Author(s): Mi Ran Shin, MD, MPH, Jared Eng, BS, Olga Morozova, MD
Originally published: December 21, 2022 Last updated: December 21, 2022
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Introduction

Cancer rehabilitation is defined as “a process that assists the individual with cancer in obtaining optimal physical, social, psychological, and vocational functioning within the limits set by the disease and its treatment.”1 With improvement in early cancer detection and treatment, there has been increasing survival rates within the oncology population but often with residual functional impairments. In the United States there are nearly 17 million cancer survivors, a number that is expected to exceed 22 million by 2030.2 However, 60-90% of these patients report physical mobility or health difficulties.2 Furthermore, 37% of adults living with cancer have challenges or need assistance with activities of daily living and 55% require help with instrumental activities of daily living.3 Nevertheless, only 2-9% are receiving cancer rehabilitation.2

Cancer rehabilitation is uniquely positioned to address improving quality of life of these patients, especially as it involves a multidisciplinary team of physiatrists, oncologists, physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs), psychologists, and nurses. This comprehensive clinical team can improve functional aspects that arise from cancer such as pain control, improving mobility, lymphedema, pelvic floor function, and cognition.4 Unfortunately, these services are underutilized or used too late in the patient’s cancer treatment course. There is an increasing role for cancer rehabilitation, as a large portion of cancer patients experience significant deficits in function and overall quality of life.

Addressing Administrative Buy-in and Institutional Support

Perceived Patient Benefits

The most robust data available about cancer rehabilitation is related to the patients perceived positive benefits. In a cancer institute survey, patients agreed that inpatient cancer rehabilitation improved their physical functioning (97%), helped them regain physical independence (94%), and prepared them with self-care including bowel and bladder care (94%).5 As for the psychological impact of cancer rehabilitation, they also reported increased or improved feelings of hope (94%), mood (84%), anxiety (90%), and spirituality (94%) by the end of their hospital stay.5 In an outpatient multidisciplinary rehabilitation program, patients with breast cancer noted improvement in functional capacity and quality of life, cognitive and social functions.6 Cochrane review also indicates that there’s moderate quality evidence that multidisciplinary interventions can enhance return to work in patients with cancer.23

Cost savings

There are several studies, most done in Europe, which have shown the benefits of cancer rehabilitation in regard to the cost. One randomized study on voice rehabilitation indicated that receiving rehabilitation versus not receiving rehabilitation is a cost-saving intervention with better health outcomes.8 In patients with lung cancer, a randomized study showed that an intensive preoperative rehabilitation improves functional lung capacity and decreases post-operative hospital length of stay.9 One systematic review found that rehabilitation interventions including group-based exercise and psychosocial interventions led to savings of €11,072 per quality-adjusted life year in cancer patients.10 Multiple studies have also found acceptable cost-effectiveness ratios for rehabilitation interventions that produced significant health gains, ultimately suggesting its cost-effectiveness in allocating scarce health care resources.25 Due to the benefit of potential cost savings in addition to improved patient health outcomes and quality of life, it is evident that hospital leadership should invest time and fundings into the development of these programs.

Decreasing hospital re-admission rate

Decreasing readmission to acute-care hospital is an indicator of a quality of care and reduces health care cost. One systematic review showed that 30-day hospital readmission rate (HRR) of patients with cancer ranged from 3% to 34%.7 It is important to note that this variability depends on a range of factors including age and the type of the cancer. It would be advisable to evaluate re-admission rates available in the literature based on the type of cancer.7 For instance, if the cancer rehabilitation program is for breast cancer, it would be prudent to review current institutional rates of readmission rate, compare to literature, and other quality indicators to assess whether developing a breast cancer rehabilitation program would be beneficial to positively impact readmission rate, and also track them after establishing breast cancer rehabilitation program.

Plan for Identifying Patients Who Need Services

The most integral component of developing a cancer rehabilitation program is identifying oncology patients who require services. One effective way of patient identification is to implement the prospective surveillance model (PSM). In this model, rehabilitation begins at diagnosis with physiatric assessment to establish patients’ baseline function and identify individuals who are predisposed to developing toxicities and impairments.11 A proactive approach with periodic follow up visits can effectively monitor the patient’s needs and provides early intervention lessening or eliminating physical, emotional, and psychosocial impairments and complications.

Establishing a system in which specific procedures or diagnoses are linked to referrals for cancer rehabilitation services is another model. For example, at the Mayo Clinic, cancer patients who have undergone axillary, inguinal, or cervical lymph node dissection are automatically referred for a quick PT or OT screening.11 To reduce unnecessary future care, follow-up visits with therapists and a physiatrist are determined by the provider upon initial evaluation. Other institutions have used diagnoses including graft versus host disease or bone metastasis instead of procedures as triggers for referral to rehabilitation services.

The most important method to identify patients is through the collaboration between clinical team members including nurses, PT/OT/SLPs, physicians, psychologists, and others. Once the team of cancer rehabilitation providers is formed (outlined below), it is critical that members work together to identify specific preexisting conditions, complications, and symptoms that can be best served with rehabilitation. Within a hospital system, the health care providers involved in the care of oncology patients should be educated on what rehabilitation offers. This will lead to the development of an effective referral system accurately identifying this target patient population.

Comprehensive Program from Prehab Through Palliative Care

Components of a comprehensive program continuum

A Comprehensive Cancer Rehabilitation Program has 5 main components: pre-habilitation, inpatient consults, inpatient rehabilitation, outpatient care, and palliative care.

Pre-habilitation care lies within the PSM, as patients are getting a baseline assessment of their functional deficits at the time of the cancer diagnosis. This should be followed by repeated visits to monitor for complications and to administer appropriate and timely treatment. For example, cancer rehabilitation PTs should evaluate patients preoperatively, immediately post-operatively and at 3, 6, 9, and 12 months after surgery.12 Periodic follow-up with physiatrists can determine the risks of adverse treatment effects and how to reduce them prospectively. Examples of pre-habilitation interventions for patients receiving radiation and/or chemotherapy include aerobic conditioning to attenuate cardiorespiratory deconditioning, protein supplementation to support an anabolic state, and psychosocial strategies to manage symptoms and challenges of systemic therapy.13

The two main components of inpatient rehabilitation include a consultative service and inpatient rehabilitation unit. The primary medical team should involve the consultative service for input for management of concerning symptoms from their treatment or condition. The main inpatient rehabilitation service would be the program’s rehabilitation admission unit where the patient’s complex medical issues are being addressed while receiving intensive rehabilitation services.

An example of a successful component of a pediatric cancer rehabilitation program involved a hybrid schedule consisting of inpatient and outpatient therapy during the day The hybrid schedules allowed more flexible treatment times and provided opportunity for patients to see the same team of providers as they transitioned from the inpatient to outpatient setting. 14

The outpatient setting is another integral component of rehabilitation where cancer patients can receive long-term care through an integrated team model. For patients who may need to travel significant distances for outpatient services, establishing community partners through networking and education of rehabilitation providers is an effective method of preventing loss of patient follow-up.14

When patients progress in their cancer course, palliative care may be the final step in their treatment. A cancer rehabilitation program should collaborate with and involve palliative care teams along with oncology in both the inpatient and outpatient settings. Using established screening tools for frailty, functioning status, and cognition can serve as potential ways to identify when to involve palliative care.12 Because the work of physiatrists and palliative care doctors are intertwined, the collaboration of the two are essential in providing the best care for patients in the later stages of their disease course.

Forming a team

Cancer rehabilitation should be based on a team-integrated model. Successful cancer rehabilitation models include various disciplines as part of the care team.15 Depending on the setting of cancer rehabilitation within the care continuum, the essential team members and their roles can vary, but the oncology service that is primarily responsible for cancer treatment should always be included. Physiatrists trained in cancer rehabilitation should be the leaders of the rehabilitation team given their experience with leading diverse rehabilitation experts as well as their unique medical knowledge. 

In the pre-treatment stage, PTs, OTs and SLPs assist with baseline functional assessment.16 Psychologists assess the patient’s emotional well-being. Social workers identify individual needs for social support to maximize providing appropriate resources.

In the inpatient consultation setting after chemotherapy or surgical resection, PT, OT, and SLPs provide functional assessment to identify patient impairments and suggest therapeutic interventions to improve their function. A psychologist can assist patients cope with emotional distress. Music therapists can add additional mental health support.17 A case manager assists with coordination of care after discharge and provides supportive measures.18

Acute inpatient rehabilitation is a common setting to address the care of the complex patient who needs daily medical care along with cancer rehabilitation. In addition to all the team members mentioned above, the expertise of a nutritionist or dietician maximizes nutritional status of the patients to capitalize on recovery.

The outpatient cancer rehabilitation team members are composed of professionals most relevant to the cancer type. For example, for head and neck cancer, it is essential to have SLPs to evaluate speech production and swallow function.8 For breast cancer, PT and/or OT help to treat lymphedema.4 Neuropsychologists assess psychological and cognitive function and assist with return to school or occupation especially for patients with brain tumors.

In the palliative stage, physiatrists trained and certified in hospice and palliative care should be involved in the care of the patients. The palliative and hospice team help to ensure comfort for patients.

Marketing of the Program

Cancer Rehabilitation program developers face the challenge of spreading awareness of the benefits of their services to both patients and other healthcare providers.

Patient education should be standard practice to discuss potential benefits of rehabilitation services with all cancer patients as part of shared decision-making about treatment options. In addition, including descriptions of rehabilitation services on institutional and systems’ websites and other marketing tools are effective.12 Increased awareness of the options and advantages of rehabilitation increases the likelihood of cancer patients seeking out the services of cancer rehabilitation programs. Additionally, patient-facing posters and clinician-led “thank you” emails improve referrals rate.19 The rehabilitation team can also form and implement a quality improvement group to tailor strategies to the centers.19

Many oncology centers participate in the interdisciplinary tumor boards where patient cases are discussed to optimize treatment plans. Several articles emphasize that participation in tumor boards provides the best practice as this dynamic communication allows to explore clinical trials and practice guidelines.20,21 The rehabilitation team, an integral part of this group, identifies functional impairments, plans rehabilitation and supportive strategies, and recognizes complications or symptoms of growth or recurrence of tumors.

Training of Staff and Interdisciplinary Education

Many healthcare providers do not understand or appreciate the breadth and clinical impact that a rehabilitation program can provide. Therefore, interdisciplinary education and collaboration to improve awareness are essential. Strategies to improve clinicians’ education and increase provider engagement can include:12

  • Integration of rehabilitation providers into existing or developing oncology and survivorship clinics.
  • Incorporate topics of cancer rehabilitation and invite cancer rehabilitation specialists to participate in Grand Rounds, conferences, and tumor board meetings.
  • Participation of cancer rehabilitation providers in the development of clinical pathways, guidelines, and referral algorithms in clinical facilities and professional organizations.
  • Education of the oncology nursing staff is particularly important as they are intimately engaged in patient care and can identify patients needing rehabilitation services.

To establish a multidisciplinary team with a strong background in cancer rehabilitation knowledge, specific training in cancer rehabilitation is vital. While limited, there are several training series that providers should complete before working specifically within the program. Options for cancer rehabilitation certification include the Survivorship Training and Rehabilitation Program or other web-based course certifications developed by organizations like Physiological Oncology Rehabilitation Institute or Summit Professional Education. To meet the standards of high-quality cancer rehabilitation, programs should also consider attaining accreditation by the Commission of Accreditation of Rehabilitation Facilities International.22

Cutting Edge/ Unique Concepts/ Emerging Issues/ Gaps in Knowledge/Evidence Base

Telehealth-based cancer rehabilitation intervention has gained popularity especially after the COVID-19 pandemic. Most recent systematic review suggests that telehealth-based cancer rehabilitation intervention can potentially improve access to care to decrease disability.23

To date, while various models of cancer rehabilitation services have been developed, very few have been empirically tested.11 To expand the evidence base for cancer rehabilitation, research gaps must address the testing of multicomponent interventions delivered alongside oncology treatment in addition to reviews and meta-analyses of these studies and effects of such interventions beyond effects on functioning such as survival, health care utilization, and costs.3 Data to support cost-benefit analysis of cancer rehabilitation implementation is needed for further growth of the specialty and high quality of patient care.

Cancer rehabilitation is a growing field of practice and training of the physiatrists with specialization in cancer rehabilitation is particularly important. To date, there are only eight fellowship programs in the USA and one in Canada; however, more fellowship programs are needed. Though the Accreditation Council for Graduate Medical Education (ACGME) does not currently provide accreditation for Cancer Rehabilitation Fellowships, ACGME accreditation is critical to the advancement of this growing specialty. Majority (78%) of current cancer rehabilitation providers agree that there should be dedicated cancer rehabilitation fellowship recognized by the ACGME.26 ACGME recognition assures excellence in physician training and promotes excellence in cancer rehabilitation care.

References

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Author Disclosure

Mi Ran Shin, MD, MPH
Nothing to Disclose

Jared Eng, BS
Nothing to Disclose

Olga Morozova, MD
Nothing to Disclose