physiotherapy educational content

1. OBJECTIVES
Etiology, stages and types of cancer
developments; Clinical manifestations, Diagnosis
of cancer;
Physiotherapy examination and treatment of
specific representative cancers: Breast and lung
cancer.

2. ETIOLOGY OF CANCER

3. CANCER
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Cancer – a large group of diseases characterized by the
uncontrolled growth and spread of abnormal cells
Neoplasm – new growth of tissue that serves no physiological
function
Tumor – clumping of neo plasmic cells
Malignant - cancerous
Benign - noncancerous
Biopsy – microscopic examination of cell development
Metastasis – malignant tumors that are not enclosed in a
protective capsule have the ability to spread to other organs
Mutant cells – disruption of RNA and DNA within normal cells may
produce cells that differ in form, quality and function from the
normal cell

4. CAUSES OF CANCER?
External Factors –
chemicals, radiation, viruses, and lifestyle
 Internal Factors – hormones, immune
conditions, and inherited mutations

Cellular change/mutation theories
Carcinogens
Oncogenes / proto oncogenes

5. FACTORS BELIEVED TO CONTRIBUTE TO GLOBAL
CAUSES OF CANCER

6. Lifetime risk – the probability that an
individual, over the course of a
lifetime, will develop cancer or die
from it
Relative risk – measure of the
strength of the relationship
between risk factors and a
particular cancer
Smoking – 30% of all cancer
deaths, 87% of lung cancer
deaths
Obesity – 50% higher risk for breast
cancer in postmenopausal
women, 40% higher risk in colon
cancer for men
Biological Factors
Some cancers such as
breast, stomach, colon, prostate, u
terus, ovaries and lung appear to
run in families
Hodgkin‟s disease and certain
leukemia's show similar patterns
University of Utah research suggests
that a gene for breast cancer
exists
A rare form of eye cancer appears to
be transmitted genetically from
mother to child
Reproductive And Hormonal Risks
For Cancer
Pregnancy and oral contraceptives
increase a woman‟s chances of
breast cancer
Late menarche, early
menopause, early first
childbirth, having many children
have been shown to reduce risk of
breast cancer

7. Occupational And Environmental
Factors
Asbestos
Nickel
Chromate
Benzene
Arsenic
Radioactive substances
Cool tars
Herbicides/pesticides
Sodium nitrate when ingested
forms
a
potential
carcinogen, nitrosamine
Sodium nitrate is still used
because it is effective in
preventing botulism
Pesticide and herbicide residues
Social And Psychological Factors
Stress has been implicated in increased
susceptibility to several types of
cancers
Sleep disturbances, diet, or a combination
of factors may weaken the body‟s
immune system
Viral Factors
Herpes-related viruses may be involved in
the development of
leukemia, Hodgkin‟s disease, cervical
cancer, and Burkitt‟s lymphoma
Epstein-Barr virus, associated with
mononucleosis, may contribute to
cancer
Human papillomavirus (HPV), virus that
causes genital warts, has been linked
to cervical cancer
Helicobacter pylori causes ulcers which
are a major factor in the development
of stomach cancer

8. PATHOPHYSIOLOGY

9. TYPES OF CANCER

10. TYPES OF CANCERS
Classification of cancers
 Carcinomas
 Sarcomas
 Lymphomas
 Leukemia's

11. cancers are classified by the type of cell that
the tumor cells resemble and is therefore
presumed to be the origin of the tumor.
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Carcinoma : Cancers derived from epithelial cells.
This group includes many of the most common
cancers, particularly in the aged, and include nearly
all those developing in
the breast, prostate, lung pancreas and colon.
Sarcoma: Cancers arising from connective
tissue (i.e. bone, cartilage, fat, nerve), each of
which develop from cells originating
in mesenchymal cells outside the bone marrow.

12. 
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Lymphoma and leukemia: These two classes of cancer
arise from hematopoietic (blood-forming) cells that leave
the marrow and tend to mature in the lymph nodes and
blood, respectively. Leukemia is the most common type
of cancer in children accounting for about 30%.
Germ cell tumor: Cancers derived
from pluripotent cells, most often presenting in
the testicle or the ovary (seminoma and dysgerminoma
respectively).
Blastoma Cancers derived from immature "precursor"
cells or embryonic tissue. Blastomas are more common
in children than in older adults

13. 
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Cancers are usually named using -carcinoma, sarcoma or -blastoma as a suffix, with the Latin or Greek
word for the organ or tissue of origin as the root.
For example, cancers of the liverparenchyma arising from
malignant epithelial cells is called hepatocarcinoma while
a malignancy arising from primitive liver precursor cells
is called a hepatoblastoma, and a cancer arising from fat
cells is called a liposarcoma. For some common
cancers, the English organ name is used. For
example, the most common type of breast canceris
called ductal carcinoma of the breast Here, the
adjective ductal refers to the appearance of the cancer
under the microscope, which suggests that it has
originated in the milk ducts.

14. 
Benign tumors(which are not cancers) are named using -oma as a
suffix with the organ name as the root. For example, a benign
tumor of smooth muscle cells is called a leiomyoma(the common
name of this frequently occurring benign tumor in the uterus
is fibroid). Confusingly, some types of cancer use the noma suffix, examples including melanoma and seminoma

Some types of cancer are named for the size and shape of the cells
under a microscope, such as giant cell carcinoma spindle cell
carcinoma, and small-cell carcinoma

15. CLINICAL MANIFESTATIONS

16. SIX CHARACTERISTICS OF MALIGNANCIES
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Sustaining proliferative signaling
Evading growth suppressors
Resisting cell death
Enabling replicative immortality
Inducing angiogenesis
Activating invasion and metastasis

17. SYMPTOMS
Local effects
Local symptoms may occur due to the
mass of the tumor or its ulceration.
For example, mass effects from lung
cancer can cause blockage of the
bronchus resulting in cough
or pneumonia; esophageal
cancer can cause narrowing of the
esophagus, making it difficult or
painful to swallow; and colorectal
cancer may lead to narrowing or
blockages in the bowel, resulting in
changes in bowel habits. Masses in
breasts or testicles may be easily
felt. Ulceration can cause bleeding
which, if it occurs in the lung, will lead
to coughing up blood, in the bowels
to anemia or rectal bleeding, in the
bladder to blood in the urine, and in
the uterus to vaginal bleeding.
Although localized pain may occur in
advanced cancer, the initial swelling is
usually painless. Some cancers can
cause build up of fluid within the chest
or abdomen.
Systemic symptoms
unintentional weight
loss, fever, being excessively
tired, and changes to the
skin. Hodgkin
disease, leukemias, and
cancers of the liver or kidney
can cause a persistent fever of
unknown origin.
Specific constellations of
systemic
symptoms, termed paraneopla
st phenomena, may occur with
some cancers. Examples
include the appearance
of myasthenia
gravis in thymoma
and clubbing in lung cancer[

19. GRADING/STAGING OF CANCER

20. GRADING
Degree of maturity or differentiation under the
microscope
•
grade – resemblance between tumor and
normal cells
2.Nuclear grade
– size and shape of nucleus, dividing
cells
1.Histologic
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Biopsy – benign or malignant - pathologist
– level of differentiation

21. TUMOR GRADES
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Microscopic apperance of cancer cells
4 degrees of severity
Grade:
GX
grade)
G1
G2
G3
G4
Grade cannot be assessed (Undetermined
Well-differentiated (Low grade)
Moderately differentiated (Intermediate grade)
Poorly differentiated (High grade)
Undifferentiated (High grade)

22. GRADING SYSTEMS
•
Different for different types of cancers
Gleason – prostate cancer
Bloom-Richardson – breast cancer
Fuhrman – kidney cancer
Gleason system
Fuhrman system

23. GRADING – TREATMENT
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For treatment and prognosis
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Lower grade  better prognosis (outcome of diease)
Higher grade  worse prognosis
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Important in treatment of  prim. brain tumors (astrocytomas)
lymphomas
breast cancer
prostate

24. STAGING
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Extent of the prim. tumor and extent of spread in the body
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Important - helps planning treatment
- helps estimating prognosis
- helps identifying clinical trials

25. STAGING SYSTEMS
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No unique staging system
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Common elements :
- Location of the primary tumor
- Tumor size and number of tumors
- Lymph node involvement (spread of cancer
into
lymph nodes)
- Cell type and tumor grade (how closely the cancer
cells resemble normal tissue)
- Presence or absence of metastasis

26. TNM - SYSTEM
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Most common (accepted by UICC, AICC)
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Based on : T  extent of the tumor
N  extent of spread to the lymph nodes
M  presence of metastasis
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Number  indicates size or extent of the prim. tumor and the
extent of spread of metastasis

27. Primary Tumor (T)
TX
Primary tumor cannot be evaluated
T0
No evidence of primary tumor
Tis
Carcinoma in situ (has not spread)
T1, T2, T3, T4
Size and/or extent of the primary tumor
Regional Lymph Nodes (N)
NX
Regional lymph nodes cannot be evaluated
N0
No regional lymph node involvement
N1, N2, N3
Involvement of regional lymph nodes (number and/or extent of
spread)
Distant Metastasis (M)
MX
M0
M1
Distant metastasis cannot be evaluated
No distant metastasis
Distant metastasis (cancer has spread to distant parts of the body)

28. OTHER CLASSIFICATION
Ann Arbour  lymphomas
Duke‟s classification  colon cancer
Breslow scale and Clark‟s level  melanoma

29. DETERMINATION OF STAGES
Physical exams  examination, looking, listening
Imaging studies X-ray, US, CT, MRI, PET
Laboratory tests  blood, urine, AST/ALT, tumor markers (CA199,CA19-5….)
Pathology reports  biopsy, cytology
Surgical reports
Lung cancer,PET scan

30. PREVENTING CANCER THROUGH DIET AND
LIFESTYLE
Table 16.2

31. DIAGNOSIS OF CANCER

32. CANCER’S SEVEN WARNING SIGNALS
Table 16.5

33. DETECTING CANCER
Blood tests
 Urineanalysis
 Tumour markers
 Diagnostic imaging
 Endoscopic examination
 Genetic testing
 Tumour biopsy
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34. TUMOUR MARKERS
prostate-specific antigen (PSA)
Prostate-specific antigen is always present in low concentrations in the blood of
adult males. An elevated PSA level in the blood may indicate prostate
cancer, but other conditions such as benign prostatic hyperplasia (BPH) and
prostatitis can also raise PSA levels. PSA levels are used to evaluate how a
patient has responded to treatment and to check for tumor recurrence.
CA 19-9
This marker is associated with cancers in the colon, stomach, and bile duct.
Elevated levels of CA 19-9 may indicate advanced cancer in the pancreas, but it is
also associated with noncancerous conditions, including
gallstones, pancreatitis, cirrhosis of the liver, and cholecystitis.
prostatic acid phosphatase (PAP)
PAP originates in the prostate and is normally present in small amounts in the
blood. In addition to prostate cancer, elevated levels of PAP may
indicate testicular cancer,leukemia, and non-Hodgkin’s lymphoma, as well as
some noncancerous conditions.
CA 15-3
This marker is most useful in evaluating the effect of treatment for women with
advancedbreast cancer. Elevated levels of CA 15-3 are also associated with
cancers of the ovary, lung, and prostate, as well as noncancerous conditions such
as benign breast or ovarian disease, endometriosis, pelvic inflammatory
disease, and hepatitis. Pregnancy and lactation also can raise CA 15-3 levels.
CA 125
Ovarian cancer is the most common cause of elevated CA 125, but cancers of
the uterus, cervix, pancreas, liver, colon, breast, lung, and digestive tract can
also raise CA 125 levels. Several noncancerous conditions can also elevate CA
125. CA 125 is mainly used to monitor the treatment of ovarian cancer.
carcinoembryonic antigen (CEA)
CEA is normally found in small amounts in the blood. Colorectal cancer is the
most common cancer that raises this tumor marker. Several other cancers can
also raise levels of carcinoembryonic antigen.
alpha-fetoprotein (AFP)
Alpha-fetoprotein is normally elevated in pregnant women since it is produced
by the fetus. However, AFP is not usually found in the blood of adults. In
men, and in women who are not pregnant, an elevated level of AFP may
indicate liver cancer or cancer of the ovary or testicle. Noncancerous conditions
may also cause elevated AFP levels.
human chorionic gonadotropin (HCG)
HCG is another substance that appears normally in pregnancy and is produced
by the placenta. If pregnancy is ruled out, HCG may indicate cancer in the
testis, ovary, liver, stomach, pancreas, and lung. Marijuana use can also raise
HCG levels.
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CA 27-29
This marker, like CA 15-3, is used to follow the course of treatment in women with
advanced breast cancer. Cancers of the
colon, stomach, kidney, lung, ovary, pancreas, uterus, and liver may also raise CA
27-29 levels. Noncancerous conditions associated with this substance are first
trimester pregnancy, endometriosis, ovarian cysts, benign breast disease, kidney
disease, and liver disease.
lactate dehydrogenase (LDH)
LDH is a protein that normally appears throughout the body in small amounts.
Many cancers can raise LDH levels, so it is not useful in identifying a specific kind
of cancer. Measuring LDH levels can be helpful in monitoring treatment for cancer.
Noncancerous conditions that can raise LDH levels include heart
failure, hypothyroidism, anemia, andlung or liver disease.
neuron-specific enolase (NSE)
NSE is associated with several cancers, but it is used most often to monitor
treatment in patients with neuroblastoma or small cell lung cancer.

35. IMAGING TECHNIQUES
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transmission imaging
X-rays, computed tomography scans (CT scans), and fluoroscopy are radiological examinations whose images
are produced by transmission. In transmission imaging, a beam of high-energy photons is produced and passed
through the body structure being examined. The beam passes very quickly through less dense types of tissue
such as watery secretions, blood, and fat, leaving a darkened area on the x-ray film. Muscle and connective
tissues (ligaments, tendons, and cartilage) appear gray. Bones will appear white.
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x-ray
X-rays are diagnostic tests that use invisible electromagnetic energy beams to produce images of
internal tissues, bones, and organs on film. X-rays may be taken of any part of the body to detect
tumor (or cancer) cells.
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bone scan
Bone scans are pictures or x-rays taken of the bone after a dye has been injected that is absorbed
by bone tissue. These scans are used to detect tumors and bone abnormalities.
Reflection imaging refers to the type of imaging produced by sending highfrequency sounds to the body part or organ being studied. These sound waves
"bounce" off of the various types of body tissues and structures at varying
speeds, depending on the density of the tissues present. The bounced sound
waves are sent to a computer that analyzes the sound waves and produces a
visual image of the body part or structure.
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computed tomography scan (Also called a CT scan or computed axial tomography or CAT
scan.)
A CT scan is a diagnostic imaging procedure that uses a combination of x-rays and computer
technology to produce cross-sectional images (often called slices), both horizontally and
vertically, of the body. A CT scan shows detailed images of any part of the body, including the
bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
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reflection imaging
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lymphangiogram (LAG)
Lymphangiogram is an imaging study that can detect cancer cells or abnormalities in the lymphatic
system and structures. It involves a dye being injected into the lymph system.
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mammogram
A mammogram is an x-ray examination of the breast. It is used to detect and diagnose breast
disease in women who either have breast problems such as a lump, pain, or nipple discharge, as
well as for women who have no breast complaints. Mammography cannot prove that an abnormal
area is cancerous, but if it raises a significant suspicion of cancer, a biopsy may be performed.
Tissue may be removed by needle or open surgical biopsy and examined under a microscope to
determine if it is cancer. Mammography has been used for about 30 years, and in the past 15 years
technical advancements have greatly improved both the technique and results. Today, dedicated
equipment, used only for breast x-rays, produces studies that are high in quality but low in radiation
dose. Radiation risks are considered to be negligible.
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ultrasound
Ultrasound, or sonography, is the most commonly used type of reflection
imaging. This technique uses high-frequency sound waves and a
computer to create images, called sonograms, of blood
vessels, tissues, and organs. Sonograms are used to view internal organs
as they function and to assess blood flow through various vessels. Tumors
in the abdomen, liver, and kidneys can often be seen with an ultrasound.
emission imaging
Emission imaging occurs when tiny nuclear particles or magnetic energy are
detected by a scanner and analyzed by computer to produce an image of the body
structure or organ being examined. Nuclear medicine uses emission of nuclear
particles from nuclear substances introduced into the body specifically for the
examination. Magnetic resonance imaging (MRI) uses radio waves with a machine
that creates a strong magnetic field that in turn causes cells to emit their own radio
frequencies.
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magnetic resonance imaging (MRI)
MRI is a diagnostic procedure that uses a combination of a large
magnet, radiofrequencies, and a computer to produce detailed images of
organs and structures within the body. An MRI is often used to examine
the heart, brain, liver, pancreas, male and female reproductive
organs, and other soft tissues. It can assess blood flow, detect tumors and
diagnose many forms of cancer, evaluate infections, and assess injuries to
bones and joints.

36. ENDOSCOPIC EXAMINATION
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colonoscopy
Colonoscopy is a procedure that allows the physician to view the entire length of
the large intestine, and can often help identify abnormal growths, inflamed
tissue, ulcers, and bleeding. It involves inserting a colonoscope, a
long, flexible, lighted tube, in through the rectum up into the colon. The
colonoscope allows the physician to see the lining of the colon, remove tissue
for further examination, and possibly treat some problems that are discovered.
endoscopic retrograde cholangiopancreatography (ERCP)
ERCP is a procedure that allows the physician to diagnose and treat problems in
the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray
and the use of an endoscope - a long, flexible, lighted tube. The scope is guided
through the person's mouth and throat, then through the
esophagus, stomach, and duodenum. The physician can examine the inside of
these organs and detect any abnormalities. A tube is then passed through the
scope and a dye is injected, which will allow the internal organs to appear on an
x-ray.
esophagogastroduodenoscopy (Also called EGD or upper endoscopy.)
An EGD (upper endoscopy) is a procedure that allows the physician to examine
the inside of the esophagus, stomach, and duodenum. A thin, flexible, lighted
tube, called an endoscope, is guided into the mouth and throat, then into the
esophagus, stomach, and duodenum. The endoscope allows the physician to
view the inside of this area of the body, as well as to insert instruments through a
scope for the removal of a sample of tissue for biopsy (if necessary).

37. 
sigmoidoscopy
A sigmoidoscopy is a diagnostic procedure that allows the physician to
examine the inside of a portion of the large intestine, and is helpful in
identifying the causes of diarrhea, abdominal
pain, constipation, abnormal growths, and bleeding. A
short, flexible, lighted tube, called a sigmoidoscope, is inserted into the
intestine through the rectum. The scope blows air into the intestine to
inflate it and make viewing the inside easier.
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cystoscopy (Also called cystourethroscopy.)
An examination in which a scope, a flexible tube and viewing device, is
inserted through the urethra to examine the bladder and urinary tract for
structural abnormalities or obstructions, such as tumors or stones.
Samples of the bladder tissue may be removed through the cystoscope
for examination under a microscope in the laboratory.

38. GENETIC STUDIES
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chromosome studies- "Cytogenetics" .
The chromosomes need to be stained in order to see them with a
microscope. When stained, the chromosomes look like strings with light
and dark "bands." A picture (an actual photograph from one cell) of all
46 chromosomes, in their pairs, is called a "karyotype." A normal female
karyotype is written 46, XX, and a normal male karyotype is written
46, XY. The standard analysis of the chromosomal material evaluates
both the number and structure of the chromosomes, with an accuracy of
over 99.9 percent. Chromosome analyses are usually performed using a
blood sample (white blood cells), prenatal specimen, skin biopsy, or
other tissue sample. Chromosomes are analyzed by specially trained
healthcare personnel that have advanced degrees in cytogenetic
technology and genetics. Chromosome studies may be performed when
a child is born with multiple birth defects. Chromosome studies may also
be performed when people have certain types of leukemias and
lymphomas, to look for specific chromosome rearrangements (changes
in the order of the chromosome material) associated with these types of
cancers.
Biochemical genetic studies
Biochemical genetic testing involves the study of enzymes in the body
that may be abnormal in some way. There are hundreds of enzyme
defects that can be studied in humans. Sometimes, rather than studying
the gene mutation which is causing the enzyme to be defective in the
first place, it is easier to study the enzyme itself (the gene product). The
approach depends on the disorder. Biochemical genetic studies may be
done from a blood sample, urine sample, spinal fluid, or other tissue
sample, depending on the disorder.
protein truncation studies
Another way to look at gene products, rather than the gene itself, is
through protein truncation studies. Testing involves looking at the
protein a gene makes to see if it is shorter than normal. Sometimes a
mutation in a gene causes it to make a protein that is truncated
(shortened). With the protein truncation test, it is possible to "measure"
the length of the protein the gene is making to see if it is the right size or
shortened. Protein truncation studies can be performed on a blood
sample. These types of studies are often performed for disorders in
which the known mutations predominantly lead to shortened proteins.
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DNA studies
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Direct DNA studies
Direct DNA studies simply look directly at the gene in question for an error. Errors in the
DNA may include a replication of the gene's DNA (duplication), a loss of a piece of the
gene's DNA (deletion), an alteration in a single unit (called a base pair) of the gene's DNA
(point mutation), or the repeated replication of a small sequence (for instance, 3 base pairs)
of the gene's DNA (trinucleotide repeat). Different types of errors or "mutations" are found in
different disorders. It is usually very important to find the mutation that is present in a
family, by studying the family member with the disorder in question (in this
case, cancer), before testing relatives without the cancer. When a particular mutation is
found in a relative with cancer, other family members can choose to have testing for the
mutation to determine if they have an increased risk to develop certain cancers and to pass
the mutation on to the next generation. The DNA needed for direct DNA studies is usually
obtained by taking a blood sample.
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indirect DNA studies
Sometimes, the gene that (when mutated) causes a condition has not yet been identified,.
Indirect DNA studies involve using "markers" to find out whether a person has inherited the
crucial region of the genetic code that is passing through the family with the disease.
Markers are DNA sequences located close to or even within the gene of interest. Because
the markers are so close, they are almost always inherited together with the disease. When
markers are this close to a gene, they are said to be "linked." If someone in a family has the
same set of linked markers as the relative with the disease, this person often also has the
disease-causing gene mutation. Because indirect DNA studies involve using linked
markers, these types of studies are also called "linkage studies."
Indirect studies usually involve blood samples from several family members, including those
with and without the disorder in question. This is to establish what pattern of markers appear
to be associated with the disease. Once the disease-associated pattern of markers is
identified, it is possible to offer testing to relatives to determine who inherited this
pattern, and as such, is at increased risk of cancer.
The accuracy of linkage studies depends on how close the markers are to the faulty gene. In
some cases, a reliable marker is not available and the test, therefore, cannot give any useful
information to the healthy family members. In many cases, several family members are
needed to establish the most accurate set of markers to determine who is at risk for the
disease in the family. Linkage studies may take many weeks to complete because of the
complexity of these studies.

40. 
endoscopic biopsy
This type of biopsy is performed through a fiberoptic endoscope (a
long, thin tube that has a close-focusing telescope on the end for
viewing) through a natural body orifice (i.e., rectum) or a small incision
(i.e., arthroscopy). The endoscope is used to view the organ in question
for abnormal or suspicious areas, in order to obtain a small amount of
tissue for study. Endoscopic procedures are named for the organ or
body area to be visualized and/or treated. The physician can insert the
endoscope into the gastrointestinal tract (alimentary tract
endoscopy), bladder (cystoscopy), abdominal cavity (laparoscopy), joint
cavity (arthroscopy), mid-portion of the chest (mediastinoscopy), or
trachea and bronchial system (laryngoscopy and bronchoscopy).

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bone marrow biopsy
This type of biopsy is performed either from the sternum (breastbone) or
the iliac crest hipbone (the bone area on either side of the pelvis on the
lower back area). The skin is cleansed and a local anesthetic is given to
numb the area. A long, rigid needle is inserted into the marrow, and cells
are aspirated for study; this step is occasionally uncomfortable. A core
biopsy (removing a small bone 'chip' from the marrow) may follow the
aspiration.
excisional or incisional biopsy
This type of biopsy is often used when a wider or deeper portion of the
skin is needed. Using a scalpel (surgical knife), a full thickness of skin is
removed for further examination, and the wound is sutured (sewed shut
with surgical thread). When the entire tumor is removed, it is called
excisional biopsy technique. If only a portion of the tumor is removed, it
is called incisional biopsy technique. Excisional biopsy is often the
method usually preferred when melanoma (a type of skin cancer) is
suspected.
fine needle aspiration (FNA) biopsy
This type of biopsy involves using a thin needle to remove very small
pieces from a tumor. Local anesthetic is sometimes used to numb the
area, but the test rarely causes much discomfort and leaves no scar. FNA
is not used for diagnosis of a suspicious mole, but may be used to biopsy
large lymph nodes near a melanoma to see if the melanoma has
metastasized (spread). A computed tomography scan (CT or CAT scan) an x-ray procedure that produces cross-sectional images of the body - may
be used to guide a needle into a tumor in an internal organ such as the
lung or liver.
punch biopsy
Punch biopsies involve taking a deeper sample of skin with a biopsy
instrument that removes a short cylinder, or "apple core," of tissue. After a
local anesthetic is administered, the instrument is rotated on the surface of
the skin until it cuts through all the layers, including the
dermis, epidermis, and the most superficial parts of the subcutis (fat).
click image to enlarge
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shave biopsy
This type of biopsy involves removing the top layers of skin by shaving it
off. Shave biopsies are also performed with a local anesthetic.
skin biopsy
Skin biopsies involve removing a sample of skin for examination under the
microscope to determine if melanoma is present. The biopsy is performed
under local anesthesia. The patient usually just feels a small needle stick
and a little burning for about a minute, with a little pressure, but no pain.

41. CANCER TREATMENTS
Surgery
 Combine surgery with radiation or
chemotherapy
 Immunotherapy
 Cancer-fighting vaccines
 Gene therapy
 Neo adjuvant chemotherapy
 Stem cell therapy


42. LUNG CANCER

43. LUNG CANCER

Cancer develops following genetic damage
to DNAand epigenetic changes. These changes
affect the normal functions of the cell, including
cell proliferation, programmed cell death
(apoptosis) and DNA repair. As more damage
accumulates, the risk of cancer increases.

44. LUNG CANCER SYMPTOMS
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
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
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Chronic, hacking, raspy coughing, sometimes with bloodstreaked mucus
Recurring respiratory infections, including bronchitis or
pneumonia
Increasing shortness of breath, wheezing, persistent
chest pain
Hoarseness
Swelling of the neck and face
Pain and weakness in the shoulder, arm, or hand
Fatigue, weakness, loss of weightand
appetite, intermittent fever, severeheadaches and body
pain
Difficulty swallowing

45. TYPES OF LUNG CANCER

Two major types of lung cancers, small cell and
non-small cell lung cancers. Non-small cell lung
cancers account for about 90% of all lung cancers
and are less aggressive (spread to other tissues
and organs slowly) than small cell cancers.
NSLC
• Adenocarcinoma
• Squamous-cell carcinoma
• Large-cell carcinoma
SCLC

46. STAGING-CLASSIFICATION
NSCLC are assigned a stage from I to IV in order of
severity -TNM classification
 In stage I, the cancer is confined to the lung.
 In stages II and III, the cancer is confined to the
chest (with larger and more invasive tumors
classified as stage III).
 Stage IV cancer has spread from the chest to
other parts of the body.
SCLC are staged using a two-tiered system:
 Limited-stage (LS) SCLC refers to cancer that is
confined to its area of origin in the chest.
 In extensive-stage (ES) SCLC, the cancer has
spread beyond the chest to other parts of the
body.

47. Breast cancer

50. BREAST SELF-EXAMINATION
Figure 16.5

51. 2/12/2014
MASTECTOMY
Benign
breast masses
Noninvasive breast tumors
Invasive breast tumors (malignant )
51

52. SURGICAL PROCEDURES FOR DIAGNOSED
BREAST CANCER
Figure 16.6

53. 2/12/2014
TYPES
Lumpectomy or wedge resection or
tylectomy or tumourectomy
 Radical halsted‟s operation(axillary
lymphnodes+PM)
 Simple mastectomy
 Extended simple mastectomy (patey‟s) no
PM involvement
 Quadrantectomy (tumour segment+ axillary
nodes)

53

54. 2/12/2014
COMPLICATIONS









Bleeding from the surgical site
Seroma - collection of fluid (lymph or serum) at the
operative site
Wound infection
Possible skin slough at wound edges
Thrombophlebitis of the axillary vein
Numbness of the back of the upper arm usually due to
sacrifice of a nerve to the skin (intercostal brachial
cutaneous nerve)
Weakness of the latissimus dorsi or serratus anterior
muscles due to compromise of the thoracodorsal or long
thoracic nerves, rare
Arm edema (swelling) is common but usually mild
Limited range of motion of the shoulder. This occurs early
after surgery, is limited and totally recoverable
54

55. 2/12/2014
TREATMENT
HRT
 Tamoxifen
 Chemotherapy
 cyclophosphamide, methotrextate and 5
fluorouracil
 Breast reconstruction
 Silicone prosthesis
 Musculocutaneos flaps

LD or TRAM flap

55

56. 2/12/2014
PHYSIOTHERAPY
 Avoid
early shoulder mobilization
 Adduction for 48 hrs then 60* abduction
 Redivac drain used
 Edema management
(elevation, compression, FUP & STM)
 If any brachial plexus injury, treat as
LMN lesion
 Usual PT protocol
56

57. REHABILITATION

58. REHABILITATION
„To minimise some of the effects which the
disease, or it‟s treatment has on them. It is
often possible to improve the quality of life
regardless of their prognosis by helping them
to achieve their maximum potential of
functional ability and independence or gain
relief from distressing symptoms‟
ACPOPC 1993

59. „With in the context of palliative care, realistic
joint goal setting gives the patient a measure
of control, often at a time when they are
experiencing helplessness and loss of
independence‟
Robinson 2000

60. PHYSIOTHERAPY



Physiotherapy in palliative care is orientated to
achieve the optimum quality of life as perceived
by the patient.
Holistic & problem solving approach to therapy
Achieve maximum
physical, psychological, social, vocational
function

61. Preventive



Aims at restricting or
inhibiting the development of
disability in the course of the
disease or treatment before
disability occurs.
Education for patient and
families commencing
immediately after diagnosis.
Mobility and exercise
programs.
Availability of therapist as a
resource for patients and
families.
Restorative




Rehabilitation is the objective
when no or little residual
disability is anticipated for some
time and patients are expected
to return to normal living styles
Encouragement, education and
treatment in achieving
physical, work and lifestyle
goals
Specific treatments as required

Supportive
Enhance independent
functioning when residual
cancer is present and
Primarily directed at promoting
progressive disability is
maximum comfort
probable.
Maintaining the highest level of function  Encouragement, education and
possible in the face of disease
treatment in achieving
physical, work and lifestyle
progression and impending death
goals.
 Availability of therapist as a
resource
(Kuchler T., Wood-Dauphinee, S. Working with people who have
Palliative

cancer: Guidelines for Physical Therapists)

62. MAJOR ISSUES OF THE PATIENT
Fatigue,
Nausea,
Pain,
Weakness,
Lack Of Confidence,
Drug Reactions,
Cachexia - Weight Loss),
Progressive Decline In Ability,
Muscle Wasting,
Disease Progression,
Ascities,
Grief Reactions.

63. AIM OF PHYSIOTHERAPY















Assess and optimise the patient‟s level of physical function
Take into consideration the interplay between the physical, psychological, social and
vocational aspects of function
Understand the patients underlying emotional, pathological and psychological condition,
Focus is the physical and functional consequences of the disease and/or its treatment, on
the patient.
Restore the patient‟s sense of self
Facilitate and optimise the patient's ability to function with safety and independence in the
face of diminishing resources.
Maintain optimum respiratory & circulatory function
Listen to patient
Set realistic goals with the patient
Prevent muscle shortening & joint contractures
Influence pain control
Educate in all aspects of physical function
Education and participation of the carer
Treat the patient with dignity – allowing them to “live until they die”
Build a relationship of confidence and trust
Fulton and Else, 1997; p817 Chartered Society of Physiotherapy

64. Multidisciplinary Teams: The way forward in Cancer Care
Aim: To look at the evolving
cancer care model
Consultan
t
Radiographe
r
Physiotherapis
t
Dietician
Nurs
e
team.”
Occupational
Therapist
Social
Worker
Speech
and
Language
therapist

65. THE ROLE OF THE PHYSIOTHERAPIST IN
PALLIATIVE CARE



Physiotherapists work with
respiratory, neurological, lymphatic, orthopaedic, m
usculoskeletal, pain and haemotalogical conditions.
Education and training of multi disciplinary team as
well as patients and carers.
Communication and collaboration.

66. PHYSIOTHERAPY INTERVENTIONS









Positioning – prevention of pressure sores
TENS – pain and nausea control
Respiratory care
Neurological rehabilitation
Mobility – Exercise tolerance, maintenance
and independence
Prevention of contractures/joint-muscle
integrity
Individual exercise programmes
Oedema management
Counselling

69. PRINCIPLES OF ASSESSMENT

70. SOAP format should be used
Functional aspects of assessment should be
given with more weight age.
Guidelines from different countries could be
used.

71. THE ICF FUNCTION CLASSIFICATION
FRAMEWORK

72. MEASUREMENT OF BODY FUNCTION AND
STRUCTURE




Mental
Functions
Sensory
Functions and
Pain
Neuromusculo
skeletal and
MovementRelated
Functions and
Structures
Functions of
the
Cardiovascular,
Hematologic, I
mmunologic, a
nd Respiratory

73. MEASUREMENT OF BODY FUNCTION AND
STRUCTURE

74. MEASUREMENT OF BODY FUNCTION AND
STRUCTURE

75. DIAGNOSTIC MEASURES OF BODY FUNCTION
AND STRUCTURE INDICATING “RED FLAGS” OR
“YELLOW FLAGS” FOR PHYSICAL THERAPISTS

76. MEASUREMENT OF ACTIVITY AND
PARTICIPATION



Mobility
Self-care
Domestic
Life, Interpe
rsonal
Relations, a
nd Major
Life Areas

77. MEASUREMENT OF ACTIVITY AND
PARTICIPATION

78. REFERENCE
Phys Ther. 2009 March; 89(3): 286–306.
doi:
10.2522/ptj.20070309
PMCID: PMC2967778
Laura S Gilchrist, Mary Lou Galantino, Meredith Wampler, Victoria G Marchese, G Stephen
Morris, Kirsten K Ness
LS Gilchrist, PT, PhD, is Associate Professor, Doctor of Physical Therapy Program, College of St Catherine,
601 25th Ave S, Minneapolis, MN 55454 (USA), and Clinical Research Scientist, Children's Hospitals and
Clinics of Minnesota, Minneapolis, Minnesota.
ML Galantino, PT, PhD, is Professor of Physical Therapy, Richard Stockton College of New Jersey,
Pomona, NJ, and Adjunct Research Scholar, University of Pennsylvania, Philadelphia, Pennsylva nia.
M Wampler, PT, DPTSc, is Physical Therapist, Harrison Medical Center, Bremerton, Washington.
VG Marchese, PT, PhD, is Assistant Professor, Department of Physical Therapy, Lebanon Valley College,
Annville, Pennsylvania, and Assistant Professor of Pediatrics, Penn State Hershey College of Medicine,
The Pennsylvania State University, Hershey, Pennsylvania.
GS Morris, PT, PhD, is Director of Clinical Research in Rehabilitation Sciences, The University of Texas MD
Anderson Cancer Center, Houston, Texas.
KK Ness, PT, PhD, is Assistant Member, Department of Epidemiology and Cancer Control, St Jude
Children's Research Hospital, Memphis, Tennessee.
Address all correspondence to Dr Gilchrist at: Email: lsgilchrist@stkate.edu
Received October 10, 2007; Accepted November 26, 2008.
Copyright © 2009, American Physical Therapy Association
Abstract
Cancer has a high incidence in the United States, where 46% of all males and 41% of all females can
expect to develop either an invasive or in situ cancer.1 An estimated 1.4 million new cases of cancer are
diagnosed each year, with nearly 13,500 of these cases occurring in individuals younger than 20 years of
age.2 In years past, survival following a diagnosis of cancer was problematic; however, dramatic progress
in the ability to diagnose cancers earlier and to provide more-effective and targeted treatments has led
to substantial increases in survival. The National Cancer Institutes Surveillance, Epidemiology, and End
Results Program estimates that 65.3% of adults diagnosed with cancer between the years 2001 and

80. THANK YOU