Cancer and psychological conditions
Recognizing cancer: red flags
Physical therapists and physical therapy assistants must recognize potential signs of cancer to ensure timely referral for medical evaluation.
General red flags for cancer (CAUTION acronym)
- Change in bowel or bladder habits (colorectal, bladder cancer)
- A sore that does not heal (skin cancer)
- Unusual bleeding or discharge (gynecologic, gastrointestinal cancers)
- Thickening or lump in the breast or elsewhere
- Indigestion or difficulty swallowing (esophageal, stomach cancer)
- Obvious change in a wart or mole (skin cancer)
- Nagging cough or hoarseness (lung, throat cancer)
Other red flags
- Unexplained weight loss (>10% body weight in 6 months)
- Persistent pain (especially at night)
- Fatigue unrelieved by rest
- Recurrent infections
- Bone pain without a known cause
- Neurologic symptoms (e.g., sudden weakness, changes in coordination)
The 5 most common cancers
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Breast cancer PT considerations: mastectory (surgical removal of the breast and surrounding tissue) will require restoration of shoulder function. Mastectomy and follow up radiation will affect the axillary lymph nodes and require lymphedema management.
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Prostate cancer PT considerations: prostatectomy (surgical removal of the prostrate) causes disruption of the pelvic with urinary incontinence and will required strengthening of the pelvic floor.
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Lung cancer PT considerations: lobectomy (removal of affected lung tissues) will require pulmonary interventions including segmental breathing secretion management, and low intensity exercise training
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Colorectal cancer PT considerations: managing treatment side effects like pelvic floor dysfunction (incontinence, urgency) and lymphedema, improving functional limitations such as balance
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Melanoma, excluding non-melanoma skin cancers PT considerations: managing side effects from treatments like surgery and radiation, and preventing skin scarring,
Universal PT considerations for patients with cancer
- Fatigue Management: Prescribe low- to moderate-intensity exercise (aerobic + resistance training).
- Bone Metastases: Avoid high-impact exercises to prevent fractures.
- Neuropathy (Chemotherapy-Induced): Balance training, fall prevention, and desensitization techniques.
- Lymphedema Management: Compression garments, manual lymphatic drainage, and exercise.
Mole changes (ABCDE Rule)
Early detection of melanoma and other skin cancers is critical.
The ABCDE rule helps in identifying suspicious moles:
- Asymmetry: One half does not match the other.
- Border irregularity: Edges are ragged, notched, or blurred
- Color variation: Different shades of brown, black, or red
- Diameter: >6 mm (size of a pencil eraser)
- Evolution: Changes in size, shape, or color over time.
PT considerations
- If a suspicious mole is noticed, refer the patient for dermatological evaluation.
- Avoid excessive pressure or friction over areas with skin abnormalities.
- Educate on sun protection and regular skin self-exams.
Common tumors
Benign tumors
- Osteochondroma
- Most common benign bone tumor
- Often occurs in long bones (femur, tibia)
- PT considerations: Monitor for joint impingement or mechanical symptoms
- Osteoid osteoma
- Small, painful bone tumor (common in young males)
- Night pain relieved by NSAIDs
- PT considerations: Differentiate from stress fractures and infection
- Enchondroma
- Benign cartilage tumor inside bones (hands, feet)
- Can cause fractures due to bone weakening
- PT considerations: Avoid excessive loading on affected areas
Malignant tumors
- Osteosarcoma
- Most common primary bone cancer (often in teenagers)
- Occurs in the epiphysis of long bones (femur, tibia)
- PT considerations: Post-surgical limb salvage or amputation rehabilitation
- Ewing’s sarcoma
- Aggressive tumor in children/adolescents
- Affects long bones, pelvis, ribs
- PT considerations: Manage chemo/radiation side effects, functional mobility training
- Chondrosarcoma
- Malignant cartilage tumor in adults (40-70 years)
- Common in the pelvis, ribs, and femur
- PT considerations: Post-surgical rehab, pain management
- Multiple Myeloma
- Cancer of plasma cells in bone marrow
- Leads to bone pain, fractures, and hypercalcemia
- PT considerations: Avoid high-impact activities due to fracture risk
Soft tissue tumors
- Lipoma (benign)
- Fatty tumor under the skin, soft and movable
- PT considerations: No functional impact unless compressing nerves
- Rhabdomyosarcoma (malignant)
- Cancer of skeletal muscle (children)
- Common in the head, neck, and extremities
- PT considerations: Strength and mobility training post-treatment
Metastatic Cancer
- When cancer cells break away from the original tumor and spread to other parts of the body
- The most common types of metastatic cancers are breast, prostate, lung, colorectal, and bladder cancers.
Common psychological conditions, physical therapy interventions, and medications
Depression
Symptoms: Persistent sadness, loss of interest, fatigue, sleep disturbances, suicidal thoughts.
PT considerations
- Encourage physical activity (moderate-intensity aerobic exercise is effective).
- Provide structured, goal-oriented therapy.
- Be aware of signs of suicidal ideation and refer if necessary.
Medications:
- SSRIs (Selective Serotonin Reuptake Inhibitors)
- Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Escitalopram (Lexapro)
- Side effects: Nausea, headache, insomnia, sexual dysfunction, weight gain
- SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
- Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta)
- Side effects: Increased BP, nausea, dizziness, dry mouth
- Tricyclic Antidepressants (TCAs)
- Examples: Amitriptyline, Nortriptyline
- Side effects: Sedation, dizziness, weight gain, dry mouth, arrhythmias
- MAOIs (Monoamine Oxidase Inhibitors) (Less common)
- Examples: Phenelzine (Nardil)
- Side effects: Hypertensive crisis with certain foods (aged cheese, wine), dizziness
Anxiety disorders
Symptoms: Excessive worry, restlessness, increased heart rate, hyperventilation, muscle tension.
PT considerations:
- Use relaxation techniques (deep breathing, guided imagery).
- Incorporate aerobic exercise to reduce anxiety.
Medications
- SSRI:
- Examples: Sertraline (Zoloft), Paroxetine (Paxil)
- Side effects: Same as for depression (nausea, insomnia, weight gain).
- Benzodiazepines:
- Examples: Lorazepam (Ativan), Alprazolam (Xanax), Diazepam (Valium)
- Side effects: Sedation, dizziness, dependency, respiratory depression
- Beta-blockers:
- Example: Propranolol (Inderal)
- Side effects: Fatigue, bradycardia, hypotension
- Buspirone
- Example: Buspar
- Side effects: Dizziness, nausea, headaches
Post-traumatic stress disorder (PTSD)
Symptoms: Flashbacks, hypervigilance, avoidance behaviors, sleep disturbances.
PT considerations:
- Maintain a calm, structured environment — closed environment
- Use gradual exposure to movement and relaxation techniques.
Medications
- SSRIs: See above
Chronic pain syndromes
Symptoms: Widespread pain, fatigue, hypersensitivity.
PT considerations:
- Use graded exercise and pacing strategies.
- Avoid overexertion.
Medications:
- SNRIs:
- See above
- Gabapentinoids:
- Example: Pregabalin (Lyrica), Gabapentin (Neurontin)
- Side effects: Drowsiness, dizziness, weight gain
Eating disorders: anorexia and bulimia
Symptoms of anorexia:
- Extreme weight loss
- Hair thinning, brittle nails
- Cold intolerance
- Severe malnutrition
Symptoms of bulimia:
- Frequent episodes of binge eating followed by purging
- Dental erosion from stomach acid
- Electrolyte imbalances
- Swelling of salivary glands
PT considerations for eating disorders:
- Monitor for over-exercise and excessive fatigue.
- Work with a multidisciplinary team (nutritionist, psychologist, MD).
- Focus on safe, balanced movement rather than excessive exercise.
Medications:
- SSRIs
- See above
- Atypical Antipsychotics
- Example: Olanzapine (Zyprexa)
- Side effects: Weight gain, sedation