer. B. TAMOXIFEN AND SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS): Tamoxifen (Nolvadex) has been the standard hormonal drug used for breast cancer. It belongs to a class of compounds called selective estrogen receptor modulators (SERMs). SERMs chemically resemble estrogen and trick the breast cancer cells into accepting it in place of estrogen. Unlike estrogen, however, they do not stimulate breast cancer cell growth. Because SERMs block estrogens effects on cancer cells, they are sometimes referred to as \"anti-estrogen\" drugs. Tamoxifen is used for all cancer stages in women of all ages with hormone receptor-positive cancers. In addition, it is used to prevent breast cancer in high-risk women. Another SERM drug, toremifene (Fareston), is an option for women with advanced cancer, but this drug is rarely used in the United States. A third drug, fulvestrant (Faslodex), works in a similar anti-estrogen way to tamoxifen but belongs to a different drug class. Fulvestrant is approved only for postmenopausal women with hormone-sensitive advanced breast cancer in which tamoxifen or aromatase inhibitors no longer work. To prevent cancer recurrence, women should take tamoxifen for 5 years following surgery and radiation. Tamoxifen is an effective cancer treatment, but it can cause unpleasant side effects and has small (less than 1%) but serious risks for blood clots and uterine (endometrial) cancer. Immediately report any signs of vaginal bleeding to the doctor, as this may be a symptom of uterine cancer. Medicine: it’s a noble profession, it serves humanity 35/122
    36. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 36 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Less serious, but discomforting, side effects include hot flashes and mood swings. According to one study, nearly 25% of women stop taking tamoxifen within 1 year because of these symptoms. By 3.5 years, over 33% stop treatment. Taking tamoxifen for fewer than 5 years, however, increases the risk for cancer recurrence and death. Talk with your doctor about antidepressants or other therapies that may help you cope with tamoxifens side effects. Many doctors now recommend that postmenopausal women switch to an aromatase inhibitor after 2 - 3 years of tamoxifen therapy. Several recent studies have indicated that switching from tamoxifen to an aromatase inhibitor significantly improves survival rates and reduces the risk of death from breast cancer as well as other causes. 5.15 AROMATASE INHIBITORS: Aromatase inhibitors block aromatase, an enzyme that is a major source of estrogen in many major body tissues, including the breast, muscle, liver, and fat. Aromatase inhibitors work differently than tamoxifen. Tamoxifen interferes with tumors ability to use estrogen by blocking their estrogen receptors. Aromatase inhibitors reduce the overall amount of estrogen in the body. Because these drugs cannot stop the ovaries of premenopausal women from producing estrogen, they are recommended only for postmenopausal women. There are currently three aromatase inhibitors approved for treating early-stage, hormone receptor-positive breast cancer in postmenopausal women:  Anastrazole (Armidex) for treatment after surgery  Exemestane (Aromasin) for women who have taken tamoxifen for 2 - 3 years  Letrozole (Femara) for treatment after surgery or for women who have completed 5 years of tamoxifen therapy All of these drugs are also approved for women with advanced (metastatic) hormone-sensitive breast cancer. Studies indicate that the introduction of aromatase inhibitors has helped greatly in prolonging survival for women with advanced cancer. Compared to tamoxifen, aromatase inhibitors are less likely to cause blood clots and uterine cancer. However, these drugs are more likely to cause osteoporosis, which can lead to bone loss and fractures. In general, recent studies indicate that aromatase inhibitors are better than tamoxifen in improving survival and reducing the risk of cancer recurrence. Unfortunately, like tamoxifen, they can cause hot flashes, as well as joint pain. 5.16 OVARIAN ABLATION: Ovarian ablation literally shuts down estrogen production from the ovaries. Medications can accomplish ovarian ablation. Destroying the ovaries with surgery or radiation can also shut down estrogen production. (Osteoporosis is one serious side effect of this approach, but several therapies are available to help prevent bone loss.) 5.16.1 CHEMICAL OVARIAN ABLATION: Drug treatment (non-chemotherapy drugs) to block ovarian production of estrogen is called chemical ovarian ablation. It is often reversible. The primary drugs used are luteinizing hormone-releasing hormone (LHRH) agonists, such as goserelin (Zoladex). (They are also sometimes called GnRH agonists). These drugs block the release of the reproductive hormones LH-RH, therefore stopping ovulation and estrogen production. Medicine: it’s a noble profession, it serves humanity 36/122
    37. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 37 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.16.2 BILATERAL OOPHORECTOMY: Bilateral oophorectomy, the surgical removal of both ovaries, may modestly improve breast cancer survival rates in some premenopausal women whose tumors are hormone receptor-positive. In these women, combining this procedure with tamoxifen may improve results beyond those of standard chemotherapies. Oophorectomy does not benefit women after menopause, and its advantages can be blunted in women who have received adjuvant chemotherapy. The procedure causes sterility and can have a major negative emotional impact on younger patients. 5.17 AFTER IMPLANT SURGERY:  Isolation: To protect others from radiation, you may be assigned a private room. Visitors and nurses will not be allowed to stay more than 30 minutes a day and will have to stay 6 feet away from you. They may have to wear a lead apron when approaching you, and you'll have to bathe, eat, and go to the bathroom with a minimum of assistance. Call your doctor when you feel you need help.  Activity: Depending on the location of the implant, you may have to stay in bed for a while. But even if you are confined to bed, it's important to exercise your legs in order to stop blood clots from forming. Lift one leg off the bed and draw big circles with your toes, then repeat with the other leg. You can also try lying on your side and pretending to pedal a bike. When you're told it's OK to get out of bed, make sure someone is with you the first time you try. If you feel weak or dizzy, sit or lie down right away.  Hand washing and bathing: Because all your body fluids and secretions---including bowel movements, urine, vomit, sweat, and blood---will be radioactive, it is very important to wash your hands every time you go to the bathroom or touch any secretions. Frequent showers are recommended. They will relieve itching caused by sweat.  Oxygen: At times during your stay, your body may need extra oxygen. It is given either through a plastic mask over your mouth and nose or through nasal prongs. If the oxygen dries out your nose or the nasal prongs bother you, tell your nurse, but don't take off the oxygen on your own.  Implant: If the implant falls out, do not attempt to pick it up or touch it with your bare skin. Call a nurse, who will pick up the implant with tongs, put it in a metal container, and call your radiation doctor.  Medicines: A variety of drugs may be needed to reduce side effects once the implant is in place. Among them are:  Antibiotics: These medicines help prevent bacterial infection. IV, as a shot, or by mouth, may give them.  Anti-Diarrhea Medicine: This medicine may be given by mouth to decrease your diarrhea. Some of these medicines coat the intestine and make the stool less watery. Others slow the movement of the intestine.  Pain Medicine: To ease pain after the operation, your doctor will probably prescribe medication to be given by IV, as a shot, or by mouth. Tell the doctor or your nurses if the pain won't go away or keeps coming back. Medicine: it’s a noble profession, it serves humanity 37/122
    38. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 38 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Anti-Nausea Medicine: This medicine calms your stomach and controls vomiting. Your doctor may suggest you take it at the same time as your pain medicine, which sometimes upsets the stomach.  Diuretics: Often called \"water pills,\" these medications rid the body and lungs of excess fluid to help you breathe more easily. They work by increasing urination. They can be given as a pill or in your IV.  Expectorants: This medicine helps thin your sputum, making it easier to cough up. This will help ease your breathing.  Steroids: This medicine reduces swelling and inflammation. While it can be helpful, it may have side effects. Nevertheless, don't stop taking it on your own. Sudden withdrawal can cause problems. 5.18 AFTER YOU LEAVE:  Always take your medicine exactly as directed. If it doesn't seem to help, let the doctor know, but keep taking it until told otherwise. If you've been prescribed antibiotics, be sure to use them up, even if you're feeling better. If a medicine makes you drowsy, avoid driving or using dangerous machinery.  If you are taking pain medicine as a shot or IV, arrange to have a friend or family member learn how to give it. Take enough medicine to keep you comfortable. You should not worry about becoming addicted to these drugs.  Do NOT take any medicine that contains aspirin or ibuprofen-like ingredients. Ask your doctor before taking any over-the-counter medication.  Try to maintain a healthy diet with items from all 5 food groups: fruits, vegetables, breads, dairy products, meat and fish. It's important to keep your strength up.  Drink 6 to 8 large glasses of liquid, such as water, juices, and milk, each day. Limit caffeinated beverages, such as coffee, tea, and soda.  Gently brush your teeth and gums with a soft-bristle brush, or rinse your mouth, 2 to 3 times every day, especially after meals. See your dentist for regular check-ups. Your dentist may need to speak to your doctor before the exam.  You'll probably be weighed once a week to determine any change in your fluid balance. If you loose too much fluid, you can become dehydrated. If you have excess fluid, you may find it hard to breath.  If breathing becomes difficult, try raising the head of your bed or putting 3 or 4 pillows under your head. Resting in a reclining chair may also help. If breathing problems continue, call your doctor right away.  Match your activity to your energy level. Nap a couple of times during the day. Go to bed early and get up late.  If your skin gets sore in the treatment area, do not rub it or attempt to put lotion on it. Cover the area to protect it from heat and cold.  If you begin to lose your hair, consider buying a scarf, hat, or wig to help hide the loss.  Using a humidifier will moisten the air in your home and make it easier to cough up your sputum. Wash the humidifier each day with soap and warm water to keep it germ-free.  Radiation therapy often weakens the immune system. To guard against infections, stay away from people who have a cold or the flu and avoid large groups. You may need flu and pneumonia shots.  You may have problems with sex after radiation therapy, but they are often temporary and many can be helped. Talk to your doctor if you are worried. He can help you find ways to handle these problems.  Your pain may never be entirely eliminated. But a pain clinic can help you learn new ways to live with it. Ask your doctor to teach you how to control the pain without medicine. Two good techniques are relaxation therapy and special breathing exercises.  To protect their ability to have children, radiation patients often make the following arrangements:  Men can put sperm in a sperm bank, where it will be kept frozen for later use.  Women can have their ovaries surgically moved out of the radiation area. Medicine: it’s a noble profession, it serves humanity 38/122
    39. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 39 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.19 CALL YOUR DOCTOR IF:  You are running a temperature.  You have chills, a cough, red or swollen skin, weakness, or achiness. You may have an infection.  You have itchy, swollen skin or a rash. You may be allergic to your medicine. 5.20 CANCER REHABILITATION: Women and men diagnosed with cancer often undergo treatment including surgery, radiation therapy, and chemotherapy. In some cases, side effects from these treatments may include pain, limited mobility, decreased strength, swelling, and fatigue. Physical therapy interventions beneficial in counteracting the above-mentioned side effects may include:  Postural awareness for retraining affected muscles and joints  Therapeutic exercises to improve flexibility and strength in the involved area  Aerobic conditioning to combat cancer related fatigue  Education on skincare, scar management, lymphedema precautions, and safety during daily activities Medicine: it’s a noble profession, it serves humanity 39/122
    40. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 40 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 5.20.1 LYMPHEDEMA REHABILITATION: Lymphedema is an accumulation of lymphatic fluid that causes swelling, and can develop when the channels and ducts that transport lymph are missing, impaired, or damaged. Secondary lymphedema (acquired lymphedema) commonly occurs following surgeries that require the removal of lymph nodes. Lymphedema can develop immediately following surgery or months to years following cancer treatment. In addition to swelling, symptoms of lymphedema may include a feeling of heaviness and tightness, skin changes, infection in the affected area, and cosmetic deformity. Although lymphedema is a chronic condition, specially trained physiotherapists can provide invaluable rehabilitative care. Early intervention and learning lifelong management techniques are essential to allow patients to lead full, normal lives. Rusk Institute employs a comprehensive care approach that emphasizes the importance of the patient's understanding of the condition and treatment. In addition to learning about precautionary measures that reduce the risk of developing lymphedema, patients benefit from a rehabilitation program that increases range of motion, flexibility, strength, and endurance. Treatment may include the following:  Manual lymphatic drainage to mobilize fluid and protein from an affected area by a non-invasive, manual therapy technique  Multi-layer bandaging to reduce swelling and assist in softening of skin and tissue in a swollen limb  Therapeutic exercises to improve lymph drainage through a program of flexibility, strength training, and aerobic activities  Patient education to allow patients to take control of their own lives. In addition to learning how to manage lymphedema at home, patients may receive guidance on specific questions from nutritionists, social workers, support groups, or other health professionals  Compression garments to help minimize swelling during daytime daily activities  Compression pumping (in select cases) to assist with circulation through the use of state- of-the-art pneumatic pumps 5.20.2 EXERCISES AFTER BREAST SURGERY:  After your operation you may feel apprehensive about moving your shoulder through its full range of movement due to discomfort from your wound. However, it is very easy to develop a very stiff and painful shoulder joint, which may eventually become 'frozen'.  Exercise is, therefore the key to a good recovery and does in fact help your wound to heal more quickly and with a more mobile and cosmetically pleasing scar. To be of sufficient benefit the exercises must be done frequently throughout the day - at least twice during the morning, afternoon and evening - 6 times in all.  Before you start the exercises make sure your clothing is loose. If you have any drains in your wound please don't be concerned about exercising whilst they are in place as the exercises actually help them to work better. Continue to exercise at home until you have regained your full range of shoulder movement. 1. Stand squarely and bend forward at the waist. Circle entire arm clockwise, then anti-clockwise. Swing forward and then backward. Swing arm sideways away from body and back again. Particularly good in the early weeks after surgery. 2. Stand straight facing a wall. Stretch upright as much as comfortable. Place your hand on a wall so you are in the most comfortable position possible. Walk your hand up then down the wall. Repeat 10 times 3. Sit with the head upright but relaxed and still. Brush the hair on the same side as the incision, then progress to whole of head Medicine: it’s a noble profession, it serves humanity 40/122
    41. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 41 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 4. Sit or stand squarely. Bring shoulders up towards ear. Relax and repeat. Sink shoulders downwards. Relax and repeat. Ease shoulders forwards. Relax and repeat. Pull shoulders back. Relax and repeat each movement 5-10 times 5. Place the hands on shoulders (or at the level of the shoulders). Move the elbows forwards and upwards then down and inwards. Repeat each movement 10 times. 6. Put your hands out horizontally in front of you. Take them up above your head as far as you can. Drop them down to the waist. 7. Starting with the arms straight out to the side of the body. Raise and lower your arms as high as you comfortably can. Repeat 10 times. It should look like a small bird flapping its wings slowly. 8. Place hands on shoulders. Move elbows sideways and upwards then back down. Should look like a small bird flapping its wings slowly. Repeat 10 times. 9. Raise the arms straight out to the side of the body, from the shoulders. Rotate the palms of the hand to face upwards then downwards. Repeat 10 times – should look you’re asking for money to be put in your hand. 10. Raise the arms straight out to the side of the body, from the shoulders. Rotate the palms of the hand to face upwards then downwards. look you’re asking for money to be put in your hand. Repeat 10 times. 11. Raise the arms straight out to the side of the body, from the shoulders. Rotate the palms of the hand to face upwards then downwards. Should look you’re asking for money to be put in your hand. Repeat 10 times. 12. Stand straight with your head slightly bent forward. Taking your hand to the back of the neck. Walk fingers down spine as far as comfortable. Walk them back up to the head and repeat 10 times. 13. Stand straight looking forward. Lower hands to the base of your spine. Walk your fingers up the spine to bra level. Walk them back down and repeat 10 times. 14. Put your right hand behind your back. Practice passing a small, light object e.g., purse, make up bag over your left shoulder to your other hand. Repeat and swap hands. Your ability to do this depends on your pre-operative range of movement. 15. In addition to these exercise it is important to gently massage the skin on the breast, chest wall or surrounding tissues. Surgery and radiotherapy can both cause the underlying tissues to be less mobile and flexible. This a major cause of breast and chest wall pain. Local gentle massage can produced some excellent results and there is absolutely no evidence that the urban myth of “it could spread cancer cells around” has any truth. It is particularly good on the breast itself and the surrounding skin, which may have stuck down onto the ribs. Put some extra virgin olive oil on the fingers and gently try to roll the skin over the ribs – be as firm as possible but do not cause any pain or bruising as this will be counter productive. At first you will not notice an improvement but with daily persistence the mobility will improve along with the pain. 16. Ball Squeeze:  While standing, sitting, or lying down, hold a rubber ball in your hand on the operated side.  Keep your arm slightly bent, with your palm toward the ceiling. Lift your hand higher than your heart. Squeeze and relax the ball.  Repeat 10 times. 17. Broom Stretch  Place the hand on your operated side over the end of a stick (a broom or cane will work). Grasp farther down the stick with your other hand, palm down.  Gently but firmly, push the end of the stick as high as you comfortably can. Hold this position for 15 seconds. Medicine: it’s a noble profession, it serves humanity 41/122
    42. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 42 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Return to starting position.  Repeat 10 times. Medicine: it’s a noble profession, it serves humanity 42/122
    43. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 43 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.0 LUNG CANCER: Lung cancer is the leading cause of cancer deaths in the United States, among both men and women. It claims more lives each year than colon, prostate, lymph and breast cancers combined. Yet most lung cancer deaths could be prevented. That's because smoking accounts for nearly 90 percent of lung cancer cases. Your risk of lung cancer increases with the length of time and number of cigarettes you smoke. If you quit smoking, even after smoking for many years, you can significantly reduce your chances of developing lung cancer. Protecting yourself from other risk factors for lung cancer, such as exposure to asbestos, radon and secondhand smoke, also decreases your risk. 6.1 SYMPTOMS: Lung cancer typically doesn't cause signs and symptoms in its earliest stages. Signs and symptoms of lung cancer typically occur only when the disease is advanced. Signs and symptoms of lung cancer may include:  A new cough that doesn't go away  Changes in a chronic cough or \"smoker's cough\"  Coughing up blood, even a small amount  Shortness of breath  Chest pain  Wheezing  Hoarseness 6.2 CAUSES: Lung cancer most commonly begins in the cells that line your lungs. Smoking causes the majority of lung cancers — both in smokers and in people exposed to secondhand smoke. But lung cancer also occurs in people who never smoked. In these cases, there may be no clear cause of lung cancer. Doctors have identified factors that may increase the risk. Medicine: it’s a noble profession, it serves humanity 43/122
    44. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 44 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.2.1 SMOKING CAUSES LUNG CANCER: Doctors believe smoking causes lung cancer by damaging the cells that line the lungs. When you inhale cigarette smoke, which is full of cancer-causing substances (carcinogens), changes in the lung tissue begin almost immediately. At first your body may be able to repair this damage. But with each repeated exposure, normal cells that line your lungs are increasingly damaged. Over time, the damage causes cells to act abnormally and eventually cancer may develop. Your lungs are full of blood vessels and lymph vessels, giving lung cancer cells easy access to travel to other parts of your body. For this reason, lung cancer may spread to other parts of your body before you experience any signs or symptoms. In many cases, lung cancer may spread before it can even be detected in the lungs. 6.3 TYPES OF LUNG CANCER: Doctors divide lung cancer into two major types based on the appearance of lung cancer cells under the microscope. Your doctor makes treatment decisions based on which major type of lung cancer you have. The two general types of lung cancer include: Small cell lung cancer. Small cell lung cancer, sometimes called oat cell carcinoma, occurs almost exclusively in heavy smokers and is less common than non-small cell lung cancer. Non-small cell lung cancer. Non-small cell lung cancer is an umbrella term for several types of lung cancers that behave in a similar way. Non-small cell lung cancers include squamous cell carcinoma, adenocarcinoma and large cell carcinoma. 6.4 RISK FACTORS A number of factors may increase your risk of lung cancer. Some risk factors can be controlled, for instance, by quitting smoking. And other factors can't be controlled, such as your sex. Risk factors for lung cancer include: Smoking. Smoking remains the greatest risk factor for lung cancer. Your risk of lung cancer increases with the number of cigarettes you smoke each day and the number of years you have smoked. Quitting at any age can significantly lower your risk of developing lung cancer. Your sex. Current or former women smokers have a greater risk of lung cancer than do men who have smoked an equal amount. Though it isn't known why, some experts speculate that women have a greater susceptibility to the cancer-causing substances found in tobacco. Others believe that estrogen may play a role. Women also are known to inhale more than men do, and they are less likely to quit. Exposure to second hand smoke. Even if you don't smoke, your risk of lung cancer increases if you're exposed to secondhand smoke. Exposure to radon gas. Radon is produced by the natural breakdown of uranium in soil, rock and water that eventually becomes part of the air you breathe. Although unsafe levels of radon can accumulate in any building, the greatest exposure risk most people face is at home. Radon testing can determine whether levels are safe. Exposure to asbestos and other chemicals. Workplace exposure to asbestos and other substances known to cause cancer — such as arsenic, chromium, nickel and tar soot — also can increase your risk of developing lung cancer, especially if you're a smoker. Family history of lung cancer. People with a parent, sibling or other first-degree relative with lung cancer have an increased risk of the disease. Excessive alcohol use. Drinking more than a moderate amount of alcohol — no more than one drink a day for women or two drinks a day for men — may increase your risk of lung cancer. Medicine: it’s a noble profession, it serves humanity 44/122
    45. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 45 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.5 TESTS AND DIAGNOSIS: 6.5.1 SCREENING: Doctors aren't sure whether you should undergo screening for lung cancer. Even if you have an increased risk of lung cancer — for instance, if you're a smoker — it isn't clear that a chest X-ray or computerized tomography (CT) scan can be beneficial. Some studies show that these tests can find cancer earlier, when it may be treated more successfully. But other studies find that these tests often reveal more benign conditions that require invasive testing and expose people to unnecessary risks. Screening for lung cancer is controversial among doctors. Studies are ongoing to determine what types of tests may be helpful and who would benefit from lung cancer screening. In the mean time, talk with your doctor if you're concerned about your risk of lung cancer. Together you can determine strategies to reduce your risk and decide whether screening tests are appropriate for you. 6.5.2 DIAGNOSIS: If there's reason to think that you may have lung cancer, your doctor can order a number of tests to look for cancerous cells and to rule out other conditions. In order to diagnose lung cancer, your doctor may recommend: Imaging tests. An X-ray image of your lungs may reveal an abnormal mass or nodule. A CT scan can reveal small lesions in your lungs. Sputum cytology. If you have a cough and are producing sputum, looking at the sputum under the microscope can sometimes reveal the presence of lung cancer cells. Before the test, you may be asked to breathe a mildly irritating mist to help you produce more sputum. Tissue samples (biopsy). A sample of abnormal cells may be removed in a procedure called a biopsy in order to diagnose lung cancer. Your doctor can perform a biopsy in a number of ways, including bronchoscopy, in which your doctor examines abnormal areas of your lungs using a lighted tube that is passed down your throat and into your lungs; mediastinoscopy, in which an incision is made at the base of your neck and surgical tools are inserted behind your breastbone to take tissue samples; and needle biopsy, in which your doctor uses X-ray or CT images to guide a needle through your chest and into a suspicious lump or nodule to collect cells. A biopsy sample may also be taken from lymph nodes or other areas where cancer has spread, such as your liver. Medicine: it’s a noble profession, it serves humanity 45/122
    46. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 46 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Medicine: it’s a noble profession, it serves humanity 46/122
    47. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 47 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.5.3 STAGING: Once your lung cancer has been diagnosed, your doctor will work to determine the extent, or stage, of your cancer. Your cancer's stage helps your doctor decide what treatment is most appropriate. Staging tests may include imaging procedures that allow your doctor to look for signs that cancer has spread beyond your lungs, such as magnetic resonance imaging (MRI), positron emission testing (PET) and bone scans. Not every test is appropriate for every person, so talk with your doctor about which procedures are appropriate for you. A. STAGES OF NON-SMALL CELL LUNG CANCER: I. Stage I. Cancer at this stage has invaded the underlying lung tissue but hasn't spread to the lymph nodes. II. Stage II. This stage cancer has spread to neighboring lymph nodes or invaded the chest wall. III. Stage IIIA. At this stage, cancer has spread from the lung to lymph nodes in the center of the chest. IV. Stage IIIB. The cancer has spread locally to areas such as the heart, blood vessels, trachea and esophagus — all within the chest — or to lymph nodes in the area of the collarbone or to the tissue that surrounds the lungs within the rib cage (pleura). Medicine: it’s a noble profession, it serves humanity 47/122
    48. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 48 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. V. Stage IV. The cancer has spread to other parts of the body, such as the liver, bones or brain. Medicine: it’s a noble profession, it serves humanity 48/122
    49. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 49 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. STAGES OF SMALL CELL LUNG CANCER: Limited. Cancer is confined to one lung and to its neighboring lymph nodes. Extensive. Cancer has spread beyond one lung and nearby lymph nodes, and may have invaded both lungs, more remote lymph nodes or other organs. 6.6 COMPLICATIONS: Lung cancer can cause complications, such as: Fluid in the chest (pleural effusion). Lung cancer can cause fluid to accumulate in the space that surrounds the lungs in the chest cavity (pleural space). Pleural effusion can result from cancer spreading outside the lungs or in reaction to lung cancer inside the lungs. Fluid accumulating in the chest can cause shortness of breath. Treatments are available to drain the fluid from your chest and reduce the risk that pleural effusion will occur again. Cancer that spreads to the pleura is considered inoperable, so surgery isn't an option for treatment. Cancer that spreads to other parts of the body (metastasis). Lung cancer often spreads (metastasizes) to other parts of the body — most commonly the opposite lung, brain, bones, liver and adrenal glands. Cancer that spreads can cause signs and symptoms, including pain, nausea, headaches or others based on what organ is affected. In some cases, treatments are available for isolated metastasis, but in most cases, the goal of treatment for metastasis is only to relieve signs and symptoms. Death. Unfortunately, survival rates haven't improved for people diagnosed with lung cancer. In most cases, the disease is fatal. Almost 60 percent, or three out of every five people, diagnosed with lung cancer die within a year. Keep in mind, however, that this number includes people diagnosed with all types of lung cancer at all stages of the disease. People diagnosed at the earliest stages have the greatest chances for a cure. Your doctor can discuss more relevant statistics about your chances for survival with you. Medicine: it’s a noble profession, it serves humanity 49/122
    50. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 50 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.7 TREATMENTS AND DRUGS: You and your doctor choose a cancer treatment regimen based on a number of factors, such as your overall health, the type and stage of your cancer, and your own preferences. Treatment options typically include one or more treatments, including surgery, chemotherapy, radiation therapy or targeted drug therapy. In some cases you may choose not to undergo treatment. For instance, you may feel that the side effects of treatment will outweigh the potential benefits. When that's the case, your doctor may suggest comfort (palliative) care to treat only the symptoms the cancer is causing, such as pain. Treatment options for non-small cell lung cancers Stage Common options I Surgery II Surgery, chemotherapy, radiation IIIA Combined chemotherapy and radiation, sometimes surgery based on results of treatment IIIB Chemotherapy, sometimes radiation IV Chemotherapy, targeted drug therapy, clinical trials, supportive care Treatment options for small cell lung cancers Stage Common options LimitedCombined chemotherapy and radiation, sometimes surgery ExtensChemotherapy, clinical trials, supportive care Medicine: it’s a noble profession, it serves humanity 50/122
    51. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 51 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.7.1 SURGERY: During surgery your surgeon works to remove the lung cancer and a margin of healthy tissue. Procedures to remove lung cancer include: Wedge resection to remove a small section of lung that contains the tumor along with a margin of healthy tissue Lobectomy to remove the entire lobe of one lung Pneumonectomy to remove an entire lung If you undergo surgery, your surgeon may also remove lymph nodes from your chest in order to check them for signs of cancer. If your lymph nodes contain cancer cells, this usually indicates that cancer has spread, even if cancer hasn't been detected outside of your chest. Lung cancer surgery carries risks, including bleeding and infection. Expect to feel short of breath after lung surgery. Your lung tissue will expand over time and make it easier to breathe. You may also feel pain in the muscles of your chest and in your arm on the side where you had the operation. Your doctor may recommend physical therapy or a rehabilitation program to help you restore your strength and range of motion. 6.7.2 CHEMOTHERAPY: Chemotherapy uses drugs to kill cancer cells. One or more chemotherapy drugs may be administered through a vein in your arm (intravenously) or taken orally. A combination of drugs usually is given in a series of treatments over a period of weeks or months, with breaks in between so that your body can recover. Chemotherapy can be used as a first line treatment for lung cancer or as additional treatment after surgery. In some cases, chemotherapy can be used to lessen side effects of your cancer. Medicine: it’s a noble profession, it serves humanity 51/122
    52. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 52 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.7.3 RADIATION THERAPY: Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. Radiation therapy can be directed at your lung cancer from outside your body (external beam radiation) or it can be put inside needles, seeds or catheters and placed inside your body near the cancer (brachytherapy). Radiation therapy can be used alone or along with other lung cancer treatments. Sometimes it's administered at the same time as chemotherapy. Radiation therapy can also be used to lessen side effects of lung cancer. 6.7.4 TARGETED DRUG THERAPY: Targeted therapies are newer cancer treatments that work by targeting specific abnormalities in cancer cells. Targeted therapy options for treating lung cancer include: Bevacizumab (Avastin). Bevacizumab stops a tumor from creating a new blood supply. Blood vessels that connect to tumors can supply oxygen and nutrients to the tumor, allowing it to grow. Bevacizumab is usually used in combination with chemotherapy and is approved for advanced and recurrent non-small cell lung cancer. Bevacizumab carries a risk of severe bleeding. Erlotinib (Tarceva). Erlotinib blocks chemicals that signal the cancer cells to grow and divide. Erlotinib is approved for people with advanced and recurrent non-small cell lung cancer that haven't been helped by chemotherapy. Erlotinib side effects include a skin rash and diarrhea. Medicine: it’s a noble profession, it serves humanity 52/122
    53. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 53 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.7.5 CLINICAL TRIALS: Clinical trials are studies of new lung cancer treatment methods. You may be interested in enrolling in a clinical trial if lung cancer treatments aren't working or if your treatment options are limited. The treatments studied in a clinical trial may be the latest innovations, but they don't guarantee a cure. Carefully weigh your treatment options with your doctor. Your participation in a clinical trial may help doctors better understand how to treat lung cancer in the future. 6.7.6 SUPPORTIVE (PALLIATIVE) CARE: When treatments offer little chance for a cure, your doctor may recommend you avoid harsh treatments and opt for supportive care instead. If you're receiving supportive care, your doctor may treat any signs and symptoms you experience to make you feel more comfortable, but you won't receive treatment aimed at stopping your cancer. Supportive care allows you to make the most of your final weeks or months without enduring treatment side effects that can negatively impact your quality of life. 6.8 PREVENTION: There's no sure way to prevent lung cancer, but you can reduce your risk if you:  Don't smoke. If you've never smoked, don't start. Talk to your children about not smoking, so they can understand how to avoid this major risk factor for lung cancer. Many current smokers began smoking in their teens. Begin conversations about the dangers of smoking with your children early, so they know how to react to peer pressure.  Stop smoking. Stop smoking now. Quitting reduces your risk of lung cancer, even if you've smoked for years. Talk to your doctor about strategies and stop-smoking aids that can help you quit. Options include nicotine replacement products, medications and support groups.  Avoid secondhand smoke. If you live or work with a smoker, urge him or her to quit. At the very least, ask him or her to smoke outside. Avoid areas where people smoke, such as bars and restaurants, and seek out smoke-free options.  Test your home for radon. Have the radon levels in your home checked, especially if you live in an area where radon is known to be a problem. High radon levels can be remedied to make your home safer. For information on radon testing, contact your local department of public health or a local chapter of the American Lung Association.  Avoid carcinogens at work. Take precautions to protect yourself from exposure to toxic chemicals at work. In the United States, your employer must tell you if you're exposed to dangerous chemicals in your workplace. Follow your employer's precautions. For instance, if you're given a face mask for protection, always wear it. Ask your doctor what more you can do to protect yourself at work. Your risk of lung damage from these carcinogens increases if you smoke.  Eat a diet full of fruits and vegetables. Choose a healthy diet with a variety of fruits and vegetables. Food sources of vitamins and nutrients are best. Avoid taking large doses of vitamins in pill form, as there may be unknown harms. For instance, researchers hoping to reduce the risk of lung cancer in heavy smokers gave them beta carotene supplements. Results showed the supplements actually increased the risk of cancer in smokers.  Drink alcohol in moderation, if at all. Limit yourself to one drink a day if you're a woman or two drinks a day if you're a man. Anyone age 65 and older should drink no more than one drink a day.  Exercise. Aim to achieve at least 30 minutes of exercise on most days of the week. Check with your doctor first if you aren't already exercising regularly. Start out slowly and continue adding more activity. Biking, swimming and walking are good choices. Add exercise throughout your day — park farther away from work and walk the rest of the way or take the stairs rather than the elevator. Medicine: it’s a noble profession, it serves humanity 53/122
    54. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 54 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.9 ALTERNATIVE MEDICINE: If your doctor has told you that your lung cancer can't be cured, you may be tempted to turn to complementary and alternative medicine for answers. Flashy Web sites claim cures are available at clinics in foreign countries, and secret herbal remedies seem to offer hope at a time when you feel you have few treatment options. But alternative lung cancer treatments aren't backed by scientific research, so there's no evidence that these therapies work. And, in many cases, the side effects of these treatments are unknown. Alternative lung cancer treatments may be expensive and require travel to distant places. Consider how you want to spend the time you have remaining. You may prefer to spend your time at home with friends and family, rather than a faraway place where you have no support system. Rather than forgoing mainstream cancer treatments, using complementary and alternative treatments along with care from your doctor may be a reasonable option. Work with your doctor to determine what complementary and alternative treatments may help relieve any signs and symptoms you experience. Your doctor can help you weigh the benefits and risks of complementary and alternative treatments. The American College of Chest Physicians reviewed available complementary and alternative treatments and found some therapies may be helpful for people with lung cancer, including:  Acupuncture. During an acupuncture session, a practitioner inserts small needles into precise points on your body. Acupuncture may relieve pain and ease cancer treatment side effects, such as nausea, vomiting and dry mouth, but there's no evidence that acupuncture has any effect on your cancer. Acupuncture can be safe when done by a certified practitioner. Ask your doctor to recommend someone in your community. But acupuncture isn't safe if you have low blood counts or take blood thinners.  Hypnosis. Hypnosis is a type of therapy that puts you in a trance-like state that can be relaxing. Hypnosis is typically done by a therapist who leads you through relaxation exercises and asks you to think pleasing and positive thoughts. Hypnosis may reduce anxiety, nausea and pain in people with cancer, and it may improve appetite.  Massage. During a massage, a massage therapist uses his or her hands to apply pressure to your skin and muscles. Massage can help relieve anxiety, distress, fatigue and pain in people with cancer. Some massage therapists are specially trained to work with people who have cancer. Ask your doctor for names of massage therapists in your community. Massage shouldn't hurt. Your massage therapist shouldn't put pressure anywhere near your tumor or any surgical wounds. Don't have a massage if your blood counts are low or if you're taking blood thinners.  Meditation. Meditation is a time of quiet reflection in which you focus your mind on something, such as an idea, image or sound. Meditation may reduce stress and improve quality of life in people with cancer. Meditation can be done on your own, or there may be instructors in your community. Ask for recommendations from your health care team or friends and family.  Yoga. Yoga combines gentle stretching movements with deep breathing and meditation. Yoga may help people with cancer sleep better. Yoga is generally safe when taught by a trained instructor, but don't do any moves that hurt or don't feel right. Many fitness centers offer yoga classes. Ask your friends and family for opinions on yoga classes they've taken. Medicine: it’s a noble profession, it serves humanity 54/122
    55. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 55 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.10 PHYSICAL THERAPY AFTER LUNG CANCER: 6.10.1 AEROBIC EXERCISE AS THERAPY FOR CANCER FATIGUE: Fatigue and impairment of physical performance are common and severe problems of cancer patients. An aerobic exercise program of precisely defined intensity, duration, and frequency can be prescribed as therapy for primary fatigue in cancer patients. Medicine: it’s a noble profession, it serves humanity 55/122
    56. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 56 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. A. TRAINING PROGRAM: The patients can carry out an aerobic training program consisting of walking on a treadmill on weekdays for 6 wk. Training is carried out by a speed corresponding to a lactate concentration of 3 ± 0.5 mmol!L-1 in capillary blood (slightly below the anaerobic threshold, 10); this intensity coincided with a heart rate of 80 ± 5% of the maximum reached during stress test. Heart rate during training is controlled continuously; lactate concentration is controlled every fifth training day. As lactate concentration sinks below 2.5 mmol!L-1 and exercise heart rate decreases as a result of training adaptation, treadmill speed is increased by 0.5 km!h-1 to maintain training intensity constant. During the first week, each patient walks five times for 3 min at the above- mentioned speed; between these training bouts, patients walk with half-speed for 3 min to recover. Patients who train at a speed of 3 km!h-1 sit during the intervals. Exercise duration is increased weekly and the number of training bouts reduced (a 5-min bout four times in the second week, an 8-min bout three times in the third, a 10-min bout three times in the fourth, a 15-min bout two times in the fifth, and 30 to 35 min without interruption in the sixth week). In the week after concluding the training program, a second assessment of cardiac function (with ECG and echocardiogram) and of maximal physical performance (with a treadmill test) is carried out. The loss of energy of cancer patients originated in extreme muscular deconditioning relates to their illness and treatment. To avoid fatigue patients must be advised to seek periods of rest and to reduce their level of activity. The patients need a higher degree of effort to carry out normal daily activities that create a self-perpetuating condition of diminished activity caused by easy fatigability and vice versa. An aerobic training program can break their circle of lack of exercise, impaired performance, and easy fatigability. Moreover, physical activity can produce secondary benefits such as improved emotional stability. As the training program leads the patients to higher levels of physical fitness, they gain self- confidence and independence. They can no longer be inactive objects of diagnostic and therapeutic measures but active participants in the rehabilitation process. For some patients, cancer fatigue can originate in the diminished level of physical activity related to disease and to many treatment modalities. Therefore, cancer patients suffering from primary fatigue should not be advised to increase the amount of daily rest. Rather, they should be counseled to carry out aerobic exercise; counseling should include a precise definition of duration, intensity, and frequency of training. Medicine: it’s a noble profession, it serves humanity 56/122
    57. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 57 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Medicine: it’s a noble profession, it serves humanity 57/122
    58. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 58 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.0 PROSTATE CANCER: Prostate cancer is cancer of the small walnut-shaped gland in males that produces seminal fluid, the fluid that nourishes and transports sperm. Prostate cancer is one of the most common types of cancer in men, affecting about one in six men in the United States. A diagnosis of prostate cancer can be scary not only because it can be life- threatening, but also because treatments can cause side effects such as bladder control problems and erectile dysfunction (impotence). But diagnosis and treatment of prostate cancer have gotten much better in recent years. Prostate cancer usually grows slowly and initially remains confined to the prostate gland, where it may not cause serious harm. While some types of prostate cancer grow slowly and may need minimal or no treatment, other types are aggressive and can spread quickly. If prostate cancer is detected early — when it's still confined to the prostate gland — you have a better chance of successful treatment. Medicine: it’s a noble profession, it serves humanity 58/122
    59. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 59 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.1 SYMPTOMS: Prostate cancer usually doesn't produce any noticeable symptoms in its early stages, so many cases of prostate cancer aren't detected until the cancer has spread beyond the prostate. For most men, prostate cancer is first detected during a routine screening such as a prostate-specific antigen (PSA) test or a digital rectal exam (DRE). When signs and symptoms do occur, they depend on how advanced the cancer is and how far the cancer has spread. Early signs and symptoms of prostate cancer can include urinary problems, caused when the prostate tumor presses on the bladder or on the tube that carries urine from the bladder (urethra). However, urinary symptoms are much more commonly caused by benign prostate problems, such as an enlarged prostate (benign prostatic hyperplasia) or prostate infections. Less than 5 percent of cases of prostate cancer have urinary problems as the initial symptom. When urinary signs and symptoms do occur, they can include:  Trouble urinating  Starting and stopping while urinating  Decreased force in the stream of urine Cancer in your prostate or the area around the prostate can cause:  Blood in your urine  Blood in your semen Prostate cancer that has spread to the lymph nodes in your pelvis may cause:  Swelling in your legs  Discomfort in the pelvic area Advanced prostate cancer that has spread to your bones can cause:  Bone pain that doesn't go away  Bone fractures  Compression of the spine Medicine: it’s a noble profession, it serves humanity 59/122
    60. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 60 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.2 CAUSES: Cancer is a group of abnormal cells that grow more rapidly than normal cells and that refuse to die. Cancer cells also have the ability to invade and destroy normal tissues, either by growing directly into surrounding structures or after traveling to another part of your body through your bloodstream or lymph system (metastasize). Microscopic cancer cells develop into small clusters that continue to grow, becoming more densely packed and hard. What causes prostate cancer and why some types behave differently are unknown. Research suggests that a combination of factors may play a role, including heredity, ethnicity, hormones, diet and the environment. 7.3 RISK FACTORS: Knowing the risk factors for prostate cancer can help you determine if and when you want to begin prostate cancer screening. The main risk factors include:  Age: After age 50, your chance of having prostate cancer increases.  Race or ethnicity: For reasons that aren't well understood, black men have a higher risk of developing and dying of prostate cancer.  Family history: If your father or brother has prostate cancer, your risk of the disease is greater than that of the average man.  Diet: A high-fat diet and obesity may increase your risk of prostate cancer. One theory is that fat increases production of the hormone testosterone, which may promote the development of prostate cancer cells.  High testosterone levels: Because testosterone naturally stimulates the growth of the prostate gland, men who use testosterone therapy are more likely to develop prostate cancer than are men who have lower levels of testosterone. Also, doctors are concerned that testosterone therapy might fuel the growth of prostate cancer that is already present. Long-term testosterone treatment also may cause prostate gland enlargement (benign prostatic hyperplasia). Medicine: it’s a noble profession, it serves humanity 60/122
    61. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 61 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.4 WHEN TO SEEK MEDICAL ADVICE: If you have difficulties with urination, see your doctor. This condition doesn't always relate to prostate cancer, but it can be a sign of prostate-related problems. Beginning at age 50, the American Cancer Society recommends having yearly screening tests for prostate cancer. If you're black or have a family history of the disease, you may want to begin at a younger age. Yearly screenings can help detect prostate cancer early, when it's easier to treat. They include:  PSA test. This blood test checks levels of prostate-specific antigen (PSA), which can be a sign of prostate cancer. While this test can detect signs of cancer, elevated PSA levels are sometimes caused by conditions other than cancer, such as prostate enlargement, infection or inflammation.  Digital rectal exam (DRE). This test involves insertion of a lubricated finger into the rectum to feel for bumps on the prostate. While it can be slightly uncomfortable, an annual DRE is a quick, simple exam that can be a lifesaver. 7.5 TESTS AND DIAGNOSIS: Prostate cancer may not cause any symptoms at first. The first indication of a problem may come during a routine screening test, such as:  Digital rectal exam (DRE). During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of your gland, you may need more tests.  Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein and analyzed for PSA, a substance that's naturally produced by your prostate gland to help liquefy semen. It's normal for a small amount of PSA to enter your bloodstream. However, if a higher than normal level is found, it may be an indication of prostate infection, inflammation, enlargement or cancer. Studies have not been able to show that routine screening decreases the chance that anyone will die of prostate cancer, but screening with PSA and DRE can help identify cancer at an earlier stage.  Transrectal ultrasound. If other tests raise concerns, your doctor may use transrectal ultrasound to further evaluate your prostate. A small probe, about the size and shape of a cigar, is inserted into your rectum. The probe uses sound waves to get a picture of your prostate gland.  Prostate biopsy. If initial test results suggest prostate cancer, your doctor may recommend biopsy. To do a prostate biopsy, your doctor inserts a small ultrasound probe into your rectum. Guided by images from the probe, your doctor uses a fine, spring-propelled needle to retrieve several very thin sections of tissue from your prostate gland. A pathologist who specializes in diagnosing cancer and other tissue abnormalities evaluates the samples. From those, the pathologist can tell if the tissue removed is cancerous and estimate how aggressive your cancer is. 7.5.1 DETERMINING HOW FAR THE CANCER HAS SPREAD: Once a cancer diagnosis has been made, you may need further tests to help determine if or how far the cancer has spread. Many men don't require additional studies and can directly proceed with treatment based on the characteristics of their tumors and the results of their pre-biopsy PSA tests.  Bone scan. A bone scan takes a picture of your skeleton in order to determine whether cancer has spread to the bone. Prostate cancer can spread to any bones in your body, not just those closest to your prostate, such as your pelvis or lower spine.  Ultrasound. Ultrasound not only can help indicate if cancer is present, but also may reveal whether the disease has spread to nearby tissues.  Computerized tomography (CT) scan. A CT scan produces cross-sectional images of your body. CT scans can identify enlarged lymph nodes or abnormalities in other organs, but they can't Medicine: it’s a noble profession, it serves humanity 61/122
    62. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 62 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. determine whether these problems are due to cancer. Therefore, CT scans are most useful when combined with other tests.  Magnetic resonance imaging (MRI). This type of imaging produces detailed, cross-sectional images of your body using magnets and radio waves. An MRI can help detect evidence of the possible spread of cancer to lymph nodes and bones.  Lymph node biopsy. If enlarged lymph nodes are found by a CT scan or an MRI, a lymph node biopsy can determine whether cancer has spread to nearby lymph nodes. During the procedure, some of the nodes near your prostate are removed and examined under a microscope to determine if cancerous cells are present. Medicine: it’s a noble profession, it serves humanity 62/122
    63. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 63 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.5.2 GRADING: When a biopsy confirms the presence of cancer, the next step, called grading, is to determine how aggressive the cancer is. The tissue samples are studied, and the cancer cells are compared with healthy prostate cells. The more the cancer cells differ from the healthy cells, the more aggressive the cancer and the more likely it is to spread quickly. Cancer cells may vary in shape and size. Some cells may be aggressive, while others aren't. The pathologist identifies the two most aggressive types of cancer cells when assigning a grade. The most common scale used to evaluate prostate cancer cells is called a Gleason score. Based on the microscopic appearance of cells, individual ratings from 1 to 5 are assigned to the two most common cancer patterns identified. These two numbers are then added together to determine your overall score. Scoring can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer). 7.5.3 STAGING: After the level of aggressiveness of your prostate cancer is known, the next step, called staging, determines if or how far the cancer has spread. Your cancer is assigned one of four stages, based on how far it has spread: A. STAGE I. Signifies very early cancer that's confined to a microscopic area that your doctor can't feel. B. STAGE II. Your cancer can be felt, but it remains confined to your prostate gland. C. STAGE III. Your cancer has spread beyond the prostate to the seminal vesicles or other nearby tissues. D. STAGE IV. Your cancer has spread to lymph nodes, bones, lungs or other organs. Medicine: it’s a noble profession, it serves humanity 63/122
    64. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 64 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.6 COMPLICATIONS: Complications from prostate cancer are related to both the disease and its treatment. One of the biggest fears of many men who have prostate cancer is that treatment may leave them incontinent or unable to maintain an erection firm enough for sex (erectile dysfunction). Fortunately, therapies exist to help cope with or treat these conditions. 7.6.1 THE TYPICAL COMPLICATIONS OF PROSTATE CANCER AND ITS TREATMENTS INCLUDE: A. SPREAD OF CANCER: Prostate cancer can spread to nearby organs or travel through your bloodstream or lymphatic system, affecting your bones or other organs. Treatments for prostate cancer that has spread can include hormone therapy, radiation therapy and chemotherapy. B. PAIN: Although early-stage prostate cancer typically isn't painful, once it's spread to bones it can be. Not all people with cancer that has spread to bones have pain, but in some cases, pain is intense and doesn't go away. Treatments directed at shrinking the cancer often can produce significant pain relief. Medications ranging from over-the-counter pain relievers to prescription narcotics can alleviate pain. If your pain is severe, you may need to see a pain specialist. While it's not always possible to make all of your pain go away, your doctor will work with you to try to control pain to a point where you're comfortable. If you're in serious pain, tell your doctor. Pain can be controlled, and there's no reason you have to suffer. C. DIFFICULTY URINATING (URINARY INCONTINENCE): Both prostate cancer and its treatment can cause incontinence. Treatment depends on the type of incontinence you have, how severe it is and the likelihood it will improve over time. Treatments include behavior modifications (such as going to the bathroom at set times rather than just according to urges), exercises to strengthen pelvic muscles (commonly called Kegel exercises), medications and catheters. If incontinence continues for a prolonged period without getting better, your doctor may suggest more aggressive procedures. These may include implanting an artificial urinary sphincter, placement of a sling of synthetic material to compress the urethra, or the injection of bulking agents into the lining of the urethra at the base of the bladder to reduce leakage. D. ERECTILE DYSFUNCTION (ED) OR IMPOTENCE: Like incontinence, ED can be a result of prostate cancer or its treatment, including surgery, radiation or hormone treatments. Medications and vacuum devices that assist in achieving erection are available to treat ED. Medications include sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). If other treatments fail, penile implants can be inserted surgically to help create an erection. E. DEPRESSION: Many men may feel depressed after a diagnosis of prostate cancer or after trying to cope with the side effects of treatment. These feelings may last for only a short time, they may come and go, or they may linger for weeks or even months. Talk to your doctor if you have depression that interferes with your ability to get things done or enjoy your life. Treatment such as counseling or antidepressant medication can make a big difference. Medicine: it’s a noble profession, it serves humanity 64/122
    65. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 65 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.7 TREATMENTS AND DRUGS: There's more than one way to treat prostate cancer. For some men a combination of treatments — such as surgery followed by radiation or radiation paired with hormone therapy — works best. The treatment that's best for each man depends on several factors. These include how fast your cancer is growing, how much it has spread, your age and life expectancy, as well as the benefits and the potential side effects of the treatment. The most common treatments for prostate cancer include the following: 7.6.1 EXTERNAL BEAM RADIATION THERAPY (EBRT): External beam radiation treatment uses high-powered X-rays to kill cancer cells. This type of radiation is effective at destroying cancerous cells, but it can also scar adjacent healthy tissue. The first step in radiation therapy is to map the precise area of your body that needs to receive radiation. Computer-imaging software helps your doctor find the best angles to aim the beams of radiation. Precisely focused radiation kills cancer in your prostate while minimizing harm to surrounding tissue. Treatments are generally given five days a week for about eight weeks. Each treatment appointment takes about 10 minutes. However, much of this is preparation time — radiation is received for only about one minute. You don't need anaesthesia with external beam radiation, because the treatment isn't painful. You'll be asked to arrive for therapy with a full bladder. This will push most of your bladder out of the path of the radiation beam. A body supporter holds you in the same position for each treatment. Ink marks on your skin help guide the radiation beam, and small gold markers may be placed in your prostate to ensure the radiation hits the same targets each time. Custom-designed shields help protect nearby normal tissue, such as your bladder, erectile tissues, anus and rectal wall. EBRT can cause mild side effects, but in most cases they disappear shortly after your course of treatment is finished. A. SIDE EFFECTS OF EBRT:  Urinary problems. The most common signs and symptoms are urgency to urinate and frequent urination. These problems usually are temporary and gradually diminish in a few weeks after completing treatment. Long-term problems are uncommon. Medicine: it’s a noble profession, it serves humanity 65/122
    66. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 66 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Loose stools, rectal bleeding, discomfort during bowel movements or a sense of needing to have a bowel movement (rectal urgency). In some cases these problems persist for months after treatment, but they improve on their own in most men. If you do have long-term rectal symptoms, medications can help. Rarely, men develop persistent bleeding or a rectal ulcer after radiation. Surgery may be necessary to alleviate these problems.  Sexual side effects. Radiation therapy doesn't usually cause immediate sexual side effects such as erectile dysfunction, but some men who've had the treatment have sexual problems later in life. 7.6.2 RADIOACTIVE SEED IMPLANTS: Radioactive seeds implanted into the prostate have gained popularity in recent years as a treatment for prostate cancer. The implants, also known as brachytherapy, deliver a higher dose of radiation than do external beams, but over a substantially longer period of time. The therapy is generally used in men with smaller or moderate-sized prostates with small and lower grade cancers. During the procedure, between 40 and 100 rice-sized radioactive seeds are placed in your prostate through ultrasound-guided needles. The implant procedure typically lasts one to two hours and is done under general anaesthesia — which means you won't be awake. Most men can go home the day of the procedure. Sometimes, hormone therapy is used for a few months to shrink the size of the prostate before seeds are implanted. The seeds may contain one of several radioactive isotopes — including iodine and palladium. These seeds don't have to be removed after they stop emitting radiation. Iodine and palladium seeds generally emit radiation that extends only a few millimetres beyond their location. This type of radiation isn't likely to escape your body in significant doses. However, doctors recommend that for the first few months you stay at least six feet (1.83 meters) away from children and pregnant women, who are especially sensitive to radiation. All radiation inside the pellets is generally exhausted within a year. A. SIDE EFFECTS OF RADIOACTIVE SEED IMPLANTS:  Urinary problems. The procedure causes urinary signs and symptoms such as frequent, slow and painful urination in nearly all men. You may require medication to treat these signs and symptoms. Some men need medications or the use of intermittent self-catheterization to help them urinate. Urinary symptoms tend to be more severe and longer lasting with seed implants than with external beam radiation. Medicine: it’s a noble profession, it serves humanity 66/122
    67. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 67 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Sexual problems. Some men experience erectile dysfunction due to radioactive seed implants.  Rectal symptoms. Sometimes this treatment causes loose stools, discomfort during bowel movements or other rectal symptoms. However, rectal symptoms from radioactive seed implants are generally less severe than with external beam radiation. Medicine: it’s a noble profession, it serves humanity 67/122
    68. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 68 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.6.3 HORMONE THERAPY: Hormone therapy involves trying to stop your body from producing the male sex hormones testosterone, which can stimulate the growth of cancer cells. This type of therapy can also block hormones from getting into cancer cells. Sometimes doctors use a combination of drugs to achieve both. In most men with advanced prostate cancer, this form of treatment is effective in helping both shrink the cancer and slow the growth of tumors. Sometimes doctors use hormone therapy in early- stage cancers to shrink large tumors so that surgery or radiation can remove or destroy them more easily. In some cases, hormone therapy is used in combination with radiation therapy or surgery. After these treatments, the drugs can slow the growth of any stray cancer cells left behind. Some drugs used in hormone therapy decrease your body's production of testosterone. The hormones — known as luteinizing hormone-releasing hormone (LH-RH) agonists — can set up a chemical blockade. This blockade prevents the testicles from receiving messages to make testosterone. Drugs typically used in this type of hormone therapy include leuprolide (Lupron, Viadur) and goserelin (Zoladex). They're injected into a muscle or under your skin once every three or four months. You can receive them for a few months, a few years or the rest of your life, depending on your situation. Other drugs used in hormone therapy block your body's ability to use testosterone. A small amount of testosterone comes from the adrenal glands and isn't suppressed by LH-RH agonists. Certain medications — known as anti-androgens — can prevent testosterone from reaching your cancer cells. Examples include bicalutamide (Casodex) and nilutamide (Nilandron). They come in tablet form and, depending on the particular brand of drug, are taken orally one to three times a day. These drugs typically are given along with an LH-RH agonist. Simply depriving prostate cancer of testosterone usually doesn't kill all of the cancer cells. Within a few years, the cancer often learns to thrive without testosterone. Once this happens, hormone therapy is less likely to be effective. However, several treatment options still exist. To avoid such resistance, intermittent hormone therapy programs have been developed. During this type of therapy, the hormonal drugs are stopped after your PSA drops to a low level and remains steady. You will need to resume taking the drugs if your PSA level rises again. A. SIDE EFFECTS OF HORMONE THERAPY: Breast enlargement (gynecomastia) Hot flashes Reduced sex drive Weight gain Erectile dysfunction Reduction in muscle and bone mass B. CERTAIN HORMONE THERAPY MEDICATIONS CAN ALSO CAUSE: Nausea Diarrhoea Fatigue Liver damage Recent reports have shown that men who undergo hormone therapy for prostate cancer may have a higher risk of having a heart attack in the first year or two after starting hormone therapy. So your doctor should carefully monitor your heart condition and aggressively treat any other conditions that may predispose you to a heart attack, such as high blood pressure, high cholesterol or smoking. Surgery to remove the testicles, which produce most of your testosterone, is as effective as other forms of hormonal therapy. Many men are not comfortable with the idea of losing their testicles, so they opt for the above-noted methods of lowering testosterone in the body. However, removing the testicles has the advantage of not having to have an injection every three or four months and can be less expensive. The surgery can be done on an outpatient basis using a local anaesthetics. Medicine: it’s a noble profession, it serves humanity 68/122
    69. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 69 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.6.4 RADICAL PROSTATECTOMY: Surgical removal of your prostate gland, called radical prostatectomy, is used to treat cancer that's confined to the prostate gland. During this procedure, your surgeon uses special techniques to completely remove your prostate and nearby lymph nodes. This surgery can affect muscles and nerves that control urination and sexual function. Two surgical approaches are available for a prostatectomy — retropubic surgery and perineal surgery.  Retropubic surgery. The gland is taken out through an incision in your lower abdomen that typically runs from just below the navel to an inch (2.54 centimeters) above the base of the penis. It's the most commonly used form of prostate removal for two reasons. First, your surgeon can use the same incision to remove pelvic lymph nodes, which are tested to determine if the cancer has spread. Second, the procedure gives your surgeon good access to your prostate, making it easy to save the nerves that help control bladder function and erections.  Perineal surgery. An incision is made between your anus and scrotum. There's generally less bleeding with perineal surgery, and recovery time may be shorter, especially if you're overweight. With this procedure, your surgeon isn't able to remove nearby lymph nodes. During either type of operation, a catheter is inserted into your bladder through your penis to drain urine from the bladder during your recovery. The catheter will likely remain in place for one to two weeks after the operation while the urinary tract heals. Medicine: it’s a noble profession, it serves humanity 69/122
    70. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 70 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. A. SIDE EFFECTS OF RADICAL PROSTATECTOMY:  Bladder control problems (urinary incontinence). These symptoms can last for weeks or even months, but most men eventually regain bladder control. Many men experience stress incontinence, meaning they're unable to hold urine flow when their bladders are under increased pressure. This can happen when you sneeze, cough, laugh or lift something heavy. In some men, urinary incontinence doesn't get better and surgery is needed to help correct the problem.  Erectile dysfunction. This is a common side effect of radical prostatectomy, because nerves on both sides of your prostate that control erections may be damaged or removed during surgery. Most men younger than age 50 who have nerve-sparing surgery are able to achieve erections afterward, and even some men in their 70s are able to maintain normal sexual functioning. Men who had trouble achieving or maintaining an erection before surgery have a higher risk of being impotent after the surgery. 7.6.5 ROBOT-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (RALRP): This is a relatively new procedure for removing the prostate. For robot-assisted laparoscopy, five small incisions are made in the abdomen through which the doctor inserts tube-like instruments, including a long, slender tube with a small camera on the end (laparoscope). This creates a magnified view of the surgical area. The instruments are attached to a mechanical device, and the surgeon sits at a console and guides the instruments through a viewing device to perform the surgery. So far, studies show that traditional open prostatectomy and robotic prostatectomy have had similar outcomes related to cancer- free survival rates, urinary continence and sexual function one year after surgery. Longer-term outcomes are not yet known. 7.6.6 WATCHFUL WAITING: The PSA blood test can help detect prostate cancer at a very early stage. This allows many men to choose watchful waiting as a treatment option. In watchful waiting (also known as observation, expectant therapy or deferred therapy), regular follow-up blood tests, rectal exams and possibly biopsies may be performed to monitor progression of your cancer. During watchful waiting no medical treatment is provided. Medications, radiation and surgery aren't used. Watchful waiting may be an option if your cancer isn't causing symptoms, is expected to grow very slowly, and is small and confined to one area of your prostate. Medicine: it’s a noble profession, it serves humanity 70/122
    71. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 71 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Watchful waiting may be particularly appropriate if you're elderly, in poor health or both. Many such men will live out their normal life spans without treatment and without the cancer spreading or causing other problems. But watchful waiting can also be a rational option if you're a younger man, as long as you know the facts, are willing to be vigilant, and accept the risk of a tumor spreading during the observation period, rendering your cancer incurable. 7.6.7 CHEMOTHERAPY: This type of treatment uses chemicals that destroy rapidly growing cells. Chemotherapy can be quite effective in treating prostate cancer, but it can't cure it. Because it has more side effects than hormone therapy does, chemotherapy is reserved for men who have hormone-resistant prostate cancer that has spread to other parts of the body. 7.6.8 CRYOTHERAPY: This treatment is used to destroy cells by freezing tissue. Original attempts to treat prostate cancer with cryotherapy involved inserting a probe into the prostate through the skin between the rectum and the scrotum (perineum). Using a rectal microwave probe to monitor the procedure, the prostate was frozen in an attempt to destroy cancer cells. This method often resulted in damage to tissue around the bladder and long-term complications such as injury to the rectum or the muscles that control urination. More recently, smaller probes and more-precise methods of monitoring the temperature in and around the prostate have been developed. These advances may decrease the complications associated with cryotherapy, making it a more effective treatment for prostate cancer. Although progress continues, more time is needed to determine how successful cryotherapy may be as a treatment for prostate cancer. Medicine: it’s a noble profession, it serves humanity 71/122
    72. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 72 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.6.9 GENE THERAPY AND IMMUNE THERAPY: In the future, gene therapy or immune therapy may be successful in treating prostate cancer. Current technology limits the use of these experimental treatments to a small number of medical centres. 7.7 PREVENTION: Prostate cancer can't be prevented, but you can take measures to reduce your risk or possibly slow the disease's development.  Eat well. High-fat diets have been linked to prostate cancer. Therefore, limiting your intake of high-fat foods and emphasizing fruits, vegetables and whole fibers may help you reduce your risk. Foods rich in lycopene, an antioxidant, also may help lower your prostate cancer risk. These foods include raw or cooked tomatoes, tomato products, grapefruit and watermelon. Garlic and some vegetables such as arugula, bok choy, broccoli, Brussels sprouts, cabbage and cauliflower also may help fight cancer. Other vitamins and minerals, including vitamin C, vitamin E and selenium, have been linked to lower prostate cancer risk, but studies haven't found a benefit to taking supplements to create high levels of these nutrients in your body. Instead, it may be helpful to choose foods that are rich in vitamins and minerals so that you can maintain healthy levels of these nutrients in your body.  Get regular exercise. Regular exercise can help prevent a heart attack and conditions such as high blood pressure and high cholesterol. When it comes to cancer, the data aren't as clear-cut, but studies do indicate that regular exercise may reduce your cancer risk, including your risk of prostate cancer. Exercise has been shown to strengthen your immune system, improve circulation and speed digestion — all of which may play a role in cancer prevention. Exercise also helps to prevent obesity, another potential risk factor for some cancers. Regular exercise may also minimize your symptoms and reduce your risk of prostate gland enlargement, or benign prostatic hyperplasia (BPH). Men who are physically active usually have less-severe symptoms than do men who get little exercise.  Ask your doctor about taking an NSAID. Nonsteroidal anti-inflammatory drugs (NSAIDs) might prevent prostate cancer. These drugs include ibuprofen (Advil, Motrin, others) and naproxen (Aleve). NSAIDs inhibit an enzyme called COX-2, which is found in prostate cancer cells. More studies are needed to confirm whether NSAID use actually results in lower rates of prostate cancer or reduced deaths from the disease. Research on prostate cancer prevention has shown that the drug finasteride (Proscar, Propecia) may prevent or delay the onset of prostate cancer in men 55 years and older. This drug is currently used to control prostate gland enlargement and hair loss in men. However, finasteride has also been shown to contribute to increasing sexual side effects and to slightly raise the risk of developing higher grade prostate cancer. At this time, this drug isn't routinely recommended to prevent prostate cancer. Medicine: it’s a noble profession, it serves humanity 72/122
    73. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 73 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.8 COPING AND SUPPORT: Once you receive a diagnosis of prostate cancer or treatment for this disease, you may experience a range of feelings — including disbelief, fear, anger, anxiety, emptiness and depression. You may not be able to get rid of these distressing feelings. But you can find positive ways to deal with them so they don't dominate your life. The following strategies can help you cope with some of the difficulties of prostate cancer:  Be prepared. Ask your doctor questions and read about prostate cancer and its potential side effects. The fewer the surprises, the more quickly you'll adapt.  Maintain as normal a routine as you can. Don't let the cancer or side effects from treatment dominate your day. Try to follow the routine and lifestyle you had before learning of your cancer. Go back to work, take a trip, join your children or grandchildren on an outing. You need activities that give you a sense of purpose, fulfillment and meaning. But realize that initially you may have some limitations. Start slowly and gradually build your level of endurance.  Get plenty of exercise. Exercise helps fight depression and is a good way to relieve tension and aggression.  Open up to a friend, a family member or a counselor. Cancer is too heavy a load to carry alone. Sometimes it helps to talk with someone about your feelings and fears. The better you feel emotionally, the better you'll be able to physically cope with your illness. You may find joining a support group helpful, because it can provide you with a sense of belonging, give you an opportunity to talk with people who understand your situation and provide you with advice. Your doctor or someone you know who has experienced prostate cancer may be able to help you locate a support group.  Don't avoid sexual contact. Your natural reaction to impotence may be to avoid all sexual contact. Don't fall for this feeling. Touching, holding, hugging and caressing can become far more important to you and your partner. In fact, the closeness you develop in these actions can produce greater sexual intimacy than you've ever had before. There are many ways to express your sexuality.  Look for the positive. Cancer doesn't have to be an all-negative experience for you. Good can come out of it. Confrontation with cancer may lead you to grow emotionally and spiritually, to identify what really matters to you, to settle long-standing disputes and to spend more time with people important to you. 7.9 ALTERNATIVE MEDICINE: A range of dietary supplements and herbal medicines claim to offer new ways to prevent or treat prostate disease, and cancer in general. Some supplements show promise and are slowly gaining acceptance in mainstream medicine. But the benefits and risks of many products and practices remain unproved. Unfortunately, the production of these products isn't well regulated, and the amount of active ingredient may vary from bottle to bottle or even pill to pill. Herbal products marketed to relieve common prostate problems, such as frequent urination or a weak urine flow, include:  African plum tree (Prunus africana)  African wild potato (Hypoxis hemerocallidea, Hypoxis rooperi)  Pumpkin (Cucurbita pepo)  Rye grass (Secale cereale)  Stinging nettle (Urtica dioica, Urtica urens)  Neem from India. Taken in small to moderate amounts, these products appear to be safe. But they haven't been studied in large, long-term trials to confirm their safety or to prove they work. Saw palmetto Medicine: it’s a noble profession, it serves humanity 73/122
    74. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 74 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Unlike other herbal supplements, saw palmetto has been widely tested, and the results show promise in the treatment of urinary symptoms caused by prostate problems. However, it is important to know that saw palmetto is recommended to treat symptoms associated with benign prostate gland enlargement, not prostate cancer. Saw palmetto works slowly. Most men begin to see an improvement in their urinary symptoms within one to three months. If after three months you haven't noticed any benefit from the product, it may not work for you. It appears safe to take saw palmetto indefinitely, but possible effects from long-term use are unknown. One drawback of this herb, and many other such herbal products, is that it may suppress PSA levels in your blood. This action can interfere with the effectiveness of the PSA test. That's why if you take saw palmetto or other herbal medicines, it's important to tell your doctor before having a PSA test. Lacking scientific evidence A few herbal and dietary products claim to help cure or prevent cancer. There's no scientific evidence that these products work, and some may be dangerous. Three popular \"cancer-fighting\" supplements include:  Chaparral. Also known as creosote bush or greasewood, chaparral (Larrea tridentata) comes from a desert shrub found in the southwestern United States and Mexico. Research hasn't shown that the herb effectively treats cancer, and it can lead to irreversible liver failure.  PC-SPES. This mixture contains eight herbs that have been used for hundreds of years in traditional Chinese medicine to treat prostate issues and other health problems. Some studies show it may reduce cancer growth, but it can also cause side effects. It was sold as a dietary supplement, but is no longer being manufactured because some batches were found to contain prescription drug ingredients. While the individual herbs are still available, the PC-SPES mixture has not been reintroduced because further studies are needed to determine whether it's safe.  Shark cartilage. Shark cartilage contains a protein that has some ability to inhibit the formation of new blood vessels within tumors in sharks. Shark cartilage therapy is based on the theory that capsules containing shark cartilage will do the same in humans — stop and shrink cancerous tumors. However, these benefits haven't been shown in humans. Talk with your doctor first Because it's not always easy to tell which products may be unsafe, interact negatively with other medications or affect your overall cancer treatment, it's best to talk with your doctor before you take any dietary or herbal product. Medicine: it’s a noble profession, it serves humanity 74/122
    75. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 75 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.10 PHYSICAL THERAPY AND EXERCISE BEFORE AND AFTER PROSTATE CANCER: 7.10.1 PHYSICAL THERAPY / EXERCISE PROGRAM: Ensuring patients maintain some level of physical activity is a core tenet of the CTCA approach. Exercise - even minimal physical exertion - increases heart rate and muscle flexion, while boosting your body's tolerance to chemotherapy and radiation treatments. Participating in daily exercise programs will enable you to gain a sense of physical control over your condition, and will provide an outlet for stress and anxiety. In addition, exercise will instil you with the motivation and the drive for optimal wellness. The exercise programs combine range-of-motion training with other light activities, like resistance training, to provide you with the right amount of exercise. Designed for patients capable of maintaining independent self-care, these programs will help you identify and address strength and stamina deficiencies, before your fatigue increases to debilitating levels.  Borg Rating of Perceived Exertion (RPE) - The Borg Rating of Perceived Exertion helps therapists determine the intensity of exercise you can tolerate. The scale ranges from 6 (no exertion at all) to 20 (maximal exertion). Since the condition of each person is unique, the Borg system measures exercise as any activity that increases heart rate. Most people achieve 65 to 75 percent of their maximum heart rate during exercise.  Flexibility Program - Stretching is a beneficial activity you may engage in to relieve joint stiffness and pain, at the same time improving your overall mobility and range-of-motion. The benefits of stretching include: o Enhancement of performance in everyday activities o Improvement of mobility and independence o Improvement and maintenance of posture and muscle balance o Injury prevention o Promotion of physical and mental relaxation Medicine: it’s a noble profession, it serves humanity 75/122
    76. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 76 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.10.2 MANUAL THERAPY: Massage therapy is one means of manual muscle therapy. If you require massage therapy, you will first obtain a referral from either a Physical or Occupational Therapist. The following list details the various forms of manual therapies you may receive from rehabilitation services:  Swedish Massage  Reflexology  Lymphedema Massage  Myofascial Release Medicine: it’s a noble profession, it serves humanity 76/122
    77. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 77 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.10.3 SEVEN BENEFITS OF REGULAR PHYSICAL ACTIVITY: Need motivation to exercise? Here are seven ways exercise can improve your life — starting today! Want to feel better, have more energy and perhaps even live longer? Look no further than old- fashioned exercise. The merits of exercise — from preventing chronic health conditions to boosting confidence and self- esteem — are hard to ignore. And the benefits are yours for the taking, regardless of age, sex or physical ability. Need more convincing? Check out seven specific ways exercise can improve your life. 1. Exercise improves your mood.  Need to blow off some steam after a stressful day? A workout at the gym or a brisk 30-minute walk can help you calm down.  Exercise stimulates various brain chemicals, which may leave you feeling happier and more relaxed than you were before you worked out. You'll also look better and feel better when you exercise regularly, which can boost your confidence and improve your self-esteem. Exercise even reduces feelings of depression and anxiety. 2. Exercise combats chronic diseases.  Worried about heart disease? Hoping to prevent osteoporosis? Regular exercise might be the ticket.  Regular exercise can help you prevent — or manage — high blood pressure. Your cholesterol will benefit, too. Regular exercise boosts high-density lipoprotein (HDL), or \"good,\" cholesterol while decreasing low-density lipoprotein (LDL), or \"bad,\" cholesterol. This one-two punch keeps your blood flowing smoothly by lowering the build-up of plaques in your arteries.  And there's more. Regular exercise can help you prevent type 2 diabetes, osteoporosis and certain types of cancer. 3. Exercise helps you manage your weight.  Want to drop those excess pounds? Trade some couch time for walking or other physical activities.  This one's a no-brainer. When you exercise, you burn calories. The more intensely you exercise, the more calories you burn — and the easier it is to keep your weight under control. You don't even need to set aside major chunks of time for working out. Take the stairs instead of the elevator. Walk during your lunch break. Do jumping jacks during commercials. Better yet, turn off the TV and take a brisk walk. Dedicated workouts are great, but activity you accumulate throughout the day helps you burn calories, too. 4. Exercise strengthens your heart and lungs.  Winded by grocery shopping or household chores? Don't throw in the towel. Regular exercise can leave you breathing easier.  Exercise delivers oxygen and nutrients to your tissues. In fact, regular exercise helps your entire cardiovascular system — the circulation of blood through your heart and blood vessels — work more efficiently. Big deal? You bet! When your heart and lungs work more efficiently, you'll have more energy to do the things you enjoy. 5. Exercise promotes better sleep.  Struggling to fall asleep? Or stay asleep? It might help to boost your physical activity during the day.  A good night's sleep can improve your concentration, productivity and mood. And, you guessed it, exercise is sometimes the key to better sleep. Regular exercise can help you fall asleep faster and deepen your sleep. The timing is up to you — but if you're having trouble sleeping, you might want to try late afternoon workouts. The natural dip in body temperature five to six hours after you exercise might help you fall asleep. 6. Exercise can put the spark back into your sex life. Medicine: it’s a noble profession, it serves humanity 77/122
    78. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 78 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Are you too tired to have sex? Or feeling too out of shape to enjoy physical intimacy? Exercise to the rescue.  Regular exercise can leave you feeling energized and looking better, which may have a positive effect on your sex life. But there's more to it than that. Exercise improves your circulation, which can lead to more satisfying sex. And men who exercise regularly are less likely to have problems with erectile dysfunction than are men who don't exercise, especially as they get older. 7. Exercise can be — gasp — fun!  Wondering what to do on a Saturday afternoon? Looking for an activity that suits the entire family? Get physical!  Exercise doesn't have to be drudgery. Take a ballroom dancing class. Check out a local climbing wall or hiking trail. Push your kids on the swings or climb with them on the jungle gym. Plan a neighbourhood kickball or touch football game. Find an activity you enjoy, and go for it. If you get bored, try something new. If you're moving, it counts! Are you convinced? Good. Start reaping the benefits of physical activity today! Medicine: it’s a noble profession, it serves humanity 78/122
    79. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 79 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 7.10.4 BLADDER CANCER REHABILITATION: As part of the Physiotherapist’s comprehensive approach to treating the whole patient and not just the illness, physical fitness consisting of cardiovascular, flexibility and strength training. Together, these activities are designed to help reduce stress, prevent fatigue and improve overall quality-of-life. A. PHYSICAL THERAPY / EXERCISE PROGRAM: Ensuring patients maintain some level of physical activity is a core tenet of the CTCA approach. Exercise—even minimal physical exertion—increases heart rate and muscle flexion, while boosting your body’s tolerance to chemotherapy and radiation treatments. Participating in daily exercise programs will enable you to gain a sense of physical control over your condition, and will provide an outlet for stress and anxiety. In addition, exercise will instill you with the motivation and the drive for optimal wellness. Exercise programs combine range-of-motion training with other light activities, like resistance training, to provide you with the right amount of exercise. Designed for patients capable of maintaining independent self-care, these programs will help you identify and address strength and stamina deficiencies, before your fatigue increases to debilitating levels. I. BORG RATING OF PERCEIVED EXERTION (RPE): The Borg Rating of Perceived Exertion helps therapists determine the intensity of exercise you can tolerate. The scale ranges from 6 (no exertion at all) to 20 (maximal exertion). Since the condition of each person is unique, the Borg system measures \"exercise\" as any activity that increases heart rate. Most people achieve 65 to 75 percent of their maximum heart rate during exercise. Medicine: it’s a noble profession, it serves humanity 79/122
    80. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 80 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. II. FLEXIBILITY PROGRAM: Stretching is a beneficial activity you may engage in to relieve joint stiffness and pain, at the same time improving your overall mobility and range-of-motion. III. THE BENEFITS OF STRETCHING:  Enhancement of performance in everyday activities  Improvement of mobility and independence  Improvement and maintenance of posture and muscle balance  Injury prevention  Promotion of physical and mental relaxation IV. PELVIC FLOOR EXERCISES FOR WOMEN: 1. PELVIC FLOOR EXERCISE ONE:  Sit on a firm chair, lean forward with a straight back, with your legs wide apart and your feet flat on the floor.  Gently draw your urethra and vagina forwards and upwards to your pubic bone, as if you were drawing them up a ramp, while looking at a high point on the wall in front of you.  You might feel a gentle tightening just above the pubic bone, or in front of the hipbones, but you must not feel a tightening around the anus or buttocks.  Hold for five to 10 seconds, rest, then repeat three or four times over a minute.  The muscle tires easily, so do only a few minutes of the exercise during the day, preferably in the morning. Weak pelvic floor muscle 2. PELVIC FLOOR EXERCISE TWO: This is designed to strengthen the deep abdominal muscles that work with the front to back muscles.  Stand comfortably, with your back and knees straight. Focus on your deep abdominal muscles, and gently draw them towards your lower back, and hold. Don’t move your trunk or pelvis. Medicine: it’s a noble profession, it serves humanity 80/122
    81. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 81 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Breathe normally. You should become aware of a gentle tension around the urethra and vagina. You will also feel a tightening of soft tissue across your lower back. There should be no tightening of the anus or buttocks.  Start by holding for five seconds, then build up over time to 10, 15, then 20 seconds.  Try to practice a total of two to three minutes of exercises spread out over the day. Any time of day is suitable. You will notice an improvement in a couple of weeks.  For the next three months, spend a total of five minutes a day practicing the exercises.  If you are unable to manage the exercises and need a bit of help, see a physiotherapist who is experienced in treating pelvic floor muscles. Strong pelvic floor muscle V. PELVIC FLOOR EXERCISES FOR MEN: The pelvic floor muscles are layers of muscle stretched like a hammock from the pubic bone at the front to the bottom of the backbone (coccyx). There are two openings through the pelvic floor - the anus (back passage) and the urethra (bladder outlet). The pelvic floor muscles support these two openings, but if they are weakened or not in good condition they cannot support the openings effectively. When a muscle is not exercised it will weaken through lack of use. The pelvic floor muscles are no exception. Like other muscles they can be damaged, a long history of constipation can weaken the pelvic floor muscles. They can also become weakened by surgery in the pelvic area. 1. HOW TO DO THE EXERCISES: You should sit, stand, or lie in a comfortable position with your legs slightly apart. First you need to identify the correct muscles. Tighten and pull up the muscle around the back passage - as if you are trying to stop yourself from passing wind. You should be able to feel the muscle move - this is the back part of the pelvic floor. Now imagine that you are about to pass water and picture yourself trying to stop the flow of urine. The muscles, which you tighten when you are trying to stop passing water, are the front parts of the pelvic floor. Slowly tighten and pull up the pelvic floor muscles, from the back towards the front- as hard as you can – this is a slow pull up. Hold the squeeze for as long as you can (up to 10 seconds) and then relax the muscles. Relax for 3 or 4 seconds before trying another pull-up. Start with doing these 5 times and increase the number gradually (up to 8-12 times). Now pull up the muscles quickly and tightly, and then relax them immediately. These are fast pull-ups. Again, start with doing these 5 times and increase the number gradually (up to 10 times). Each time you do a series of slow pull-ups, you might try to hold each pull-up for a little longer. And each time you do a series of fast pull-ups try to do more. You should exercise your pelvic floor 3 times a day. Once you have identified the correct muscles and have mastered the exercises, you should be able to do them in any position Medicine: it’s a noble profession, it serves humanity 81/122
    82. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 82 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. without anyone noticing. You could try to get into the habit of doing the exercises every time you do something else that you do regularly for example; every time you clean your teeth or every time you work at the kitchen sink. However, especially when you first start to perform these exercises correctly, you will need to be able to concentrate fully on doing them so ideally try to set aside a quiet time to do them – they don’t take long! 2. HOW LONG TO CONTINUE WITH THE EXERCISES: Like any group of muscles, it is in your own interest to keep them in good shape - so really everyone should be exercising their pelvic floor muscles from childhood through to old age. If you already have some symptoms that might be caused by a weakened pelvic floor, do not be disappointed if you do not notice any improvement even after a month or two of exercising - it is a long process, which needs patience and some willpower. It may help to talk to a specialist continence adviser or a continence physiotherapist about the exercises to make sure you are doing them properly. They may also be able to suggest additional exercises, exercise devices or muscle stimulation which could speed up the process. Tips:  Practice pelvic floor muscle exercises regularly to make the muscles stronger  Try and breathe naturally and avoid tightening your buttocks, leg and upper tummy muscles whilst you are doing your exercises.  Stop exercising if your muscles begin to ache- you have done enough. Take a break.  Don’t give up. Keep doing the exercises. Medicine: it’s a noble profession, it serves humanity 82/122
    83. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 83 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Medicine: it’s a noble profession, it serves humanity 83/122
    84. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 84 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 8.0 LEUKEMIA: Leukemia is a type of cancer. Cancer is a group of many related diseases. All cancers begin in cells, which make up blood and other tissues. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. Leukemia is cancer that begins in blood cells. NORMAL BLOOD CELLS Blood cells form in the bone marrow. Bone marrow is the soft material in the center of most bones. Immature blood cells are called stem cells and blasts. Most blood cells mature in the bone marrow and then move into the blood vessels. Blood that flows through the blood vessels and heart is called the peripheral blood. The bone marrow makes different types of blood cells. Each type has a special function:  White blood cells help fight infection.  Red Blood Cells  Red blood cells carry oxygen to tissues throughout the body.  Platelets  Platelets help form blood clots that control bleeding. In people with leukemia, the bone marrow produces abnormal white blood cells. The abnormal cells are leukemia cells. At first, leukemia cells function almost normally. In time, they may crowd out normal white blood cells, red blood cells, and platelets. This makes it hard for blood to do its work. 8.1 TYPES OF LEUKEMIA: The types of Leukemia are grouped by how quickly the disease develops and gets worse. Leukemia is either chronic (gets worse slowly) or acute (gets worse quickly):  Chronic Leukemia—Early in the disease, the abnormal blood cells can still do their work, and people with chronic Leukemia may not have any symptoms. Slowly, chronic leukemia gets worse. It causes symptoms as the number of Leukemia cells in the blood rises.  Acute leukaemia—The blood cells are very abnormal. They cannot carry out their normal work. The number of abnormal cells increases rapidly. Acute leukemia worsens quickly. The type of white blood cell that is affected also groups the types of leukaemia. Leukemia can arise in lymphoid cells or myeloid cells. Leukemia that affects lymphoid cells is called lymphocytic leukemia. Leukemia that affects myeloid cells is called myeloid leukemia or myelogenous leukemia. Medicine: it’s a noble profession, it serves humanity 84/122
    85. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 85 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Signs & Type Incidence Initial Remission Prognosis Symptoms tachycardia, chest pain, irregular menstruation, jt. Median survival with rx: 1 year Acute Lymphocytic 50% (average 12 Median age: 20 pain, HA, vomiting, Median survival without rx: 2-4 Leukemia (ALL) months) irritability, weeks p dx seizures, papilledema Acute Mean survival with rx: 5 yr (60- Typical s/s listed Myelogenous Median age: 4 90% 70% of children); if relapse, above Leukemia (AML) usually occurs < 3 yrs anorexia, night Chronic sweats, sense of Median survival with rx: 3 yrs Myelogenous Median age: 49 abdominal fullness 90% Survival after 80% blast crisis: 2 Leukemia (CML) (due to months splenomegaly) Anorexia, DOE, sense of abdominal Chronic Median age: 60 Mean survival with rx: 6 years fullness, Lymphocytic (risk increases 90% Primary cause of death: nonspecific Leukemia (CLL) with age) infection symptoms due to anemia (fatigue/ malaise) 8.1.1 COMMON TYPES OF LEUKEMIA:  Chronic lymphocytic leukemia (chronic lymphoblastic leukemia, CLL) accounts for about 7,000 new cases of leukemia each year. Most often, people diagnosed with the disease are over age 55. It almost never affects children.  Chronic myeloid leukemia (chronic myelogenous leukemia, CML) accounts for about 4,400 new cases of leukemia each year. It affects mainly adults.  Acute lymphocytic leukemia (acute lymphoblastic leukemia, ALL) accounts for about 3,800 new cases of leukemia each year. It is the most common type of leukemia in young children. It also affects adults.  Acute myeloid leukemia (acute myelogenous leukemia, AML) accounts for about 10,600 new cases of leukemia each year. It occurs in both adults and children. Hairy cell leukemia is a rare type of chronic leukemia. This booklet does not deal with hairy cell leukemia or other rare types of leukemia. Together, these rare leukemias account for about 5,200 new cases of leukemia each year. Medicine: it’s a noble profession, it serves humanity 85/122
    86. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 86 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 8.2 LEUKEMIA RISKS No one knows the exact causes of leukemia. Doctors can seldom explain why one person gets this disease and another does not. However, research has shown that people with certain risk factors are more likely than others to develop leukemia. A risk factor is anything that increases a person's chance of developing a disease. 8.2.1 RISK FACTORS FOR LEUKEMIA: Very high levels of radiation —People exposed to very high levels of radiation are much more likely than others to develop leukemia. Very high levels of radiation have been caused by atomic bomb explosions (such as those in Japan during World War II) and nuclear power plant accidents (such as the Chernobyl [also called Chornobyl] accident in 1986).  Medical treatment that uses radiation can be another source of high-level exposure. Radiation used for diagnosis, however, exposes people to much lower levels of radiation and is not linked to leukemia.  Working with certain chemicals—Exposure to high levels of benzene in the workplace can cause leukemia. Benzene is used widely in the chemical industry. Formaldehyde is also used by the chemical industry. Workers exposed to formaldehyde also may be at greater risk of leukemia.  Chemotherapy—Cancer patients treated with certain cancer-fighting drugs sometimes later develop leukemia. For example, drugs known as alkylating agents are associated with the development of leukemia many years later.  Down syndrome and certain other genetic diseases—Some diseases caused by abnormal chromosomes may increase the risk of leukemia.  Human T-cell leukemia virus-I (HTLV-I)—This virus causes a rare type of chronic lymphocytic leukemia known as human T-cell leukemia. However, leukemia does not appear to be contagious.  Myelodysplastic syndrome—People with this blood disease are at increased risk of developing acute myeloid leukemia. In the past, some studies suggested exposure to electromagnetic fields as another possible risk factor for leukemia. Electromagnetic fields are a type of low-energy radiation that comes from power lines and electric appliances. However, results from recent studies show that the evidence is weak for electromagnetic fields as a risk factor. Most people who have known risk factors do not get leukemia. On the other hand, many who do get the disease have none of these risk factors. People who think they may be at risk of leukemia should discuss this concern with their doctor. The doctor may suggest ways to reduce the risk and can plan an appropriate schedule for checkups. 8.3 SYMPTOMS OF LEUKEMIA: Like all blood cells, leukemia cells travel through the body. Depending on the number of abnormal cells and where these cells collect, patients with leukemia may have a number of symptoms. 8.3.1 COMMON SYMPTOMS OF LEUKEMIA:  Fevers or night sweats  Frequent infections  Feeling weak or tired  Headache  Bleeding and bruising easily (bleeding gums, purplish patches in the skin, or tiny red spots under the skin)  Pain in the bones or joints Medicine: it’s a noble profession, it serves humanity 86/122
    87. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 87 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Swelling or discomfort in the abdomen (from an enlarged spleen)  Swollen lymph nodes, especially in the neck or armpit  Weight loss Such symptoms are not sure signs of leukemia. An infection or another problem also could cause these symptoms. Anyone with these symptoms should see a doctor as soon as possible. Only a doctor can diagnose and treat the problem. In the early stages of chronic leukemia, the leukemia cells function almost normally. Symptoms may not appear for a long time. Doctors often find chronic leukemia during a routine checkup—before there are any symptoms. When symptoms do appear, they generally are mild at first and get worse gradually. In acute leukemia, symptoms appear and get worse quickly. People with this disease go to their doctor because they feel sick. Other symptoms of acute leukemia are vomiting, confusion, loss of muscle control, and seizures. Leukemia cells also can collect in the testicles and cause swelling. Also, some patients develop sores in the eyes or on the skin. Leukemia also can affect the digestive tract, kidneys, lungs, or other parts of the body. 8.4 LEUKEMIA DIAGNOSES? If a person has symptoms that suggest leukemia, the doctor may do a physical exam and ask about the patient's personal and family medical history. The doctor also may order laboratory tests, especially blood tests. The exams and tests may include the following:  Physical exam—The doctor checks for swelling of the lymph nodes, spleen, and liver.  Blood tests—The lab checks the level of blood cells. Leukemia causes a very high level of white blood cells. It also causes low levels of platelets and hemoglobin, which is found inside red blood cells. The lab also may check the blood for signs that leukemia has affected the liver and kidneys.  Biopsy—The doctor removes some bone marrow from the hipbone or another large bone. A pathologist examines the sample under a microscope. The removal of tissue to look for cancer cells is called a biopsy. A biopsy is the only sure way to know whether leukemia cells are in the bone marrow. There are two ways the doctor can obtain bone marrow. Some patients will have both procedures:  Bone marrow aspiration: The doctor uses a needle to remove samples of bone marrow.  Bone marrow biopsy: The doctor uses a very thick needle to remove a small piece of bone and bone marrow. Medicine: it’s a noble profession, it serves humanity 87/122
    88. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 88 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Local anesthesia helps to make the patient more comfortable.  Cytogenetics—The lab looks at the chromosomes of cells from samples of peripheral blood, bone marrow, or lymph nodes.  Spinal tap—The doctor removes some of the cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). The doctor uses a long, thin needle to remove fluid from the spinal column. The procedure takes about 30 minutes and is performed with local anesthesia. The patient must lie flat for several hours afterward to keep from getting a headache. The lab checks the fluid for leukemia cells or other signs of problems.  Chest x-ray—The x-ray can reveal signs of disease in the chest. A person who needs a bone marrow aspiration or bone marrow biopsy may want to ask the doctor the following questions:  Will you remove the sample of bone marrow from the hip or from another bone?  How long will the procedure take? Will I be awake? Will it hurt?  How soon will you have the results? Who will explain them to me?  If I do have leukemia, who will talk to me about treatment? When? 8.4.1 DIFFERENTIAL DIAGNOSIS Disease Signs/Symptoms Diagnosis Cancer Anemia, infection, easy bruising and bleeding, CBC and peripheral smear, bone irritability, fatigue, bone pain, bleeding gums, marrow examination, histochemical HA, raised non-pruritic rash, WBC<10,000 or studies, cytogenetics, > 100,0001,2 immunopheotyping, molecular biology studies, lumbar puncture. 1,2 Rheumatoid Arthritis Early morning stiffness of affected jts, general Clinical criteria, serum rheumatoid factor afternoon fatigue and malaise, anorexia, (RF) or anti-cyclic citrullinated peptide general weakness, occasional low-grade antibody (anti-CCP), x-rays. 1 fever, jt pain, swelling, and stiffness, mostly simultaneous (B) jt. involvement.1,3 Legg Calve Perthes Pain in the hip joint and gait disturbance, thigh Dx is based on symptoms followed by a muscles may become wasted. 1 bone scan or MRI to confirm the dx. 1 Slipped Capital Femoral The first symptom may be hip stiffness, then a AP and frog-leg lateral x-ray studies of Epiphysis limp may develop, then pain that radiates both hips are taken. Show widening of from hip down to anterior-medial thigh to the epiphyseal line or apparent posterior knee. 1 and inferior displacement of the femoral head. Ultrasonography and MRI can Medicine: it’s a noble profession, it serves humanity 88/122
    89. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 89 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. help Sickle Cell Anemia Severe pain in long bones, hands, feet and Family history is taken into jts. Severe abdominal pain develops, and consideration, laboratory tests for vomiting may occur. Typically in the black hemolytic anemia. 1 population. 1 Infection Severe jt. pain, warmth, tenderness, effusion, Arthrocentesis with synovial fluid restricted A & PROM, and sometimes examination and culture, blood culture, redness, possible high or low-grade fever. 1 CBC and ESR. 1 8.5 LEUKEMIA TREATMENT: Many people with leukemia want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress after a diagnosis of cancer can make it hard to think of everything to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor—to take part in the discussion, to take notes, or just to listen. The doctor may refer patients to doctors who specialize in treating leukemia, or patients may ask for a referral. Specialists who treat leukemia include hematologists, medical oncologists, and radiation oncologists. Pediatric oncologists and hematologists treat childhood leukemia. Whenever possible, patients should be treated at a medical center that has doctors experienced in treating leukemia. If this is not possible, the patient's doctor may discuss the treatment plan with a specialist at such a center. 8.5.1 GETTING A SECOND OPINION: Sometimes it is helpful to have a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it. There are a number of ways to find a doctor for a second opinion:  The patient's doctor may be able to suggest a doctor who specializes in adult or childhood leukemia. At cancer centers, several specialists often work together as a team.  The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers. A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists. The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at http://www.abms.org. (Click on \"Who's Certified.\") 8.5.2 PREPARING FOR TREATMENT: The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs. Treatment depends on a number of factors, including the type of leukemia, the patient's age, whether leukemia cells are present in the cerebrospinal fluid, and whether the leukemia has been Medicine: it’s a noble profession, it serves humanity 89/122
    90. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 90 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. treated before. It also may depend on certain features of the leukemia cells. The doctor also takes into consideration the patient's symptoms and general health. These are some questions a person may want to ask the doctor before treatment begins:  What type of leukemia do I have?  What are my treatment choices? Which do you recommend for me? Why?  What are the benefits of each kind of treatment?  What are the risks and possible side effects of each treatment?  If I have pain, how will you help me?  What is the treatment likely to cost?  How will treatment affect my normal activities?  Would a clinical trial (research study) be appropriate for me? Can you help me find one? People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information. 8.5.3 METHODS OF TREATMENT: The doctor is the best person to describe the treatment choices and discuss the expected results. Depending on the type and extent of the disease, patients may have chemotherapy, biological therapy, radiation therapy, or bone marrow transplantation. If the patient's spleen is enlarged, the doctor may suggest surgery to remove it. Some patients receive a combination of treatments. People with acute leukemia need to be treated right away. The goal of treatment is to bring about a remission. Then, when signs and symptoms disappear, more therapy may be given to prevent a relapse. This type of therapy is called maintenance therapy. Many people with acute leukemia can be cured. Chronic leukemia patients who do not have symptoms may not require immediate treatment. The doctor may suggest watchful waiting for some patients with chronic lymphocytic leukemia. The health care team will monitor the patient's health so that treatment can begin if symptoms occur or worsen. When treatment for chronic leukemia is needed, it can often control the disease and its symptoms. However, chronic leukemia can seldom be cured. Patients may receive maintenance therapy to help keep the cancer in remission. A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on \"The Promise of Cancer Research\" has more information about clinical trials. In addition to anticancer therapy, people with leukemia may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of therapy, or to ease emotional problems. This kind of treatment is called symptom management, supportive care, or palliative care. A. CHEMOTHERAPY: Most patients with leukemia receive chemotherapy. This type of cancer treatment uses drugs to kill leukemia cells. Depending on the type of leukemia, the patient may receive a single drug or a combination of two or more drugs. People with leukemia may receive chemotherapy in several different ways:  By mouth  By injection directly into a vein (IV or intravenous)  Through a catheter (a thin, flexible tube) placed in a large vein, often in the upper chest—A catheter that stays in place is useful for patients who need many IV treatments. The health care Medicine: it’s a noble profession, it serves humanity 90/122
    91. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 91 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. professional injects drugs into the catheter, rather than directly into a vein. This method avoids the need for many injections, which can cause discomfort and injure the veins and skin.  By injection directly into the cerebrospinal fluid—If the pathologist finds leukemia cells in the fluid that fills the spaces in and around the brain and spinal cord, the doctor may order intrathecal chemotherapy. The doctor injects drugs directly into the cerebrospinal fluid. This method is used because drugs given by IV injection or taken by mouth often do not reach cells in the brain and spinal cord. (A network of blood vessels filters blood going to the brain and spinal cord. This blood-brain barrier stops drugs from reaching the brain.) The patient may receive the drugs in two ways:  Injection into the spine: The doctor injects the drugs into the lower part of the spinal column.  Ommaya reservoir: Children and some adult patients receive intrathecal chemotherapy through a special catheter called an Ommaya reservoir. The doctor places the catheter under the scalp. The doctor injects the anticancer drugs into the catheter. This method avoids the discomfort of injections into the spine. Patients receive chemotherapy in cycles: a treatment period, then a recovery period, and then another treatment period. In some cases, the patient has chemotherapy as an outpatient at the hospital, at the doctor's office, or at home. However, depending on which drugs are given, and the patient's general health, a hospital stay may be necessary. Some people with chronic myeloid leukemia receive a new type of treatment called targeted therapy. Targeted therapy blocks the production of leukemia cells but does not harm normal cells. Gleevec, also called STI-571, is the first targeted therapy approved for chronic myeloid leukemia. Medicine: it’s a noble profession, it serves humanity 91/122
    92. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 92 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. BIOLOGICAL THERAPY: People with some types of leukemia have biological therapy. This type of treatment improves the body's natural defenses against cancer. The therapy is given by injection into a vein. For some patients with chronic lymphocytic leukemia, the type of biological therapy used is a monoclonal antibody. This substance binds to the leukemia cells. This therapy enables the immune system to kill leukemia cells in the blood and bone marrow. For some patients with chronic myeloid leukemia, the biological therapy is a natural substance called interferon. This substance can slow the growth of leukemia cells. Patients may want to ask these questions about chemotherapy or biological therapy:  Why do I need this treatment?  What drugs will I get?  Should I see my dentist before treatment begins?  What will the treatment do?  Will I have to stay in the hospital?  How will we know the drugs are working?  How long will I be on this treatment?  Will I have side effects during treatment? How long will they last? What can I do about them?  Can these drugs cause side effects later on?  How often will I need checkups? Medicine: it’s a noble profession, it serves humanity 92/122
    93. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 93 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. C. RADIATION THERAPY: Radiation therapy (also called radiotherapy) uses high-energy rays to kill leukemia cells. For most patients, a large machine directs radiation at the spleen, the brain, or other parts of the body where leukemia cells have collected. Some patients receive radiation that is directed to the whole body. (Total-body irradiation usually is given before a bone marrow transplant.) Patients receive radiation therapy at a hospital or clinic. These are some questions a person may want to ask the doctor before having radiation therapy:  Why do I need this treatment?  When will the treatments begin? How often will they be given? When will they end?  How will I feel during therapy? Will there be side effects? How long will they last? What can we do about them?  Can radiation therapy cause side effects later on?  What can I do to take care of myself during therapy?  How will we know if the radiation is working?  Will I be able to continue my normal activities during treatment?  How often will I need checkups? D. STEM CELL TRANSPLANTATION: Some patients with leukemia have stem cell transplantation. A stem cell transplant allows a patient to be treated with high doses of drugs, radiation, or both. The high doses destroy both leukemia cells and normal blood cells in the bone marrow. Later, the patient receives healthy stem cells through a flexible tube that is placed in a large vein in the neck or chest area. New blood cells develop from the transplanted stem cells. There are several types of stem cell transplantation:  Bone marrow transplantation—The stem cells come from bone marrow. Medicine: it’s a noble profession, it serves humanity 93/122
    94. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 94 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Peripheral stem cell transplantation—The stem cells come from peripheral blood. Medicine: it’s a noble profession, it serves humanity 94/122
    95. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 95 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Umbilical cord blood transplantation—For a child with no donor, the doctor may use stem cells from umbilical cord blood. The umbilical cord blood is from a newborn baby. Sometimes umbilical cord blood is frozen for use later. Stem cells may come from the patient or from a donor:  Autologous stem cell transplantation—This type of transplant uses the patient's own stem cells. The stem cells are removed from the patient, and the cells may be treated to kill any leukemia cells present. The stem cells are frozen and stored. After the patient receives high-dose chemotherapy or radiation therapy, the stored stem cells are thawed and returned to the patient. Medicine: it’s a noble profession, it serves humanity 95/122
    96. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 96 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Allogeneic stem cell transplantation—This type of transplant uses healthy stem cells from a donor. The patient's brother, sister, or parent may be the donor. Sometimes the stem cells come from an unrelated donor. Doctors use blood tests to be sure the donor's cells match the patient's cells. Medicine: it’s a noble profession, it serves humanity 96/122
    97. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 97 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Syngeneic stem cell transplantation—This type of transplant uses stem cells from the patient's healthy identical twin. After a stem cell transplant, patients usually stay in the hospital for several weeks. The health care team protects patients from infection until the transplanted stem cells begin to produce enough white blood cells. These are some questions a person may want to ask the doctor before having a stem cell transplant:  What kind of stem cell transplant will I have? If I need a donor, how will we find one?  How long will I be in the hospital? What care will I need when I leave the hospital?  How will we know if the treatment is working?  What are the risks and the side effects? What can we do about them?  What changes in normal activities will be necessary?  What is my chance of a full recovery? How long will that take?  How often will I need checkups? 8.5.4 SIDE EFFECTS OF TREATMENT FOR LEUKEMIA: Because cancer treatment may damage healthy cells and tissues, unwanted side effects are common. Specific side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, health care providers will explain possible side effects and suggest ways to manage them. A. CHEMOTHERAPY: The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially leukemia cells. Chemotherapy can also affect other rapidly dividing cells:  Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.  Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair may be somewhat different in color and texture.  Cells that line the digestive tract: Chemotherapy can cause mouth and lip sores, nausea and vomiting, diarrhea, and poor appetite. Many of these side effects can be controlled with drugs. Some anticancer drugs can affect a patient's fertility. Women may have irregular menstrual periods or periods may stop altogether. Women may have symptoms of menopause, such as hot flashes and vaginal dryness. Men may stop producing sperm. Because these changes may be permanent, some men have their sperm frozen and stored before treatment. Most children treated for leukemia appear to have normal fertility when they grow up. However, depending on the drugs and doses used and the age of the patient, some boys and girls may be infertile when they mature. Because targeted therapy (sometimes used for chronic myeloid leukemia) affects only leukemia cells, it causes fewer side effects than most other anticancer drugs. However, Gleevec may cause patients to retain water. This may cause swelling or bloating. Medicine: it’s a noble profession, it serves humanity 97/122
    98. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 98 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. BIOLOGICAL THERAPY: The side effects of biological therapy differ with the types of substances used, and from patient to patient. Rashes or swelling where the biological therapy is injected are common. Flu-like symptoms also may occur. The health care team may monitor the blood for signs of anemia and other problems. C. RADIATION THERAPY: Radiation therapy may cause patients to become very tired as treatment continues. Resting is important, but doctors usually advise patients to try to stay as active as they can. In addition, when patients receive radiation therapy, it is common for their skin to become red, dry, and tender in the treated area. Other side effects depend on the area of the body that is treated. If chemotherapy is given at the same time, the side effects may be worse. The doctor can suggest ways to ease these problems. D. STEM CELL TRANSPLANTATION: Patients who have stem cell transplantation face an increased risk of infection, bleeding, and other side effects because of the large doses of chemotherapy and radiation they receive. In addition, graft-versus-host disease (GVHD) may occur in patients who receive stem cells from a donor's bone marrow. In GVHD, the donated stem cells react against the patient's tissues. Most often, the liver, skin, or digestive tract is affected. GVHD can be mild or very severe. It can occur any time after the transplant, even years later. Steroids or other drugs may help. The NCI offers a fact sheet called \"Questions and Answers About Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation.\" It is available on the Internet at http://cancer.gov/publications. Also, information specialists at the NCI's Cancer Information Service at 1-800-4-CANCER can send this fact sheet and answer questions about stem cell transplantation. 8.5.5 WHAT HAPPENS AFTER TREATMENT FOR LEUKEMIA? A. SUPPORTIVE CARE: Leukemia and its treatment can lead to other health problems. Patients receive supportive care to prevent or control these problems and to improve their comfort and quality of life during treatment. Because people with leukemia get infections very easily, they may receive antibiotics and other drugs to help protect them from infections. The health care team may advise them to stay away from crowds and from people with colds and other contagious diseases. If an infection develops, it can be serious and should be treated promptly. Patients may need to stay in the hospital for treatment. Anemia and bleeding are other problems that often require supportive care. Patients may need transfusions of red blood cells to help them have more energy. Platelet transfusions can help reduce the risk of serious bleeding. Dental care also is very important. Leukemia and chemotherapy can make the mouth sensitive, easily infected, and likely to bleed. Doctors often advise patients to have a complete dental exam and, if possible, undergo needed dental care before chemotherapy begins. Dentists show patients how to keep their mouth clean and healthy during treatment. Medicine: it’s a noble profession, it serves humanity 98/122
    99. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 99 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. NUTRITION: Patients need to eat well during cancer therapy. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy. But eating well can be difficult. Patients may not feel like eating if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Foods may taste different. The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet. Patients and their families may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful ideas and recipes. The \"National Cancer Institute Booklets\" section tells how to get this publication. C. FOLLOWUP CARE: Followup care after treatment for leukemia is an important part of the overall treatment plan. Regular checkups ensure that any changes in health are noted. The doctor can find problems and treat them as soon as possible. Checkups may include a careful physical exam, blood tests, x-rays, bone marrow aspiration, or spinal tap. The doctor can explain the followup plan—how often the patient must visit the doctor and what tests are needed. The NCI has prepared a booklet for people who have completed their treatment to help answer questions about followup care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for getting the most out of medical visits. It describes the kinds of help people may need. D. SUPPORT FOR PEOPLE WITH LEUKEMIA: Living with a serious disease such as leukemia is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group. Groups may offer support in person, over the telephone, or on the Internet. People living with cancer may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support. The Cancer Information Service can provide information to help patients and their families locate programs, services, and publications. Medicine: it’s a noble profession, it serves humanity 99/122
    100. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 100 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 8.5.6 WHAT DOES THE FUTURE HOLD FOR PATIENTS WITH LEUKEMIA?: Doctors all over the country are conducting many types of clinical trials. These are research studies in which people take part voluntarily. Studies include new methods of treatment and supportive care for patients with leukemia. Research already has led to advances, and researchers continue to search for more effective approaches. Patients who join these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take very careful steps to protect their patients. Researchers are testing new biological therapies and new anticancer drugs, doses, and treatment schedules. They also are working with various drugs and with combinations of drugs, biological therapy, radiation therapy, and stem cell transplantation. Patients who are interested in being part of a clinical trial should talk with their doctor. They may want to read the NCI booklet Taking Part in Cancer Treatment Research Studies. It explains how clinical trials are carried out and explains their possible benefits and risks. NCI's Web site includes a section on clinical trials at http://www.cancer.gov/clinicaltrials. This section of the Web site provides general information about clinical trials. It also offers detailed information about ongoing studies of leukemia treatment. The Cancer Information Service at 1-800-4-CANCER can answer questions and provide information about clinical trials. 8.6 LEUKEMIA AT A GLANCE:  Leukemia is a cancer of the blood cells.  While the exact cause(s) of leukemia is not known, risk factors have been identified.  Leukemias are grouped by how quickly the disease develops (acute or chronic) as well as by the type of blood cell that is affected.  People with leukemia are at significantly increased risk for developing infections, anemia, and bleeding.  Diagnosis of leukemia is supported by findings of the medical history and examination, and examining blood under a microscope. Leukemia cells can also be detected and further classified with a bone marrow aspiration and/or biopsy.  Treatment of leukemia depends on the type of leukemia, certain features of the leukemia cells, the extent of the disease, and prior history of treatment, as well as the age and health of the patient.  Most patients with leukemia are treated with chemotherapy. Some patients also may have radiation therapy and/or bone marrow transplantation. 8.7 PHYSICAL THERAPY INTERVENTIONS: 8.7.1 EVIDENCE:  PT and HEP: LE strengthening and stretching, aerobic exercise found to be beneficial for gait7  8 wk exercise training program which improved muscle strength, endurance and functional mobility8 Medicine: it’s a noble profession, it serves humanity 100/122
    101. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 101 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. A. MAKING THERAPY FUN: Wii Fit (aerobic capacity, balance, strength) Dance Dance Revolution (aerobic capacity)  Yoga Poses: River, down dog, gorilla, cobra, bridge, boat, tree, airplane, lying twist, dragon, cat, triangle (flexibility, ROM)  Jungle Gym (strength, aerobic capacity)  Basketball (strength, ROM, aerobic capacity)  Scavenger Hunt (strength)  Painting/Whiteboard drawing (strength, ROM)  Aqua Therapy (aerobic capacity, strength)  Ride Bike (ROM, aerobic capacity, strength)  Simon Says (strength, ROM, flexibility, aerobic capacity)  Red Light / Green Light (aerobic capacity) I. RECOMMENDED INTERVENTION: 3/wk for 6 wks, therapy consists of: ROM, strengthening exercises, aerobic exercises, flexibility exercises. II. PHYSICAL THERAPY PRECAUTIONS:  HR may not be accurate in patients taking chemotherapy, so use MET, BP, face rating for fatigue7  Bone metastases patients’ should avoid all contact sports7  Adriomycin: may have cardiac side effects that impair cardiac fxn and oxygen transport which will limit ability to participate in exercise7  High number of REPs should be avoided due to fatigue7  Nadir is the lowest point the white blood count reaches, usually occurs 7 - 14 days after chemo or radiation.  At this point the patient is extremely susceptible to infections.  The importance of good handwashing and hygiene practices cannot be overemphasized when treating these patients.  Fatigue is a side effect: be aware of pt getting tired during tx so we may have to take frequent breaks. III. PSYCHOSOCIAL MANIFESTATIONS:  Depression/Sadness since he is away from family and friends  Anxiety about being in the hospital, and side effects of treatment  Fear of hospitals, doctors, or procedures that may take place  Anger due to a lack of understanding  Family dynamic issues o The investigators of this study used the Short-Form 36 as a quality of life assessment measure.  Compared to families with healthy children, families with children who have cancer reported decreased physical and psychosocial quality of life in the following domains: physical role, bodily pains, general health perceptions, energy/vitality, social function, emotional role, and mental health. 10 Medicine: it’s a noble profession, it serves humanity 101/122
    102. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 102 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  Characteristics of the child that enhanced the quality of life of family with a child who has cancer: improve health status, decreased intensity of the treatment, and a increased time period.10  School: patient may have difficulty catching up in school, which may frustrate patient  Sports: patient is very interested in sports, and may have difficulty sitting out during sports IV. OTHER INFORMATION: · A lot of bruising may indicate abuse; therefore it is very important to rule out abuse. Medicine: it’s a noble profession, it serves humanity 102/122
    103. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 103 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.0 LYMPHOMA: Lymphoma is a type of cancer involving cells of the immune system, called lymphocytes. Just as cancer represents many different diseases, lymphoma represents many different cancers of lymphocytes-about 35 different subtypes, in fact. Lymphoma is a group of cancers that affect the cells that play a role in the immune system, and primarily represents cells involved in the lymphatic system of the body. Medicine: it’s a noble profession, it serves humanity 103/122
    104. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 104 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  The lymphatic system is part of the immune system. It consists of a network of vessels that carry a fluid called lymph, similar to the way that the network of blood vessels carry blood throughout the body. Lymph contains white blood cells called lymphocytes. Lymphocytes attack a variety of infectious agents as well as many cells in the precancerous stages of development.  Lymph nodes are small collections of lymph tissue that occur throughout the body. The lymphatic system involves lymphatic channels that connect thousands of lymph nodes scattered throughout the body. Lymph flows through the lymph nodes, as well as through other lymphatic tissues including the spleen, the tonsils, the bone marrow, and the thymus gland.  These lymph nodes filter the lymph, which may carry bacteria, viruses, or other microbes. The lymph nodes, or glands as they may be called, filter the lymph, which may on various occasions carry different microbial organisms. At infection sites, large numbers of these microbial organisms collect in the regional nodes and produce the swelling and tenderness typical of a localized infection. These enlarged and occasionally confluent collections of lymph nodes (so-called lymphadenopathy) are often referred to as \"swollen glands.\" Lymphocytes recognize pathogens (infections and abnormal cells) and destroy them. There are 2 major subtypes of lymphocytes: B lymphocytes and T lymphocytes, also referred to as B cells and T cells. Medicine: it’s a noble profession, it serves humanity 104/122
    105. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 105 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  B lymphocytes produce antibodies (proteins that circulate through the blood and lymph and attach to infectious organisms and abnormal cells). The combination attachment cell or antibody microbial organism essentially alerts other cells of the immune system recognize and destroy these intruders, also known as pathogens.  T cells, when activated, can kill pathogens directly. T cells also play a part in the mechanisms of immune system control, to prevent the system from inappropriate overactivity or underactivity.  After fighting off an invader, some of the B and T lymphocytes \"remember\" the invader and are prepared to fight it off if it returns. Cancer occurs when normal cells undergo a transformation whereby they grow and multiply uncontrollably. Lymphoma is a malignant transformation of either lymphocytes B or T cells or their subtypes.  As the abnormal cells multiply, they may collect in 1 or more lymph nodes or in other lymph tissues such as the spleen.  As the cells continue to multiply, they form a mass often referred to as a tumor.  Tumors often overwhelm surrounding tissues by invading their space, thereby depriving them of the necessary oxygen and nutrients needed to survive and function normally.  Because of their uncontrolled growth, lymphomas can encroach on and/or invade neighboring tissues or distant organs.  In lymphoma, abnormal lymphocytes travel from one lymph node to the next, and sometimes to remote organs, via the lymphatic system.  While lymphomas are often confined to lymph nodes and other lymphatic tissue, they can spread to other types of tissue almost anywhere in the body. Lymphoma development outside of lymphatic tissue is called extranodal disease. Lymphomas fall into 1 of 2 major categories. Hodgkin lymphoma (HL, previously called Hodgkin's disease) and all other lymphomas (non-Hodgkin lymphomas or NHLs).  These 2 types occur in the same places, may be associated with the same symptoms, and often have similar gross physical characteristics. However, they are readily distinguishable via microscopic examination.  Hodgkin disease develops from a specific abnormal B lymphocyte lineage. NHL may derive from either abnormal B or T cells and are distinguished by unique genetic markers. Medicine: it’s a noble profession, it serves humanity 105/122
    106. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 106 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  There are 5 subtypes of Hodgkin disease and about 30 subtypes of non-Hodgkin lymphoma.  Because there are so many different subtypes of lymphoma, the classification of lymphomas is complicated and includes both the microscopic appearance and well-defined genetic and molecular rearrangements.  Many of the NHL subtypes look similar, but they are functionally quite different and respond to different therapies with different probabilities of cure. HL subtypes are microscopically distinct, and typing is based upon the microscopic differences as well as extent of disease. Lymphoma is the most common type of blood cancer in the United States. It is the sixth most common cancer in adults and the third most common in children. Non-Hodgkin lymphoma is far more common than Hodgkin disease.  In the United States, about 54,000 new cases of NHL and 7000 new cases of HL were diagnosed in 2004, and the overall incidence is increasing.  About 24,000 people die of NHL and 1400 of HL each year, with the survival rate of all but the most advanced cases of HL greater than that of other lymphomas.  Lymphoma can occur at any age, including childhood. Hodgkin disease is most common in 2 age groups: young adults aged 16-34 years and in older people aged 55 years and older. Non-Hodgkin lymphoma is more likely to occur in older people. 9.1 LYMPHOMA CAUSES: The exact causes of lymphoma are not known. Several factors have been linked to an increased risk of developing lymphoma, but it is unclear what role they play in the actual development of lymphoma. These risk factors include the following:  Age: Generally the risk of NHL increases with advancing age. HL in the elderly is associated with a poorer prognosis than that observed in younger patients.  Infections o Infection with HIV o Infection with human T-lymphocytic virus type 1 (HTLV-1) o Infection with Epstein-Barr virus (EBV), one of the etiologic factors in mononucleosis o Infection with Helicobacter pylori, a bacterium that lives in the digestive tract o Infection with hepatitis B or hepatitis C virus  Medical conditions that compromise the immune system o HIV o Autoimmune disease o Diseases requiring immune suppressive therapy, often used following organ transplant o Inherited immunodeficiency diseases (severe combined immunodeficiency, ataxia telangiectasia, among a host of others)  Exposure to toxic chemicals o Farm work or an occupation with exposure to certain toxic chemicals such as pesticides, herbicides, or benzene and/or other solvents o Black hair dye, which for more than 20 years has been linked to higher rates of NHL  Genetics: Family history of lymphoma The presence of these risk factors does not mean a person will actually develop lymphoma. In fact, most people with one or several of these risk factors do not develop lymphoma Medicine: it’s a noble profession, it serves humanity 106/122
    107. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 107 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.2 LYMPHOMA SYMPTOMS: Often, the first sign of lymphoma is a painless swelling in the neck, under an arm, or in the groin.  Lymph nodes or tissues elsewhere in the body may also swell. The spleen, for example, often becomes enlarged in lymphoma.  The enlarged lymph node sometimes causes other symptoms by pressing against a vein or lymphatic vessel (swelling of an arm or leg), a nerve (pain, numbness, or tingling), or the stomach (early feeling of fullness).  Enlargement of the spleen may cause abdominal pain or discomfort.  Many people have no other symptoms. 9.2.1 SYMPTOMS OF LYMPHOMA MAY INCLUDE THE FOLLOWING:  Fevers  Chills  Unexplained weight loss  Night sweats  Lack of energy  Itching These symptoms are nonspecific. This means that they could be caused by any number of conditions unrelated to cancer. For instance, they could be signs of the flu or other viral infection, but in those cases, they would not last very long. In lymphoma, the symptoms persist over time and cannot be explained by an infection or another disease 9.3 WHEN TO SEEK MEDICAL CARE: Swelling in the neck, armpit, or groin, or unexplained swelling in an arm or leg should prompt one to seek medical attention. Such swellings may have many causes or have nothing to do with lymphoma, but they should be checked. If any of the following symptoms persist for more than a few days, seek medical attention:  Fevers  Chills  Unexplained weight loss  Night sweats  Lack of energy  Itching 9.4 EXAMS AND TESTS: If a person has swelling or symptoms described in the Symptoms section, his or her health care provider will ask many questions about the symptoms (when they began, recent illnesses, past or current medical problems, any medications, workplace, health history, family history, and habits and lifestyle). These questions are followed by a thorough examination. If, after an initial interview and examination, the health care provider suspects that a patient may have lymphoma, the patient will undergo a series of tests designed to provide further clarification. At some point in this workup, the patient will likely be referred to a specialist in cancer (oncologist). Medicine: it’s a noble profession, it serves humanity 107/122
    108. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 108 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.4.1 BLOOD TESTS: Blood is drawn for various tests.  Some of these tests evaluate the function and performance of blood cells and important organs, such as the liver and kidneys.  Certain blood chemicals or enzymes (lactate dehydrogenase [LDH]) may be determined. High levels of LDH in cases in which NHL is suspected may indicate a more aggressive form of the disorder.  Other tests may be done to learn more about lymphoma subtypes. A. BIOPSY: If there is a swelling (also called lump or mass), a sample of tissue from the swelling will be removed for examination. This is called a biopsy. Any of several methods can be used to obtain a biopsy of a mass.  Masses that can be seen and felt under the skin are relatively easy to biopsy. A hollow needle can be inserted into the mass and a small sample removed with the needle (called a core-needle biopsy). This is usually done in the health care provider's office with a local anesthetic.  Core-needle biopsy does not always obtain a good-quality sample. For that reason, many health care providers prefer a surgical biopsy. This involves removal of the entire swollen lymph node through a small incision in the skin. This procedure often is done with a local anesthetic, but it sometimes requires a general anesthetic.  If the mass is not immediately under the skin but is instead deep inside the body, access is somewhat more complicated. The specimen is usually obtained via laparoscopy. This means making a tiny incision in the skin and inserting a thin tube with a light and a camera on the end (a laparoscope). The camera sends pictures of the inside of the body to a video monitor, and the surgeon can see the mass. A small cutting tool on the end of the laparoscope can remove all or part of the mass. This tissue is withdrawn from the body with the laparoscope.  A pathologist (a physician who specializes in diagnosing diseases by looking at cells and tissues) examines the tissue sample with a microscope. The pathologist's report will specify whether the tissue is lymphoma and, with the use of appropriate biologic tools, the type and subset of lymphoma. Medicine: it’s a noble profession, it serves humanity 108/122
    109. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 109 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. IMAGING STUDIES: If there is no palpable mass in the presence of persistent symptoms, imaging studies will likely be carried out in order to determine whether a mass is present and, if so, how then to direct a biopsy.  X-rays: In certain parts of the body, such as the chest, a simple x-ray can sometimes detect lymphoma.  CT scan: This test provides a 3-dimensional view and much greater detail and may detect enlarged lymph nodes and other masses anywhere in the body.  MRI scan: This test uses differences in magnetic fields among different types of tissue to create pictures of the inside of the body. Similar to the CT scan, MRI gives 3-dimensional images with excellent detail. MRI provides better definition than CT scan in certain parts of the body, especially the brain and the spinal cord.  Lymphangiogram: This approach, which provides an image of the lymphatic system by tracing a dye that moves though the system, has essentially been replaced by either CT scan, MRI, or PET (see below).  Galliums scan: Lymphomas tend to collect a substance called gallium. For this test, a tiny amount of radioactive gallium is injected into the body. A scan is then done to find areas where the gallium has collected. Collections of gallium suggest a tumor.  Positron-emission tomographic (PET) scan: PET scan is a newer alternative to lymphangiogram and gallium scan for detecting areas in the body that are affected by lymphoma. A tiny amount of a radioactive substance is injected into the body and then traced on the PET scan. Sites of radioactivity on the scan indicate areas of increased metabolic activity, which implies a tumor. C. BONE MARROW EXAMINATION: Most of the time, an examination of the bone marrow is necessary to see if the marrow is affected by the lymphoma. This is done by collecting a biopsy of the bone marrow.  Samples of both liquid (aspirate) and solid bone marrow (biopsy) are taken, usually from a hip bone.  A pathologist examines the bone marrow under a microscope.  Bone marrow containing certain types of abnormal B or T lymphocytes confirms lymphoma.  Bone marrow biopsy can be an uncomfortable procedure, but it can usually be performed in a medical office. Most people receive pain medication prior to the procedure to make them more comfortable. D. OTHER TESTS:  Lumbar puncture: This test, sometimes called a spinal tap, is a method for collecting a sample of the fluid surrounding the brain and spinal cord. This fluid is called cerebrospinal fluid. If the lymphoma has affected the central nervous system, the cerebrospinal fluid will likely contain lymphoma cells.  Organ function tests: These tests are usually done before starting treatment to make sure that one's organs are healthy enough to withstand the side effects of therapy. Examples include an echocardiogram or MUGA scan for the heart and pulmonary function tests for the lungs. Medicine: it’s a noble profession, it serves humanity 109/122
    110. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 110 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.4.2 STAGING: Staging is the classification of a cancer type by its size and whether and how much it has spread around the body. Determining a cancer's stage is very important because it tells the oncologist which treatment is most likely to work and what are the chances of remission or a cure (prognosis). Staging of lymphomas, as in all cancers, is based on the microscopic examination and on the results of imaging studies and related tests that reveal the extent of the cancer involvement. HL is often described as being \"bulky\" or \"nonbulky.\" Nonbulky means the tumor is small; bulky means the tumor is large. Nonbulky disease has a better prognosis than bulky disease. NHL is a complicated set of diseases with a complex classification system. In fact, the classification system is continuously evolving as we learn more about these cancers. The newest classification system takes into account not only the microscopic appearance of the lymphoma but also its location in the body and genetic and molecular features. Grade is also an important component of the NHL classification.  Low grade: These are often called \"indolent\" lymphomas because they grow slowly. Low-grade lymphomas are often widespread when discovered, but because they grow slowly, they usually do not require immediate treatment unless organ function is compromised. They are rarely cured and can transform over time to a combination of indolent and aggressive types.  Intermediate grade: These are rapidly growing (aggressive) lymphomas that usually require immediate treatment, but they are often curable.  High grade: These are very rapidly growing and aggressive lymphomas that require immediate, intensive treatment and are much less often curable. The \"staging,\" or evaluation of extent of disease, for both HL and NHL, are similar.  Stage I (early disease) - Lymphoma located in a single lymph node region or in one area or organ outside the lymph node  Stage II (locally advanced disease) - Lymphoma located in two or more lymph node regions all located on the same side of the diaphragm or in one lymph node region and a nearby tissue or organ. (The diaphragm is a flat muscle that separates the chest from the abdomen.)  Stage III (advanced disease) - Lymphoma affecting two or more lymph node regions, or one lymph node region and one organ, on opposite sides of the diaphragm  Stage IV (widespread or disseminated disease) - Lymphoma outside the lymph nodes and spleen that has spread to another area or organ such as the bone marrow, bone, or central nervous system Both HL and NHL are further classified with letters.  An \"A\" or \"B\" designation indicates whether the person with lymphoma had symptoms such as fevers and/or weight loss at the time of diagnosis. \"A\" indicates no such symptoms, and \"B\" indicates symptoms.  An \"E\" designation indicates that the tumor spread directly from a lymph node into an organ or that a single organ outside the lymphatic system is affected with no apparent lymphatic involvement. Medicine: it’s a noble profession, it serves humanity 110/122
    111. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 111 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.4.3 PROGNOSTIC FACTORS: Several risk factors have been extensively evaluated and shown to play a role in treatment outcome. For HL, the International Prognostic Index includes the following 7 risk factors: 1. Male sex 2. Age 45 years or older 3. Stage IV disease 4. Albumin (blood test) less then 4.0 g/dL 5. Hemoglobin (red blood cell level) less than 10.5 g/dL 6. Elevated white blood cell (WBC) count of 15,000/mL 7. Low lymphocyte count less than 600/mL or less than 8% of total WBC The absence of any of the above risk factors is associated with an 84% rate of control of Hodgkin disease, whereas the presence of a risk factor is associated with a 77% rate of disease control. The presence of 5 or more risk factors was associated with a disease control rate of only 42%. The outcomes for these patients were also determined by the treatment they received, which occurred primarily in the 1980s. Newer treatments for Hodgkin lymphoma may improve these predicted outcomes. Furthermore, new treatments are being developed for patients with greater risk factors. The International Prognostic Index for NHL includes 5 risk factors: 1. Age older than 60 years 2. Stage III or IV disease 3. High LDH 4. More than one extranodal site 5. Poor performance status (as a measure of general health) - From these factors, the following risk groups were identified:  Low risk: 0-1 risk factor, 5-year lymphoma-free survival (LFS) of 70%  Intermediate risk: 2-3 risk factors, 5-year LFS of 49-50%  Poor risk: 4-5 risk factors, 5-year LFS of 26% A T-cell NHL subtype is usually considered an additional risk factor. However, a T-cell anaplastic large cell NHL has a lower risk than B-cell NHL. The prognostic models were developed to evaluate groups of patients and are useful in developing therapeutic strategies. 9.5 LYMPHOMA TREATMENT: General health care providers rarely undertake the sole care of a cancer patient. The vast majority of cancer patients receive ongoing care from oncologists but may in fact be referred to more than one oncologist should there be any question about the disease. Patients are always encouraged to gain second opinions if the situation so warrants this approach.  Although medical treatments are fairly standardized, not all physicians behave similarly.  One may choose to speak with more than one oncologist to find the one with whom he or she feels most comfortable.  In addition to one's primary care physician, family members or friends may offer information. Also, many communities, medical societies, and cancer centers offer telephone or Internet referral services. Once one settles in with an oncologist, there is ample time to ask questions and discuss treatment regimens. Medicine: it’s a noble profession, it serves humanity 111/122
    112. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 112 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  The doctor will present each type of treatment, discuss the pros and cons, and make recommendations based on published treatment guidelines and his or her own experience.  Treatment for lymphoma depends on the type and stage. Factors such as age, overall health, and whether one has already been treated for lymphoma before are included in the treatment decision- making process.  The decision of which treatment to pursue is made with the doctor (with input from other members of the care team) and family members, but the decision is ultimately the patient's.  Be certain to understand exactly what will be done and why, and what can be expected from these choices. As in many cancers, lymphoma is most likely to be cured if it is diagnosed early and treated promptly.  The most widely used therapies are combinations of chemotherapy and radiation therapy.  Biological therapy, which takes advantage of the body's innate cancer-fighting ability, is used in some cases. In addition to the oncologist, the medical team may include a specialist in radiation therapy (radiation oncologist), 1 or more nurses, a dietitian, a social worker, and other professionals as needed. The goal of medical therapy in lymphoma is complete remission. This means that all signs of the disease have disappeared after treatment. Remission is not the same as cure. In remission, one may still have lymphoma cells in the body, but they are undetectable and cause no symptoms.  When in remission, the lymphoma may come back. This is called recurrence.  The duration of remission depends on the type, stage, and grade of the lymphoma. A remission may last a few months, a few years, or may continue throughout one's life. The latter is in all likelihood a cure.  Remission that lasts a long time is called durable remission, and this is the goal of therapy.  The duration of remission is a good indicator of the aggressiveness of the lymphoma and of the prognosis. A longer remission generally indicates a better prognosis. Remission can also be partial. This means that the tumor shrinks after treatment to less than half its size before treatment. The following terms are used to describe the lymphoma's response to treatment:  Improvement: The lymphoma shrinks but is still greater than half its original size.  Stable disease: The lymphoma stays the same.  Progression: The lymphoma worsens during treatment.  Refractory disease: The lymphoma is resistant to treatment. The following terms to refer to therapy:  Induction therapy is designed to induce a remission.  If this treatment does not induce a complete remission, new or different therapy will be initiated. This is usually referred to as salvage therapy.  Once in remission, one may be given yet another treatment to prevent recurrence. This is called maintenance therapy. Medicine: it’s a noble profession, it serves humanity 112/122
    113. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 113 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.5.1 MEDICAL TREATMENT: Standard first-line therapy (primary therapy) for lymphoma includes radiation therapy for most early- stage lymphomas, or a combination of chemotherapy and radiation. For later-stage lymphomas, chemotherapy is primarily used, with radiation therapy added for control of bulky disease. Biological therapy, or immunotherapy, is increasingly being used in addition to or as an alternative to these standard therapies. A. RADIATION THERAPY: Radiation therapy uses high-energy rays to kill cancer cells. It is considered a local therapy, meaning that it should be used to target areas of the body involved by tumor masses. A radiation oncologist will plan and supervise therapy.  The radiation is targeted at the affected lymph node region or organ. Occasionally, nearby areas are also irradiated to kill any cells that might have spread there undetected.  Depending on how and where the radiation is administered, it may cause certain side effects such as fatigue, loss of appetite, nausea, diarrhea, and skin problems. Radiation of lymph node areas may result in suppression of the immune system to varying degrees. Irradiation of the underlying bone and the marrow within the bone may result in suppression of the blood counts.  The radiation is usually administered in short bursts on 5 days a week over the course of several weeks. This keeps the dose of each treatment low and helps prevent or lessen side effects. B. CHEMOTHERAPY: Chemotherapy is the use of powerful drugs to kill cancer cells. Chemotherapy is a systemic therapy, meaning that it circulates through the bloodstream and affects all parts of the body. Ideally, chemotherapy can find and kill cancer cells anywhere in the body. Unfortunately, chemotherapy also affects healthy cells; this accounts for its well-known side effects.  The side effects of chemotherapy depend partly on the drugs used and the doses.  Some people, because of variability in metabolism of chemotherapy drugs, tolerate chemotherapy better than other people.  The most common side effects of chemotherapy include suppression of blood counts, which could result in increased susceptibility to infection (low white blood cell count), anemia (low red blood cell count), or blood clotting problems (low platelet). Other side effects may include nausea and vomiting, loss of appetite, hair loss, sores in the mouth and digestive tract, fatigue, muscle aches, and changes in fingernails and toenails. Specific drugs may confer other, specific side effects.  Medications and other treatments are available to help people tolerate these side effects, which can be severe.  It is very important to discuss and review the potential side effects of each chemotherapy drug in the treatment with the oncologist, pharmacist, or oncology nurse. Medications to lessen the side effects should also be reviewed. I. CHEMOTHERAPY PILLS: Chemotherapy may be given in pill form, but it is typically a liquid infused directly into the bloodstream through a vein (intravenous).  Most people who receive intravenous chemotherapy will have a semi-permanent device placed in a large vein, usually in the chest or arm. Medicine: it’s a noble profession, it serves humanity 113/122
    114. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 114 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.  This device allows the medical team quick and easy access to the blood vessels, both for administering medications and for collecting blood samples.  These devices come in several types, usually referred to as a \"catheter,\" \"port,\" or \"central line.\" II. DRUG COMBINATIONS; Experience has shown that combinations of drugs are more efficient than monotherapy.  Combinations of different drugs both increase the chance that the drugs will work and lower the dose of each individual drug, reducing the chance of intolerable side effects.  Several different standard combinations are used in lymphoma. Which combination one receives depends on the type of lymphoma and the experiences of the oncologist and the medical center where a person is receiving treatment.  The combinations of drugs are usually given according to a set schedule that must be followed very strictly.  In some situations, chemotherapy can be given in the oncologist's office. In other situations, one must stay in the hospital. III. CHEMOTHERAPY CYCLES.  One cycle includes the period of actual treatment, usually several days, followed by a period of rest for several weeks to allow recovery from side effects caused by the chemotherapy, particularly anemia and low white blood cells.  Standard treatment typically includes a set number of cycles, such as 4 or 6.  Spreading the chemotherapy out this way allows a higher cumulative dose to be given, while improving the person's ability to tolerate the side effects. C. BIOLOGICAL THERAPY: Biological therapies are sometimes referred to as immunotherapy because they take advantage of the body's natural immunity against pathogens. These therapies are attractive because they offer anticancer effects without many of the undesirable side effects of standard therapies. There are many different types of biological therapies. The following are some of the most promising for treating lymphoma: I. MONOCLONAL ANTIBODIES: Antibodies are substances produced by lymphocytes to fight pathogens. Every cell, organism, or pathogen within our body carries markers on its surface that antibodies may recognize. These surface markers are called antigens. A monoclonal antibody is an antibody that is made in a laboratory to find and attach itself to a specific antigen. Monoclonal antibodies can be used to help one's own immune systems kill tumor cells and other pathogens directly, or they can deliver cancer-killing therapies (such as radiation or chemotherapy) directly to a specific antigen found on cancer cells. II. CYTOKINES: These naturally occurring chemicals are produced by the body to stimulate the cells in the immune system and other organs. They can also be produced artificially and administered in large doses to patients with greater effect. Examples include interferons and interleukins, which stimulate the immune system, and colony-stimulating factors, which stimulate the growth of blood cells. Medicine: it’s a noble profession, it serves humanity 114/122
    115. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 115 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. III. VACCINES: Unlike the more familiar vaccines for infectious diseases such as polio and flu, cancer vaccines do not prevent the disease. Rather, they are designed to stimulate the immune system to mount a specific response against the cancer. They also create a \"memory\" of the cancer so that the immune system activates very early in cases of recurrence, thus preventing the development of a new tumor. The subtype and classification of a lymphoma may determine whether biologic therapy will be used to treat an individual patient's lymphoma. Monoclonal antibodies are being increasingly used in the treatment of B cell NHLs, usually in combination with chemotherapy. Monoclonal antibodies may also be given as maintenance therapy following chemotherapy, particularly in low-grade disease. Interferon may be used in indolent, low-grade lymphomas, or as adjunctive therapy in patients with hepatitis associated lymphomas. Colony-stimulating factors, such as growth factors for white blood cells, may be used to stimulate recovery of the white cells following chemotherapy. Other therapies under continuing development include drugs that target cancer cells on a molecular level, various new monoclonal antibodies, and other biologic therapies. 9.5.2 MEDICATIONS: Numerous chemotherapy and biological drug combinations may be prescribed by an oncologist. Which type and combination of therapy depends on many factors, including the type and stage of lymphoma, whether treating adolescents, young adults, or older adults, the ability to tolerate chemotherapy side effects, and if any previous treatment for the lymphoma has occurred. Oncologists often work together regionally to decide which combination of chemotherapy and biological drugs are currently working best for their patients. Because of this regional collaboration, the drug combinations often vary and are able to change rapidly when improved results occur. 9.5.3 OTHER THERAPIES: A. WATCHFUL WAITING: Watchful waiting means choosing to observe and monitor the cancer rather than treat it right away. This is strategy is sometimes used for indolent recurrent tumors. Treatment is given only if the cancer starts to grow more rapidly or to cause symptoms or other problems.  Stem cell transplantation is usually not used as a primary therapy in lymphoma.  Stem cell transplantation is usually reserved for lymphoma that has been previously treated into remission but has recurred.  Stem cell therapy as primary therapy has been used for aggressive T-cell NHL in first remission, usually as part of a clinical trial. Stem cell therapy is also considered when standard primary treatment is unable to control the lymphoma and achieve remission.  This procedure, which requires a lengthy hospital stay, involves very high doses of chemotherapy to kill the aggressive cancer cells.  The chemotherapy doses are so high that the chemotherapy also stops the patient's bone marrow from producing healthy new blood cells.  The patient then receives a transfusion of healthy bone marrow or blood stem cells, either from previously collected stem cells from the patient himself or herself (called autologous transplantation) or from a donor (called allogeneic transplantation), to \"kick start\" the bone marrow into producing healthy blood cells.  This is a very intensive therapy with a lengthy recovery period. Medicine: it’s a noble profession, it serves humanity 115/122
    116. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 116 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. CLINICAL TRIALS: An oncologist may belong to a network of investigators who offer novel treatments for various types of cancers. These novel therapies are newer agents that have been recently developed, and extensive data on treatment results are not yet known. Such new agents can be offered in the context of a clinical trial. Usually, a consent form that explains the drug, its known side effects, its potential side effects, and alternatives to the drug treatment are presented to the patient. If the treatment seems promising for the particular subtype of lymphoma, and the patient is fully appraised of the potential benefits and risks associated with such treatment and is interested in receiving such treatment, then the consent form is signed by the patient and the managing physician, and possibly other involved parties. The patient is then enrolled in a treatment protocol that specifies exactly how a patient is to be treated with the new therapy. Alternatively, an oncologist may refer a patient to another institution to receive investigational treatment or intensive treatment, such as a stem cell transplant. C. COMPLEMENTARY/ALTERNATIVE THERAPIES: Several alternative therapies have undergone preliminary testing in lymphoma. None has been found to work better than or as well as standard medical therapies. A few therapies, still felt to be experimental, have been found to be potentially helpful as complements to medical therapy, however.  Acupuncture has been helpful in relieving musculoskeletal symptoms, as well as in controlling nausea and vomiting associated with chemotherapy.  The supplements coenzyme Q10 and polysaccharide K (PSK) are undergoing further evaluation to determine their effects on treatment outcome. Both drugs have immune enhancing properties. PSK has been used more extensively in Japan as part of an anticancer therapy.  Neither of these therapies has undergone extensive blind studies and cannot be considered a part of any planned therapeutic endeavor. 9.6 NEXT STEPS: Follow-up After completion of primary therapy for lymphoma, all appropriate tests will be repeated to see how well the therapy worked.  The results of these tests will tell the oncologist whether the patient is in remission.  If the patient is in remission, the oncologist will recommend a schedule of regular testing and follow-up visits to monitor the remission and to catch any recurrence early.  Keeping up with these visits and tests is very important in order to avoid advanced or widespread disease. If lymphoma recurs after treatment, the oncologist will likely recommend further treatment. 9.7 PREVENTION: There is no known way to prevent lymphoma. A standard recommendation is to avoid the known risk factors for the disease. However, some risk factors for lymphoma are unknown, and therefore impossible to avoid. Infection with viruses such as HIV, EBV, and hepatitis are risk factors that can be avoided with frequent hand washing, practicing safe sex, and by not sharing needles, razors, toothbrushes, and similar personal items that might be contaminated with infected blood or secretions. Medicine: it’s a noble profession, it serves humanity 116/122
    117. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 117 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 9.8 OUTLOOK: The outlook for HL is very good. It is one of the most curable cancers. The 5-year survival rate after treatment is greater than 80% for adults and greater than 90% for children. As a result of refinements in and more aggressive approaches to therapy, the outlook for NHL has improved significantly in the last few decades. The 5-year survival rate after treatment is 55% for adults and about 80% for children. The addition of immunotherapy to standard treatment for NHLs may further improve survival rates. Many people live with lymphoma in remission for many years after treatment. Currently more than 400,000 people in the United States are living with lymphoma. 9.9 SUPPORT GROUPS AND COUNSELLING: Living with lymphoma presents many new challenges for an individual and his or her family and friends.  There may be many worries about how the lymphoma will affect one's ability to \"live a normal life,\" that is, to care for family and home, to hold a job, and to continue the friendships and activities one enjoys.  Many people feel anxious and depressed. Some people feel angry and resentful; others feel helpless and defeated. For most people with lymphoma, talking about their feelings and concerns can be helpful.  Friends and family members can be very supportive. They may be hesitant to offer support until they see how the affected person is coping. If the affected person wishes to talk about his or her concerns, it is important to let them know to do so.  Some people don't want to \"burden\" their loved ones, or they prefer talking about their concerns with a more neutral professional. A social worker, counsellor, or member of the clergy can be helpful if one wishes to discuss their feelings and concerns about having lymphoma. The treating haematologist or oncologist should be able to recommend someone.  Many people with lymphoma are helped profoundly by talking to other people who have lymphoma. Sharing such concerns with others who have been through the same thing can be remarkably reassuring. Support groups of people with lymphoma may be available through the medical centre where one is receiving treatment. The American Cancer Society also has information about support groups all over the United States. 9.10 PHYSICAL THERAPY INTERVENTIONS FOR LYMPHOMA: Physical therapy helps you fight lymphoma, the rehabilitation therapists will deliver an Oncology Rehabilitation Program to promote your physical and cognitive functioning. Consisting of activities like cardiovascular, flexibility and strength training, the individualized program aims to reduce stress, prevent fatigue, and improve your overall quality of life throughout your lymphoma cancer treatment. The oncology rehabilitation services consists of physical therapists (PTs), occupational therapists (OTs), speech and language pathologists, and massage therapists. Our team strives to educate you about the physical and psychological benefits of physical fitness during lymphoma cancer treatment. 9.10.1 PHYSICAL EVALUATION: Prior to initiating therapy your rehabilitation team will conduct a thorough physical evaluation for you. Part of this initial evaluation consists of a functional assessment, which measures your ability to perform activities of daily living (ADLs). Medicine: it’s a noble profession, it serves humanity 117/122
    118. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 118 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. A. PHYSICAL THERAPY / EXERCISE PROGRAM: Exercise—even minimal physical exertion—increases heart rate and muscle flexion. It can also boost the body’s tolerance to conventional lymphoma cancer treatments, such as chemotherapy and radiation therapy. Taking part in a daily exercise program can also help you gain a sense of physical control over your condition, and provide a healthy outlet for stress and anxiety. PT’s strive to help you become more physically capable, active and strong. The rehabilitation therapy team will work with you to develop a customized physical therapy/exercise program. The exercise programs combine range-of-motion training with other light activities, like resistance training, to provide you with the right amount of exercise for you. B. BORG RATING OF PERCEIVED EXERTION (RPE) - The Borg Rating of Perceived Exertion helps our therapists determine the intensity of exercise you can tolerate. The scale ranges from 6 (no exertion at all) to 20 (maximal exertion). Since the condition of each person is unique, the Borg system measures exercise as any activity that increases heart rate. Most people achieve 65 to 75 percent of their maximum heart rate during exercise. C. FLEXIBILITY PROGRAM: Stretching is a beneficial activity you may engage in to relieve joint stiffness and pain and, at the same time, improve your overall mobility and range-of-motion. The benefits of stretching include:  Enhancement of performance in everyday activities  Improvement of mobility and independence  Improvement and maintenance of posture and muscle balance  Injury prevention  Promotion of physical and mental relaxation D. MANUAL THERAPY: Massage therapy provides one means of manual muscle therapy. If you would like to incorporate massage therapy into your lymphoma cancer treatment, you will first obtain a referral from either your physical or occupational therapist. Some forms of manual therapies we provide include reflexology and myofascial release. Medicine: it’s a noble profession, it serves humanity 118/122
    119. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 119 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 10.0 PALLIATIVE CARE: Palliative care, also called comfort care, is primarily directed at providing relief to a terminally ill person through symptom management and pain management. The goal is not to cure, but to provide comfort and maintain the highest possible quality of life for as long as life remains. Well-rounded palliative care programs also address mental health and spiritual needs. The focus is not on death, but on compassionate specialized care for the living. Palliative care is well suited to an interdisciplinary team model that provides support for the whole person and those who are sharing the person's journey in love. Palliative care may be delivered in hospice and home care settings or in hospitals. Because medical needs vary depending on the disease that is leading toward death, specialized palliative care programs exist for common conditions such as cancer and AIDS. Specialized care giving is also needed if organic changes in the brain lead to coma or dementia. Our related page on death with dignity discusses the use of advance medical directives, power of attorney arrangements, and the right to die, including the controversial topic of voluntary euthanasia. It cannot be stressed enough that top-quality palliative care can make the difference between a gentle death and one in which suffering is so terrible and prolonged that assisted suicide becomes an attractive alternative. When people enter a hospice or begin palliative care, their loved ones may begin to experience increased feelings of grief and bereavement. These feelings may intensify as people put final affairs in order, which may include funeral and memorial planning. Medicine: it’s a noble profession, it serves humanity 119/122
    120. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 120 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 10.1 THE ROLE OF PHYSIOTHERAPY IN PALLIATIVE CARE: Physiotherapy is concerned with the care management and rehabilitation of patients from diagnosis to the end of life. Palliative care physiotherapy differs from conventional rehabilitation by virtue of the certain knowledge that all patients will decline during the period of care. The time and course of the decline can vary considerably; some patients grow progressively weaker, some remain on a plateau for weeks or months and then decline suddenly, some remain active until death. Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. In this context, physiotherapy is an important part of palliative care. Physiotherapy aims to improve patient’s quality of life by helping them to achieve their maximum potential of functional ability and independence or gain relief from distressing symptoms. 10.1.1 CONDITIONS SEEN IN PALLIATIVE CARE:  Cancer  End stage cardiac disease  End stage pulmonary disease  End stage renal disease  MND  Progressive cerebellar atrophy  MS Medicine: it’s a noble profession, it serves humanity 120/122
    121. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 121 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 10.1.2 AIMS OF PHYSIOTHERAPY:  Maintain optimum respiratory function  Maintain optimum circulatory function  Prevent muscle atrophy  Prevent muscle shortening  Prevent joint contractures  Influence pain control  Optimize independence & function  Increase confidence  Educate caretakers Pain, lymphoedema, incontinence, respiratory dysfunction and musculoskeletal problems including difficulty with mobility can receive physiotherapy. Although it is typically thought of as such, palliative care should not be limited to the end stage of life. A palliative approach to care can begin much earlier and can be applied not only to conditions usually considered for palliation (typically cancer) but also to chronic and debilitating neuromuscular disorders, cardio thoracic diseases, and HIV and AIDS. In cancer care, formalized physiotherapy involvement dates back to the 1960s – before the commencement of the modern hospice movement – and was confined to restoration directed at those patients with a relatively stable or encouraging prognosis. Today, the involvement of physiotherapists in the field of oncology is diverse and includes specific roles which are evidence based and commonly applicable, including:  Prevention – through whole body and target specific exercise and education programs.  Acute and post acute care – postoperative cardiopulmonary intervention; return to physical function post surgery through targeted large muscle mass exercise programs; specific management for recovery of musculoskeletal and neuromotor function (eg. following mastectomy); biopsychosocial approaches to pain management.  Acute institutional and community based rehabilitation through simple measures (eg. wheelchair retraining after spinal cord compression, and gait re-training following neurological dysfunction).  Palliative care – by utilizing all of the above applications and including other physiotherapy specific skills in symptom control management (eg. TENS for pain relief, lymphoedema and incontinence programs laser therapy for wound and ulcer management, and maintenance of mobility and physical function to optimize quality of life and contribute positively to easing carer burden). Physiotherapy, incorporating early intervention and community follow up, can contribute significantly to the maintenance of functional independence and quality of life among patients receiving palliative care. Specifically, physiotherapy contributed to significantly higher functional levels on mid-survival follow up; Medicine: it’s a noble profession, it serves humanity 121/122
    122. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:008B Revision: 01 Page: 122 of 122 PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. improved maintenance of functional independence, patient satisfaction and quality of life; and reduced demand for costly formal inpatient care as patients were significantly more likely to be discharged to, and prefer to die at, home. In the past, rehabilitation was perceived as a treatment, which was to lead to full recovery of a patient. This concept of rehabilitation may seem paradoxical in palliative care, especially for patients with an advanced illness who are approaching death. At present, the purpose of rehabilitation is to improve the quality of life, so that patient life will be as comfortable and productive as possible and he/she will be able to function at a minimum level of dependency regardless of life expectancy. Rehabilitation plays a significant role in palliative care. Physiotherapy aims to optimize patient’s level of physical function and take into consideration the interplay between the physical, psychological, social, and vocational domains of functions. Medicine: it’s a noble profession, it serves humanity 122/122
    123. Filename: PTPM008B PTM of Oncology and Palliative Care-related Medical Journal Directory: C:\\Users\\Anjum\\Documents\\Shadab Mulla\\Mullsons Medical Journals Template: C:\\Users\\Anjum\\AppData\\Roaming\\Microsoft\\Templates\\ Normal.dot Title: PHYSICAL THERAPY MANAGEMENT OF ONCOLOGY AND PALLIATIVE CARE-RELATED PATIENTS Subject: Author: Abdulrehman Mulla Keywords: Comments: Creation Date: 6/6/2009 5:25 PM Change Number: 5 Last Saved On: 6/7/2009 8:30 PM Last Saved By: Abdulrehman S. Mulla Total Editing Time: 31 Minutes Last Printed On: 6/7/2009 8:30 PM As of Last Complete Printing Number of Pages: 122 Number of Words: 38,164 (approx.) Number of Characters: 217,537 (approx.)

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