12/15/2018 PEDIATRIC CANCERS OBJECTIVES AND THE ROLE OF PHYSICAL THERAPY • Identify and describe common pediatric ALONG THE oncology diagnoses. CONTINUUM OF CARE • Recognize the associated side effects of medical Stacey Caviston PT, DPT, PCS treatments for pediatric cancers and their Kristen DeVirgilio PT, DPT impact on function. Megan Ryninger PT, DPT, PCS January 25, 2019 • Develop and implement effective physical therapy examinations, treatment strategies, and overall plan(s) of care for pediatric patients in all stages of cancer treatment. • Discuss the differences between pediatric and adult cancers. 1 ADULT VERSUS PEDIATRIC CANCERS • Pediatric cancers are not strongly linked to lifestyle factors • Less health co-morbidities lend to improved GENERAL response and tolerance of treatment OVERVIEW • Cancer treatment can have long term side effects Pediatric Cancers • More inpatient admissions COMMON PEDIATRIC CANCERS KEY STATISTICS • Leukemia • Pediatric cancers make up < 1% of all cancers • Brain and spinal cord tumors diagnosed each year • Neuroblastoma • Wilms tumor • An estimated 10,590 new cancer cases will be diagnosed among children 0 to 14 years of age in • Lymphoma (including both Hodgkin and Non the US in 2018. Hodgkin) • Rhabdomyosarcoma • Cancer is the second-leading cause of death • Retinoblastoma among children ages 1-14 years (after accidents), • Bone cancer (including osteosarcoma and Ewing accounting for 13% of deaths in 2015. sarcoma) 1 12/15/2018 INCIDENCE RATES INCIDENCE RATES American Cancer Society. Cancer Facts & Figures 2018. Atlanta: American Cancer Society; 2018. American Cancer Society. Cancer Facts & Figures 2018. Atlanta: American Cancer Society; 2018. ETIOLOGY GENERALIZED SIGNS AND SYMPTOMS • Inherited familial syndromes • Unusual mass or swelling • Neurofibromatosis type 1 • Paleness • Li-Fraumeni syndrome • Loss of energy • Genetic syndromes • Increase in bleeding or bruising • Down Syndrome • Persistent, localized pain or limping • Germline mutations • Prolonged/unexplained fever • Environmental factors • Frequent headaches often associated with • Ionizing radiation vomiting • Lifestyle factors • Sudden eye or vision changes • Not typically a factor in pediatric cases • Sudden unexplained weight loss GENERAL DIAGNOSTIC TESTS STAGING • Medical history and physical exam • Currently no national system for pediatrics • Blood tests • Bone marrow aspiration and biopsy • Staging systems vary by: • Lumbar puncture • Diagnosis • Biopsy • Trial group/current protocol • Chest x-ray • Computed tomography (CT) or positron emission tomography (PET) scan • Magnetic resonance imaging (MRI) • Ultrasound 2 12/15/2018 MEDICAL INTERVENTIONS CHEMOTHERAPY • Chemotherapy • Cytotoxic medications used to kill cancerous cells by: • Killing cancer cells • Radiation therapy • Stopping cancer cells from dividing • Most common methods of administration: • Surgery • Oral • Intravenous • Intrathecal • Steroids • Malignant cancers receive multiple chemotherapy agents via individualized road maps COMMON TYPES OF CHEMOTHERAPY CHEMOTHERAPY SIDE EFFECTS AGENTS Chemotherapy Agent Possible Side Effects Common Diagnoses Vincristine Hair loss, peripheral neuropathy, constipation, low blood Acute leukemia, Hodgkin’s/non-Hodgkin’s • Nausea/vomiting counts, nausea, vomiting, mouth sores, diarrhea, loss of lymphoma, neuroblastoma, appetite, taste changes, abdominal cramping rhabdomyosarcoma, Ewing’s sarcoma, • Fatigue Wilms’ tumor, multiple • Fever myeloma, chronic leukemias, thyroid cancers, brain tumors, and some blood • Pain disorders • Hearing loss Cisplatin Low blood counts, nausea, vomiting, kidney toxicity, low Hodgkin’s/non-Hodgkin’s lymphoma, magnesium/potassium/calcium, peripheral neuropathy, neuroblastoma, sarcomas • Anemia/neutropenia high frequency hearing loss, loss of appetite, taste changes, • Bruising/bleeding liver dysfunction, hair loss, changes in fertility • Diarrhea or constipation Etoposide Low blood counts, low platelet counts, hypotension, loss of Hodgkin’s and non-Hodgkin’s lymphoma, • Nerve/muscle effects fertility, nausea, vomiting, hair loss, mouth sores, diarrhea, Wilm’s tumor, rhabdomyosarcoma, Ewing’s poor appetite, nerve damage sarcoma, neuroblastoma, brain tumors, and • Secondary malignancies can be used for conditioning for bone marrow transplant • Hair loss • Mouth sores High dose methotrexate Low blood counts, mouth sores, poor appetite, nausea, Acute lymphoblastic leukemia, sarcomas, • Weight loss vomiting, kidney toxicity, kidney failure, skin rash, diarrhea, non-Hodgkin’s lymphoma, and cutaneous T hair loss, eye irritation, liver problems, radiation recall, loss of cell lymphoma • Infection fertility • Changes in appetite Doxorubicin Heart damage, fatigue, nausea, vomiting, mouth sores, bone Soft tissue and bone sarcomas, acute marrow suppression lymphoblastic leukemia, acute myeloid leukemia, Hodgkin lymphoma Ifosfamide Damage to lining of bladder, mouth sores, nausea, vomiting, Soft tissue and bone sarcoma nerve damage, blurred vision, hair loss RADIATION THERAPY TYPES OF RADIATION • Use of high energy particles or waves to destroy cancer cells by inhibiting cell growth and X-ray/photon Proton division • Total brain irrigation • Targets tumor at • Deposit energy in higher intensity • Method of administration depends on type and small packets along • Depth of energy is stage of cancer their path through the released and can be • External tissue controlled • Internal • Can damage healthy • Fewer short term and • Systemic tissue long term side effects • Decreases risk of secondary malignancies 3 12/15/2018 RADIATION THERAPY GENERAL SIDE DOSE DISTRIBUTION EFFECTS • Fatigue • Hair Loss • Integumentary changes • Immunosuppression Fowler JF. What can we expect from dose escalation using proton beams? Clin Oncol. 2003;15(1):S10-S15. • Secondary malignancies TYPES OF SURGERIES SURGERY • Biopsy • Curative • Palliative • Gross total resection • Relieve pain • Clear margins • Minimize symptoms • Gross total resection versus partial resection • Improve quality of life • Reconstruction • Limb salvage • Amputation SURGICAL SIDE EFFECTS STEROIDS • Pain • Corticosteroids are man-made drugs that work like cortisol, a natural hormone in your body. • Fatigue • Appetite loss • Prescribed as part of treatment or as a • Integumentary changes supportive measure • Numbness • Bleeding • Common corticosteroids used in pediatric • Infection cancer treatment: • Physical impairments • Dexamethasone • Prednisone • Cognitive impairments 4 12/15/2018 STEROID SIDE EFFECTS PEDIATRIC CANCER PROGNOSIS • Increased appetite • The 5-year relative survival for the most recent time • Weight gain period (2007-2013) is 83%, although rates vary considerably depending on cancer type, patient age, and • Muscle weakness other characteristics. • Mood swings • Depends on several factors including: • Nausea • Type of tumor • Insomnia • Location of tumor • High glucose levels • Grade of tumor • High blood pressure • Staging • Avascular necrosis (AVN) • Speed of growth • Hearing loss • Treatment options • Age of child • Immunosuppression • Childhood cancer survivors can experience late and long • Gastrointestinal issues term effects from treatment in a variety of body systems. BONE MARROW, STEM CELL, AND SURVIVAL RATES CORD BLOOD TRANSPLANTS • Healthy marrow or stem cells are infused into pt’s blood stream • Goal of transplant is engraftment • Indications • Patients with relapsed ALL and AML • Patients with life threatening disease • Patients with Neuroblastoma • Some patients with brain tumors American Cancer Society. Cancer Facts & Figures 2018. Atlanta: American Cancer Society; 2018. BONE MARROW, STEM CELL, AND TRANSPLANT PROCESS CORD BLOOD TRANSPLANTS • Types of Transplant • Pre-transplant conditioning • Bone Marrow • High doses of chemo and or radiation • Stem Cells • Umbilical Cord Blood • Transplant • Cells are administered • Source of cells • Allogenic - Donor • Post-transplant • Autogenic - Self • Await engraftment • Syngenic - Identical twin • Usually 12-17 days 5 12/15/2018 BONE MARROW AND STEM CELL TRANSPLANT – SIDE EFFECTS • Graft vs. Host Disease (GVHD) • Mucositis • Nausea/Vomiting • Venous Occlusive Disease (VOD) • Steroid induced myopathy • Sterility SOLID TUMORS • Cardiac and pulmonary disease • High risk of life threatening infection • Secondary malignancies COMMON DIAGNOSES OSTEOSARCOMA • Osteosarcoma • Tumor cells arise from osteoblast cells and • Ewing’s Sarcoma primarily affect the ends of the long bones • Rhabdomyosarcoma • Most common malignant bone tumor in children • Neuroblastoma and adolescents • ~ 400 new pediatric cases each year in the United States • ~ 2% of childhood cancers • Common sites: • Distal femur • Proximal tibia • Proximal humerus OSTEOSARCOMA SIGNS AND OSTEOSARCOMA STAGING SYMPTOMS • Pain • Simplified • Stiffness or tenderness • Local • Progressively worse over time • Resectable • Wakes from sleep • Non-resectable • Swelling • Metastatic • Musculoskeletal Tumor Society (MSTS) staging • Palpable mass in arm or leg system • Difficulty walking or limp • Grade (G) Stage Grade Tumor Metastasis • Fracture • Extent of primary tumor (T) IA G1 T1 M0 • Metastases (M) • Fatigue IB G1 T2 M0 • TNM staging system IIA G2 T1 M0 • Weight loss • (T) Tumor IIB G2 T2 M0 G1 or T1 • Anemia • (N) Nodes III M1 • (M) Metastasized G2 orT2 • (G) Grade 6 12/15/2018 OSTEOSARCOMA TREATMENT OSTEOSARCOMA PROGNOSIS • Chemotherapy: Total 6 cycles • Positive Prognostic Factors • Neoadjuvant: Prior to surgery or radiation • 2 cycles