Adrian Cristian

Julie Silver

Frances Atupulazi

Yan Li

12: Cancer Rehabilitation

PATIENT CARE

GOALS

Provide competent patient care that is compassionate, appropriate, and effective for the evaluation, treatment, education, and advocacy for patients diagnosed with cancer and associated problems all along the care continuum and survival trajectory.

OBJECTIVES

Cancer patients often have one or more physical impairments associated with their cancer diagnosis and its treatments. They have been identified as having poor physical and mental health as well as unmet rehabilitation needs to address these impairments (1). An impairment-driven approach to cancer rehabilitation has been described by one of the authors and should serve as a guide to the assessment and treatment of the cancer patient at various stages of the disease process (2).

This section will address a general approach to the assessment and rehabilitation treatment plan of the cancer patient as well as focus on four commonly seen conditions in cancer patients: (a) cognitive dysfunction, (b) lymphedema in breast cancer, (c) chemotherapy-induced peripheral neuropathy (CIPN), and (d) radiation fibrosis.

PATIENT ASSESSMENT

An impairment-based approach: In the data-gathering phase of the assessment of the cancer patient, the following information is important for the physiatrist to obtain.

Medical Histories and Data Gathering

A. History of Present Illness: This is a thorough history of the cancer presentation and its course since the time of the initial diagnosis. It includes the type of cancer and its stage. In addition, a chronology of the types of treatments that have been used to treat the cancer including chemotherapy, surgery, and radiation therapy is very helpful. It is important that the information collected be very detailed and specific. This often entails speaking with the medical oncologist, radiation oncologist, and surgeons involved in the care of the patient and obtaining records that accurately define these interventions, their success, and complications to date. Examples include (a) the names of the chemotherapeutic medications, dosages, route of administration, number of treatment cycles to date and projected for the future; (b) total irradiation doses, number of treatments to date and planned for the future, as well as parts of the body that were irradiated; and (c) description of the surgeries performed, organs that were altered or removed as a result of the surgery, as well as plans for future surgical interventions. This is important to guide the physiatrist in identifying specific impairments associated with both the disease and its treatments.

B. Past Medical History: Significant comorbidities such as coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, previous cancers treated, and pertinent past surgeries are important to note as they may have an impact on the rehabilitation program.

C. Review of Systems: In the review of systems, a cancer-specific checklist approach can be useful. The checklist should include impairments that are associated with specific cancers as well as those generally seen in cancer patients. Table 12.1 provides a sample list.

TABLE 12.1 Examples of Prehabilitation Interventionsa

^aThis is not meant to be a complete list.

Specific cancers should lead physicians to pursue relevant avenues of investigation. For example:

Unfortunately, pain is a highly prevalent symptom among those carrying a cancer diagnosis, and the physiatrist would therefore do well to spend some time assessing for possible sources of this pain with some regularity. These sources are likely to be both nociceptive and neuropathic in nature and their prompt, precise identification is an important cornerstone of any plan of care. A protocol for the investigation of pain-related complaints that can yield significant information would assess location, intensity, quality, radiation, and aggravating and alleviating factors.

D. Social and Functional History: Given that a primary goal of cancer rehabilitation is to maximize the level of function and quality of life, it is important to establish a baseline level of function for activities of daily living (ADLs), IADLs, and work. In addition, the physiatrist should ascertain the nature of social support available to the patient, living arrangements (e.g., house vs. apartment; stairs, etc.), and difficulties with driving. Drug (smoking) and alcohol habits are also important to factor into the development of treatment.

E. Allergies and Medications: An updated medication list should be documented. This should include chemotherapy medications such as platins (cisplatin, carboplatin), plant alkaloids (vinblastin, vincristine), and taxanes (paclitaxel, docetaxel), which have been associated with CIPN. It is important to also document a list of allergies and any advance directives. Medications should also be reviewed for potential drug–drug or drug–herb interactions and side effects.

Physical Examination

Using the information gathered from the review of medical records and interviewing the patient, the physiatrist performs a physical examination with focus on body systems that may have been adversely impacted by cancer and its treatment. Vital signs such as blood pressure and heart rate in the supine and sitting or standing position may indicate the presence of orthostatic changes. Respiratory rate and pulse oximetry provide an indication of pulmonary function and oxygenation, respectively.

Inspection of the patient can yield significant information such as atrophy of muscles, fibrosis of soft tissues, lymphedema, medial winging of the scapula, contractures, scars, and deformities. Palpation provides information about tender areas over the spine, extremities, and trunk.

Inspection of the skin is important to look for evidence of infection, ulcerations, or atrophy, especially in areas treated with radiation therapy. The skin and underlying soft tissues in these areas should also be palpated for evidence of loss of elasticity. An assessment of range of motion is important for the joints of the upper and lower extremities as well.

Lymphedema is generally characterized by nonpainful swelling. In patients with lymphedema it is important to determine the stage. Stage 0 is considered subclinical and not evident on physical examination, though the patient may complain of heaviness. Stage 1 is considered mild and pitting in nature. With elevation, pitting edema can usually be reversed. Stage 2 is characterized by increasing fibrosis, which on examination feels more firm than with stage 1. This firmness also means that the pitting that is seen in stage 1 is typically no longer present. In this stage, nonpitting edema is less responsive to elevation. Due to the chronic excess protein in the interstitial spaces and deposition of adipose tissue, the tissue becomes fibrotic and the skin starts to harden. Stage 3 is considered severe, and the swelling is considered cartilage like and has been described as “lymphostatic elephantiasis.” In addition to stage of lymphedema, the physiatrist should also evaluate for the following: (a) evidence of erythema or warmth in the arm, suggesting possible skin infection; (b) tenderness on palpation of the arm; and (c) restriction to range of motion at the shoulder, elbow, wrist, and hand. It is also beneficial to establish circumferential measurements in the affected extremity at the time of initial assessment and then subsequently chart the changes with appropriate treatments.

Appropriate goal setting is important, as is the reality that in active treatment the patient’s medical status may change quickly. If the patient’s cancer diagnosis is associated with a rapid decline, it is a good idea to be proactive in anticipating possible future impairments and introducing interventions to minimize the impact of the decline in function.

The rehabilitation professional should understand cancer stage and grade, with the former generally being more important in terms of developing a rehabilitation treatment plan. Tumor grade is a description of how abnormal the cells look under the microscope. This is generally reported from G1 (low grade) to G4 (high grade). Cancer staging describes the extent or severity of a patient’s malignancy and is based on the TNM system, which stands for: T = tumor (size of the primary tumor); N = nodes (whether the cancer has spread to regional lymph nodes); M = metastasis (distant spread). For example, in a woman diagnosed with breast cancer classified as T3 N2 M0, this means that she has a large tumor that has spread outside the breast to regional lymph nodes, but there is no distant spread. The TNM system is used to stage the patients from stage 0 to 4. The TNM classification system is specific to the cancer type; for example, in bladder cancer T3 N0 M0 is stage 3, whereas in colon cancer this would be stage 2. Moreover, not every cancer has a TNM classification; for example, cancers of the brain and spinal cord are classified according to their cell type and grade. Regardless of the oncology classification used, it is important for rehabilitation professionals to understand the extent of the cancer involvement, particularly if there is distant metastasis to areas such as the brain and/or bone.

Prehabilitation is really the beginning of the cancer rehabilitation care continuum and has been defined as “a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments” (2). The research on cancer prehabilitation is evolving, but there is often a “window of opportunity” between the diagnosis and beginning of treatment in which to better prepare patients for upcoming stressors such as surgery or chemotherapy (Table 12.1) (2). In general, treatments should not be delayed as that may adversely affect survival outcomes.

Cancer rehabilitation, though often thought of as a distinct field of medicine, may be better considered as part of the oncology care continuum. This shift in conceptualization may help to improve the delivery of cancer rehabilitation care, because it means that physiatrists and other rehabilitation health care professionals will work as part of a larger interdisciplinary oncology team. Indeed, most cancer patients are closely followed by oncologists who are more likely to refer patients and work collaboratively with rehabilitation professionals if the latter are well-integrated members of an oncology service line. This is not to say, for example, that all physiatrists who are cancer rehabilitation specialists must work in the same department or even the same institution as the referring oncologists. However, there clearly has been a significant disconnect between the evidence-based need for cancer rehabilitation services, which for some types of cancer may be over 90% of the patients, and the delivery of these services, which has been reported to be abysmally low (2).

This trend underscores the referral process as a key barrier to be overcome in the process of delivering better care. Oncologists and other key members of the oncology team, such as nurse navigators, who are responsible for the overall outcomes of these patients and/or the referral process, must be educated about cancer rehabilitation and develop close working relationships with rehabilitation professionals that they have confidence in.

Consider that there are really three ways that the rehabilitation care may take place. The first way is that the oncology and rehabilitation departments are separate entities and don’t have much overlap or collaboration. This has historically been the case, and it has resulted in a significant gap in care. The second way is that the oncology health care team becomes part of the rehabilitation care continuum. This could work but is unlikely as oncologists tend to work with large well-established interdisciplinary teams already and are not likely to become very involved with another large well-established but separate interdisciplinary team. The third way, which is most likely to be successful, is for the cancer rehabilitation physiatrist and other specialists to become well integrated into the oncology care continuum—working closely with the oncologists and other key members of the team. For the physiatrist in private practice, this may mean networking with oncology colleagues and attending lectures, such as Grand Rounds, or being present when cases are discussed, such as at Tumor Board.

PROSPECTIVE SURVEILLANCE MODEL

The PSM is designed to proactively follow patients throughout the care continuum in an attempt to allow for the early identification of impairments caused by cancer or cancer treatment (4). If impairments are identified, then the goal is to refer patients for appropriate rehabilitation interventions. Although there is overlap between the definitions of PSM and cancer prehabilitation, they are not the same. However, both are important in the cancer care continuum. For the purposes of this discussion, the differences can be quickly summarized as follows:

Although prehabilitation is a discrete period of time, interventions may be conducted and assessed beyond the prehabilitation interval. For example, a prehabilitation exercise regimen that begins prior to the start of acute cancer treatments may be continued and followed during and after treatment. A recent review on cancer prehabilitation outlined many opportunities to perform baseline assessments, to provide pretreatment interventions to improve outcomes, and to potentially increase cancer treatment options (e.g., a lung cancer patient who is deemed a high-risk surgical candidate may undergo prehabilitation in order to reduce the risk of complications during the peri- and postoperative period) (5).

SCREENING CANCER SURVIVORS

The term cancer screening often means screening tests such as a mammogram or colonoscopy that is designed to help diagnose cancer in its early stage. However, there are other types of screening that survivors should undergo. One of the most important types of screening is screening for physical impairments and functional problems. Unfortunately, this type of screening is not consistently performed in this population, although it should be. In order for patients to be referred by oncology providers to the rehabilitation team, a screening process must take place. Therefore, this type of screening should ideally be performed by the oncology team at designated intervals throughout the care continuum (Table 12.2).

Distress screening has become an increasingly standard part of oncology care and provides a unique opportunity to perform dual screening—for physical and emotional problems—simultaneously. It makes a lot of sense to combine these screenings not only from a time management and human resource perspective but also from an evidence-based perspective. This is because physical impairments and disability are often the root causes of distress in survivors. In fact, research has shown that a leading cause of distress is physical disability (6) and that more often than not physical problems (versus emotional ones) lead to a decreased health-related quality of life in cancer survivors (7).

SAFETY CONCERNS IN CANCER SURVIVORS

There has been recent interest in establishing both effective and safe rehabilitation interventions in the cancer survivor population (3). Because exercise is known to help prevent primary cancers from developing and likely will help prevent cancer recurrence in some types of cancer, there has been a tendency to encourage patients to exercise regardless of whether they have been screened for impairments and received appropriate rehabilitation interventions. Unfortunately, the “rehabilitation” of cancer survivors too often does not include any oversight by trained rehabilitation professionals. Establishing appropriate screening protocols, identifying impairments, and referring patients to skilled rehabilitation professionals is critical. However, even when all of this is in place, there still may be safety concerns. These patients may be elderly and/or frail. They often have comorbidities and have endured one or more oncology treatments that have caused new problems in an attempt to control the cancer. They may have advanced disease with metastasis to the bone or central nervous system. Brain metastases may cause a myriad of issues that include difficulty with cognition, speech, swallowing, and mobility. Even patients without brain malignancy may be susceptible to cognitive problems due to delirium or Mild Cognitive Impairment (MCI) from chemotherapy. Safety in this population, so often prone to a complex interaction of symptoms and their triggers, is an important and evolving topic that cannot be adequately covered in this chapter. Nevertheless, it’s important to note that cancer survivors should be treated by a highly skilled interdisciplinary rehabilitation team that is extremely knowledgeable about the different issues that may arise.

TABLE 12.2 Improving Cancer Rehabilitation Care

EXAMPLES OF REHABILITATION IN CANCER SURVIVORS

Lymphedema is a well-known and important example of cancer-related sequelae that may be treated, though not cured, by rehabilitation interventions. Poorly treated lymphedema may have devastating results and is an important condition to screen for and treat. Lymphedema most commonly occurs in the upper extremities of breast cancer survivors but may also occur in the lower extremities in other patient populations (e.g., gynecologic cancers) or in the face and neck (e.g., head and neck cancers). The mainstay of treatment is controlling the fluid collection, and this is usually accomplished with complex (also called complete) decongestive therapy (CDT)—a combination of interventions that include hands-on manual lymphatic drainage (MLD) as well as compression wraps.

CIPN is the most common neurologic sequelae in oncology patients. CIPN is frequently caused by drugs that fall into the class of taxanes. It usually begins slowly and worsens over the course of chemotherapy. Once the offending drug is discontinued, there is an opportunity for improvement. Similar to other peripheral nerve injuries, the healing usually takes place over the course of 1 year or so, and the prognosis is generally better if there is significant improvement early on. Rehabilitation interventions likely won’t affect neurologic recovery but can improve functional problems, including gait and balance issues, which can be significant.

Cancer-related fatigue (CRF) is a very common problem and affects the majority of survivors. The accepted definition for CRF is an unusual, persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with functioning (8). Distinguishing normal fatigue from CRF is important—fatigue is deemed to be pathologic when it occurs during usual daily activities, persists for long periods of time, and does not respond to rest (9,10). Clinical guidelines for CRF have been developed by the National Comprehensive Cancer Network (11). One of the best antidotes to CRF is exercise. However, in this potentially fragile population, it is important to consider physical impairments and functional problems before recommending any formal exercise. Traditional exercise screening protocols may not be adequate to assess safety. For example, a young breast cancer survivor may have CIPN that affects her balance, and she could potentially fall off of a treadmill. Or, this same young woman may have cardiomyopathy as a result of chemotherapy and have a cardiac event on the treadmill. There are many examples that could be given here, but the point is that prescribing exercise in cancer survivors involves a sophisticated understanding of the patient’s physical and functional impairments as well as cardiopulmonary status.

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