Rehabilitation Should Be Part of Cancer Treatment

Eric Wisotzky, MD

Associate Member, Georgetown Lombardi Comprehensive Cancer Center

Director, Cancer Rehabilitation, MedStar National Rehabilitation Network

Assistant Professor, Rehabilitation Medicine

Imagine your breast cancer patient, Mrs Robinson, after cancer treatment. She has been through surgery, chemotherapy, and radiation. She is now fatigued, deconditioned, with impaired shoulder range of motion, and impaired balance from neuropathy. She is unable to get back to her job working in retail as she is too tired, can’t reach up to take things off a high shelf, and she is worried about falling.

Now imagine that same patient who has had a rehabilitation specialist as part of her treatment team from day one. She has been engaging in exercise throughout her treatment process. For this reason, she has minimal fatigue. She has been doing range of motion and strengthening exercises for her shoulder, so she has no problems reaching overhead. In addition, she has been strengthening her legs and engaging in a balance rehabilitation program, so she is not at risk for falls. The major functional sequalae of her cancer treatments have been averted through a proactive rehabilitation program.

Cancer rehabilitation has been defined as, “medical care that should be integrated throughout the oncology care continuum and delivered by trained rehabilitation professionals who have it within their scope of practice to diagnose and treat patients’ physical, psychological, and cognitive impairments in an effort to maintain or restore function, reduce symptom burden, maximize independence, and improve quality of life in this medically complex population.”¹

The key points in this definition are that this is medical care that cancer patients should expect and that it should be delivered by trained rehabilitation professionals: physiatrists, physical therapists, occupational therapists, or speech language pathologists.

What sets trained rehabilitation professionals apart from trainers is the length and scope of training. Trainers (available at most gyms) typically gain their certification in less than a year (often online), while rehabilitation professionals often have four or more years of training and have expertise in diagnosing and treating physical impairments. Rehabilitation professionals will also have a stronger understanding of complex medical issues cancer patients face.

So why do cancer patients need rehabilitation? It has been demonstrated that cancer survivors have poor physical health-related quality of life compared with age-matched controls.² Given that physical performance and activity levels correlate with physical quality of life in cancer survivors,³ it should seem obvious that rehabilitation should be incorporated into the cancer treatment continuum to preserve and restore function and quality of life.

Another critical point regards distress. Distress has become a required symptom to be tracked for cancer center accreditation. While distress is often intuitively linked with psychological factors, most are unaware that distress is most strongly linked with physical function. One study showed that physical disability was the number one source of distress in cancer survivors. ⁴ It is clear that cancer centers must screen for and treat physical disability and distress as well.

To further support the concept that rehabilitation is critical to cancer care, consider a few studies that demonstrate that rehabilitation interventions may in fact enhance cancer treatment outcomes. A recent systematic review reported six studies demonstrating a 41% to 51% decreased risk of breast cancer mortality associated with physical activity.⁵

Another example is a recent study demonstrating that late-stage gastrointestinal cancer patients undergoing chemotherapy and radiation were more likely to complete treatment and had fewer hospitalizations if given a rehabilitation program including exercise and relaxation techniques.⁶

Different models exist for the incorporation of rehabilitation into cancer care. Involving a physiatrist— a physician specializing in physical medicine and rehabilitation (PM&R)—can have many benefits. The physiatrist has expertise in coordinating a rehabilitation team. This physician can really help bring together all the critical rehabilitation services to foster high-quality interdisciplinary care. The physiatrist is also a great liaison between the oncology team and the rehabilitation team in that he or she can help all members of the rehabilitation team to understand the complex medical issues these patients face. Physiatrists are able to diagnose anatomic problems leading to disability through history taking, physical examination, image interpretation, bedside ultrasound, and electrodiagnostic skills. Physiatrists can provide treatment options for patients such as prescribing skilled rehabilitation, equipment prescriptions, medications for pain and spasticity, as well as therapeutic injections with corticosteroid or botulinum toxin.

While physiatrists may not be part of the cancer care model at many cancer centers, this can change. Oncologists can reach out to PM&R departments inquiring about a physiatrist who may be interested in caring for their patients. In addition, cancer centers would benefit from posting job advertisements in PM&R journals looking for physiatrists to join their care teams. Talking to oncology colleagues at cancer centers that incorporate physiatrists can help to better understand how this partnership helps patients.

For many cancer centers without physiatrists, linking with physical/occupational therapists and speech language pathologists can be another way of ensuring high-quality rehabilitation services are available for patients. These relationships can be further established by ensuring that rehabilitation specialists are present at tumor boards as well as cancer committee and National Accreditation Program for Breast Centers (NAPBC) meetings.

Lastly, to ensure that cancer patients receive the rehabilitation services they need in a systematic fashion, it is critical to have standardized methods of identifying the rehabilitation needs of cancer patients.

At Georgetown Lombardi Comprehensive Cancer Center, we are implementing screening protocols for all cancer patients at all visits to ensure rehabilitation needs are addressed in a timely fashion. Standardized methods such as these will introduce rehabilitation interventions before patients’ function declines significantly. Through these approaches, we can hope to keep our patients’ functioning in their family, vocational, and recreational roles. We owe this to our patients to not just treat their cancer but also to preserve their function, quality of life, and overall dignity.

References

1. Silver, Rai VS, Fu JB, et al. Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services. Support Care Cancer. 2015;23(12): 3633-3643.
2. Weaver KE, Forsyth LP Reeve BB, et al. Mental and physical health—related quality of life among US cancer survivors: population estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev. 2012;21(11):2108-2117.
3. Penttinen, HM, Saarto T, Kellokumpu-Lehtinen P, et al. Quality of life and physical performance and activity of breast cancer patients after adjuvant treatments Psychooncology. 2011;20(11):1211-1220.
4. Banks E, Byles JE, Gibson RE, et al. Is psychological distress in people living with cancer related to the fact of diagnosis, current treatment or level of disability? Findings from a large Australian study. Med J Aust. 2010;193(5 Suppl):S62-S67.
5. Ballard-Barbash R, Friedenreich CM, Courneya KS, et al. Physical activity, biomarkers, and disease outcomes in cancer survivors: a systematic review. J Natl Cancer Inst. 2012;104(11): 815-840.
6. Cheville AL, Alberts SR, Rummans TA, et al. Improving adherence to cancer treatment by addressing quality of life in patients with advanced gastrointestinal cancers. J Pain Symptom Manage. 2015;50(3):321-327.