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Managing the Cancer Patient in the Acute Care Setting

Managing the Cancer Patient in the Acute Care Setting

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Managing the Cancer Patient in the Acute Care Setting

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  1. Managing the Cancer Patient in the Acute Care Setting Kathryn E. Tasillo, PT, DPT

  2. Disclosure • There is no relationship that could reasonably by viewed as creating a conflict of interest, or the appearance of a conflict of interest, that might bias the content of the presentation. Nor is there any significant financial interest in any product, instrument, device, service or material discussed in the presentation, including the source of any third-party compensation related to the presentation. "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  3. WHO WE ARE Carolinas HealthCare System has a unique story to share. Operating as a fully integrated system and connecting and transforming care delivery throughout the Carolinas, our overarching goal is to provide seamless access to coordinated, high quality healthcare – and provide that care closer to where our patients live. With 42 hospitals and 900+ care locations, the depth and breadth of services results in a full continuum of integrated care including: • Prevention and general wellness • Primary care at more than 180 locations • Specialty care via several nationally recognized service lines • Critical care with one of the largest virtual (e-ICU) programs in the nation • Continuing care including home health, skilled nursing, hospice, palliative care centers, inpatient/outpatient rehab, and long-term acute care hospital ""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  4. AT-A-GLANCE • 42 hospitals and 900+ care locations in North Carolina, South Carolina and Georgia • More than 7,800 licensed beds • More than 11 million patient encounters in 2013 • 3,000+ system-employed physicians, 14,000+ nurses and more than 60,000 employees • $1.5 billion in community benefit in 2013 • More than $8 billion in annual revenue • The region’s only Level I trauma center • One of five academic medical centers in North Carolina • One of the largest HIT and EMR systems in the country "Managing "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  5. WHERE WE ARE "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  6. Learning Objectives • General Overview of Cancer Statistics and Basics • Tests/Treatments/Side Effects/Lab Values • Special Patient Populations • Rehabilitation Considerations • How to Handle End of Life • Issues across Continuum of Care "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  7. Cancer Statistics1 • The National Cancer Institute estimates that approximately 14.5 million Americans with a history of cancer were alive in 2014 and is expected to be almost 19 million by 2024. • About 1,685,210 new cancer cases are expected to be diagnosed in 2016. This equates to 4,620 cases/day. • In 2016, about 595,690 Americans are expected to die of cancer, almost 1,630 people per day. Cancer is the second most common cause of death in the US, exceeded only by heart disease, accounting for nearly 1 of every 4 deaths. • The 5-year relative survival rate for all cancers diagnosed between 2003 and 2009 is 68%, up from 49% in 1975-1977 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  8. “Lack of health insurance and other barriers prevent many Americans from receiving optimal health care. According to the US Census Bureau, approximately 48.6 million Americans (15.7%) were uninsured in 2011, including one in three Hispanics and one in 10 children (18 years of age and younger). Uninsured patients and those from ethnic minorities are substantially more likely to be diagnosed with cancer at a later stage, when treatment can be more extensive and more costly. The Affordable Care Act is expected to substantially reduce the number of people who are uninsured and improve the health care system for cancer patients.” (1) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  9. Stanly Co. 495.6 Gaston Co. 482.3 Mecklenburg Co. 451.0 Cabarrus Co. 499.6 Union Co. 429.7 (2) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  10. (2) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  11. (2) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  12. (2) ""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  13. Biology of Cancer3 • Senescence • Contact inhibition "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  14. Where to begin? • Chart Review • Medical History • Current Symptoms • Current Treatments • Recent but Completed Treatments • Potential POC • Overall what does the patient want? "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  15. C = change in bowel or bladder habits A = A sore that does not heal U = unusual bleeding or discharge T = thickening or lump in the breast or elsewhere I = indigestion or difficulty in swallowing O = obvious change in a wart or mole N = nagging cough or hoarseness (4) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  16. Common Diagnostic Tests4 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  17. Primary vs. metastatic4 • Original tumor and location • Tumors that are a result of metastasis from the primary site • Can also come from external or genetic factors "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  18. "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  19. Common Metastatic Patterns "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  20. Staging Cancer4,5 ""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  21. Staging Examples5 • T1, NO, MO • T2, N1, MO • “Clinical” vs. “pathological” • Stage IV is always a Stage IV • T1,NO, MO  rT2, rN1, rM1 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  22. "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  23. Grade of Cellular differentiation4,5 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  24. ""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  25. Treatments4,6 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  26. Side Effects of Treatments 6,7 • Emotional Effects • Anxiety/panic attacks • Depression • Fear • Psychosocial Social Worker is available to follow both during and after hospital stay • Some psych medications have to be adjusted during cancer treatments "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  27. Early Late Radiation7 • Radiation Fibrosis • Lymphedema • Pain • Infertility • Pneumonitis • Pulmonary fibrosis • Radiation myelitis • Myelopathy • Joint problems • Secondary cancer • Skin changes • Swelling • Fatigue • Hair loss in the treatment area • Mouth problems • Nausea & vomiting • Sexual changes • Urinary & bladder changes "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  28. Early Late Chemotherapy7 • “Chemo Brain” or “chemo fog” • Cardiac toxicity • Central & cranial NS changes • Peripheral neuropathy • Pulmonary toxicity • Pulmonary fibrosis • Gastrointestinal toxicity • Liver Damage • Kidney and urinary damage • Sexual & fertility changes • Skin & nail changes • Tissue fibrosis • Alopecia • Psychosocial issues • Secondary cancer (rare) • Bone marrow suppression • Appetite loss & weight changes • Taste changes • Mucositis • Infection • Fatigue • Alopecia • Memory/cognitive changes • Nausea/vomiting • Diarrhea/constipation • Peripheral neuropathy • Pain "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  29. Chemo Drugs8,9,10 • Alkylating Agents • Busulfan, Cisplatin, Carboplatin, Chlorambucil, Cyclophosphamide (cytoxan), Ifosamide, Dacarbazine (DTIC), mechlorethamine, melphalan, temozolomide • Nitrosoureas • Carmustine (BCNU), Lomustine (CCNU) • Antimetabolites • 5-fluorouracil, capecitabine, 6-mercaptopurine, methotrexate, gemcitabine, cytarabine (ara-C), fludarabine, pemetrexed "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  30. Chemo Drugs cont’d8,9,10 • Anthracyclines and Related Drugs • Topoisomerase II Inhibitors • Mitotic Inhibitors • Corticosteroid Hormones • Prednisone, dexamethasone "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  31. Mucositis12,13 Trismus12,13 • Tonic contraction of muscles of mastication • Restriction to opening mouth due to trauma, surgery or radiation • Can lead to difficulty speaking, swallowing, and reduced nutritional intake • Compromised oral hygiene • Depends on amount of radiation • Most common, debilitating complication • Oral mucosa very sensitive to chemo and radiation • Can impact nutrition • More complicated by nausea and vomiting • Shows up 5-10 days after treatment begins • Can last 1-6 weeks but depends on treatment • “Magic mouthwash” "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  32. Precautions and Considerations 7 • Osteoporosis • Many cancer treatments may result in rapid and severe bone loss • Decreased bone mass increases risk of falls and fractures • Rehab considerations: • Spinal precautions • Weight bearing and resistive exercises • Proper nutrition • Steroid Myopathy • Onset: insidious or rapid • Impairments: Proximal upper and lower extremity weakness • Rehab considerations/functional limitations: • Difficulty ambulating • Difficulty climbing stairs • Difficulty getting up from a chair • Dyspnea "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  33. Medications "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  34. Pain Medications8,9,10 • Opiods/Narcotics • Morphine, Dilaudid • Chart on next slide • Nonopiods • Tylenol, Aspirin • NSAIDs • Ibuprofen, Naproxen, Toradol, Advil, Nuprin, Indocin "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  35. "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  36. Anti-emetics 5 • Zofran (ondansetron) • Phenergan (promethazine) • Ativan (lorazepam) • Marinol (dronabinol) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  37. Neuropathy13 • Chemotherapy induced peripheral neuropathy (CIPN) • Neuropathic pain "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  38. PNS13 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  39. Presentation13 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  40. Diagnostic ClassificationCommon Terminology Criteria for Adverse Events Version 4.0313 "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  41. Neurotoxic Chemotherapeutics13 Classes Indications "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  42. (13) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  43. Functional Implications13 • Deficits could be mild • Teach visual compensation • Skin protection • Shoes, temperatures • Assess gait • Handwriting • Buttoning • Balance • Falls • Stair negotiation • Decreased UE function "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  44. Lab Values "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  45. CBC 8,9,10 ""Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  46. WBCs8,9,10 • Produced in bone marrow • Indicates infection, inflammation • Leukocytosis • Leukopenia "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  47. ANC 8,9,10,14 • Total number of neutrophils (mature white cells) circulating in the body • Calculated by multiplying WBCs x neutrophils • For instance, if the WBC count is 8,000 and 50% of the WBCs are neutrophils, the ANC is 4,000 (8,000 × 0.50 = 4,000). • Body’s ability to fight infection • Neutropenia – ANC is BELOW 1,000 • Severe neutropenia – ANC is below 500 – severe risk of infection  Neutropenic Fever • Neutropenic precautions – White Protective Environment Sign outside of room • Neupogen (filgrastim) "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  48. Hgb/HCT14 • Hgb • HCT - % of RBCs in the blood • Decreased • Anemia, nutritional deficit, recent hemorrhage , fluid retention • Low BP, SOB • Increased • Hemoconcentration, polycythemia vera, dehydration • Blood clots "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  49. Platelets8,9,10 • Thrombocytopenia • Avoid using BP cuffs • Use soft toothbrushes • Monitor for changes that indicate intracranial bleeding (LOC, restlessness, H/A, seizures) • If available, encourage the ambulating patient to wear shoes • Maintain bedrest during ACTIVE bleeding • Protect from trauma • Thrombocytosis • Recent hemorrhage, infection, surgery • Glucocorticoids may increase counts "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."

  50. Fibrinogen33 • Fibrinogen 150-400 mg/dL • Produced in the liver • Tests are run to check for: • Bleeding disorders, thrombotic events, suspected DIC, abnormalities in coagulation panel (PT/PTT), liver disease, dysfibrinogenemia, and occasionally risk of CAD • Increased levels can be seen in: • Inflammation, tissue damage/trauma, infection, cancer, acute coronary syndrome, strokes • Decreased levels can be seen in: • Afibrinogenemia, hypofibrinogenemia, end stage liver disease, severe malnutrition, disseminated intravascular coagulation (DIC), abnormal fibrinolysis, and large volume blood transfusions "Managing the Cancer Patient in the Acute Care Setting," 10/23/16."This information is the property of Kathryn E. Tasillo, PT, DPT, and should not be copied or otherwise used without express written permission of the author."