This document provides information about physiotherapy interventions for pelvic cancers. It discusses the various types of pelvic cancers and their symptoms, assessments related to pelvic cancers including lymphedema management, prehabilitation recommendations, exercise programs for gynecological cancers, education approaches, oncology massage therapy, and pelvic floor rehabilitation. The document emphasizes the importance of a multidisciplinary team approach to optimize cancer treatment outcomes and management of post-treatment impairments through various physiotherapy modalities.

1. PHYSIOTHERAPY IN PELVIC CANCER
MUSKAN RASTOGI
MPT FIRST YEAR

2. WHAT IS PELVIC CANCER?
Pelvic cancer refers to various cancers involving the structures and organs in the pelvis.
• Bladder cancer
• Cervical cancer(f.)
• Anal cancer
• Rectal cancer
• Ovarian cancer(f.)
• Uterine cancer(f.)
• Vaginal and vulvar cancer(f.)
• Testicular cancer(m.)
• Prostate cancer(m.)
• Chondrosarcoma
• Osteosarcoma f.- female m.-
male
Pelvic cancers list

3. CAUSES AND RISK FACTORS
 GENETIC- for e.g. ovarian and breast cancer
 INFECTION- e.g. HPV for cervical cancer
 SEXUAL CONTACT- cervical cancer
 SMOKING
 OLDER AGE- ABOVE 50 YEARS OF AGE

4. SYMPTOMS
 CERVICAL CANCER
• Abnormal vaginal bleeding that occurs after
sex, after menopause, or between menstrual
periods
• Foul-smelling, bloody, or unusual vaginal
discharge
• Lower back pain
• Pain during sexual intercourse
• Pelvic pain
• Periods that are longer or heavier than usual

5. OVARIAN CANCER
•Abdominal bloating
•Constipation
•Diarrhea
•Frequent urination or urgent need to urinate
•Loss of appetite or feeling full quickly after eating a small amount of
food
•Nausea
•Pelvic pain
UTERINE OR ENDOMETRIAL CANCER
•Pelvic pain or cramping, like menstrual pain
•Rapidly growing fibroids and a feeling of fullness in the pelvic area
•Unusual vaginal discharge that is watery and pink, blood-tinged, or
brown in color and foul-smelling

6. VAGINAL AND VULVAR CANCER
•Abnormal vaginal discharge or bleeding
•Blood in the urine or stool
•Changes in the color of the vulva
•Constipation
•Frequent urination
•Itching, burning or bleeding vulva
•Pelvic or abdominal pain, especially with sexual intercourse
•Sores, lumps or ulcers on the vulva
CHONDROSARCOMA AND OSTEOSARCOMA
• Bone pain or swelling in the pelvic area

7. ANAL AND RECTAL CANCER
•Blood in the stool or bleeding from the anus
•Changes in bowel habits
•Itching and discharge from the anus
•Narrow stool
•Pain or lumps in the anus
•Pelvic or abdominal pain
BLADDER CANCER
•Abdominal or pelvic pain or
tenderness
•Blood in the urine
•Bone pain
•Fatigue
•Frequent, urgent or painful urination
•Incontinence

8. ASSESSMENT RELATED TO PELVIC CANCERS
 Important to review the patient’s cancer history, including the location of the cancer, presence and
location of metastatic disease, diagnostic testing results such as PET/CT scans, bone scans, CT of chest,
abdomen, and pelvis if available.
 Deep vein thrombosis.
 Lymphedema -History Pertinent information to gather from the patient includes
 (1) When and how long ago did they notice swelling of the extremity?
 (2) Were there any associated circumstances around the time that the swelling was first noticed—cuts, bruises,
redness of skin, trauma to limb, etc.?
 (3) Did the swelling start gradually or suddenly?
 (4) Is this the first time that the patient has noticed swelling of the limb or have there been other times as well?
 (5) Was there a recent change in their cancer history such as progression of disease?
 (6) Is the swelling present in one extremity or more?
 (7) Has the patient experienced a perception of heaviness of the limb accompanied by difficulty wearing pants ?

9.  (8) Is there any associated weakness, numbness, or tingling sensation of the affected limb?
 Physical Examination Inspection:
 (1) Is the patient obese?
 (2) Any cuts, bruises, erythema, skin changes such as cobble stoning, skin overgrowth, and wart-like changes
indicative of more advanced disease deformities of the limb as well as distribution of the swelling.
 Palpation: tissue fibrosis, tender points, pitting versus nonpitting edema, presence of axillary cords, or
regional lymphadenopathy (i.e., axillary or supraclavicular lymphadenopathy).
 Range of motion: any restrictions in the range of motion of proximal and/or distal joints in the affected
extremity. In addition, circumferential measurements of the affected and nonaffected limb as well as
assessment of muscle strength and sensory deficits are important components of the physical
examination. Lastly, a functional assessment of the person’s ability to use the affected limb

10.  Evaluation of the pelvic floor will be broken down into each of the following four systems:
 Musculoskeletal
 Bladder and Bowel
 Sexual function.
 The pelvic floor rehabilitation intake visit should begin with history taking and assessment of the
patient’s signs and symptoms, pain, vital signs, posture, and balance.
 A thorough screen of the abdominal wall, spine, sacroiliac joint (SIJ), hip, and lower extremities should be
performed and can identify contributing musculoskeletal factors originating outside the pelvis.
Sensation and reflex testing of the lumbar area should be done.

11.  The massage therapist also reviews the medical chart of the person with cancer prior to the treatment
session to understand the type of cancer, stage of cancer, and the treatment rendered. This treatment
commonly includes surgery, radiation therapy, and chemotherapy in gynecological cancers.
 This is followed by a physical assessment of the patient’s skin to
 Identify any surgical scars and their integrity, wounds and
 Areas of potential skin infection as marked by erythema and access
 Medi ports for delivery of chemotherapy, lymphedema, skin bruises, and areas treated by radiation
therapy. Muscles are examined for atrophy and bones for deformities.
 Palpation is an essential assessment component and muscles are palpated for tender points and
tightness.
 It is also important to briefly assess for any insensate areas or areas of altered sensation as a result
of chemotherapy.

12. PREHABILITATION
 Multimodal interventions to provide a comprehensive approach to the treatment of patients with cancer.
 Identification of functional impairments can allow for the design of individual exercise programs to
improve functional outcomes and prevent injury. However, while exercise is beneficial, it does not fully
constitute a pre-rehabilitation program.
 Additional components should include assessing and optimizing nutrition, mental health, and smoking
cessation.
 Before participation in a prehabilitation program, patients should be screened for other medical
comorbidities to prevent injury.
 Participation in a comprehensive prehabilitation program enables patients with cancer to maintain, if not
improve, health, function, and quality of life during and after cancer treatment.

13.  The most common gynecologic cancers are uterine, ovarian, and cervical, though cancer can occur
in various locations along the reproductive tract.
 Treatment of gynecologic cancer generally involves surgical management and adjuvant treatment
based on multiple factors, including cancer stage and grade.
 Shared symptoms are seen with many different types of cancers, such as fatigue, pain, and
neuropathy
 Symptoms after treatment of gynecologic cancers may also include
 Lower limb lymphedema (LLL)
 Pelvic floor dysfunction
 Bowel/bladder impairment
 Sexual dysfunction
 Reduced quality of life

14.  Although there is no single exercise protocol or dose that has shown to be superior for gynecological
cancer patients yet, we can comfortably state that staying active in a variety of ways is vital for cancer
treatment and recovery.
 Teaching, training, and supervision from experienced physical therapists, fitness trainers, and exercise
physiologists specializing in cancer rehabilitation allow patients to safely increase their physical fitness and
adherence to their exercise program.
 There is strong evidence that increasing physical activity and limiting sedentary behavior lower the risk of
endometrial cancer, with more limited evidence for ovarian cancer. It is important to note that there is a
significant linear correlation between physical activity and melanoma risk, and therefore patients engaging
in outdoor physical activity should be educated on sun-safe practices.

15. • The National Comprehensive Cancer Network (NCCN) and the American College of Sports Medicine
(ACSM) recommend physical activity, including aerobic exercise and resistance training, for cancer
undergoing active cancer treatment and posttreatment.
• Exercise can help patients tolerate treatment better, decrease complications, and increase chemotherapy
completion rates, translating to improved treatment outcomes.
• Exercise may have these effects by increasing perfusion and oxygenation of tumor cells by normalizing
tumor blood vessels and promoting immune cell mobilization and infiltration into tumors.
• Exercise may also work synergistically with chemotherapy to impact tumor growth.
• Patients need not limit activity before surgery, as there is strong evidence that the cardiopulmonary benefits
of exercise help patients better tolerate anesthesia, with fewer complications postoperatively.

16. EPEC-FAST
PROGRAMME
Exercise Phase * Details
Warm-Up
10 min Low-intensity warm-up using an exercise bike or a treadmill
Exercise phase
40 min
Aerobic exercise (20 min)
Walking on a treadmill or cycling on an exercise bike. The exercise phase will be performed at a level of 40–60% of maximum heart
rate.
Pillar strength training (10 min)
Consists of 4 exercises to improve stability and strength of the hip, and 3 exercises to improve core stability and strength. Patients
are recommended to perform 8 repetitions of each of the hip stability movements per leg, and a set of 10–15 repetitions of each
core muscle exercise. A stability ball may be used to facilitate some of the exercises
Hip movements:-Hip flexion
-Hip extension
-Hip extension
-Hip adduction
-Hip abduction
Core movements:-Crunch
-Back
-Opposite arm/leg raise
Resistance training (10 min)
Consists of 1 set of 8 to 12 repetitions of 8 exercises that include all the major muscle groups. After initial phase of repetitions, this
can be increased up to 20–25 repetitions (40–60% of 1 RM) during 1 session. A dumb-bell, stability ball or bench may be used to
facilitate the exercises.
Exercises:-Basic squat
-Lateral raise
-Dumb-bell deadlift
-Shoulder press
-Hamstring curl
-Dumb-bell biceps curl
-Overhead triceps extension
-Calf raise
Cool down
10 min
Set of 6 stretching and flexibility exercises. Four repetitions of each of the following muscle groups will be performed for 10–30 s.-
Lower back
-Tensor fasciae latae
-Hip flexor
-Quadriceps
-Hamstring
-Calf

17. Prehabilitation Recommendations
 No studies on prehabilitation exist in the gynecologic oncology patient population.
 However, screening patients for the earlier listed and other impairments along with counselling
patients about the importance of exercise should be part of a general prehabilitation program in
this population.
 In addition, addressing nutrition, stress reduction, and smoking cessation should also be a part of a
prehabilitation program for the gynecology oncology population.

18. PHYSIOTHERAPY INTERVENTIONS APPLIED IN PELVIC CANCER
EXERCISE
 Exercise- beneficial effects on complications such as cancer-related fatigue, obesity and/or cachexia, osteopenia/osteoporosis,
cardiotoxicity, chemo-related neurotoxicity, lymphedema, anxiety, depression, and sleep disturbances.
 Patients who exercise better tolerate medical and surgical treatments, with less complications of treatment, higher
chemotherapy completion rates, and improved outcomes.
 No single exercise protocol or dose has shown to be superior for gynecological cancer patients
 A collaborative team-based approach is essential to the success of an exercise program for patients with gynecological cancer.
 TYPES OF EXERCISE GIVEN
i. Aerobic
ii. Anaerobic
iii. Muscle strengthening
iv. Balance training
v. Flexibility training.

19. Education
• Patient education is a primary component of pelvic floor rehabilitation for all GYN
oncology patients.
• Motivation to participate and belief in the effectiveness of pelvic floor rehabilitation are
dependent on the successful communication between therapist and patient.
• Patients who have cognitive limitations or learning impairments must have instructions
that are designed to their specific needs.
• Smartphone apps, links to online resources, videos, and podcasts can supplement a
traditional paper handout and provide various learning tools for your patients.

20. Lymphedema Management
• Complete decongestive therapy (CDT) is a combination therapy for the management of lymphedema
that includes MLD, compression, exercise, skin care, patient education, and self-management.
• MLD is a specialized manual therapy technique centered on the anatomy of the lymphatic system. The
light tissue compression used in the course of MLD is aimed at reducing swelling through improved
lymphatic contractility, uptake of interstitial fluid, rerouting of lymph into non-obstructed lymphatics, and
development of accessory lymph collectors.
• Compression modalities most used in lymphedema treatment are compression bandages (CBs),
Adjustable Velcro compression devices (AVCDs), and compression garments.
• The basic exercise modes are applicable in the management of lymphedema: range of motion;
stretching flexibility exercises to increase or maintain range of motion and minimize scar tissue and joint
stiffness that may decrease lymph flow; resistance or weight lifting; aerobic conditioning; and
lymphedema remedial/decongestive exercises combined with compression.

21. • It is proposed that Kinesiotaping facilitates lymphatic drainage by enabling the upper layers of the
skin to be lifted away from muscle fascia creating convolutions in the skin therein opening up
lymphatic channels and facilitating vascular and lymphatic flow. It is further suggested that it aids
myofascial release and increases reabsorption of lymph in surrounding tissues. In lymphedema
management, KT is of interest and may be considered as a desirable alternative to compression as it is
lightweight and does not limit movement or function and the muscle activity further encourages
lymphatic flow.
• Educating patients on self-reported symptoms that may include perceived swelling, heaviness, tingling,
pain, sensory changes and changes in fit of clothing is important, as these symptoms may occur
before the onset of visible swelling and indicate subclinical lymphedema enabling an opportunity for
early intervention and treatment.

22. Oncology Massage Therapy
Massage therapy was noted to have a beneficial role in reducing anxiety, stress and improving mood disturbance,
as well as in reducing pain and promoting relaxation.
There are five main passive techniques of massage: effleurage, petrissage, friction, tapotement, and vibration.
The contraindications to massage therapy are based on the therapist’s knowledge of the patient, the cancer and
its metastatic sites, as well as the treatments used to treat the cancer—chemotherapy, radiation therapy, and
surgery.
Massage therapy should not be performed
(1) Directly over a surgical site until the surgical scar is fully healed with no evidence of infection;
(2) Directly over a mediport access site
(3) Directly over skin that is actively treated with radiation therapy and deep pressure therapy;
(4) Over areas with known lymphedema, lymphatic involvement of cancer, or bone metastasis;
(5) In patients with coagulation disorders complicated by hemorrhage, low platelet counts, or on medications
such as warfarin or heparin;
(6) Over skin with infection; and
(7) On days when the patient is receiving chemotherapy.

23. Caution
• Massage will not resolve pain resulting from pressure of the tumor on surrounding sites, nerve impingement
(radiating pain), or bone pain from metastases.
• Light touch massage can reduce anxiety or distress, whereas deep massage can worsen the pain by increasing
inflammation or potentially causing fragile bones to break.
• No oils or lotions should be used on the field of treatment, during radiation.
• Rocking motions should be avoided with patients who are experiencing nausea.
• Practicing diligent handwashing and using clean equipment and linens will reduce the risk of infection.
• It is also important to use extra caution during a massage session to avoid the carotid artery, suboccipital
triangle, supraclavicular fossa, posterior knee, femoral triangle, and abdominal cavity.
Massage Treatment Session
To maximize the benefits of the oncology massage therapy session, it is important to make sure that the patient
is comfortable, relaxed, and warm. The ambiance in the massage therapy room should be conducive to a positive
experience for the patient. Proper positioning with the use of bolsters and pillows is essential to ensure a
comfortable position during the treatment session. Patient may be supine or prone on a massage therapy table
or seated on a chair depending on the goals of the treatment session. Areas of the body not being massaged
should be covered with blankets or sheets for warmth and modesty.

24. Pelvic Floor Rehabilitation
• Educate patients about the long-term effects following cancer treatment and how these can impact pelvic floor
function. learn how to cope with the “new normal” and can handle reeducation for bowel and bladder and
sexual health.
• Behavioural Modifications
Many pelvic floor symptoms related to urogenital and bowel function respond dramatically to behavioural
modifications. Daily routine, fluid, diet, voiding, and toileting habits can significantly improve urinary urgency and
frequency and bowel irregularity.- Bladder Diary. Bladder training to regulate overactive bladder
• Control of diet and fluid intake.
• Self-Care Hygiene products and self-care techniques are important to maintaining vulvar and perineal health.
• Pelvic floor muscle exercises have been known to improve urinary incontinence, bowel incontinence,
constipation, support dysfunction, and pelvic organ prolapse. appropriate. Muscle training should include
exercises to address endurance, power, coordination, velocity, and flexibility. Vaginal dilators or manual digital
insertion can also provide additional proprioceptive feedback for improved muscle awareness during
strengthening.
• Biofeedback.

25. Cancer-related fatigue
• Fatigue tends to worsen both with progression of cancer and with subsequent chemotherapy and
radiation, affecting quality of life, mood, pain tolerance, cognition, and sleep. Patients suffering from CRF
are more likely to be sedentary, accelerating deconditioning.
• It is important to keep in mind that the cause of CRF is often multifactorial, and cancer patients may have
other noncancer factors contributing to fatigue so an individualized approach to treatment is critical.
• Evaluation into and treatment of medical causes of fatigue such as anemia, psychological causes such as
“catastrophizing” and depression, and sleep disorders are necessary. Overtraining and poor nutritional
status can also contribute to fatigue and should be monitored on a regular basis.
• Exercise alone, or combined with psychological interventions, is recommended as a first-line option for
treating CRF. Many types of exercise have been shown to be safe and beneficial for slowing the
progression of CRF, even in patients with advanced metastatic disease, including aerobic exercises,
anaerobic exercises, and seated exercises. Supervised aerobic and resistance training, in comparison to
self-administered regimens, appear more effective at improving CRF and quality of life.

26. • Patients who have completed primary treatment appear to benefit from a combination of
exercise and psychological interventions, whereas patients receiving primary treatment can
benefit from exercise alone.
• A modality of traditional acupuncture, infrared laser moxibustion, is another exciting
potential treatment for CRF.
• Yoga, may provide some benefit to those with CRF especially in the short-term period
among breast cancer survivors.
• Relaxation exercise or meditation.

27. REFERENCES
 CRISTIAN A. BREAST CANCER AND GYNECOLOGICAL CANCER REHABILITATION. ELSEVIER
HEALTH SCIENCES; 2020 SEP 15.
 SMITS A, LOPES A, DAS N, BEKKERS R, MASSUGER L, GALAAL K. EXERCISE PROGRAMME IN
ENDOMETRIAL CANCER; PROTOCOL OF THE FEASIBILITY AND ACCEPTABILITY SURVIVORSHIP
TRIAL (EPEC-FAST). BMJ OPEN. 2015 DEC 1;5(12):E009291.
 SMITS A, GALAAL K, WINNAN S, LOPES A, BEKKERS RL. FEASIBILITY AND EFFECTIVENESS OF THE
EXERCISE PROGRAM IN ENDOMETRIAL CANCER; FEASIBILITY AND ACCEPTABILITY
SURVIVORSHIP TRIAL (EPEC-FAST). CANCERS. 2022 NOV 14;14(22):5579.