Overview
Rehabilitation services for patients with history of or active cancer is an important and distinct part of comprehensive cancer care. Physiatrists are crucial in identifying and assessing limitations due to functional deficits or symptoms (e.g., pain) and working with an interdisciplinary team to address these issues. A rehabilitation team can not only address and improve survivorship issues for patients but can contribute to caregiver health as well. People with cancer are living longer due to better surveillance, different (often less toxic) treatment options, and more access to care. Despite the potential benefits, however, use of rehabilitation services in the care of patients with cancer is still limited.
Performance measures and outcomes
There are various scales to assess performance status. Clinical oncologists often use the Karnofsky Performance Scale (KPS), an 11-point ordinal scale to rate a patient’s overall performance status and thereby determine treatment eligibility. The KPS ranges from 100% (normative, no complaints, no evidence of disease) to 0% (dead). KPS levels that suggest a need for physiatric intervention include 70% (cares for self, unable to carry on normative activity or do active work) through 40% (disabled, requires special care and assistance). The clinician may or may not query patients regarding their functional capabilities, and the assignment of KPS scores does not require the clinician to observe a patient engaging in specific tasks. Therefore, KPS scores are highly subjective. Nonetheless, KPS scores are prognostic and remain an important determinant of treatment eligibility, particularly in clinical trials. The finding that collapsing the KPS scale to 5 rather than 10 points did not lessen its prognostic capabilities led to the widespread adoption of the 5-point Eastern Cooperative Oncology Group (ECOG) performance scale as a more succinct alternative. ECOG scores are ordinal but more limited than the KPS scores in that they range from 0 (asymptomatic, fully able to carry on all predisease activities without restriction) to 5 (death). ECOG scores are currently more commonly used in clinical practice and as eligibility criteria for clinical trials. Somewhat counterintuitively, lower ECOG scores imply better function, whereas the reverse is true for KPS scores.
The Spinal Cord Independence Measure (SCIM) is a tool specifically for those with spinal cord injury. It measures functional status in self-care, respiration and sphincter management, and mobility. It has been validated and is reproducible in those with spinal cord injury. Like the KPS, patients can report information required for the SCIM.
The Functional Assessment of Cancer Therapy-Brain (FACT-BR) is a 50-item scale used in adults over the age of 18 to assess quality of life in those with primary or secondary brain tumors. Responses are given on a 5 point Likert scale and it is a self-administered survey.
The Disability Rating Scale (DRS) is a tool to assess functional changes over recovery from a traumatic brain injury. It was designed for use in the inpatient rehabilitation setting to track a patient from “coma to community.” The higher the score, the greater the disability (i.e., a score of zero indicates no disability and that of 29 would designate someone in a vegetative state). It can be self-administered or scored through interview with a patient or family member.
The Functional Independence Measure (FIM) is widely used throughout the rehabilitation care spectrum. It is an 18-item ordinal scale with scores ranging from 1 (total assist) to 7 (independent) that evaluates physical, psychological, and social function. It contains 13 motor tasks and 5 cognitive tasks. This score is assigned by a trained practitioner via direct observation.
Lymphedema and upper quadrant-specific questionnaires have been developed for use among cancer survivors and the general population.2 The Disabilities of the Arm, Shoulder, and Hand questionnaire and University of Pennsylvania Shoulder Score have been widely to characterize disability among breast cancer cohorts.3 One can also measure limb volume to gauge treatment outcome.
Outcomes of treatment can also be measured using more global tools. For example, the Timed UP and Go test assesses ambulation. The Berg Balance test and 6 Minute Walk tests assess mobility.
Studies have shown FIM improvement in all functional domains after inpatient rehabilitation admissions in hematologic as well as solid tumor cancers.1 Further, presence of metastatic disease did not take away from functional gains. Patients can often be discharged home as well and studies demonstrate that radiation therapy can often augment the functional gain.2 For instance, a 2013 retrospective study of 215 charts found that patients achieved increases in FIM scores regardless of age.3 This study by Cole et al. furthers this by also showing improvement in cognitive function.4 A small study of ten individuals also demonstrated improvement in FIM, KPS, and FACT-BR after receiving care by a multidisciplinary inpatient rehabilitation team.5
Cutting Edge/ Emerging and Unique Concepts and Practice
Rehabilitation services are gradually being incorporated into major national organizations’ recommended plans of care for cancer. The National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS), for instance, designate rehabilitation services as a critical, but not mandatory, component of care.
The current model for rehabilitation care within a cancer framework divides services into preventative rehabilitation, restorative rehabilitation, supportive rehabilitation, and palliative rehabilitation. Another framework can be used to also differentiate needs from active treatments and survivorship issues.
Academic institutions, professional organizations, and national associations have all displayed greater interest in collaborations and innovative models. Livestrong YMCA, for example, provides an example of a successful community-academic program where the two namesake organizations, Livestrong and the YMCA, partnered to create a 12-week physical activity program designed “to get survivors back on their feet.” A study completed with Yale and the Dana Farber Cancer Institute found that participants experienced increased physical activity and quality of life.
Gaps in the Evidence- Based Knowledge
More research in specific protocols for cancer rehabilitation, consideration of benefits of outpatient regimens, and elucidating how long these improvements in function last might help provide direction to future policy.
References
- Guo Y, Shin KY, Hainley S, Bruera E, Palmer JL. Inpatient rehabilitation improved functional status in asthenic patients with solid and hematologic malignancies. Am J Phys Med Rehabil. 2011 Apr;90(4):265-71. doi: 10.1097/PHM.0b013e3182063ba6. PMID: 21273895.
- Marciniak CM, Sliwa JA, Spill G, Heinemann AW, Semik PE. Functional outcome following rehabilitation of the cancer patient. Arch Phys Med Rehabil. 1996 Jan;77(1):54-7. doi: 10.1016/s0003-9993(96)90220-8. PMID: 8554474.
- Hunter EG, Baltisberger J. Functional outcomes by age for inpatient cancer rehabilitation: a retrospective chart review. J Appl Gerontol. 2013;32(4):443-456. doi:10.1177/0733464811432632
- Cole RP, Scialla SJ, Bednarz L. Functional recovery in cancer rehabilitation. Arch Phys Med Rehabil. 2000 May;81(5):623-7. doi: 10.1016/s0003-9993(00)90046-7. PMID: 10807103.
- Huang ME, Wartella JE, Kreutzer JS. Functional outcomes and quality of life in patients with brain tumors: a preliminary report. Arch Phys Med Rehabil. 2001 Nov;82(11):1540-6. doi: 10.1053/apmr.2001.26613. PMID: 11689973.
Original Version of the Topic
Andrea L. Cheville, MD. Functional outcomes after rehabilitation of cancers. 9/20/2014
Author Disclosure
Arpit Arora, MD
Nothing to Disclose