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Journal of Clinical Oncology, Vol 26, No 16 (June 1), 2008: pp. 2610-2611 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2008.16.6850
The Oncology-Rehabilitation Interface: Better Systems NeededDepartment of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH The enormous discrepancy between the incidence of disabling physical impairments among individuals with cancer and the provision of medical rehabilitation services to address these problems has once again been documented by Cheville et al1 in this issue of Journal of Clinical Oncology. In particular, the difference between receipt of rehabilitation care during acute hospitalization and the extremely low rate for outpatients is impressive, but hardly surprising. The extent to which presence of advanced cancer has accentuated the magnitude of the differences between inpatient and outpatient rehabilitation service delivery is unclear, because similar trends would likely be found even among those with less extensive disease. In the inpatient setting, rehabilitation services such as physical and occupational therapy are often readily available, and are integral to the discharge-planning process to attain basic function sufficient for homegoing and avoid costly prolonged hospitalization. On the other hand, rehabilitation goals among outpatients are typically more varied and focused on specific impairments, such as lymphedema, contracture, motor-sensory deficits, deconditioning, and musculoskeletal pain syndromes. Active recognition of the impairments as remediable issues is required. Additional barriers not seen during inpatient care may be present, such as insurance authorization obstacles2 and inconvenience. The main problem, however, is that more effective systems are needed to recognize rehabilitation needs, provide rehabilitation care, and facilitate evidence-based outcomes of rehabilitation in the cancer population.3 Multiple studies have documented increased levels of disability among cancer patients and survivors.4,5 Yet, many gaps exist in our knowledge of how this broad-based information can be applied clinically. Which impairments justify vigilant screening? In which situations are the problems most remediable? What are best practices for treatment? How does the presence of advanced cancer affect appropriate rehabilitation management? Some cancer-related impairments, such as amputation, and conditions affecting the brain or spinal cord produce obvious and devastating clinical care needs. A wide range of treatable musculoskeletal disorders can also occur in the setting of cancer, a fact that is probably underappreciated, including among many rehabilitation practitioners. There is a need to more closely examine the extent of rehabilitation needs in historically elusive, yet common, cancer subpopulations, including those with advanced cancer. In depicting a model of rehabilitation care that has worked in a major cancer hospital, Grabois6 described "lessons learned," including the need for a core triad of strong administrative support, a physiatrist as medical director of rehabilitation services, and effective marketing. Clinical service lines including inpatient, consultative, and outpatient rehabilitation should be present, as well as an emphasis on scientific productivity, and educational dimensions including medical student and resident rotations, sponsorship of seminars, and development of cancer rehabilitation fellowships. Significantly, Grabois also spoke of the real-world importance of having adequate staff capacity to minimize patient waiting times, and of maintaining a convenient location. Such a model immerses rehabilitation in the culture and workings of the facility. Despite examples such as this, integration of rehabilitation into cancer care remains problematic. In a survey of National Cancer Institute–designated cancer centers, 70% of facilities reported services to treat lymphedema, but there was little discussion of other mainstream rehabilitation services.7 Challenges are even greater in institutions that are not dedicated cancer hospitals, where the majority of cancer patients are treated, and where rehabilitation services simultaneously need to meet the needs of other patient populations. What specific strategies can be employed to improve rehabilitation access for oncology patients? Lehmann,8 O’Toole,9 and Mosvas10 describe consultative models to screen oncology patients for rehabilitation needs, such as assigning rehabilitation personnel to meet regularly with the oncology team or using information such as the Karnofsky score to trigger rehabilitation assessment. However, data on long-term results of such screening systems are highly limited. Among inpatients, including those with advanced cancer, gains in functional status have been reported with both traditional acute rehabilitation11 and with interdisciplinary rehabilitation provided on a consultative basis,12 suggesting that future efforts at optimizing the rehabilitation screening process among oncology inpatients would be highly worthwhile. Among outpatients, screening presents even greater challenges. For example, do best care outcomes and cost effectiveness happen when a physiatrist sees all at-risk patients and triages the rehabilitation interventions, or when the patients go directly to other rehabilitation disciplines such as physical or occupational therapy, with physiatrist care reserved for those with the most complicated needs? Empirically, successful outpatient programs have cultivated specific service lines and consistent processes. Historically, many programs have been directed towards lymphedema and postmastectomy management, or other postsurgical issues. But there are other problems, often more global, to which there is a need to respond, especially as the evidence grows stronger. For example, because multiple studies have shown that individuals with cancer benefit from exercise programs,13 processes that routinely expedite exercise are needed. Areas ripe for future development include better integration of rehabilitation into self-advocacy tools,14 survivor clinics and care plans,15 and group-based care models. Especially for outpatients, it has been suggested that rehabilitation systems should move away from centralized care, with more direct outreach to oncology areas.16 Cheville et al's1 finding of apparent underservice among outpatients would seem to lend credence to this direction of care. In fact, such outreach may be particularly beneficial to those with advanced cancer. The need for more consistent and validated metrics for rehabilitation research has been identified.17 This is particularly true for outpatient care. Cheville et al's1 study employs some simple measures that include range of motion, limb girths, manual muscle testing, timed walk, and a numerically-based functional distress scale. Further exploration of tools that lend themselves to office-based application would be of great interest, both for screening and for objective monitoring of effects of rehabilitation care, including research applications. The authors hint at a few points that deserve greater emphasis. One is the factor about time since diagnosis with metastatic disease, which, in this study, averaged 30 months. The presumption is that there should have been plenty of time to identify and address the rehabilitation need. Although this is likely the case, with advanced disease, the patients’ status can be highly dynamic, which compounds the challenges of screening. Another point is the undertreatment among minority and socioeconomically disadvantaged groups. Here, the distinction between recognition of the rehabilitation need and referral, which pertain to basic quality of care within the medical system would be of interest, compared with more downstream barriers such as lack of transportation, conflicting life responsibilities, or insurance denials, relating to greater social stressors. Third, the issue of patients’ interest in receiving rehabilitation has received minimal prior attention; it is highly commendable that the authors explored this angle. Patients might deprioritize rehabilitation until their functional problems become more severe, which the authors’ results suggest. This observation lends further support to the need to maximize access and convenience, because a basic presumption is that impairments can be most readily addressed when they are mild. Until better systems are widespread, what can be done? Of course, oncologists can be mindful of impairments and disability, refer early, and clearly indicate any precautions. Communication, especially about prognostic concerns, helps to avoid confusion and mixed messages. The oncologist is encouraged to become familiar with local rehabilitation options and referral mechanisms, especially with regard to experience in treating cancer patients, specific programs, location of care, and waiting times. Often, direct referral can be made to a rehabilitation therapy discipline, such as physical, occupational, or speech therapy. Cancer rehabilitation settings may have programs in which new patients are screened first by, or jointly with, a physiatrist. For complicated cases, referral to a physiatrist should be made; examples include when multiple therapies are anticipated with consequent need for increased coordination of care, when consideration of interventions such as medications, injections, or electrodiagnostic testing is desired, or when in doubt about whether the patient is a candidate for rehabilitation. A recent book, After Cancer Treatment,18 discusses maximizing physical recovery and well-being from a rehabilitation perspective, and can be a useful resource for patients. Lastly, an important consideration beyond the scope of this study is cost effectiveness.19 Although data are limited, there are patients who maintain function without formal rehabilitation. Conversely, some impairments might not be remediable, and expending resources would be wasteful. Future research efforts should examine this issue. In the meantime, the present results support that, for patients with metastatic breast cancer, 90% of patients have at least one disabling impairment, with most considered to be remediable. Therefore, effective screening and care mechanisms to meet these needs are greatly warranted. Such care will benefit patients and also assist the oncology team. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES
1. Cheville AL, Troxel AB, Basford JR, Kornblith AB: Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer. J Clin Oncol 26:2621-2629, 2008 2. Germain P: Barriers to the optimal rehabilitation of surgical cancer patients in the managed care environment: An administrator's perspective. J Surg Oncol 95:386-392, 2007[CrossRef][Medline] 3. Hewitt M, Greenfield S, Stovall E: From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC, Committee on Cancer Survivorship: Improving Care and Quality of Life, National Cancer Policy Board, Institute of Medicine and National Research Council, National Academies Press, 2006 4. Hewitt M, Rowland JH, Yancik R: Cancer survivors in the United States: Age, health and disability. J Gerontol A Biol Sci Med Sci 58:82-91, 2003[Medline] 5. Hudson MM, Mertens AC, Yasui Y, et al: Health status of adult long-term survivors of childhood cancer: A report from the childhood cancer survivor study. JAMA 290:1583-1592, 2003 6. Grabois M: Integrating cancer rehabilitation into medical care at a cancer hospital. Cancer 92:1055-1057, 2001 (suppl)[CrossRef][Medline] 7. Tesauro GM, Rowland JH, Lustig C: Survivorship resources for post-treatment cancer survivors. Cancer Pract 10:277-283, 2002[CrossRef][Medline] 8. Lehmann JF, DeLisa JA, Warren CG, et al: Cancer rehabilitation: Assessment of need, development, and evaluation of a model of care. Arch Phys Med Rehabil 59:410-419, 1978[Medline] 9. O’Toole DM, Golden AM: Evaluating cancer patients for rehabilitation potential. West J Med 155:384-387, 1991[Medline] 10. Movsas SB, Chang VT, Tunkel RS, et al: Rehabilitation needs of an inpatient medical oncology unit. Arch Phys Med Rehabil 84:1642-1646, 2003[CrossRef][Medline] 11. Greenberg E, Treger I, Ring H: Rehabilitation outcomes in patients with brain tumors and acute stroke. Am J Phys Med Rehabil 85:568-573, 2006[CrossRef][Medline] 12. Sabers SR, Kokal JE, Girardi JC, et al: Evaluation of consultation-based rehabilitation for hospitalized cancer patients with functional impairment. Mayo Clin Proc 74:855-861, 1999[Abstract] 13. Knols R, Aaronson NK, Uebelhart D, et al: Physical exercise in cancer patients during and after medical treatment: A systematic review of randomized and controlled clinical trials. J Clin Oncol 23:3830-3842, 2005 14. Walsh-Burke K, Marcusen C: Self advocacy training for cancer survivors: The cancer survivor toolbox. Cancer Pract 7:297-301, 1999[CrossRef][Medline] 15. Earle CC: Failing to plan is planning to fail: Improving the quality of care with survivorship care plans. J Clin Oncol 24:5112-5116, 2006 16. Clark J, Ford S, Hegedus P: Developing a comprehensive cancer rehabilitation program. J Oncol Manag 13:13-21, 2004[Medline] 17. Frontera WR, Fuhrer MJ, Jette AM, et al: Rehabilitation Medicine Summit: Building research capacity. Am J Phys Med Rehabil 84:913-917, 2005[CrossRef][Medline] 18. Silver J: After Cancer Treatment. Baltimore, MD, Johns Hopkins University Press, 2006 19. Gordon LG, Scuffham P, Graves N, et al: A cost effectiveness analysis of two rehabilitation support services for women with breast cancer. Breast Cancer Res Treat 94:123-133, 2005[CrossRef][Medline]
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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