1. “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

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

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

4. 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.

5. 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)

7. “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.

8. “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

9. “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

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

11. 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

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

13. Cognitive Function Evaluation Imaging Neuropsychologic testing
NCCN Guidelines Cognitive Function

14. 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

15. 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

16. 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

17. 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

19. 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

20. Peripheral Neuropathy
Can also be also caused by
Surgery
Radiation
Tumor compressing directly on nerves
Chemicals released by tumors
Infections

21. Incidence of Peripheral Neuropathy
30 – 40% of patients treated with chemotherapy will develop some degree of peripheral neuropathy
Not predictable

22. 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

23. Symptoms Sensory Motor Autonomic Pain Tingling Numbness Weakness
Decreased balance
Autonomic
Constipation
Dizziness

24. 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

25. Other Symptoms Feeling off balance Difficulty walking Constipation
Difficulty with fine motor skills
Buttoning
Picking up objects
Holding objects

26. 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

27. 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

28. Risk for Neuropathy History of alcohol abuse Diabetes HIV or AIDS
Malnutrition
Vitamin B 12, B6, folic acid deficiency
Hypothyroidism

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

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

31. 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

32. 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)

33. 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

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

36. 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

37. 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

38. 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

39. AICR – American Institute for Cancer Research

40. 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

41. 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.