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)

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 metaphysis 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 pelvis, ribs, femur
  • PT considerations: Post-surgical rehab, pain management
• Multiple Myeloma
  • Cancer of plasma cells in bone marrow
  • Leads to bone pain, fractures, hypercalcemia
  • PT considerations: Avoid high-impact activities due to fracture risk

Soft tissue tumors

• Lipoma (benign)
  • Fatty tumor under skin, soft and movable
  • PT considerations: No functional impact unless compressing nerves
• Rhabdomyosarcoma (malignant)
  • Cancer of skeletal muscle (children)
  • Common in head, neck, extremities
  • PT considerations: Strength and mobility training post-treatment

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

Definitions

Anorexia

Severe calorie restriction due to intense fear of gaining weight. May involve excessive exercise and malnutrition

Bulimia

Cyclical binge eating followed by purging. Done to maintain normal body weight

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