PHYSIOTHERAPY

MANAGEMENT OF CANCER
PATIENTS
Introduction
■ Cancer is a pathologic process characterized by dysregulated cell
growth and systemic spread
■ All tissue types have neoplastic potential and can become
cancerous
■ Tissues distinguished by rapid cell turnover (gastrointestinal mucosa),
hormone sensitivity (breast and prostate), and regular exposure to
environmental mutagens (lung and skin) have higher rates of malignant
transformation
■ Any tissue can develop cancer, means that cancer rehabilitation must
address all body parts and systems
■ Despite broad scope, field condenses into a manageable
body of expertise predominantly focused on sequelae of
cancer treatment, maladaptive host responses (e.g.,
paraneoplastic syndromes), erosive effects of cancer on
bones and neural tissue
■ With ever-increasing cancer survivorship, number of
patients whose disease has been eliminated or
successfully temporized continues to grow
■ Given magnitude of current need, physiatrists can elect
to treat patients who are cured of their cancers or whose
cancers have progressed to being widely metastatic
ETIOLOGY OF CANCER
CANCER
 Cancer – a large group of diseases characterized by the uncontrolled
growth and spread of abnormal cells
 Neoplasm – new growth of tissue that serves no physiological function
 Tumor – clumping of neo plasmic cells
 Malignant - cancerous
 Benign - noncancerous
 Biopsy – microscopic examination of cell development
 Metastasis – malignant tumors that are not enclosed in a protective capsule
have the ability to spread to other organs
 Mutant cells – disruption of RNA and DNA within normal cells may produce cells
that differ in form, quality and function from the normal cell
CAUSES OF CANCER?
 External Factors –
chemicals, radiation, viruses, and lifestyle
 Internal Factors – hormones, immune conditions,
and inherited mutations.
FACTORS BELIEVED TO CONTRIBUTE TO GLOBAL CAUSES OF
CANCER
Lifetime risk –
• The probability that an individual, over the
course of a lifetime, will develop cancer
or die from it
• Relative risk – measure of the
strength of the relationship
between risk factors and a
particular cancer
• Smoking – 30% of all cancer
deaths, 87% of lung cancer deaths
• Obesity – 50% higher risk for breast
cancer in postmenopausal women, 40%
higher risk in colon cancer for men
Biological Factors
•Some cancers such as
• breast, stomach, colon, prostate, u terus,
ovaries and lung appear to run in families
• Hodgkin‟s disease and certain
leukemia's show similar patterns
• University of Utah research suggests that
a gene for breast cancer exists
• A rare form of eye cancer appears to be
transmitted genetically from mother to
child
• Reproductive And Hormonal Risks For
Cancer
• Pregnancy and oral contraceptives
increase a woman‟s chances of breast
cancer.
 Occupational And Environmental Social And Psychological Factors
Factors • Stress has been implicated in increased
susceptibility to several types of cancers
• Sleep disturbances, diet, or a combination of
•Asbestos factors may weaken the body‟s immune system
•Nickel Chromate
•Benzene Viral Factors
•Arsenic • Herpes-related viruses may be involved in the
•Radioactive substances development of leukemia, Hodgkin‟s disease,
•Cool tars cervical cancer, and Burkitt‟s lymphoma
• Epstein-Barr virus, associated with
•Herbicides/pesticides
mononucleosis, may contribute to cancer
•Pesticide and herbicide residues
• Human papillomavirus (HPV), virus that
•Sodium nitrate causes genital warts, has been linked to
cervical cancer
• Helicobacter pylori causes ulcers which are a
major factor in the development of stomach
cancer
PATHOPHYSIOLOGY
TYPES OF CANCER
TYPES OF CANCERS
Classification of cancers
 Carcinomas

 Sarcomas

 Lymphomas

 Leukemia's
 cancers are classified by the type of cell that the tumor
cells resemble and is therefore presumed to be the origin
of the tumor.
 Carcinoma : Cancers derived from epithelial cells. This group
includes many of the most common cancers, particularly in the
aged, and include nearly all those developing in
the breast, prostate, lung pancreas and colon.
 Sarcoma: Cancers arising from connective tissue (i.e.
bone, cartilage, fat, nerve), each of which develop from
cells originating in mesenchymal cells outside the bone
marrow.
 Lymphoma and leukemia: These two classes of cancer arise from
hematopoietic (blood-forming) cells that leave the marrow and tend to
mature in the lymph nodes and blood, respectively. Leukemia is the
most common type of cancer in children accounting for about 30%.
 Germ cell tumor: Cancers derived from pluripotent cells, most often
presenting in the testicle or the ovary (seminoma and dysgerminoma
respectively).
 Blastoma Cancers derived from immature "precursor" cells or
embryonic tissue. Blastomas are more common in children than in
older adults
 CLINICAL
MANIFESTATIONS
SIX CHARACTERISTICS OF MALIGNANCIES

 Sustaining proliferative signaling

 Evading growth suppressors
 Resisting cell death
 Enabling replicative immortality
 Inducing angiogenesis
 Activating invasion and metastasis
SYMPTOMS
Local effects Systemic symptoms
Local symptoms may occur due to the mass of
the tumor or its ulceration. • unintentional weight loss, fever, being
For example, mass effects from lung cancer excessively tired, and changes to the
can cause blockage of the bronchus resulting
in cough or pneumonia; esophageal cancer skin. Hodgkin disease, leukemias, and
can cause narrowing of the esophagus, cancers of the liver or kidney can cause
making it difficult or painful to swallow; and
colorectal cancer may lead to narrowing or a persistent fever of unknown origin.
blockages in the bowel, resulting in changes in Specific constellations of
bowel habits. Masses in breasts or testicles • Systemic symptoms, termed
may be easily felt. Ulceration can cause
bleeding which, if it occurs in the lung, will lead paraneoplast phenomena, may occur
to coughing up blood, in the bowels to with some cancers. Examples include
anemia or rectal bleeding, in the bladder to the appearance of myasthenia gravis in
blood in the urine, and in the uterus to vaginal
bleeding. thymoma and clubbing in lung cancer[
Although localized pain may occur in advanced
cancer, the initial swelling is usually painless.
Some cancers can cause build up of fluid within
the chest or abdomen.
GRADING/STAGING OF CANCER
 GRADING
•Degree of maturity or differentiation under the microscope

1. Histologic grade – resemblance between tumor and normal

cells
2.Nuclear grade – size and shape of nucleus, dividing cells

 Biopsy – benign or malignant - pathologist

– level of differentiation
 TUMOR GRADES

 Microscopic apperance of cancer cells

 4 degrees of severity

 Grade:
 GX Grade cannot be assessed (Undetermined grade)
 G1 Well-differentiated (Low grade)
 G2 Moderately differentiated (Intermediate grade)
 G3
Poorly differentiated (High grade)
 G4
Undifferentiated (High grade)
 GRADING SYSTEMS
• Different for different types of cancers

Gleason – prostate cancer

Bloom-Richardson – breast cancer
Fuhrman – kidney cancer

Gleason system

Fuhrman system
 GRADING – TREATMENT
 For treatment and prognosis

 Lower grade  better prognosis (outcome of diease)

 Higher grade  worse prognosis
TNM - SYSTEM
 Most common (accepted by UICC)

 Based on : T  extent of the tumor

N  extent of spread to the lymph nodes
M  presence of metastasis

 Number  indicates size or extent of the primary tumor and the extent of
spread of metastasis
Primary Tumor (T)
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ (has not spread)
T1, T2, T3, T4 Size and/or extent of the primary tumor

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement
N1, N2, N3Involvement of regional lymph nodes (number and/or extent of spread)

Distant Metastasis (M)

MX Distant metastasis cannot be evaluated

M0 No distant metastasis
M1 Distant metastasis (cancer has spread to distant parts
of the body)
OTHER CLASSIFICATION
Ann Arbour  lymphomas

Duke‟s classification  colon cancer

Breslow scale and Clark‟s level  melanoma

 DETERMINATION OF STAGES
Physical exams  examination, looking, listening

Imaging studies X-ray, US, CT, MRI, PET

Laboratory tests  blood, urine, AST/ALT, tumor markers (CA19- 9,CA19-5….)

Pathology reports  biopsy, cytology Surgical

reports

Lung cancer,PET scan

PREVENTING CANCER THROUGH DIET AND LIFESTYLE

Table 16.2
DIAGNOSIS OF CANCER
CANCER’S SEVEN WARNING SIGNALS

Table 16.5
DETECTING CANCER
 Blood tests
 Urineanalysis

 Tumour markers

 Diagnostic imaging

 Endoscopic examination

 Genetic testing

 Tumour biopsy
TUMOUR MARKERS
prostate-specific antigen (PSA)
Prostate-specific antigen is always present in low concentrations in the blood of adult males. An
elevated PSA level in the blood may indicate prostate
cancer, but other conditions such as benign prostatic hyperplasia (BPH) and prostatitis can also
raise PSA levels. PSA levels are used to evaluate how a patient has responded to treatment
and to check for tumor recurrence.
prostatic acid phosphatase (PAP)
PAP originates in the prostate and is normally present in small amounts in the
blood. In addition to prostate cancer, elevated levels of PAP may
indicate testicular cancer,leukemia, and non-Hodgkin’s lymphoma, as well as some
noncancerous conditions.
CA 125
Ovarian cancer is the most common cause of elevated CA 125, but cancers of the uterus,
cervix, pancreas, liver, colon, breast, lung, and digestive tract can also raise CA 125 levels.
Several noncancerous conditions can also elevate CA
125. CA 125 is mainly used to monitor the treatment of ovarian cancer.
carcinoembryonic antigen (CEA)
CEA is normally found in small amounts in the blood. Colorectal cancer is the most
common cancer that raises this tumor marker. Several other cancers can also raise levels of
carcinoembryonic antigen.
alpha-fetoprotein (AFP)
Alpha-fetoprotein is normally elevated in pregnant women since it is produced by
the fetus. However, AFP is not usually found in the blood of adults. In
men, and in women who are not pregnant, an elevated level of AFP may indicate
liver cancer or cancer of the ovary or testicle. Noncancerous conditions may also cause
elevated AFP levels.
human chorionic gonadotropin (HCG)
HCG is another substance that appears normally in pregnancy and is produced by the
placenta. If pregnancy is ruled out, HCG may indicate cancer in the testis, ovary, liver,
stomach, pancreas, and lung. Marijuana use can also raise HCG levels.
🞭
CA 19-9
This marker is associated with cancers in the colon, stomach, and bile duct. Elevated levels of
CA 19-9 may indicate advanced cancer in the pancreas, but it is also associated with
noncancerous conditions, including
gallstones, pancreatitis, cirrhosis of the liver, and cholecystitis.
CA 15-3
This marker is most useful in evaluating the effect of treatment for women with advancedbreast
cancer. Elevated levels of CA 15-3 are also associated with cancers of the ovary, lung, and
prostate, as well as noncancerous conditions such as benign breast or ovarian disease,
endometriosis, pelvic inflammatory
disease, and hepatitis. Pregnancy and lactation also can raise CA 15-3 levels.
CA 27-29
This marker, like CA 15-3, is used to follow the course of treatment in women with
advanced breast cancer. Cancers of the
colon, stomach, kidney, lung, ovary, pancreas, uterus, and liver may also raise CA 27-29 levels.
Noncancerous conditions associated with this substance are first trimester pregnancy,
endometriosis, ovarian cysts, benign breast disease, kidney disease, and liver disease.
lactate dehydrogenase (LDH)
LDH is a protein that normally appears throughout the body in small amounts. Many cancers can
raise LDH levels, so it is not useful in identifying a specific kind of cancer. Measuring LDH
levels can be helpful in monitoring treatment for cancer.
Noncancerous conditions that can raise LDH levels include heart failure,
hypothyroidism, anemia, andlung or liver disease.
neuron-specific enolase (NSE)
NSE is associated with several cancers, but it is used most often to monitor treatment in
patients with neuroblastoma or small cell lung cancer.
 IMAGING TECHNIQUES
•Transmission imaging
•X-ray
•Computed tomography scan
•Bone scan
•Lymphangiogram (LAG)
•Mammogram
•Reflection imaging
•Ultrasound
•Emission imaging
•Magnetic resonance imaging
ENDOSCOPIC EXAMINATION
 colonoscopy
Colonoscopy is a procedure that allows the physician to view the entire length of the large
intestine, and can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It
involves inserting a colonoscope, a
long, flexible, lighted tube, in through the rectum up into the colon. The
colonoscope allows the physician to see the lining of the colon, remove tissue for further
examination, and possibly treat some problems that are discovered.
 endoscopic retrograde cholangiopancreatography (ERCP)
ERCP is a procedure that allows the physician to diagnose and treat problems in the liver,
gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope
- a long, flexible, lighted tube. The scope is guided through the person's mouth and throat, then
through the
esophagus, stomach, and duodenum. The physician can examine the inside of these organs and
detect any abnormalities. A tube is then passed through the scope and a dye is injected, which
will allow the internal organs to appear on an x-ray.
 esophagogastroduodenoscopy (Also called EGD or upper endoscopy.)
An EGD (upper endoscopy) is a procedure that allows the physician to examine the inside of the
esophagus, stomach, and duodenum. A thin, flexible, lighted tube, called an endoscope, is guided
into the mouth and throat, then into the esophagus, stomach, and duodenum. The endoscope
allows the physician to view the inside of this area of the body, as well as to insert instruments
through a scope for the removal of a sample of tissue for biopsy (if necessary).
 sigmoidoscopy
A sigmoidoscopy is a diagnostic procedure that allows the physician to examine the
inside of a portion of the large intestine, and is helpful in identifying the causes of
diarrhea, abdominal
pain, constipation, abnormal growths, and bleeding. A
short, flexible, lighted tube, called a sigmoidoscope, is inserted into the intestine through
the rectum. The scope blows air into the intestine to inflate it and make viewing the inside
easier.

 cystoscopy (Also called cystourethroscopy.)

An examination in which a scope, a flexible tube and viewing device, is inserted through
the urethra to examine the bladder and urinary tract for structural abnormalities or
obstructions, such as tumors or stones.
Samples of the bladder tissue may be removed through the cystoscope
for examination under a microscope in the laboratory.
 GENETIC STUDIES 

• Chromosome studies
• Biochemical genetic studies
• Protein truncation studies
• DNA studies


🞭 endoscopic biopsy
This type of biopsy is performed through a fiberoptic endoscope (a
long, thin tube that has a close-focusing telescope on the end for
viewing) through a natural body orifice (i.e., rectum) or a small
incision (i.e., arthroscopy). The endoscope is used to view the organ in
question for abnormal or suspicious areas, in order to obtain a small
amount of tissue for study. Endoscopic procedures are named for the
organ or body area to be visualized and/or treated. The physician can
insert the endoscope into the gastrointestinal tract (alimentary tract
endoscopy), bladder (cystoscopy), abdominal cavity (laparoscopy),
joint cavity (arthroscopy), mid-portion of the chest (mediastinoscopy),
or trachea and bronchial
🞭 bone marrow biopsysystem (laryngoscopy and bronchoscopy).
This type of biopsy is performed either from the sternum (breastbone)
or the iliac crest hipbone (the bone area on either side of the pelvis on
the lower back area). The skin is cleansed and a local anesthetic is
given to numb the area. A long, rigid needle is inserted into the
marrow, and cells are aspirated for study; this step is occasionally
uncomfortable. A core biopsy (removing a small bone 'chip' from the
marrow) may follow the aspiration.
🞭 excisional or incisional biopsy
This type of biopsy is often used when a wider or deeper portion of
the skin is needed. Using a scalpel (surgical knife), a full thickness of
skin is removed for further examination, and the wound is sutured
(sewed shut with surgical thread). When the entire tumor is removed, it
is called excisional biopsy technique. If only a portion of the tumor is
removed, it is called incisional biopsy technique. Excisional biopsy is
often the method usually preferred when melanoma (a type of skin
cancer) is suspected.
🞭 fine needle aspiration (FNA) biopsy
This type of biopsy involves using a thin needle to remove very small
pieces from a tumor. Local anesthetic is sometimes used to numb the area,
but the test rarely causes much discomfort and leaves no scar. FNA is not
used for diagnosis of a suspicious mole, but may be used to biopsy large
lymph nodes near a melanoma to see if the melanoma has metastasized
(spread). A computed tomography scan (CT or CAT scan) - an x-ray
procedure that produces cross-sectional images of the body - may be used
to guide a needle into a tumor in an internal organ such as the lung or
liver.
🞭
punch biopsy
Punch biopsies involve taking a deeper sample of skin with a biopsy
instrument that removes a short cylinder, or "apple core," of tissue. After a
local anesthetic is administered, the instrument is rotated on the surface of
the skin until it cuts through all the layers, including the
dermis, epidermis, and the most superficial parts of the subcutis (fat).
🞭 shave biopsy
This type of biopsy involves removing the top layers of skin by shaving it
off. Shave biopsies are also performed with a local anesthetic.
🞭 skin biopsy
Skin biopsies involve removing a sample of skin for examination under the
microscope to determine if melanoma is present. The biopsy is performed
under local anesthesia. The patient usually just feels a small needle stick
and a little burning for about a minute, with a little pressure, but no pain.
Prognosis and Metastatic Spread
■ Cancer presents patients and clinicians with a staggering array
of prognoses, differential treatment approaches, and patterns
of metastatic spread.
■ In planning a long-term rehabilitation approach, it is important to
anticipate
– where cancer is likely to spread,
– how it will respond to treatment,
– what cumulative toxicities might be associated with
ongoing therapies, and
– how long patients will live,
■ Implications of regional and distant spread at time of diagnosis
vary considerably by cancer type
■ Information informs rehabilitation goal setting, determines level of
emphasis placed on symptom-oriented versus disease-modifying
treatments
■ Lung, breast, colon, and melanoma commonly spread to brain, regular
neurologic screening examinations should therefore be incorporated
into posttreatment, surveillance care
■ Prostate, breast, and lung cancer commonly produce bone metastases
■ Musculoskeletal pain in cancer populations can be due to primary or
secondary consequences of bony disease and should trigger an
appropriate evaluation
CANCER TREATMENTS
 Surgery
 Combine surgery with radiation or
chemotherapy
 Immunotherapy

 Cancer-fighting vaccines

 Gene therapy

 Neo adjuvant chemotherapy

 Stem cell therapy

PRINCIPLES OF
ASSESSMENT
•SOAP format should be used.
•Functional aspects of assessment should be given
with more weight age.
•Guidelines from different countries could be used.
THE ICF FUNCTION CLASSIFICATION
FRAMEWORK
MEASUREMENT OF BODY FUNCTION AND
STRUCTURE
 Mental
Functions
 Sensory Functions
and Pain
 Neuromusculo
skeletal and
Movement- Related
Functions and
Structures
 Functions of the
Cardiovascular,
Hematologic,
Immunologic, and
Respiratory Systems
MEASUREMENT OF BODY FUNCTION AND
STRUCTURE
MEASUREMENT OF BODY FUNCTION AND
STRUCTURE
DIAGNOSTIC MEASURES OF BODY FUNCTION AND
STRUCTURE INDICATING “RED FLAGS” OR “YELLOW FLAGS”
FOR PHYSICAL THERAPISTS
MEASUREMENT OF ACTIVITY AND
PARTICIPATION

 Mobility
 Self-care
 Domestic Life,
Interpe rsonal
Relations, a
nd Major Life
Areas
MEASUREMENT OF ACTIVITY AND
PARTICIPATION
 Cancer Rehabilitation
A concept that is defined by the patient and involves helping a person with cancer to
obtain maximum physical, social, psychological, and vocational functioning within the
limits imposed by the disease and its treatment.
REHABILITATION
“To minimise some of the effects which the disease, or
its treatment has on them. It is often possible to
improve the quality of life regardless of their prognosis
by helping them to achieve their maximum potential of
functional ability and independence or gain relief from
distressing symptoms"
ACPOPC 1993
“With in the context of palliative care,
realistic joint goal setting gives the
patient a measure of control, often at
a time when they are experiencing
helplessness and loss of
independence"
Robinson 2000
Cancer Rehabilitation Approaches
• Preventive, when the disease can be predicted and appropriate prior
training can reduce the severity of its effect

• Restorative, when the disability can be expected to result in only minimal

or residual handicap

• Supportive, when the disability must be tolerated and appropriate

gains made toward control of problems and improvement in
performance

• Palliative, when there is advanced disease and the basic disability

cannot be corrected, but training can aid performance

A hi st ory of c anc er rehabilitation. DeLisa J A. Cancer Vol 92, Issue S4, 1 5 t h Aug 2001, 970-974
Impairments associated with surgery
& chemotherapy
• Impaired postoperative healing

• Neurologic deficits

• Musculoskeletal disorders due to maladaptive movement

• Peripheral neuropathy

• Cognitive dysfunction

• Cardiomyopathy

• Pulmonary fibrosis
 Impairments associated with
radiation therapy
• Desquamation of dermis

• Muscle hypertonicity

• Tissue necrosis & fibrosis

• Delayed radiation myelopathy

• Delayed brachial & lumbar plexopathy

• Delayed encephalopathy

• Cerebral atrophy
• Constitutional symptoms

• Fatigue & pain

• Functional decline

• Impairments caused by tumour effects

• Bone metastases

• Brain Tumours: primary & metastases

• Epidural spinal cord compression

• Brachial & lumbar plexopathy BUT THIS 70s momentum failed to progress
due to lack of education, prioritise or PMR’s
• Paraneoplastic syndromes bias towards other field

• Cadiopulmonary metastases
PHYSIOTHERAPY
 Physiotherapy in palliative care is orientated to achieve the
optimum quality of life as perceived by the patient.
 Holistic & problem solving approach to therapy
 Achieve maximum
physical, psychological, social, vocational function
 Preventive Restorative
Rehabilitation is the objective when no
Aims at restricting or or little residual disability is anticipated
inhibiting the development of for some time and patients are
disability in the course of the
disease or treatment before expected to return to normal living
disability occurs. styles
Education for patient and Encouragement, education and
families commencing
immediately after diagnosis. treatment in achieving physical, work
Mobility and exercise and lifestyle goals
programs. Specific treatments as required
Availability of therapist as a
resource for patients and
families.
Supportive
Enhance independent
functioning when residual cancer
Palliative is present and progressive
Primarily directed at promoting disability is probable.
maximum comfort Encouragement, education and
treatment in achieving physical, work
Maintaining the highest level of function possible and lifestyle goals.
in the face of disease progression and impending
death
MAJOR ISSUES OF THE PATIENT

Fatigue, Nausea,
Pain, Weakness,
Lack Of Confidence, Drug
Reactions, Cachexia - Weight
Loss),
Progressive Decline In Ability,
Muscle Wasting,
Disease Progression,
Ascities,
Grief Reactions.

AIM OF PHYSIOTHERAPY
Assess and optimise the patient‟s level of physical function
 Take into consideration the interplay between the physical, psychological, social and vocational aspects
of function
 Understand the patients underlying emotional, pathological and psychological condition,
 Focus is the physical and functional consequences of the disease and/or its treatment, on the patient.

 Restore the patient‟s sense of self

 Facilitate and optimise the patient's ability to function with safety and independence in the face of diminishing
resources.
 Maintain optimum respiratory & circulatory function
 Listen to patient
 Set realistic goals with the patient
 Prevent muscle shortening & joint contractures
 Influence pain control
 Educate in all aspects of physical function
 Education and participation of the carer
 Treat the patient with dignity – allowing them to “live until they die”
 Build a relationship of confidence and trust

Fulton and Else, 1997; p817 Chartered Society of Physiotherapy

Multidisciplinary Teams: The way forward in Cancer Care

Aim: To look at the evolving

cancer care model

Consultant
Physiotherapist
Radiographer

Dietician
Nurs
e

team.”
Occupational Speech
Therapist and
Language
Social
therapist
Worker
 THE ROLE OF THE PHYSIOTHERAPIST IN PALLIATIVE CARE

 Physiotherapists work with respiratory, neurological, lymphatic,

orthopaedic, m usculoskeletal, pain and haemotalogical
conditions.
 Education and training of multi disciplinary team as well as
patients and carers.
 Communication and collaboration.
 PHYSIOTHERAPY INTERVENTIONS

 Positioning – prevention of pressure sores

 TENS – pain and nausea control
 Respiratory care
 Neurological rehabilitation
 Mobility – Exercise tolerance, maintenance and
independence
 Prevention of contractures/joint-muscle integrity
 Individual exercise programmes
 Oedema management
 Counselling
52% had psychological problems, 35% had generalised weakness, 30% had ADL problems, 25%
had difficulties with ambulation, 7% had deficits in transfer & 7% had deficits in communication
Willingness to refer/accept a patient with advanced cancer regardless of estimated prognosis, only
8.4% of oncologists were willing in contrast to 15.1% physiatrists reported as 35% willing to accept
the referrals.