Patient Safety in Cancer Rehabilitation




Cancer patients receive rehabilitation services in acute hospitalizations, rehabilitation wards, outpatient rehabilitation facilities, and home settings. Given the complexity and acuity of their medical care coupled with the long-term effects of the cancer and its treatments, patient safety is a significant concern in the delivery of rehabilitation services for this population. Cancer survivorship is growing in importance as a significant number of adults and children diagnosed with cancer are surviving beyond the 5-year mark. The goal of this article is to provide an overview to rehabilitation clinicians on the topic of patient safety in the rehabilitation of cancer patients.


It has been estimated that there are 1.5 million people diagnosed with cancer each year and that there are 13 million cancer survivors in the United States as of 2010. More than 60% of those diagnosed are surviving 5 years or more. This is due to a combination of factors, such as earlier diagnosis and advances in the treatment of various types of cancer. Cancer survivors, however, often have to live with the long-term effects of their underlying disease as well as effects of treatments, such as surgery, chemotherapy, and radiation therapy (RT), on their bodies. Rehabilitation professionals have a great deal to offer these survivors and provide rehabilitative services for them throughout their life span, including periods of acute hospitalizations for surgical and medical treatments, acute and subacute inpatient rehabilitation admissions, outpatient rehabilitation programs, and rehabilitation in the home setting as well as the end-stages of their disease. Given the complexity of the medical care rendered to these patients, it is important for rehabilitation professionals to provide these services in a safe manner. The goal of this article is to describe the basic principles of patient safety in the delivery of cancer rehabilitation services. An excellent resource on the topic of cancer rehabilitation in general as well as patient safety in the care of cancer patients is available for interested readers.


Why is the cancer patient at risk during rehabilitation?


Cancer-Related Complications


Depending on the type of cancer, its location, and extent of metastasis, there are many specific cancer-related complications of which rehabilitation professionals should be aware. They range from general in nature to organ or organ system specific.


Pulmonary complications


The lung is a common site of both primary cancer and metastatic disease for cancers of the breast, colon, kidney, and gastrointestinal tract. The location of the cancer can be a cause of bronchial obstruction, pleural effusion, pneumothorax, and phrenic nerve paralysis. Metastatic disease to the ribs also is a source of pain with inspiration. Other complications include pulmonary embolisms (PEs) and pneumonia. Patients with a history of exposure of lungs to RT for the treatment of cancer can have radiation pneumonitis or pulmonary fibrosis. These complications are compounded in patients with history of chronic obstructive pulmonary disease. The significance of these complications in the rehabilitation setting is decreased exercise capacity, shortness of breath, and pain.


Cardiac complications


Pericardial effusions and involvement of the pleura secondary to cancer can be a cause of constrictive pericarditis. Patients with a history of RT or chemotherapy may also have sustained injury to the heart muscle and the coronary arteries. Patients may present in the rehabilitation setting with symptoms of angina on exertion.


Gastrointestinal complications


Depending on the type of cancer, complications include dysphagia, nausea, vomiting, poor nutritional intake and appetite, bowel obstruction, and diarrhea. The diarrhea may also be related to infections of the gastrointestinal tract.


Renal complications


Fluid and electrolyte disorders are a significant source of morbidity in cancer patients. These disorders may be due to an underlying cancer (eg, multiple myeloma, lymphoma, or leukemia) or its treatments (eg, bone marrow transplant). Hypercalcemia and changes in potassium and sodium levels can present with altered mental status and weakness. Hypovolemia has several sources and may present with orthostatic hypotension, which contributes to falls.


Endocrine complications


The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is the second most common paraneoplastic endocrine disorder. It is seen in patients with small cell lung cancer and is a complication of chemotherapeutic medications (vincristine, vinblastine, cisplatin, and cyclophosphamide). Rehabilitation professionals should be aware of its presentation—changes in mental status, nausea, vomiting, weakness, muscle cramps, and seizures. Thyroid dysfunction, such as hypothyroidism, is seen in patients with a history of thyroid cancer or RT to the neck region for cancer. The clinical presentation includes cognitive slowing, fatigue, cold intolerance, and pleural/pericardial effusions. Cancer patients with diabetes deserve special mention because the combination of tight glycemic control and inadequate nutritional intake can lead to symptomatic hypoglycemia while patients undergo rehabilitation. Rehabilitation professionals should be aware of the clinical presentation of hypoglycemia, which includes sweating, anxiety, tremor, nausea, and fatigue and can progress to altered mental status, syncope, and seizures.


Hematological complications


Bone marrow infiltration from cancer can have a profound effect on cancer patients, which in turn affects their rehabilitation program. Anemia manifests through decreased exercise tolerance, angina symptoms, dizziness, and tachycardia. Neutropenia predisposes to infections and thrombocytopenia increases the risk of hemorrhages. Hyperviscosity syndrome characterized by erythrocytosis, leukocytosis, and thrombocytosis can lead to intracranial hemorrhaging and respiratory failures.


Infectious disease complications


Cancer patients are at increased risk of infections secondary to their underlying cancer diagnosis as well as its treatment (eg, bone marrow transplant). Common examples are pneumonia, urinary tract infection, gastrointestinal infections, and cellulitis. These infections have implications for their rehabilitation, including reduced ability to tolerate a rehabilitation program. For example, pneumonia is associated with shortness of breath and decreased oxygen saturation during therapy sessions.


Venous thromboembolic events


Between 3% and 18% of cancer patients have venous thrombosis. There is a significant increase in mortality among cancer patients with a venous thromboembolic event. The increased risk is often associated with a hypercoagulable state, decreased mobility, presence of varicose veins, fractures, use of oral corticosteroids, oral contraceptives, central venous catheters, and certain chemotherapy medications (cyclophosphamide, methotrexate, tamoxifen, and thalidomide).


Orthopedic complications


There are several types of cancer that metastasize to bone with breast, lung, prostate, renal, and thyroid being the most common sites of origin. Metastasis is the most common malignant process affecting the bones. Of all the new cases of invasive carcinoma diagnosed annually in the United States, approximately 50% eventually metastasize to bones. These metastatic lesions and other destructive processes affecting bones, such as myeloma and lymphoma, predispose the bone to an impending fracture. A pathologic fracture in these settings exposes patients to extreme pain, urgent hospitalization, and the risk of surgery in less than ideal circumstances. Mirels proposed a scoring system to classify pathologic fracture risk based on 4 characteristics : site of lesion (upper limb, lower limb, or peritrochanter) ; type of lesion (blastic, mixed, or lytic) ; size of lesion relative to the diameter of the bone (<1/3; 1/3–2/3; >2/3); and pain (mild, moderate, or functional). Each of these characteristics was assigned progressive scores ranging from 1 to 3. The highest scores were for lytic lesions in the peritrochanter region, greater than two-thirds in size relative to the diameter of the bone and pain with function. Functional pain is caused by muscles contracting around a lesion. A patient’s inability to perform a straight leg raise may indicate an impending pathologic fracture of the hip. The rate of pathologic fracture was 0% for lesions less than one-third the size of the cortex, 5% for lesions between one-third and two-thirds the size of the cortex, and 81% for lesions occupying more than two-thirds of the cortex. Harrington suggests that both lytic and blastic long bone metastases are at risk for developing pathologic fractures in instances where greater than 50% of the circumferential cortical bone has been destroyed or where the pain with weight-bearing stresses persists, increases, or recurs despite adequate local irradiation. Moreover, lesions of the proximal femur are at a high risk for fracture if they are in excess of 2.5 cm in any dimension or if they are associated with avulsion of the lesser trochanter. In a study done by Fidler, fractures were highly unlikely to occur (2.3%) when less than 50% of the cortex was destroyed and most likely to occur (80%) when greater than 75% of the cortex was destroyed. Pain was the only subjective variable in this classification system. Mild, moderate, or functional pain was assigned a score from 1 to 3, respectively. Rate of fracture was only 10% among patients with mild to moderate pain. All the patients with functional pain, however, progressed to a fracture.


Nervous system complications


Cancer patients with metastatic disease to the brain or those with primary brain tumors can have seizures, communication disorders secondary to aphasia, swallowing dysfunction, hemiparesis, and impaired balance. Cognitive deficits in sustained attention, short-term and delayed recall, processing speed, executive function, organizational skills, self-awareness, and mental fatigue can have a significant impact on the rehabilitation program. Fluctuating cognition and arousal due to underlying disease and treatments also affect rehabilitation.


Communication and swallowing complications


Head and neck cancer patients can have significant impairments in communication and swallowing function, including increased risk of aspiration secondary to the underlying cancer or its treatments. RT can lead to fibrosis of key muscles and structures used in the swallowing mechanism, such as base of the tongue, epiglottis, hypopharynx, and larynx, increasing the risk of aspiration as well as having an adverse effect on overall oral nutritional intake and hydration.


Impact on the Cancer Patient


Medical debility


Cancer patients can be significantly debilitated due to location, type, and extent of involvement of the cancer as well as treatments rendered, such as surgery, chemotherapy, and RT. Because cancer occurs in 76% of adults over age 55, cancer patients often have additional comorbidities from other medical diagnoses, such as coronary artery disease and diabetes, as well as the impact from earlier treatments for a recurrence of the cancer or other cancers. Many patients also receive steroids as part of their treatment protocols, which can cause a myopathy, furthering their already debilitated state as well as increasing the risk of fractures due to the demineralizing effect on bone.


Metastatic disease


There is a significant number of cancers that often metastasize to different parts of the body, such as bone, brain, lungs, and spinal cord. The presence of metastatic disease can pose safety risks to patients undergoing rehabilitation depending on its location. Examples are (1) metastasis to bone that increases the risk of pathologic fractures in vertebral bodies and long bones and (2) metastasis to the brain, which can lead to cognitive and physical impairments, such as memory loss, impaired judgment, hemiparesis, aphasia, and impaired balance, leading to increased risk of falling and difficulty understanding and following medical instructions as well as patients’ ability to advocate for their needs. Metastatic disease can also compress peripheral and central nervous system tissues, such as the brachial and lumbosacral plexus, peripheral nerves, and spinal cord, all of which have a profound effect on patients undergoing rehabilitation. It has been estimated that 25% to 30% of all cancer patients have metastatic disease to the lung and metastasis to the pleura occurs in 12% of breast cancer patients and 7% to 15% of lung cancers patients. Metastasis to the heart occurs in 8.4% of cancer patients. All of these pose an increased safety risk to patients undergoing rehabilitation programs.


Chemotherapy


There are myriad chemotherapeutic agents used in the treatment of cancer, often combined for maximal antineoplastic effects. These treatments, however, are often associated with significant toxicities in both the short term and long term of a patient’s life. Short-term generalized toxicities are varied; examples are nausea, vomiting, alopecia, mouth sores, and fatigue. Some toxicities have direct effects on organs: (1) doxorubicin and daunorubicin have direct effect on the heart, causing cardiomyopathy; (2) platins (cisplatin, carboplatin, and oxaliplatin), vinca alkaloids (vincristine and vinblastine), and taxanes (paclitaxel and docetaxel) cause damage to peripheral nerves; and (3) bleomycin, busulfan, methotrexate, and carmustine are linked with pulmonary fibrosis. Other toxicities have more generalized effects that are important in the rehabilitation setting. Examples are (1) infections, such as pneumonias secondary to a compromised immune system; (2) decreased hemoglobin, affecting the ability to tolerate an aerobic exercise program; and (3) decreased platelet counts, increasing the risk of bleeding.


Radiation therapy


RT has both short-term and long-term effects seen in the rehabilitation setting. Short-term effects include nausea, vomiting, alopecia, fatigue, localized skin irritation and blisters, loss of appetite, and mouth sores, all of which can affect a patient’s ability to tolerate a rehabilitation program. Long-term effects include myelopathy, plexopathy, encephalopathy, lymphedema, pulmonary fibrosis, accelerated atherosclerosis, osteoporosis, delayed healing, and osteonecrosis. Radiation fibrosis can cause injuries to peripheral nerve as well as injuries to muscles, bones, and connective tissues, in turn leading to contractures in limbs with an increased risk of falling if RT effects are in the lower extremities. Cognitive impairments also are seen in patients undergoing RT to the brain, in turn leading to impaired judgment or memory loss, which also increases safety risks, such as falls and difficulty understanding medical instructions.


Surgical treatments


Surgical treatments for cancer can alter a patient’s anatomy by removal of both diseased and healthy tissue, including bone, muscles, peripheral nerves, and connective tissues, in turn leading to significant impairments and disabilities. Lack of knowledge about the type of surgery performed as well as specific precautions after it places patients at risk.


Pain management


Pain is common in cancer patients. It has been estimated that 28% of newly diagnosed patients, 50% to 70% of patients receiving antineoplastic therapy, and 64% to 80% patients with advanced disease experience pain. Opioid medications are commonly used to treat pain in the cancer patient population; however, side effects from opioids can lead to drowsiness, impaired cognition, and falls. Invasive procedures, such as injections and nerve blocks used to treat cancer pain, pose their own safety risks.


Access to rehabilitative services


Access to rehabilitative services also is limited by lack of cancer-specific rehabilitative expertise, depleted financial reserves, limited medical insurance, and fragmented social support systems.




Patient assessment with an emphasis on patient safety


Medical History


The medical history is an important communication tool between rehabilitation clinicians caring for cancer patients as patients move along the continuum of care. The key elements of this document are (1) cancer diagnosis—type of cancer and stage and extent of metastatic disease (based on radiology and pathology reports); (2) complications related to the cancer infections, deep vein thrombosis (DVT), and anemia as well as treatments for the complications; and (3) treatments: chronology of all the treatments rendered, including surgeries, chemotherapy, and RT. Description of surgeries should include (1) type of surgery; (2) diseased and nondiseased structures removed, including bone, muscles, and peripheral nerves ; (3) postoperative precautions and instructions; (4) contact information for the surgeon who performed the surgery; and (5) future planned surgeries. Description of chemotherapy protocols should include (1) chemotherapeutic agents used in the past and present; (2) number of cycles and dates of chemotherapy cycles; (3) complications associated with the chemotherapy; and (4) diagnostic reports for key organs that may have been affected by the chemotherapy (eg, echocardiogram for patients with cardiomyopathy, pulmonary function tests for patients with pulmonary disease, and nerve conduction studies for patients with peripheral neuropathy). Description of RT treatments should include (1) structures that were irradiated, (2) total amount of radiation delivered to the structures in the past (remote and distant), (3) dates of the radiation treatments in the past and number of treatments planned for the future, and (4) side effects or long-term effects of the RT. Pain assessment includes (1) location, duration, quality, intensity, radiation, aggravating factors, and alleviating factors and (2) treatments rendered—medications, procedures, and their side effects. Other important information includes (1) past medical and surgical history (eg, diabetes, heart disease, and pulmonary disease); (2) allergies; (3) medications; (4) review of systems; (5) social and functional status; (6) pertinent laboratory values—hemoglobin, white blood cell, and platelet count; (7) pertinent radiology reports; (8) contact information for all key clinicians in a patient’s care—hematologist/oncologist, radiation oncologist, surgeon, primary care and physical therapists, occupational therapists, and speech pathologists who worked with the patient in the past as well as hospitals where the patient received treatments.


Physical Examination


The physical examination should focus on specific organ systems affected by the cancer. Key components are (1) vital signs, such as, temperature, respiratory rate, and oxygen saturation; it is useful to obtain heart rate and blood pressure readings in the supine, sitting, or standing position; (2) cardiopulmonary assessment; (3) neurological assessment: (a) cranial nerves, speech, and swallow; (b) brief cognitive evaluation that includes, at minimum, orientation to person, place, and time; immediate and delayed recall; and ability to follow instructions; (c) motor strength testing of key muscle groups; (d) sensory testing—light touch, pinprick, temperature, position sense, and vibration; (e) muscle stretch reflexes; (f) trunk control; and (g) gait; (4) musculoskeletal system: range of motion for all the key joints and spine and presence of contractures; and (5) skin: evidence of pressure ulcers and myofascial restrictions to movement.




Patient assessment with an emphasis on patient safety


Medical History


The medical history is an important communication tool between rehabilitation clinicians caring for cancer patients as patients move along the continuum of care. The key elements of this document are (1) cancer diagnosis—type of cancer and stage and extent of metastatic disease (based on radiology and pathology reports); (2) complications related to the cancer infections, deep vein thrombosis (DVT), and anemia as well as treatments for the complications; and (3) treatments: chronology of all the treatments rendered, including surgeries, chemotherapy, and RT. Description of surgeries should include (1) type of surgery; (2) diseased and nondiseased structures removed, including bone, muscles, and peripheral nerves ; (3) postoperative precautions and instructions; (4) contact information for the surgeon who performed the surgery; and (5) future planned surgeries. Description of chemotherapy protocols should include (1) chemotherapeutic agents used in the past and present; (2) number of cycles and dates of chemotherapy cycles; (3) complications associated with the chemotherapy; and (4) diagnostic reports for key organs that may have been affected by the chemotherapy (eg, echocardiogram for patients with cardiomyopathy, pulmonary function tests for patients with pulmonary disease, and nerve conduction studies for patients with peripheral neuropathy). Description of RT treatments should include (1) structures that were irradiated, (2) total amount of radiation delivered to the structures in the past (remote and distant), (3) dates of the radiation treatments in the past and number of treatments planned for the future, and (4) side effects or long-term effects of the RT. Pain assessment includes (1) location, duration, quality, intensity, radiation, aggravating factors, and alleviating factors and (2) treatments rendered—medications, procedures, and their side effects. Other important information includes (1) past medical and surgical history (eg, diabetes, heart disease, and pulmonary disease); (2) allergies; (3) medications; (4) review of systems; (5) social and functional status; (6) pertinent laboratory values—hemoglobin, white blood cell, and platelet count; (7) pertinent radiology reports; (8) contact information for all key clinicians in a patient’s care—hematologist/oncologist, radiation oncologist, surgeon, primary care and physical therapists, occupational therapists, and speech pathologists who worked with the patient in the past as well as hospitals where the patient received treatments.


Physical Examination


The physical examination should focus on specific organ systems affected by the cancer. Key components are (1) vital signs, such as, temperature, respiratory rate, and oxygen saturation; it is useful to obtain heart rate and blood pressure readings in the supine, sitting, or standing position; (2) cardiopulmonary assessment; (3) neurological assessment: (a) cranial nerves, speech, and swallow; (b) brief cognitive evaluation that includes, at minimum, orientation to person, place, and time; immediate and delayed recall; and ability to follow instructions; (c) motor strength testing of key muscle groups; (d) sensory testing—light touch, pinprick, temperature, position sense, and vibration; (e) muscle stretch reflexes; (f) trunk control; and (g) gait; (4) musculoskeletal system: range of motion for all the key joints and spine and presence of contractures; and (5) skin: evidence of pressure ulcers and myofascial restrictions to movement.

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Apr 17, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Patient Safety in Cancer Rehabilitation
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