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

• 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.

• 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.

• Lung cancer PT considerations: lobectomy (removal of affected lung tissues) will require pulmonary interventions including segmental breathing secretion management, and low intensity exercise training

• Colorectal cancer PT considerations: managing treatment side effects like pelvic floor dysfunction (incontinence, urgency) and lymphedema, improving functional limitations such as balance

• 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