“Cancer Rehabilitation: Improving Function and Quality of Life.” Carolina Gutierrez, MD Clinical Assistant Professor Cancer Rehabilitation Department of Physical Medicine and Rehabilitation, UTHealth TIRR Memorial Hermann September 15, 2016

“Cancer Rehabilitation: Improving Function and Quality of Life.”

Outline Cancer rehabilitation – definition “Chemo brain” Neuropathy Recommendations for cancer survivors

What is Cancer Rehabilitation? Is medical care that should be integrated throughout the oncology care continuum … delivered by trained rehabilitation professionals who have it within their scope of practice to diagnose and treat patients’ physical, psychological and cognitive impairments … in an effort to maintain or restore function, reduce symptom burden, maximize independence and improve quality of life in this medically complex population.

Cancer Survivor A cancer survivor is defined as anyone who has been diagnosed with cancer, from the time of diagnosis through the balance of his or her life. CDC (Centers for Disease Control and Prevention)

“Chemo Brain" Chemo brain is a common term used by cancer survivors to describe thinking and memory problems that can occur after cancer treatment. Chemo brain can also be called chemo fog, chemotherapy-related cognitive impairment or cognitive dysfunction. http://www.mayoclinic.org/diseases-conditions/chemo-brain/home/ovc-20170224

“Chemo Brain" Forgetting things that they usually have no trouble recalling Trouble concentrating Trouble remembering details like names, dates, and sometimes larger events American Cancer Society

“Chemo Brain" Trouble multi-tasking, like answering the phone while cooking, without losing track of one task Taking longer to finish things (disorganized, slower thinking and processing) Trouble remembering common words American Cancer Society

Is it Really Chemo Brain? Can occur after Cancer Chemotherapy Hormone therapy Surgery

Cognitive Function Patients who report cognitive impairment should be screened for potentially reversible factors that may contribute to cognitive impairment such as depression, sleep disturbance and fatigue NCCN Guidelines Cognitive Function

Cognitive Function Assessment Focused history Contributing factors Medication Hormonal status Depression/anxiety Pain Fatigue Comorbidities Use of alcohol/other agents NCCN Guidelines Cognitive Function

Cognitive Function Evaluation Imaging Neuropsychologic testing NCCN Guidelines Cognitive Function 1.2016

Cognitive Function Interventions Education and counseling Occupational therapy Speech therapy Management Depression/emotional distress Sleep disturbances Fatigue Symptoms as pain Medical comorbidities NCCN Guidelines Cognitive Function 1.2016

What you can tell your patients Use a daily planner Get enough rest and sleep Exercise your brain Take a class, learn a new language Regular physical activity Have routines Do not multitask Ask for help http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/chemotherapyeffects/chemo-brain

What you can tell your patients Keep a record of your memory problems Time of the day Things that can make it better / worse Since when Try not to dwell on how much these problems bother you http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/chemotherapyeffects/chemo-brain

Tips for patients Encourage them to talk to their doctors Have a list of all the medications including supplements with them Have a family member or a close friend coming to the appointments with them Can help with the information disclosed in the consult Can describe changes Write down the questions for your doctor http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/chemotherapyeffects/chemo-brain

Neuropathy Other names Damage to the peripheral nerves Peripheral neuropathy CIPN – Chemotherapy-Induced peripheral neuropathy Damage to the peripheral nerves Affects quality of life, survivorship, and modifications in oncological treatments

Peripheral Neuropathy Can also be also caused by Surgery Radiation Tumor compressing directly on nerves Chemicals released by tumors Infections https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Incidence of Peripheral Neuropathy 30 – 40% of patients treated with chemotherapy will develop some degree of peripheral neuropathy Not predictable https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Chemotherapy-Induced Peripheral Neuropathy CIPN May change depending on: Chemotherapy agent Dose Duration of exposure (cumulative) Usually sensory symptoms Rare motor symptoms (Thalidomide and Paclitaxel) Autonomic symptoms - rare

Symptoms Sensory Motor Autonomic Pain Tingling Numbness Weakness Decreased balance Autonomic Constipation Dizziness https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Other Symptoms Cramping Burning Pain – shooting, stabbing Constant Intermittent Decrease sensation to light touch Decrease sensation to temperature Sensitivity to heat or cold or touch https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Other Symptoms Feeling off balance Difficulty walking Constipation Difficulty with fine motor skills Buttoning Picking up objects Holding objects https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Course of Neuropathy Start in fingers and toes  Progress to hand and feet  Followed by arms and legs Can begin Any time after initiation of treatment Can be sudden Usually are mild and slowly worsen Get better slowly – months Sometimes permanent https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Risk for Neuropathy Having had chemotherapy, surgery or radiation before High dose or long course of chemotherapy Taking more than one agent than can cause neuropathy Multiple myeloma, lymphoma, lung or breast cancer Nerve damage from prior injury or illness https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Risk for Neuropathy History of alcohol abuse Diabetes HIV or AIDS Malnutrition Vitamin B 12, B6, folic acid deficiency Hypothyroidism https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx

Diagnosis History Physical exam Strength Reflexes Sensation to light touch NCS-EMG – nerve conduction study/electromyography

Treatment Symptoms & Side effects Pain management Education Skin protection Sharp objects Cold / Heat Skin inspection Fall prevention Appropriate foot wear

Preventive Agents No established agents recommended for the prevention of chemotherapy-induced peripheral neuropathy Preliminary data may suggest potential protective effect of exercise in CIPN Uptodate

Cytotoxic Chemotherapy Agents Platinum drugs, such as cisplatin (Platinol), oxaliplatin (Eloxatin), carboplatin (Paraplatin) Taxanes, such as paclitaxel (Taxol, Abraxane), docetaxel (Taxotere) Vinca alkaloids, such as vincristine (Oncovin, Vincasar), vinorelbine (Navelbine), and vinblastine (Velban) Podophyllotoxins, such as etoposide (Etopophos, VePesid, Toposar, VP-16) and teniposide (Vumon) Epothilones, such as ixabepilone (Ixempra) Thalidomide (Thalomid) and lenalidomide (Revlimid) Bortezomib (Velcade) Interferon Methotrexate (Rheumatrex, Trexall, Amethopterin, MTX) Fluorouracil (5-FU, Adrucil) Cytarabine (Cytosar-U)

Acute Neurotoxicity Syndrome Not always peripheral Non cumulative Improves within days of each dose Recurring with subsequent doses Oxaliplatin Paclitaxel Uptodate, Prevention and treatment of chemotherapy-induced peripheral neuropathy

Additional Recommendations For Survivorship American Cancer Society (ACS) American Institute for Cancer Research (AICR) American College of Sports Medicine (ACSM)

ACS Recommendations Achieve and maintain a healthy weight throughout life Adopt a physically active lifestyle Consume a healthy diet, with an emphasis on plant foods If you drink alcoholic beverages, limit consumption ACS – American Cancer Society

ACSM Guidelines Cancer patients and survivors should adhere to the 2008 federal Physical Activity Guidelines for Americans 150 minutes per week of moderate intensity aerobic activity Avoid inactivity For those with disease or undergoing treatment Exercise recommendations should be tailored to Exercise tolerance and specific diagnosis Close attention to cancer survivors response to physical activity Safely progress exercise programs & avoid injury ACSM – American College of Sports Medicine 2011

AICR’S Guidelines For Cancer Survivors Recommendations to Reduce Your Cancer Risk Be as lean as possible without becoming underweight. Be physically active for at least 30 minutes every day. Avoid sugary drinks, and limit consumption of energy-dense foods Eat more of a variety of vegetables, fruits, whole grains and legumes. Limit consumption of red meats and avoid processed meats. Limit alcoholic drinks to two for men and one for women a day. Limit consumption of salty foods and foods processed with salt. Do not rely on supplements to protect against cancer. Do not smoke or chew tobacco. AICR – American Institute for Cancer Research

AICR – American Institute for Cancer Research

AICR’S Guidelines For Cancer Survivors Recommendation for new mothers Best for mothers in the general population to breastfeed exclusively for up to six months and then add other liquids and foods. Note: new mothers receiving chemotherapy should not breastfeed. AICR – American Institute for Cancer Research

So how do we get patients on a road to better health during and after cancer treatment? We need a comprehensive team based approach to meet patient functional needs. Using guidelines we have just reviewed, I will describe a case that illustrates how cancer rehabilitation can help a patient be successful on their journey.

http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/chemotherapyeffects/chemo-brain https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/neuropathy.aspx