Impairment-Driven Cancer Rehabilitation Improves Survivors' Quality of Life

Adrienne Hill, DO

Assistant Professor

Physical Medicine and Rehabilitation

Comprehensive Cancer Center

at Wake Forest Baptist Health

Winston-Salem, NC

Context: Gap in Care

Cancer is one of the leading causes of death in the United States, and is one of the most common, impairmentcausing, and costly diseases affecting Americans. The good news is that more people are surviving as a result of diagnostic and therapeutic advancements.¹

The cancer patient’s journey is an intense fight on two fronts: (1) overcoming and managing disease and,(2) coping with often debilitating and even disabling adverse effects and impairments. Cancer- and treatment-related impairments may include profound fatigue, chronic pain, decreased physical and cognitive function, as well as many others. Many times, impairments exist long after treatment. Few patients are prepared for the discouraging and devastating toll that is taken as a result of cancer and its treatment.

Survivors are commonly told to expect a “new normal” before having received rehabilitation services that may facilitate higher level functioning. The lack of comprehensive rehabilitation services is a profound source of unnecessary suffering for survivors. Evidence suggests that 65% to 90% of patients with cancer have functional impairments with fewer than 30% who actually get referred for rehabilitation services. Excluding inpatient consults, less than 2% of patients receive rehabilitation care.^2,3

Figure 1. Survivorship Care Continuum

Solution: Impairment-Driven Cancer Rehab

Impairment-driven cancer rehabilitation can provide a solution by focusing on screening and treating physical and psychosocial impairments simultaneously and across the continuum of care. If patients with cancer are routinely screened for impairments and then appropriately referred to trained rehabilitation professionals, it is reported that patients will experience significant improvements in function, decreased disability, and increased health-related quality of life.⁴

One model of cancer rehabilitation is the Survivorship Training and Rehabilitation program (STAR). The program provides a framework for the development of a multidisciplinary cancer rehab team. The STAR program incorporates training for clinicians, nurses, therapists, and support staff, and provides protocols to ensure the highest quality of cancer care. The model consists of the following: patient screening prior to undergoing acute cancer treatments, early identification of impairments, prehabilitation(if indicated), outcomes tracking, and treatment of functional deficits throughout the survivorship continuum.

Prehabilitation is a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment. It includes physical and psychological assessments that establish a baseline functional level, impairment identification, and interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments (Figures 1 and 2).

Figure 2. Cancer Prehabilitation vs Usual Care and Education

Four outcomes should be monitored and include clinician education, patient function, patient satisfaction, and referrals/revenue to the institution.

Impairment driven cancer rehabilitation is a critical part of high-quality care. The American Cancer Society, Institute of Medicine, and the Commission on Cancer mandate that cancer rehabilitation and survivorship care must be a distinct and well-developed part of cancer treatment.

The need for access to rehab services is urgent and cannot be met by general wellness programs. Cancer patients need specialized medical rehabilitation services designed specifically for their unique needs. The goal of a cancer rehabilitation program is to help cancer survivors have the best possible life every day during and after cancer. Cancer rehabilitation has been proven to be cost effective and should be standard of care to reduce disability and maximize patients’ quality of life. As Dr Barry Brooks with the US Oncology Network states, “Cancer rehabilitation before, during, and after therapy is the largest unaddressed need in oncology. Routine referrals to cancer rehabilitation are not optional—they are absolutely essential to high quality care.”

References

1. American Cancer Society. Cancer Facts & Figures 2012. Atlanta, GA: American Cancer Society; 2012.
2. Silver et al. Impairment-Driven Cancer Rehabilitation: CA: A Cancer Journal for Clinicians, Sept 2013,63:5.
3. Cheville AL, Troxel AB, Basford JR, Kornblith AB. Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer. J Clin Oncol. 2008;26(16):2621-2629.
4. Hansen DG, Larsen PV, Holm LV, et al. Association between unmet needs and quality of life of cancer patients: a population-based study. Acta Oncol. 2013;52(2):391-399.