Physical Activity in Metastatic Bone

Disease
Related online courses
Physical activity programme – Physioplus
Role of Physical Activity in Non-Communicable Diseases –
Physioplus
The Role of Physical Activity in Specific Conditions – Physioplus
Introduction
Metastatic Bone Disease (MBD) is a secondary cancer that has spread
or metastasised to the bone from a cancerous organ. Primary cancers
that most commonly metastasise to bone include cancers of the
lungs, breasts, thyroid, kidneys, prostate. The skeletal areas
commonly affected by MBD include upper arm bones, long bones of
the leg, pelvis, ribs, spine, and skull.

Keeping physically active can bring many benefits to cancer patients

of all stages and is widely recommended. See Physical activity in
cancer for more information. As healthcare professionals, it is
important for us to be knowledgeable on the principles, precautions,
and contraindications when recommending exercises and advising
people with MBD on physical activity. Not only can this improve the
quality of care, it may also help to debunk myths on exercise and
cancer such as "cancer patients only need rest".

Please watch the video below if you would like to know more on the
biology of MBD:

General Principles
 Treat people as individuals - Take into account both the medical
and social situation of the person. Keeping the patient's goals, desires,
expectations, anxieties as a central part of care delivery. The views and
anxieties of families and care givers should also be considered but the
person’s own views comes first.
 Emphasise the importance of staying active - Understand the
risks of sedentary lifestyle. Encourage people to get involve in valued
occupations which require some extent of physical exertion. Challenge
one another to #justkeepmoving
 Importance of rest and recovery - High-quality recovery periods
between physical activity should be implemented to allow time for the
body to recuperate. While sleep can be disrupted in cancer patients, it
is known that staying active can improve sleep quality[1].
 Awareness of 'red flag' symptoms -

 Bone pain in the vertebral column that worsens night: indicates high
risk of spinal MBD and imminent fracture.
 Bone pain on weight bearing (especially in the proximal femur):
indicates high risk of MBD in the long bones and imminent fracture.
 Worsening and intractable bone pain at any time.
 Awareness of symptoms that could indicate Metastatic
Spinal Cord Compression (MSCC) -
 Back or neck pain
 Pain with a rapid crescendo and radiating in a band-like fashion
around the chest or abdomen
 Numbness or tingling sensation in toes, fingers or buttocks
 Unsteadiness on feet
 Progressive weakness in legs
 Bladder or bowel problems

People at risk of MBD

Individuals that are at risk of MBD should be assessed with a plain
X-ray followed by radiological review and if indicated, an
orthopaedic opinion. A baseline assessment on general pain, fatigue,
fear/anxiety, co-morbidities, adequate nutrition, motivational state,
understanding the likely benefits of physical activity, should be done
before and since the diagnosis. This can help individuals to set
realistic and appropriate activity goals. If there is no red flag
symptoms, healthcare professionals should recommend global health
guidelines of 150 minutes of moderate aerobic activity (or 75 minutes
of vigorous exercise) per week plus strength exercises on two or more
days per week[2].

People with asymptomatic MBD

A recent plain film X-ray could be reviewed for MBD lesions to
determine the level of fracture risk in people with asymptomatic
MBD. This can then be used to determine a baseline Mirels’ score[3],
which will then indicate best practice for clinical treatment. If the
Mirels’ score is 7 or under, people with MBD can be considered to be
at low risk of fracture and should be encouraged to be as active as
possible within pain-free limits. If it is 8 or above, the individual
should be referred for an orthopaedic opinion.

People with symptomatic MBD

In people with symptomatic MBD and new onset of bone pain, or
bone pain that has changed in nature or intensity, risk of fracture
should be considered until proven otherwise. Functional pain which
is pain on weight bearing should be of particular concern. Imaging,
radiological review and an orthopaedic opinion should be sought in
the first instance. However, this does not mean people with
symptomatic MBD should remain sedentary. In fact, lack of activity
can lead to muscle atrophy and also increase the likelihood of
skeletal complications such as fractures and bone pain. A general
advice would be to avoid stress on the affected limb. Recommended
exercise programmes should include resistance exercises targeting
the unaffected limbs. People with MBD should be advised to restrict
any movement that causes pain, and seek medical advice if pain does
not resolve quickly or if there are increased episodes of breakthrough
pain. They should also be advised against exercises that induce high
torsion, such as yoga-style twists, using the rowing machine, and
swinging in golf and tennis. Walking aids can be used to take the
weight off affected lower limbs.

If people with MBD do undergo surgical fixation, prophylactic or

otherwise, they should be encouraged to keep mobile as much as
possible after the procedure in consultation with their orthopaedic
surgeon. Orthopaedic fixation should enable immediate weight
bearing. Any adaptive equipment necessary for mobilization should
be provided and the importance of reducing sedentary time should be
emphasised.

Conclusion
The evidence of physical activity improving multiple outcomes in
people living with cancer, including those with MBD, is considerable
and growing. People with MBD/ at risk of MBD should be
encouraged to be as active as realistically possible while being aware
 of worrying symptoms and signs that should lead them to seek
medical attention.

Resources
 Physical activity in patients with metastatic bone disease: Guidance
for healthcare professionals  by the Macmillan Cancer Support.
 Metastatic Bone Disease: A Guide to Good Practice  by British
Orthopaedic Oncology Society & British Orthopaedic Association.

Related articles
Skeletal Metastases - PhysiopediaIntroduction [1][2][3][4] Cancer is
created in the body when abnormal cells begin to rapidly multiply.
These cancer cells can end up traveling to other parts of the body if
they enter into the bloodstream and/or lymph vessels. The term
'metastasis' refers to the process in which cancer cells travel to a new
place and begin to grow in its new location. A cancer is always named
for the place that it first formed; this is called its primary site. For
instance, if a person has breast cancer that has spread to the bone, it
still is labeled as breat cancer and not bone cancer. Cancer that
actually originates in the bone is called primary bone cancer and is
less common than a bone metastasis. The definition of a skeletal
metastasis is a cancer of the bone that has originated from another
site. Bones are a common site for certain cancers such as breast
cancer and prostate cancer. The most common sites for skeletal
metastases are the spine (this is the most common site), pelvis,
femur, humerus, ribs, and skull. Skeletal metastases are common
with other cancers. When one gets skeletal metastases, this usually
means one has an advanced cancer. “Its prevalence is rising due to
higher rate of diagnosis, better systemic treatment, longer lives with
the disease and higher disease burden rate”.[4] There are two types
of bone cells, osteoblast and osteoclast. Osteoblast is the forming of
new bone, the tumor signals to the bone to overproduce bone cells.
Osteoclast is what dissolves the bone, leaving weakened bones. With
osteoclast, you develop osteolytic lesions which are when the bone
breaks down. This allows excess calcium to be released into the
bloodstream. Osteoblastic or osteolytic changes will be seen in most
cancers, sometimes both are seen. This 3-minute computer-animated
video explains the process of cancer spreading to bone and how the
cancer affects the bone once it has implanted. Prevalence Bone is the
third most common site for metastatic cancer[5] Skeletal metastasis
is much more common than primary bone cancers Account for 70%
of all malignant bone tumors[4] About 10,000 cases of bone
metastases are reported each year in the United States[5] Of these
10,000 cases, 75% caused by tumors in breast, prostate, lung, and
kidney[5] More than 2 out of 3 breast and prostate cancers that
spread to other parts of the body spread to the bone[5] Clinical
Presentation[4] The most common symptoms of skeletal metastases
include pain, fractures, and anemia.[6][7] Pain usually is worse at
night and may get better with movement, but can become constant
and may be worse during activity.[1]Pain is usually localized to the
site of metastases, but can refer to areas around the site.[8] Pain
usually increases to severe intensity. Weakening of bones due to
metastases puts patients at risk for fractures. Fractures can happen
with fall, injury, or during everyday activities. Most common are in
the long bones of arms and legs and bones of the spine.[1] Tumors in
the spine can cause compression on the spinal cord resulting in
numbness or tingling in the abdomen and legs, bowel and bladder
problems, and difficulty walking.[8] [9] Metastases in the bones
producing blood cells in pelvis, ribs, spine, skull, upper arms, and
long bones of legs may cause abnormalities in blood cells.[6][8]
Anemia is a common abnormality for patients with skeletal
metastases, especially with chemotherapy and radiation therapy.
Patients exhibit weakness, fatigue, and shortness of breath.[8]
Patients with a white blood cell abnormality are prone to infections;
whereas, patients with deviations in platelets counts cause
abnormalities in bleeding and clotting.[8] Associated Co-morbidities
Any cancer can metastasize into the bone. The most common
metastasizing cancers include prostate, breast, kidney, thyroid, and
lung.[1]Cancers that have metastasized to other organs or the lymph
system are more likely to metastasize to bone. Hypercalcemia can
present as the cancer weakens the bones. With excessive lysis of the
bone, the integrity of the bone is compromised which can lead to
pathological fractures. When the bone breaks down, excess calcium is
released into the blood which can lead to:[1][10] Feeling
tired/drowsiness Trouble thinking clearly Loss of appetite Pain
Frequent urination Increased thirst Constipation Nausea Vomiting
Coma [6] Diagnostic Tests[1][2][3][4] If a person has cancer, lab
tests and imaging tests may be done to see if the cancer has spread to
other sites. This is how skeletal metastases are discovered in their
early stages. In other situations, symptoms of skeletal metastases
may be the first indicator that the cancer has spread. These
symptoms include bone pain, fractures, symptoms of spinal cord
compression, and/or symptoms of hypercalcemia (these symptoms
are explained in more detail under 'Characteristics/Clinical
Presentation'). Lab tests and imaging tests are then performed to
confirm whether or not a skeletal metastasis is causing these
symptoms. Test Description X-rays Often the first test performed if a
person is having symptoms of a skeletal metastasis. X-rays help to
show the bone density and can also indicate if there are any fractures
in the bone that may have been caused by cancer. X-rays can tell if
osteolytic or osteoblastic changes have occurred. Lesions appear as
lighter, darker, or holes in bone. There is at least 25-75% loss of
mineral before lesion is visible on an X-ray. By the time the lesions
are visible, there is significant damage already done. Bone Scan
Injects with radiotracer, then special x-rays taken to find site of
metastases which will show up darker and denser. Sometimes can be
hard to differentiate from infections, arthritis, and old fractures. Can
follow the progression of cancer. Better for osteoblastic. Computed
Tomography (CT) Shows cross-sectional images of the body. Often
used if a metastasis is thought to be osteolytic since a bone scan may
not show the tumor. Shows size and shape of tumor. Tumor Markers
Certain cancers release substances called 'tumor markers'. These can
be detected through blood tests and higher levels of tumor markers
indicate that cancer has spread in the body. However, this test does
not help indicate where the cancer has spread. Other Blood Tests Can
suggest there is a lesion present, but cannot diagnose skeletal
metastases. Cancer can cause increased levels of calcium and alkaline
phosphates in the blood. Blood tests can help show if these levels are
higher than normal. Urine Tests If the bone has become damaged by
skeletal metastases, certain substances may be released into the
urine. N-telopeptide is measured. Magnetic Resonance Imaging
(MRI) Shows cross-sectional images of the body using radiowaves
and strong magnets and is useful at looking at the spine and spinal
cord. It is the test most often used if a person is experiencing
symptoms of spinal cord compression looking at nerve roots being
compressed by tumor or bone fragments. Used to define a bone mass
and can determine if it is a tumor, infection, or bone damage from
other causes. Positron Emission Tomography (PET) Shows the whole
body at once and is useful in detecting tumors throughout the body.
Injected with a slightly radioactive form of sugar which collects in
cancer cells.[1] Can find small tumors not seen on other tests. The
scans are not very detailed and so if cancer is thought to be seen,
MRI or CT scans are used to have a more thorough scan. Needle
Biopsy There are two types--fine needle biopsy and core needle
biopsy. With fine needle biopsy, a thin needle is inserted and a little
bit of fluid and tissue fragments are removed from the tumor. With
core needle biopsy, a larger needle is used to remove a small cylinder
of tissue. The samples are then looked under a microscope. CT used
to guide needle. Surgical Bone Biopsy With this test, the bone is cut
into and a small part of the tumor is removed and inspected under a
microscope. Diagnoses of the type of cancer is done this way. MRI
T2W sagittal image showing (a) metastasis with cord compression
(prostate)[4] Differential Diagnosis Multiple Myeloma Infection
Primary sarcoma Arthritis Low Back Pain Traumatic Fracture
Aetiology Metastatic bone cancer starts with a tumor within another
organ of the body. Cancer cells that break from the tumor and travel
to and through the circulatory or lymph system. Some of these cells
have an outer make up that helps to adhere to the bony network of
cells. Other cancer cells secrete a substance to change the bone cells
for easier attachment or increased growth of the cancer cells that do
metastasize in the bone. Once the cancer is within the bone, it either
increases production of osteoclasts or osteoblasts. An increase in
osteoclasts weakens the bone leading to the increased risk of
fracture. An increase in osteoblasts amplifies the production of bone
cells causing sclerotic changes in the skeletal system.[1] Systemic
Involvement As a metastases, skeletal metastases results from cancer
in another organ of the body. These cancers could cause symptoms
from another system; however, skeletal metastases can also directly
lead to other systemic symptoms: Neurological-spinal lesion,
hypercalcemia Cardiovascular-blood pathology, hypercalcemia
Gastrointestinal-hypercalcemia Genitourinary-hypercalcemia
Besides the metastases, systemic treatment can produce side effects
throughout the body; including blood pathology, nerve damage,
kidney damage, and heart damage.[1] Medical Management[1][4][11]
[12] Treatment is aimed first at maintaining or improving QOL and
then at disease control and possible cure.[4] The best treatment is
the treatment of the primary cancer. Management is made by a
multidisciplinary team to come up with best treatment for each
individual. Treatments for skeletal metastases can work to shrink
and/or slow down the growth of cancer. It can also help reduce the
symptoms that the cancer is causing. However, in most cases
treatments do not make the metastases disappear completely. The
treatments offered for skeletal metastases are influenced by many
factors including: the type of cancer which bones are affected how
many bones are affected whether the bones are weak or broken
previous treatments symptoms general health The following are
potential treatment options for skeletal metastases: Chemotherapy:
this is the main treatment used for skeletal metastases and often can
help shrink the tumors and reduce the symptoms caused by the
cancer. With chemotherapy, anti-cancer drugs are put into the body
by mouth or through a vein. Can shrink tumors, but doesn’t make
them go away. Usually done with other treatments. These drugs can
affect both cancer and normal cells because the drugs can’t tell the
difference. Damage of healthy and cancer cells cause side effects.
Some side effects of chemotherapy are: loss of hair, loss of appetite,
nausea and vomiting, mouth sores, diarrhea, increased chance of
infection, problems with bruising and bleeding, and feeling weak or
fatigue. Side effects depends on type and amount of drugs and how
long chemotherapy is. Hormone Therapy: Some hormones contribute
to the growth of cancers. By keeping these hormones from affecting
the cancer cells, certain types of cancers can be treated. Hormone
therapy has multiple approaches. One approach is to surgically
remove the organ producing the hormone. The more common
approaches are prescribed drugs that can either keep the hormones
from being produced or keep the hormones from affecting the cancer
cells. The most common side effect of hormone therapy is hot flashes,
but can depend of type of hormone therapy used. Immunotherapy:
With this type of treatment, the immune system is strengthened to
help fight the cancer cells. Man-made versions of proteins to kill
cancer cells. The side effects vary but may include fever, chills,
nausea, loss of appetite, rashes, and fatigue. Radiopharmaceuticals:
Drugs that have radioactive elements are injected into the body
through a vein. The drugs go into the cancerous bones and work to
kill the cancer cells. Works better than external beam, but could be
combined treatment. This treatment can reduce pain and be done
more than once, but with reduced effects. Works best for
osteoblastic. The main side effect is a lower blood cell count which
can increase the risk for infection and bleeding. Bisphosphonates:
Drugs that work to slow the breakdown of bone (this can be caused
by certain skeletal metastases) can be taken by mouth or given
through a vein. Cancer treatments are usually done intravenously.
Benefits of bisphosphonates are that they can help with the
following: reduce bone pain, slow down bone damage, lower high
blood calcium levels, and decrease risk for broken bones. Common
side effects are fatigue, fever, nausea, vomiting, diarrhea, anemia,
weakness, arthralgia, myalgia, and bone/joint pain. Something to be
cautious about is that another side effect is osteonecrosis of the jaw
(a portion of the jaw lacks blood supply and dies). It is important to
have routine dental check-ups. Denosumab: A drug that helps slow
down the breakdown of bone and reduces chance of developing a
fracture. It is injected under the skin every four weeks. Common side
effects are nausea, diarrhea, and fatigue. High likelihood of causing
low blood calcium, usually need to take calcium and vitamin D
supplements. Bone cement: Bone cement can be injected into a bone
to help stabilize and reduce symptoms of pain. Multiple types of
cement with different effects. External Radiation Therapy: This is
similar to receiving an x-ray except the radiation beams are much
more intense. Radiation helps to destroy cancer cells or helps to slow
down the growth of tumors. Can be done in large or small doses. Side
effects are: fatigue, loss of appetite, blistering and peeling, and low
blood count. Side effects can be reduced with the right dose and aim
of the beam. Ablation Therapy: Heat, cold, or chemicals may be used
to destroy tumors. This is performed by placing a needle or probe
directly into the tumor. This treatment is often well tolerated and a
person can usually return to their normal activities in a few days.
Used only on 1 or 2 tumors. CT can be used to guide the needle.
Several types of techniques done, patient based as to which one is
used. Surgery: This is done to help reduce a person's symptoms and
to help stabilize a weakened bone. Screws, plates, pins, and rods can
be used to help keep a bone from staying unstable. Surgery should
not be rushed or first choice of treatment. It could cause permanent
or irreversible harm to the patient. Pain medications: Bone pain is a
common symptom of skeletal metastases. Pain medication taken by
mouth is the most common method. Common medications used to
start with are acetaminophen (Tylenol) or non-steroidal anti-
inflammatory drugs (NSAIDS) such as ibuprofen (Motrin). If these
drugs are not helping reduce the pain, opioids such as codeine,
hydrocodone, morphine, and oxycodone may be prescribed. Side
effects for these medications vary and should be looked into before
beginning a medication. Here is the ACR Appropriateness Criteria
Narrative and Rating tables. One is for skeletal bone metastases and
non-skeletal metastases.:
https://acsearch.acr.org/docs/71097/Narrative/
https://acsearch.acr.org/docs/69354/Narrative/ Physical Therapy
Management[13] Physical therapy intervention focuses on optimizing
the functional capacity of patients, keeping patients from becoming
bed-bound, preventing pathological fracture, and helping them to
maintain as much independence as possible. Thus, therapy takes on
more of a maintenance or palliative role with these individuals. There
is a great risk involved with working with skeletal metastasis, with
the primary risk being additional fractures. Patients should be
informed of this risk and that the alternative treatment of bed rest
can have devastating side effects as well. In a study conducted by
Bunting et al. in 1985, fifty-four patients with bony metastases but no
evidence of impending fractures on skeletal survey were observed
while they underwent rehabilitation programs at a rehabilitation
hospital. During this treatment period, 16 fractures occurred in 12
patients, but only 1 of these clearly occurred while the patient was
participating in rehabilitation activities. Six fractures clearly
occurred while the patients were in bed. This evidence suggests that
an intervention of bed rest would not prevent fractures any more
than rehabilitation would cause fractures. Manual muscle testing,
passive or active-assisted range of motion are not evaluated on an
extremity with a bony lesion due to risk of fracture. Only active
movement is assessed, and this is likely to be limited by pain.
Likewise, resistive exercise involving an affected area is generally
contraindicated. Treatment sessions, when appropriate, should focus
on training the patient to use residual function or to develop
compensatory techniques, assistive device training, and educating
both the patient and family members. In summary, effective
rehabilitation can help prevent a patient with skeletal metastases
from becoming unnecessarily or prematurely bed-bound and/or
dependent in activities of daily living. While achievements may be
limited, they can be invaluable in helping the patient maintain some
control over his or her life.                    Promoting Adherence to
Physical Activity Advice - PhysiopediaIntroduction Physical Activity
(PA) can be described as any body movements produced by skeletal
muscles that requires energy expenditure[1]. Based on this
definition, the level of PA ranges from sedentary to vigorous.
However, public health guidelines refer to “Physical Activity” as
health-enhancing physical activity[2]. Since sedentary activity has
shown to adversely affect cardio-metabolic markers in healthy
adults[3], we can use the term “Physical Activity” to describe any
non-sedentary activities that may include active recreational,
occupational, and household activities as well as structured exercise
regime. There is vast evidence on the benefits of regular physical
activity. Among others, it is effective in preventing cardiovascular,
cerebrovascular, and cancer diseases; and in improving overall
physical and mental health status[4]. There are many studies that
examine the effectiveness of various clinical and community
interventions to increase physical activity levels of general and
specific population. However, other studies show that about 50% of
adult population who start a physical activity program will drop out
within a few months[5]. This article will cover the general principles,
characteristics, examples, and evidences of interventions that
promote adherence to physical activity in general population.  Risk
Factors for Non-adherence to Physical Activity[6] The following table
lists the factors that may lead to lower adherence to physical activity
level as recommended by public health guidelines: Factors associated
with non-adherence to physical activity Notes Demographic Factors
older age correlates of inactivity among older adults include poor
health status, poor perception of overall health, depressive
symptoms, mobility limitations, pain and fear of pain, lower self-
efficacy, lower social support, maladaptive beliefs, and lack of
encouragement from physicians. female gender women tend to adopt
moderate PA rather than vigorous. Other correlates of less PA among
women include social environment that is not as supportive as men's
and multiple roles that women play (i.e. family and work). non-white
ethnicity lower participation of PA among non-white people may
partly be an effect of differences in socioeconomic background.
However, barriers and facilitators of PA among non-white ethnicity
have not been well-examined. low socioeconomic background several
likelys reason for less participation in PA are financial constraint,
lack of facilities in their communities, lack of social support, and lack
of work flexibility. Health Related Factors chronic illnesses - poor
general health and physical function - obesity - Cognitive and
Psychological Factors Greater perceived barriers to physical activity
the most commonly reported barrier is lack of time. Other barriers
include lack of facilities, fatigue, poor health, and self-consciousness
about appearance. Lack of enjoyment of physical activity Enjoyment
is consistenly associated with greater PA level. Low expectations of
benefits from physical activity - Poor psychological health - Low self-
efficacy for physical activity self-efficacy is someone's confidence in
their ability to be physically active in a regular basis. Self-efficacy is
needed in maintaining PA adherence in the long-term and it can be
the target of intervention. Low self-motivation for physical activity -
Lack of readiness to change physical activity behaviors - Poor fitness
level - Behavioural Factors Prior physical activity - Smoking - Type A
behavior Type A behaviour is associated with competitiveness,
striving for achievement, and aggresiveness. Type A behaviour is
associated with higher level of PA but lower adherence to supervised
PA program. Social Factors Lack of cohesion in exercise group The
influence of cohesion in exercise group on PA level is not as strong as
that of physician's and social support. Lack of physician
influence/advice for physical activity Physician's support has shown
a consistent influence towards PA level. Lack of social support for
physical activity Social support has shown a consistent influence
towards PA level. Program-related Factors High physical activity
intensity Adherence may be lower for high-intensity PA as compared
to lower-intensity PA program. Long physical activity duration Some
evidence shows that completing several short PA programs lead to
higher adherence than one long PA program, while maintaining the
same health benefit. Environmental Factors Lack of access to
facilities/parks/trails Inconvenient access to facilities may lead to
lower adherence to PA. Lack of neighborhood safety Neighborhood
safety is particularly important among women, older adults, and
individuals with lower education level. General Principles of Effective
Physical Activity Promotion Interventions Based on the risk factors
described above and the available evidence, the following general
principles of an effective intervention were generated[6]. A program
aimed to promote adherence to physical activity should Incorporate
multiple components of intervention (which will be discussed below)
Include cognitive-behavioural strategies to address psychological
issues of non-adherence Provide sufficient intensity by at least
providing guidance on how to start PA program and an ongoing/
follow-up support Be a tailored approach to suit individual cases[7]
Use a lifestyle approach to PA, which is associated with greater
adherence[8] while maintaining the same health benefit[9]. Lifestyle
PA includes leisure, occupational, and household physical activities
Intervention Components and the Evidence A systematic review by
Kahn et al (2002)[7] categorised individual interventions based on
their approach: informational, social-behavioural, and
environmental or policy. Listed below are examples of interventions
of each approach that have shown effectiveness in promoting
adherence to PA.  Interventions Description Evidence Informational
Approach Health Education Providing participants with necessary
information such as the benefits of exercise, appropriate exercise
techniques, and physiological changes related to exercise. Health
Education alone is not sufficient to promote long term adherence.
However, it is a foundational component of a combined intervention.
[6] Point-of-decision prompts/signs to encourage stair use Posting
signs about the benefit of taking the stairs in multistorey buildings to
encourage stair use instead of an elevator/escalator. This
intervention is likely to be effective across diverse population
provided that a good care is taken to deliver the message if targeting
a specific population (i.e. obese population tends to take the stairs if
the message about potential weight loss is included).[7] Community-
wide PA campaigns A combined intervention that includes
informational approach through mass media and social approach
through self-help groups, risk factors screening, counseling, and/or
health education in various community settings. Since many studies
examined this type of intervention as a combined package, it was
hard to distinguish which intervention component that contributes
the most to the increase of PA level. This combined intervention is
likely to be effective across diverse population[7]. Behavioural
Approach Health risk appraisal This intervention provides
information of participant's current health, risk factor, and/or fitness
level. As a part of multicomponent intervention, health risk appraisal
can help increase participant's intrinsic motivation and it can be used
to monitor changes over time[6]. Goal-setting With the help of
healthcare/exercise professional, participant must set their own
goals that are realistic, specific, and time-bound. In line with the
guideline from American Heart Foundation on the prevention of
heart diseases and the US Association of Diabetes Educators[10].
Self-monitoring Participant is asked to keep a physical activity
'diary'. In line with the guideline from American Heart Foundation
on the prevention of heart diseases and the US Association of
Diabetes Educators[10]. Participants (fit adults and sedentary adults)
who received self-monitoring as the only intervention showed
significant exercise frequency over 18 weeks period. However, this
intervention had little effect on participants who already exercise
regularly[11] Reinforcement and incentives As compared to self-
monitoring, this intervention encourages participants to report their
PA to another person that may give them incentives for completed
goals. This intervention is usually combined with self-monitoring
and/or goal setting. Participants (fit adults and sedentary adults)
who received reinforcement and incentives as the only intervention
showed significant exercise frequency over 18 weeks period.
However, this intervention had little effect on participants who
already exercises regularly[11] Problem solving Participant is
encouraged to identify potential barriers to their PA plans. Then,
they create, implement, and evaluate the solutions to those barriers.
The evidence for problem solving is not available as a standalone
intervention but as a part of counseling program or cognitive-
behavioural therapy[12][13]. Relapse prevention Participants is
asked to identify future situations that may lead to lapses in PA
adherence. Then, they create and implement prevention strategies.
In line with the guideline from the US Association of Diabetes
Educators[10]. Stimulus control Teaching participants how to
structure their daily environment in such a way that encourages PA.
The evidence for stimulus control is not available as a standalone
intervention but as a part of counseling program or cognitive-
behavioural therapy Cognitive restructuring Teaching participants to
recognize and replace maladaptive thoughts with positive ones that
can encourage PA. An example of maladaptive thought: a belief that
PA must be vigorous and painful to give any health benefit. The
evidence for cognitive restructuring is not available as a standalone
intervention but as a part of counseling program or cognitive-
behavioural therapy Motivational Interviewing Increasing
participant's intrinsic motivation by negotiating behaviour changes.
The distinguishing characteristic of motivational interviewing is that
it is guiding instead of directing. In line with the guideline from
American Heart Foundation on the prevention of heart diseases[10].
Social Approach Enhancing social support Social support includes
group activity programs, family/friends involvement, and interaction
with personal trainers/healthcare professionals. Various research
have shown that social support (i.e. from community, friends, and
family) is effective in increasing PA levels and improving health
status in older adults, women, and socio-economically disadvantaged
people[14][7]. Modeling Sharing success stories with participants.
The evidence for modeling is not available as a standalone
intervention but as a part of counseling program or cognitive-
behavioural therapy Environment and Policy Enhancing access to
leisure physical activity facilities Providing an easy access to facilities
that promote PA e.g. parks, bicycle trails, footpath, fitness centres.
and activity clubs. Other environmental characteristics such as
neighbourhood safety, lighting, weather, and pollution can also affect
PA participation. Many studies reported that enhanced access to PA
facilities combined with other interventions (informational,
behavioural, and social approaches) can effectively increase PA level
of people across diverse backgrounds. However, it is hard to
distinguish the contribution of this particular intervention due to the
multicomponent nature of the examined interventions[7]. Resources
The Motivate2Move website, created by Wales Deanery, has a useful
section on sedentary behaviour. The Move More plan is a value-
based, whole systems approach aiming to create a culture of physical
activity resulting in Sheffield becoming the most active city in the UK
by 2020. This is a comprehensive document which includes
suggestions to promote adherence to PA advice.Physical Activity in
Cancer - PhysiopediaIntroduction Cancer is a condition where cells
in a specific part of the body grow and reproduce uncontrollably. The
cancerous cells can invade and destroy surrounding healthy tissue,
including organs. There are more than 200 different types of cancer,
each with its own methods of diagnosis and treatment. For more
detailed information on the pathophysiology and management of
several of the different forms of cancer take a look at the Oncology
Physiopedia page. Decrease in physical fitness has been reported in
both patients and survivors of childhood and adult cancers. This
decline in physical activity is secondary to the side effects of both the
disease and its treatment[1]. Cancer survivors have an increased risk
for negative health and psychosocial effects following treatment.
Beyond people with cancer, insufficient physical activity is the
leading risk factors of death worldwide. By addressing physical
activity and stress reduction techniques patients can control some of
these modifiable risk factors[2]. Furthermore, such adverse effects
are aggravated by physical inactivity (such as reduced bone mineral
density, loss of muscle mass, increased BMI and impaired motor
performance) therefore more emphasis is being placed on integrating
exercise and activity both during and after treatment[3]. With the
increasing number of people diagnosed with cancer and surviving it,
quality of life outcomes are increasing in importance with numerous
studies supporting physical activity and its positive impact. In one
systematic review, exercise and physical activity had a clinically
relevant positive impact on health related quality of life both during
and after medical intervention in people with cancer[4]. Watch these
videos to learn more: Definitions Physical Activity Physical activity is
defined as any bodily movement produced by skeletal muscles that
result in energy expenditure.It includes all forms of activity, such as
everyday walking or cycling to get from A to B, active play, work-
related activity, active recreation (such as working out in a gym),
dancing, gardening or playing active games, as well as organised and
competitive sport[1]. Exercise is a subset of physical activity that is
planned, structured, repeated and has a final or an intermediate
objective to the improvement or maintenance of physical fitness[2]
Besides having significant health benefits, PA is also preventative in
many diseases including cardiovascular disease and diabetes.
General recommendations for daily physical activity are based on age
and can be found in the WHO publication Global Recommendations
on Physical Activity for Health[5] Cancer Cancer is a related group of
diseases in which cell’s in the body begin to grow and divide
uncontrollably. It can spread to other areas of the body. The National
Cancer Institute states there are over 100 types of cancer based on its
location in the body and can be found in both children and adults[6].
In 2018, an estimated 17 million new cases of cancer occurred
worldwide. In 2018 the incidence of cancer is about 3 times higher in
countries with a high Human Development Index (HDI)[7]. The four
most common cancers occurring worldwide are lung, female breast,
bowel and prostate cancer. These four account for around 4 in 10 of
all cancers diagnosed worldwide. [8] Considering Ireland as an
example, in this country the cancer is a major cause of morbidity and
mortality with 40,000 new cases being diagnosed each year and over
9000 dying annually, which is approximately 30% of all deaths. [9]
Benefits of PA for Individuals with Cancer Physical activity is not
only beneficial for patients following activity cancer treatment but
also during to help with the negative side effects secondary to the
treatment itself. It has a positive impact on both physical and
psychosocial factors such as fatigue, low mood and stress, overall de-
conditioning and loss of independence[10]. Specific programs also
provide benefits following treatments including post surgical tumour
removal and lymphoedema management[10]. Other benefits of
exercise including helping to maintain a healthy body weight, anti-
thrombotic effect decreasing platelet adhesiveness, improved
endothelial function, increased HDL cholesterol, decreased risk of
NIDDM and reduced risk of other diseases e.g. heart disease,
diabetes, osteoporosis and hypertension. PA as a Preventative
Method for Cancer Physical activity has also been linked to the
reduced risk of many cancers[11] including Breast, Colon,
Endometrial and Prostate, as well as some cancers associated with
increased weight gain[10]. It also prevents the re-occurrence of the
same cancers[12]. Cancer prevention by modifying environmental
and lifestyle factors is the most viable long term strategy. Physical
activity has been shown to reduce the risk of colon, breast and
endometrial cancers by 25-50% in physically active individuals.
There is emerging evidence for prostate, ovarian, lung and GI
cancers. For cancer prevention 4-5 hours of moderate exercise per
week is required. This reduced risk is likely due to insulin resistance,
endogenous sex and metabolic hormone levels, inflammation, growth
factors and enhanced immune function. Physical activity decreases
obesity and central adipose tissue which are established risk factors
for colon, postmenopausal, endometrial, kidney and oesophageal
cancers. Obesity mediates the carcinogenic effect via a shift in sex
and metabolic hormone balance in the body, influencing insulin
resistance, inflammatory pathways, energy related signalling and
growth factors. Role of the Physiotherapist There is a growing body
of evidence that supports the role of the physiotherapist in the care of
patients with cancer. This ranges from; Prevention – exercise to
prevent cancer (especially colon and post-menopausal breast cancer).
Obesity is strongly linked to the development of a number of cancers
(adipose tissue is a tumour friendly environment). In the acute
setting the physiotherapist can be involved in the pre-op assessment
and enhanced recovery after surgery. Advice and education on
lymphedema prevention, wound, stretching and massage, return to
work and physical activity. Exercise prescription is a large part of
rehabilitation post op. The physiotherapist has a role in developing a
tailored and individualised rehabilitation program and specific
exercise instruction post breast surgery. The Breast Cancer
Physiopedia page has detailed information of physiotherapy
management in the breast cancer patient. They can also encourage
exercise during chemo/radiotherapy. Physiotherapists play an
essential role in the interdisciplinary and holistic approach to
palliative care by providing increased quality of life, function, and
overall experience through physical and functional dimensions of
care. PA in Paediatric Cancer There are few systematic reviews that
exist summarising the positive effects of physical activity in
paediatric oncology in comparison to adult studies. However,
Baumann and Bloch (2013)[13] determined that exercise
interventions are not only feasible and safe, but also no adverse side
effects were reported.  There was a positive effect on fatigue, strength
and quality of life[13]. Beyond physical benefits there was increased
self report of improvements in comfort and resilience to the disease
following a relatively short term supervised exercise training
programs[14]. Li et al. (2013) reported an adventure based health
education program led to statistically significant improvements in
their participants’ self-efficacy[15]. Physical activity has also been
shown to safe and effective despite the aggressiveness of neoadjuvant
chemotherapy during treatment for solid tumours in paediatric
cancer patients[16]. More studies are needed regarding cognitive
abilities, growth and re-integration into peer groups, school and
sports. Guidelines for PA in Cancer there are a large number of
studies which show that physical activity is safe and appropriate for
prior to, during and after active treatment[1][3][4][5][13][14][17].
With any exercise program it is important for an individual to consult
with their doctor and medical team prior to beginning any
intervention. The American Cancer Society (ACS), American Society
of Clinical Oncology (ASCO), and American College of Sports
Medicine (ACSM) have all made physical activity recommendations
for cancer survivors post-diagnosis,Which also factor for
improvements in managing some of the common side effects such as
fatigue and pain. The most agreed-upon recommendations are that
all patients should avoid inactivity and return to normal daily
activities as soon as possible after diagnosis. That they engage in at
least 150 minutes of moderate or 75 minutes of vigorous aerobic
exercise per week, and that they include resistance-training exercises
at least two days per week.[18] [19] To improve flexibility, adults
should also stretch the major muscle groups and tendons on days
they participate in other types of activity; older adults will also
benefit from balance exercises.[20] Barriers to PA in Cancer Exercise
is safe both during and after most types of cancer treatment,
including intensive life-threatening treatments such as bone-marrow
transplants. Despite the proven benefits of exercise, even while
receiving treatments, research shows that the many cancer patients
report significant decreases in their physical activity levels after their
cancer diagnosis.[21] Patients have identified both psychological and
physical barriers as factors in their decrease in activity. The
Memorial sloan Kettering Cancer study recruited 622 cancer patients
and identified psychological barriers including difficulty getting
motivated (67% of subjects) and trouble remaining disciplined
(65%). Physical barriers, including fatigue (78%) and pain (71%)
associated with cancer treatments, as factors contributing to this
decrease in activity. [22] Other physical activity related issues to be
considered include; Being immuno-compromised (secondary to low
white cell count) leads to a high risk of infection. Patients need to be
aware of the cleanliness of their environment. For example very busy
public gyms increase infection risk and so hand washing must always
be a priority. Having low platelet and haemoglobin levels (Anaemia)
leave patients fatigued and at higher risk for internal bleeding.
Contact and high impact sports are not recommended when blood
counts are low. Make sure to check with a physician before engaging
in activity Over 90% of patients undergoing cancer treatment
experience fatigue and pain related symptoms. It is important to
encourage daily low intensity physical activity to prevent de-
conditioning and further increase fatigue. Fear and feeling
overwhelmed sometimes makes it harder to prioritise physical
activity amongst their other chemotherapy, radiation and medication
schedules. Contra-indications to PA in Cancer Bertorello et al. (2011)
studied physical activity and late effects on long term Acute
Lymphoblastic Leukaemia survivors and determined not only is
exercise NOT contra-indicated but should be promoted as much as
possible[23] and No exercise related risks were encountered in either
adults or children with haematological cancer[24]. However, if a
child or adult has an implanted device for chemotherapy, such as a
Broviac, or a feeding tube or catheter, swimming may be contra-
indicated due to the high risk of infection. Precautions Also, with
certain cancers extra precautions need to be considered[25][26].
Bone cancer or osteosarcoma: patients need to understand their
weight bearing status which can change based on the integrity of the
bone. They are at higher risk for fracture and should consider lower
impact activities such as swimming or yoga. This is also true of
patients with osteoporosis. Chemotherapy induced peripheral
neuropathy: Sensation changes or loss in the hands and/or feet may
make certain activities more difficult or increase likelihood of
injuries and falls. Stationary biking is a good alternative to running
because of its low impact and allows longer duration of activity prior
to fatigue. Following breast cancer resections, patients should begin
with gentle range of motion activities and should avoid aggressive
upper extremity strengthening programs. A physical therapist can
progress their exercise program to help prevent lymphodema and
further injury to the area. Patients with compromised/reduced
immune function (this includes those with low white blood cell count
as well as those on immuno-suppressing medication) should avoid
exercising in public gyms or swimming pools, due to risk of infection.
Promotion of PA Yoga THRIVE is a therapeutic yoga program for
cancer survivors. It is a research based, modified program to help
with physical manifestations of cancer treatment like joint stiffness
and pain and also emotional symptoms like stress and fatigue[27].
One study found that gross motor function improved in children
participating in therapeutic yoga[28]. It is important to acknowledge
that yoga has not been proven to cure or prevent cancer; however it
can have positive benefits during and after treatment. More studies
are needed for yoga as a complementary therapy for cancer
patients[29]. The Pediatric Oncology Exercise Manual (or POEM) is
an evidence based tool for both parents and health professionals
aimed at increasing physical activity for children with cancer. Stride
to Survive is another exercise guide aimed towards young adults who
have completed treatment and want to begin a safe exercise program
and increase their physical activity. Resources The Motivate2Move
website, created by Wales Deanery, has a very useful section on
Physical Activity effects in Cancer The University of Calgary has a
series of relevant infographics and a comprehensive document on PA
in Pediatric Cancer, POEM Cancer Research UK has Exercise
Guidelines for Cancer Patients The American Cancer Society has
comprehensive information on their website about Physical Activity
and the Cancer Patient Cancer Care Ontario has a document with
detailed information about Exercise for People with Cancer Cormie
P, Zopf EM, Zhang X, Schmitz KH. The impact of exercise on cancer
mortality, recurrence, and treatment-related adverse effects.
Epidemiologic reviews. 2017 Jan 1;39(1):71-92.Physical activity and
advanced cancer: the views of oncology and palliative care physicians
in Ireland. – Physiospot – Physiotherapy and Physical Therapy in the
SpotlightPhysical activity (PA) levels play an important role in
maintaining the quality of life and enhancing the physical function of
advanced cancer patients. A brief exercise prompt by physicians can
increase PA levels of patients diagnosed with cancer. This study
explores the views of Irish oncology and palliative care physicians
towards PA for patients with advanced cancer. A web-based survey
with closed- and open-ended questions was used to explore
physicians’ views. The survey presented a Likert-style questionnaire
and open text responses to two patient case studies. Quantitative
data were analysed using descriptive statistics, and qualitative data
were analysed using content analysis. Forty participants completed
the study, a response rate of 41%. Responding physicians
acknowledged the importance of physical activity for patients with
advanced cancer. Twenty-six physicians (67%) agreed that patients
look to them for PA recommendations and 30 physicians (77%)
indicated a need for more information on providing PA
recommendations. Case study responses highlighted concerns
relating to PA prescription for patients with bone metastases
including the aggravation of symptom control and increased fracture
risk. The results of this study identify a need for physician education
on providing PA recommendations for patients with advanced
cancer. Concerns over the prescription of PA to patients with bone
metastases highlight the need to disseminate the evidence on the
benefits of PA for patients with metastatic cancer to healthcare
professionals.Renal Cancer - PhysiopediaDefinition/Description
Cancer is the unchecked overgrowth of cells in the body. Normal cell
lifecycles allow for division, growth, and apoptosis (cell death). With
cancer cells, the cell may be damaged or mutated, but instead of cell
death occuring, the bad cell keeps reproducing. As a result, a mass of
cells, or tumor, begins to grow. The tumor may cause damage from
the nutrients it steals from healthy cells, the space it takes up in vital
organs, or the pressure it places on important structures. [1] Renal
cancer is cancer that forms in tissues of the kidneys. Renal cancer
includes renal cell carcinoma, renal pelvis carcinoma, and Wilms
tumor. Renal cell carcinoma forms on the lining of small tubes in the
kidney and affect blood filtration and waste removal. Renal pelvis
cacinoma forms in the center of the kidney where urine collects.
Wilms tumor is a pediatric cancer that typically develops before the
age of five. [2] Renal cell carcinoma (RCC), or renal cancer, is
categorized into four major types, determined by cellular origin:
Clear cell : 80% of cases  Papillary : 10% to 15% of cases
Chromophobe : 4% of cases  Collecting duct : 1% of cases [3] When a
tumor spreads to another location in the body, or metastasizes, the
tumor still exhibits the same kind of abnormal cells as the original
tumor. Therefore, if kidney cancer cells metastasize in the liver, the
cancer cells are not classified as liver cancer cells. These "distant"
tumors are metastatic kidney cancer cells. The disease is still kidney
cancer and is treated as such. As of 2002, the International
TNM Staging System was adopted to better understand the extent of
patients' diseases and predict outcomes. Categories include
T: Tumor, N: Node, M: Metastasis. Further primary
tumor classification of stages was accomplished utilizing 1-4, with 1
being the least aggressive and 4 being the most aggressive tumor.[4]  
                         [5]   International TNM Staging System for Kidney
Cancer Primary Tumor (T) T1a Confined to kidney and less than 4 cm
in size T1b Confined to the kidney and between 4 and 7cm in size T2
Confined to the kidney and greater than 7 cm in size T3a Outside
renal capsule invading the adrenal, renal sinus or perinephric fat T3b
Tumor is invading the renal vein T3c Tumor is invading the vena
cava T4 Tumor is outside Gerota’s fascia and is invading adjacent
organs Regional Lymph Nodes (N) N0 No regional lymph node
metastasis N1 Metastasis in a single regional lymph node N2
Metastasis in more than one regional lymph node Distant
Metastasis (M) M0 No distant metastasis M1 Distant Metastasis  [4]
Prevalence The most common renal neoplasm in adults is renal cell
carcinoma. RCC accounts for close to 90% of all renal neoplasms and
approximately 3% of all cancers.[6]  Renal cancer occurs 1.6 times
more in males than females. The incidence is on the rise, with a peak
incidence occurring between 60 and 70 years of age. In 2012, 64,770
new cases of renal cell and renal pelvis cancer were reported in the
United States. Due to medical management, the death rate has
remained steady. In 2012, 13,570 deaths due to renal cell and renal
pelvis cancer were reported in the United States.[3]
Characteristics/Clinical Presentation Common symptoms of kidney
cancer include:[3] Blood in your urine (which may make urine look
rusty or darker red) Pain during urination Pain in the side that
doesn’t go away A lump or mass in the side or abdomen Weight loss
for no known reason Fever Feeling very tired Breastbone pain (renal
cancer is the most common tumor to spread to the sternum) [7] The
classic triad of symptoms includes: blood in the urine, pain in the
side, and a palpable mass in the abdomen. However, renal cancer
typically goes undetected, especially in the early stages, although
nonspecific symptoms like feeling fatigued or unexplained weight
loss may be present.[3]  Thus, it is imperative that the physical
therapist take a thorough history and ask follow-up questions should
a patient present with any of these symptoms.  It should be noted
that although these are symptoms of renal cancer, they could also be
symptoms of some other pathology such as an infection, bladder
cancer, or a kidney cyst.[8]  If a patient is experiencing these
symptoms, he or she should contact their primary care physician as
soon as possible for a complete examination. About 25-30% of
patients have metastatic disease at the time of diagnosis.  Renal
cancer most often spreads to the lungs (75%), regional lymph nodes
(65%), bones (40%), and liver (40%).[3]   The patient may complain
of a cough or bone pain secondary to metastasis to the lungs or bone,
respectively. Associated Co-morbidities An associated co-morbidity is
a disorder or disease that predisposes a person to develop renal
cancer. Studies have found the following co-morbidities associated
with renal cancer:[3][8] Von Hippel-Lindau (VHL) syndrome: VHL is
a rare disease that runs in some families. It’s caused by changes in
the VHL gene. People with a changed VHL gene have an increased
risk of renal cancer. They may also have cysts or tumors in the eyes,
brain, or other parts of the body. Family members of those with VHL
can have a test to check for a changed VHL gene. Hereditary papillary
renal carcinoma: This is a genetic condition that increases the risk of
developing the papillary type of renal cancer, which is the second
most common subtype of renal cancer. Birt-Hogg-Dubé Syndrome:
This is a rare hereditary disease that affects the skin and is
characterized by multiple non-cancerous tumors of the hair follicles,
particularly on the face, neck, and upper chest. These bumps will
typically appear when someone is between the ages of 20-40 years
old. Having this disease increases a person’s susceptibility to
developing renal cancer. Medications When possible, surgical
treatment to remove the tumor is a preferred treatment method of
renal cancer. However, if a person has a metastatic tumor (i.e. cancer
that has spread to other organs) the primary care physician will most
likely recommend additional treatment. The most commonly used
treatments for kidney cancer are various forms of medication from
two categories: targeted therapies or immunotherapy.[9] Targeted
therapies, which work by targeting the cancer at a cellular level, have
expanded the options for the treatment of kidney cancer. Targeted
treatments block specific abnormal signals present in kidney cancer
cells that allow them to grow. These medications have shown promise
in treating kidney cancer that has spread to other areas of the body.
The targeted medications Axitinib (Inlyta), Bevacizumab (Avastin),
Pazopanib (Votrient), Sorafenib (Nexavar) and Sunitinib (Sutent)
block signals that play a role in the growth of blood vessels that
provide nutrients to cancer cells and allow cancer cells to spread.
Temsirolimus (Torisel) and Everolimus (Afinitor) are targeted
medications that block a signal that allows cancer cells to grow and
survive. Targeted therapy medications can cause serious side effects,
such as: a severe rash, diarrhea, and fatigue.[9] Anyone experiencing
these symptoms should contact their doctor immediately. Whereas
targeted therapies specifically block the renal cancer cells from
growing and spreading, immunotherapy works in a more general way
by using the body's immune system to fight the cancer.
Immunotherapy medications include Interferon and Aldesleukin
(Proleukin), which are synthetic versions of chemicals made in your
body. Side effects of these medications include: chills, fever, nausea,
vomiting and loss of appetite.[9] Again, anyone experiencing these
symptoms should contact their doctor immediately. Diagnostic
Tests/Lab Tests/Lab Values If a patient experiences symptoms that
suggest kidney cancer, he or she should schedule a physical exam
with his or her primary care physician. In addition to a physical
exam, a patient may be given one or more of the following tests:[3]
[8] Urine tests: The lab checks urine for blood and other signs of
disease. Blood tests: The lab checks blood for several substances,
such as creatinine. A high level of creatinine may mean the kidneys
aren’t doing their job. Ultrasound: An ultrasound device uses sound
waves that can’t be heard by humans. The sound waves make a
pattern of echoes as they bounce off organs inside the abdomen. The
echoes create a picture of the kidneys and nearby tissues. The picture
can show a kidney tumor. CT scan: A computed tomography (CT)
scan both prior to and following administration of intravenous
contrast remains the radiologic modality for choice to work up a
renal mass. An x-ray machine linked to a computer takes a series of
detailed pictures of the abdomen. The patient may receive an
injection of contrast material so that the urinary tract and lymph
nodes show up clearly in the pictures. The CT scan can show cancer
in the kidneys, lymph nodes, or elsewhere in the abdomen. MRI: A
large machine with a strong magnet linked to a computer is used to
make detailed pictures of your urinary tract and lymph nodes. You
may receive an injection of contrast material. MRI can show cancer
in your kidneys, lymph nodes, or other tissues in the abdomen. IVP:
The patient may receive an injection of dye into a vein in his or her
arm. The dye travels through the body and collects in the kidneys.
The dye makes them show up on x-rays. A series of x-rays then tracks
the dye as it moves through the kidneys to the ureters and bladder.
The x-rays can show a kidney tumor or other problems. (It should be
noted that IVP is not used as commonly as CT or MRI for the
detection of kidney cancer). Biopsy: A biopsy is the removal of tissue
to look for cancer cells. In some cases, the patient’s primary care
physician will do a biopsy to diagnose kidney cancer. The physician
inserts a thin needle through the patient’s skin into the kidney to
remove a small sample of tissue. The physician may use ultrasound
or a CT scan to guide the needle. Once removed, the tissue is then
examined by a pathologist who will use a microscope to check for
cancer cells. Surgery: After surgery to remove part or all of a kidney
tumor, a pathologist can make the final diagnosis by checking the
tissue under a microscope for cancer cells. Etiology/Causes If a
patient is diagnosed with renal cancer, their first question might be
“how did this happen?” The truth is that although there are risk
factors that can contribute to the development of renal cancer, a
person can have none of these risk factors and still get renal cancer.
However, there are some associated risk factors that can contribute
to the development of renal cancer, including:[10] Smoking: Smoking
tobacco is an important risk factor for kidney cancer. People who
smoke have a higher risk than nonsmokers. The risk is higher for
those who smoke more cigarettes or for a long time. Age: Being over
the age of 40 years old. Obesity: Being obese increases the risk of
renal cancer. Hypertension: Having high blood pressure may
increase the risk of renal cancer. Hypertension is considered to be
present when a person’s blood pressure is consistently measured at
140/90 mmHg or above. Family history of renal cancer: People with
a family member who had renal cancer have a slightly increased risk
of the disease. Long-term dialysis Occupation: Coke oven workers in
the iron and steel industry; asbestos and cadmium exposure can
increase a person’s risk. Gender: Men are twice more likely than
women to develop renal cancer. Systemic Involvement Lungs Lungs
are the most common location in the body for kidney cancer cells to
metastasize. Patients may experience difficulty breathing due to
decreased lung function as a result of the space occupying lesions.
Significant areas of the lung are removed to extract the tumor,
further decreasing lung function. Liver Fever, weight loss, and
decreased liver function may result from renal cancer metastases
spreading to the liver. Bone Bone pain and improper healing
fractures may result from renal cancer metastases invading bone.
Brain Brain metastases are the most dangerous because the tumor
can compress and damage brain tissue. Removing important brain
tissue around the tumor is an option but will lead to further deficits.
[11] Medical Management (current best evidence) Patients with renal
cell cancer may work with a team of health care professionals to
coordinate their care.  Urologist  Surgeon  Urologic Oncologists
Medical Oncologists  Radiation Oncologists  Oncology Nurse
Registered Dietician[12] Rcc is primarily treated by surgical
interventions. Although aggressive, a radical nephrectomy is the
preferred method of treatment for both localized and metastasized
diseased. This consists of the removal of:  Kidney Gerota’s fascia :
fibroareolar tissue surrounding the kidney and perirenal fat  Adrenal
gland  Regional lymph nodes Partial nephrectomy is a less aggressive
surgical option; however, it does present a 3% to 6% risk the tumor
will reoccur. This procedure is more challenging and often requires
an open procedure. A partial nephrectomy is often elected for
patients with: Smaller mass, less than 4cm. Solitary kidney Masses in
both kidneys Renal insufficiency Presence of hereditary disorder
related to RCC. Laparoscopic nephrectomy is growing in popularity
due to the reduction in hospital stay, postoperative pain, and
recovery time. Less invasive options still require further
investigation. Patients with small tumors (less than 3 cm) and
increased surgical risk due to comorbidities may benefit from
percutaneous thermal ablation. Radiofrequency heat or cryoablation
may be utilized in this treatment option. Chemotherapy Medical
treatment in addition to surgery is offered for advanced localized and
metastasized tumors. Unfortunately, response to medical modalities
are not very effective. Merely 4% to 6% of patients respond to
chemotherapy. This is primarily collecting duct RCC, because clear
cell and papillary RCC produce a protein that transports the drug out
of the cell. [3] Physical Therapy Management (current best evidence)
Maintaining physical strength is important while undergoing renal
cancer treatment and a physical therapist will be able to provide an
exercise plan specifically designed for a patient’s needs.
Furthermore, if a patient had surgery to remove the tumor, modest
exercise can help regain muscle tone and help to rebuild the muscles
that were cut, increase that patient’s range of motion, and help to
prevent complications that can occur post-surgery such as:
respiratory infection, pressure sores, and the formation of a deep
vein thrombosis (DVT).[13] Exercise can have the additional benefit
of reducing stress and depression, which can be common occurrences
in patients undergoing cancer treatment. Physical therapy can also
be used to combat fatigue, which is not only a common symptom of
renal cancer but it can be a side effect of treatment (e.g.
chemotherapy)[13]. A physical therapist can work with a patient to
build up endurance and reduce the incidence and severity of fatigue.
This will be an important factor in increasing a patient’s
independence and ability to maintain a high quality of life. A physical
therapist can also work with the patient regarding his or her diet,
which will play an important role throughout the treatment process.
Eating the proper foods can help a patient feel better and give him or
her more energy. Furthermore, a healthy well-balanced diet can help
the patient build strength, prevent body tissue breakdown, prevent
infection, and it promotes the natural regeneration of normal tissues.
Differential Diagnosis The following a list of conditions that may
present as renal cancer. Lower Thoracic Disk Herniation Radiculitis/
Radicular pain Uteral Colic Renal Colic (abdominal pain caused by
kidney stones) Renal Lithiasis (kidney stones) Prostate Cancer
Prostatis Testicular Cancer Osteomyelitis  Urinary Tract
Infection[10] Case Reports/ Case Studies Sciatica leading to the
discovery of a renal cell carcinoma Atypical presentations and rare
metastatic sites of renal cell carcinoma: a review of case reports
Hereditary leiomyomatosis and renal cell cancer presenting as
metastatic kidney cancer at 18 years of age: implications for
surveillance Renal cancer and Wegener's granulomatosis: a case
report Resources Kidney Cancer Association National Cancer
Institute American Cancer Society Mayo Clinic