Author(s): Mi Ran Shin, MD, MPH, Olga Morozova, MD, Anisa Benbourenane
Originally published: December 21, 2022 Last updated: October 30, 2025
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Introduction

Cancer rehabilitation is 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 to maintain or restore function, reduce symptom burden, maximize independence, and improve quality of life in this medically complex population.”1 Advances in early detection and novel therapeutic strategies have led to a dramatic increase in survival rates.

The number of cancer survivors in the United States is an estimated 18.6 million and is projected to exceed 22 million by 2035.2 Recent large-scale studies revealed that 27.9% of cancer survivors report a mobility disability, and nearly 10% report a self-care disability. These rates are sharply higher than those observed in adults without a history of cancer.3 This suggest that currently, more than 5 million survivors live with a mobility disability.

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 team improves function and addresses impairments such as pain, poor mobility, lymphedema, pelvic floor dysfunction, and cognitive changes.4

Recognition of cancer rehabilitation as essential to high-quality oncology care is now established by major bodies, including the Commission on Cancer (CoC) and the American Society of Clinical Oncology (ASCO), which have integrated rehabilitation referrals and recommendations into their standards and clinical practice guidelines.5,6

Addressing Administrative Buy-in and Institutional Support

Perceived patient benefits

Recent mixed-methods studies show that patients are highly likely to recommend rehabilitation services when they feel comfortable with the process and observe improvements in their health and function.7 Key drivers of satisfaction include staff knowledge, quality of care, and a supportive environment. In recent meta-analyses and large-scale retrospective studies, multidisciplinary rehabilitation has been shown to produce statistically and clinically significant improvements in global physical and mental health, physical function, and the ability to participate in social roles and activities across a wide range of cancer types.8

Exercise, a cornerstone of cancer rehabilitation, has a particularly strong evidence base for improving overall quality of life and physical functioning while concurrently reducing the burden of common debilitating symptoms such as cancer-related fatigue, anxiety, and depression.9 Beyond improving quality of life, rehabilitation interventions can directly impact cancer outcomes. The Phase III CHALLENGE study, found that a structured exercise program for colon cancer survivors led to a 28% improvement in disease-free survival.10

Cost savings

Recent systematic reviews and meta-analyses confirm that rehabilitation interventions, particularly those involving exercise, are cost-effective for various cancer types.11 For example, a specialized cardio-oncology rehabilitation program had an incremental cost-effectiveness ratio (ICER) of €1,383.24 per quality-adjusted life year (QALY) gained.12 Another study found a 12-week exercise intervention for breast cancer survivors lowered unplanned healthcare costs by over $2,200 per patient, with a payer benefit of approximately $3,000 per patient in the first six months.13

Decreasing hospital re-admission rate

Decreasing readmission to acute-care hospital is an indicator of quality of care and reduces health care cost. Research has shown that a patient’s functional status at discharge is a powerful predictor of readmission risk. The oncology population is particularly vulnerable, with 30-day readmission rates reported to be as high as 21% to 34%.14 Cancer rehabilitation directly addresses many of the common and preventable causes of readmission. By improving strength, mobility, endurance, and self-management skills, rehabilitation interventions can mitigate these risks. Furthermore, prehabilitation has been shown to reduce surgical complications and decrease the initial hospital length of stay, both of which are precursors to readmission.15

Plan for Identifying Patients Who Need Services

Identifying oncology patients who require services has evolved from reactive, provider-driven referrals to proactive screening via the Prospective Surveillance Model (PSM), and now toward AI-driven predictive analytics. In the PSM model, rehabilitation begins at diagnosis with an assessment to establish baseline function and identify individuals predisposed to impairments. A proactive approach with periodic follow-ups allows for early intervention.16 This model has evolved into the electronic PSM (ePSM), which uses digital infrastructure like patient portals to automate the collection of Patient-Reported Outcomes (PROs) that screen for impairments, provide personalized education, and trigger clinical alerts.17

The most advanced strategies integrate PROs directly into the institutional Electronic Health Record (EHR). In this model, PRO data drives automated clinical decision support tools that alert the care team to moderate or severe symptoms and prompt an appropriate response, such as a rehabilitation referral.18 In this model, patients complete regular PRO symptom screens, and the data is fed directly into the EHR. This information then drives automated clinical decision support tools that alert the patient’s care team to moderate or severe symptoms and prompt a clinically appropriate response, which can include a referral to rehabilitation services.

The cutting edge involves leveraging Artificial Intelligence (AI) and Machine Learning (ML) to mine EHR data. These algorithms can identify complex patterns to predict which patients are at highest risk for developing functional impairments, enabling intervention before a crisis occurs.19 For instance, an AI model could analyze a patient’s treatment regimen, baseline comorbidities, and real-time biometric data from a wearable device to flag them for a pre-habilitative intervention aimed at preventing treatment-related cardiotoxicity.19

Implementing such a system presents challenges as EHR data can be complex and variable. For instance, accurately identifying a patient’s metastatic status solely through diagnostic codes has been found to be challenging.18 Moreover, a barrier to the equity of these digital systems is the “digital divide,” as access to and persistent use of patient portals are not universal and are strongly associated with sociodemographic factors.20 Without deliberate strategies to ensure equitable access, these technology-based identification systems risk exacerbating existing health disparities.

Effective patient identification systems are built on a foundation of human coordination and interdisciplinary collaboration, which technology can support but never replace. Therefore, technology must be paired with human coordination. A rehabilitation navigator is central to this model, acting on technology-driven alerts, providing patient education, ensuring referral completion, and managing screening for patients without digital access to ensure equity.21 Combining a navigator with a collaborative team establishes the clear clinical pathways necessary for an effective referral system.

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 with physiatrists to monitor for complications and to administer appropriate and timely treatment. A growing body of evidence strongly supports a multimodal prehabilitation approach, which is more effective than single-modality interventions.22 These programs typically combine three core components: a tailored exercise regimen, nutritional counseling, and psychological support.22 Research demonstrates that multimodal prehabilitation significantly improves preoperative functional capacity and can lead to a reduction in postoperative complications and hospital length of stay.22 Accelerated by the COVID-19 pandemic, telehealth-delivered prehabilitation has emerged as a feasible and effective delivery model, overcoming geographical barriers and improving patient access.23

Both inpatient and subsequent outpatient physical and occupational therapy have been shown to lead to significant improvements in quality of life, physical function, and social participation for cancer survivors.8 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.

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.50 An innovative approach in pediatric cancer rehabilitation involves developing integrated care networks (ICNs) to provide multidisciplinary services close to home.50 Common outpatient offerings include the use of electrodiagnostic studies to precisely diagnose and characterize nerve injury in chemotherapy-induced peripheral neuropathy24 or the use of botulinum toxin injections to manage pain and pain and muscle spasms related to radiation.25

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. This integration is formally termed “palliative rehabilitation,” where the focus shifts from long-term restoration to the optimization of function to achieve immediate, patient-centered goals.26 These goals may include maintaining the strength to perform basic self-care, managing pain to allow for more meaningful social interaction, or preserving mobility for safe transfers at home. The 2024 ASCO clinical practice guideline update on the integration of palliative care calls for a palliative care consultation early in the course of the disease.27

Forming a team

Cancer rehabilitation should be based on a team-integrated model. Depending on the setting of cancer rehabilitation within the care continuum, 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; Psychologists assess the patient’s emotional well-being; Social workers identify individual needs for social support to maximize providing appropriate resources.28
  • 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. Registered Dietitians provide nutritional counseling to manage treatment side effects, combat malnutrition, and support overall health. Music therapists can add additional mental health support.29 A case manager assists with coordination of care after discharge and provides supportive measures.30
  • 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,31 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.

Crucially, an effective program functions as a truly interdisciplinary team, characterized by regular communication, shared goal-setting, and a coordinated plan of care, rather than as a multidisciplinary team where specialists work in parallel silos.32

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.  Increased awareness of the options and advantages of rehabilitation increases the likelihood of cancer patients seeking out the services of cancer rehabilitation programs. Recent studies show that digital and social media can be tailored for specific audiences and disseminated at low cost, making them accessible and effective educational tools to improve awareness.33 The rehabilitation team can also form and implement quality improvement groups to tailor strategies to the centers.34

However, the most effective strategy for driving utilization is direct clinical integration. By embedding physiatrists and rehabilitation navigators within oncology clinics and having them actively participate in multidisciplinary tumor boards, the rehabilitation team becomes a visible, trusted, and seamlessly accessible part of the care process.16,35

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. Recent systematic and scoping reviews highlight that interprofessional education (IPE), often using simulation-based learning, is critical for improving collaboration, clarifying roles, and developing a shared understanding among team members in cancer care.36 Moreover, one quality improvement initiative that educated oncology staff and nurses to help identify patients suitable for rehabilitation led to a 50% increase in referrals.37

This educational partnership must be bidirectional. While oncologists need to understand the scope of rehabilitation, the rehabilitation team must also maintain a deep, current understanding of the rapidly evolving oncology landscape. New targeted therapies, immunotherapies, and cellular therapies constantly emerge, each with unique functional side effects. To provide precise and effective care, the physiatrist must be fluent in these developments, which requires attending oncology grand rounds, staying current with key literature, and engaging in continuous dialogue with oncology colleagues.38

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

Telehealth-based cancer rehabilitation is now well-established as a feasible, safe, and effective modality for delivering a range of services.39 However, the field is moving beyond simple video visits toward an integrated digital health ecosystem.40 This includes wearable devices for remote monitoring of physical activity and symptoms, mobile health applications for delivering self-management interventions, and virtual reality platforms for immersive therapy.40 This convergence of technologies creates a continuous data stream that enables personalized, adaptive care that can be delivered to the patient at home. However, it is not a universal replacement for in-person care, particularly for evaluations requiring a detailed physical or neurologic examination or for interventions that require manual therapy.39 Recent clinical guidelines and research have clarified the best practices for managing some of the most common and debilitating cancer-related impairments.

  • Cancer-Related Fatigue (CRF) The 2024 ASCO guideline recommends exercise, cognitive-behavioral therapy (CBT), and mindfulness-based programs. Importantly, the guideline explicitly advises against routine prescription of wakefulness agents, psychostimulants, or antidepressants for the primary management of CRF.6
  • Cancer-Related Cognitive Impairment (CRCI) It is now understood that CRCI, often called “chemo brain,” is not limited to chemotherapy and can result from hormonal therapies, radiation, and immunotherapies. With no approved pharmacologic treatments, the most robust evidence supports non-pharmacologic interventions, including aerobic exercise, formal cognitive rehabilitation and training programs, and compensatory strategy training. There is growing interest in delivering these interventions via accessible, web-based platforms.41
  • Cardiotoxicity and Cardio-Oncology Rehabilitation (CORE) In response to the growing recognition of treatment-related cardiotoxicity, the specialized field of Cardio-Oncology Rehabilitation has emerged. In this field, evidence-based, multidisciplinary programs utilize structured, monitored exercise and comprehensive cardiovascular risk factor management to mitigate the cardiovascular effects of cancer treatment.38 These programs are not only clinically effective but also highly cost-effective.12
  • AI-Driven Adaptive Rehabilitation The convergence of digital health and AI is paving the way for adaptive, real-time personalized interventions to monitor symptoms, predict treatment effects, and deliver psychosocial support.42 For example, AI-driven systems are being developed to analyze real-time data from wearable sensors to adjust exercise intensity.43 AI can also use natural language processing to power chatbots that provide tailored psychological support.44 One pilot study found that a generative AI chatbot led to significant reductions in anxiety and stress among young adult patients, with 80% of participants disclosing concerns they had not previously shared with their healthcare providers.45 This overall approach shifts the paradigm from static rehabilitation plans to dynamic, continuously optimized interventions.

The formalization of cancer rehabilitation as a subspecialty, marked by the creation of a standardized curriculum for fellowships in the National Resident Matching Program (NRMP) Match, has been a crucial development. The strength of these programs is increasingly evident, as their curricula align with expert consensus on the field’s core services,46 and their graduates report feeling significantly more prepared to enter the field than physiatrists without this specialized training.47 The integration of these successful, specialist-led models confirms cancer rehabilitation’s essential role in comprehensive cancer care.

Despite significant progress, critical gaps in the evidence base remain. Recent bibliometric analyses of the cancer rehabilitation literature highlight several key areas that require further research.

  • There is a stark underrepresentation of studies conducted in low- and middle-income countries, where the cancer burden is disproportionately high and growing, and access to rehabilitation services is severely limited.48
  • There is also a limited focus on pediatric cancer populations, whose rehabilitation needs related to growth, development, and long-term survivorship differ significantly from those of adults.49
  • Finally, while the use of technology is growing, more rigorous implementation science research is needed to understand how to best integrate proven digital health tools into complex clinical workflows to bridge the research-to-practice gap.

Future research must prioritize these areas to ensure that the benefits of cancer rehabilitation are advanced and equitably distributed to all survivors.

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Original Version of the Topic

Mi Ran Shin, MD, MPH, Jared Eng, BS, Olga Morozova, MD. Development of a Comprehensive Cancer Rehabilitation Program. 12/21/2022

Author Disclosure

Mi Ran Shin, MD, MPH
Nothing to Disclose

Anisa Benbourenane
Nothing to Disclose

Olga Morozova, MD
Nothing to Disclose