A Brave New World: Cancer Rehabilitation as Standard of Care

March 2019 Vol 10, No 3

Cancer rehabilitation is about making sure patients can take care of themselves and function independently, according to Stacye Mayo, MOT, OT/L, CLT-LANA, Senior Director of Clinical Operations for ReVital, a nationwide comprehensive cancer rehabilitation program.

At the AONN+ 9th Annual Navigation & Survivorship Conference, Ms Mayo, along with Ashley Lightner, PT, DPT, CLT, Program Director for ReVital, discussed the importance of rehabilitation for patients with cancer and highlighted the vital role of rehabilitation providers as part of the multidisciplinary oncology care team.

Ms Mayo told the story of her aunt who was diagnosed with breast cancer over 50 years ago. Her radical mastectomy (standard of care at the time) saved her life but led to significant impairment. One of her arms was 3 times the size of the other due to lymphedema, so her medical team told her to hold her arm in the air and let gravity help with the swelling. “So, my aunt held her arm up in the air all the time, and that’s the vision I have of her,” Ms Mayo recalled. “She lived to be 91, and back then, that was remarkable. But that was 45 years of being a survivor with her arm in the air.”

Now, people are living longer than ever because of medical advancements, and cancer, in many ways, is considered a chronic illness. “But despite this progress, we haven’t made a lot of advancements when it comes to sending patients to rehab for impairments,” she said. Studies have shown that as many as 90% of patients with cancer have at least 1 impairment that should be addressed by occupational, physical, or speech therapy, but only about 2% of these impairments are ever treated (with the exception of lymphedema). “That number is pretty startling,” she noted.

These cancer-related impairments decrease function and quality of life, hinder compliance, increase the cost of cancer, and set off a negative ripple effect on general health. But now, the importance of rehabilitation is increasingly included in cancer guidelines from organizations like the Institute of Medicine and the National Comprehensive Cancer Network (NCCN) and is aligned with several measures in the Oncology Care Model.

“Rehab is one thing patients can actually take control of to make themselves feel better, and that tends to be a great patient satisfier,” said Ms Mayo. “I’m not saying we can alleviate every type of cancer pain, but we can definitely address musculoskeletal and a lot of neuropathic pain.” Rehab can also help with range of motion, balance, and fatigue and can reduce unnecessary emergency department visits.

Goals for Cancer Rehabilitation

“As navigators, I’m sure not a day goes by that you don’t hear patient concerns about pain, fatigue, neuropathy, and fear of falling,” said Ms Lightner. “Other than medication, there isn’t a whole lot you can offer patients to address those concerns, but hopefully, with rehab, you’ll have another tool in your toolbox.”

According to Ms Lightner, the ultimate goal of rehab is to help people with cancer live well beyond their cancer diagnosis. This is accomplished through a series of steps. First: helping patients to achieve their maximal possible physical, social, psychological, and vocational functioning.

“We do this by identifying musculoskeletal and neurological impairments, and then we design specific treatment plans based on those findings and on the goals of those patients; by doing this we’re helping to prevent problems that can compound and be worse down the line,” she said.

Research has suggested that many patients avoid telling their physicians about their impairments because they’re afraid it will sound like they’re complaining, or that their providers will stop treatment. However, they do often open up to nurses and navigators. “So it’s important to listen to those concerns and try to facilitate some sort of intervention,” she noted.

Second, cancer rehabilitation should help oncology teams maintain their focus on saving lives by lightening their load and building a net of support around patients. Cancer rehab also serves to empower patients. “Often, patients don’t get to choose how many radiation treatments they’ll receive, or how much or what kind of chemotherapy they’ll get. Those things are obviously needed, so there’s not a lot of wiggle room,” said Ms Lightner. “But they can choose to participate in therapy, and to improve their overall outcomes because of it. It contributes to not just physical but emotional well-being.”

Education is another vital component of cancer rehabilitation. “We know that education is provided from diagnosis through survivorship care, but we also know that we actually retain about 20% of what we hear,” she noted. “Add onto that anxiety, fear, and stress, and that number will probably drop pretty drastically.”

She offered the example of a colorectal cancer survivor who came to her institution for rehab 2 or 3 years after completion of treatment. Her pain from radiation treatment was so severe that she could not have sex with her husband or even wear underwear. But after 2 weeks of seeing a pelvic floor therapist, her pain went from an 8 to a 2. “For years she was dealing with this, and she thought she just had to live with it because she was lucky to be alive,” Ms Lightner said. “It’s very important to educate patients on how they can empower themselves and advocate for themselves, and navigators are a huge part of that.”

Cancer rehab requires a multidisciplinary team approach. Therapists should work with nurse navigators, oncologists, and other medical professionals to ensure the best care possible for patients. This approach promotes treatment compliance and patient tolerance of treatment. For example, if a patient says she wants to stop chemotherapy treatment because of painful neuropathy, cancer rehab therapists can decrease those side effects so the patient can remain on treatment. Or, if a patient is in too much pain to raise her arms over her head to get into position for radiation treatments, physical therapy can make all the difference.

A team approach also decreases the risk for lapses in treatment. “When a patient ends up in the hospital or inpatient rehab, their cancer treatment stops,” she noted. “If we can keep them healthy throughout the process and keep them on treatment, their outcomes will be better.”

According to Ms Lightner, medical teams are now realizing the importance of cancer rehabilitation. They receive feedback from oncology teams noting how much rehab empowers their patients, improves overall outcomes, and allows patients to go into surgeries more informed and relaxed. “We’re hoping to help the patient and the medical team in this process,” she said.

Where Is Cancer Rehab Today?

Processes and protocols have been built on NCCN guidelines and best practices so that patients who might benefit from cancer rehab can be identified more easily. “We have standing orders in a lot of locations,” she noted. “Patients are coming to see us at diagnosis, before they have surgery, chemotherapy, or radiation, and it’s helping to eliminate steps for the medical team.”

Prospective surveillance is now initiated early in the continuum and consists of a pretreatment evaluation: collecting baseline measurements, subjective history/comorbidities, conducting patient-specific education, and identifying impairments. If impairments are identified, treatment is initiated; otherwise, ongoing surveillance continues.

In the past, the majority of cancer-related impairments, such as incontinence, fatigue, sexual dysfunction, trismus, and balance dysfunction, would have been ignored, said Ms Lightner. But with an increased focus on education and patient advocacy, she is hopeful that will change.

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Last modified: August 10, 2023

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