- Email: [email protected]
Cancer rehabilitation
Cancer Rehabilitation Andrea L. Cheville Cancer-related functional impairments and the associated economic burden are likely to increase in coming decades. A variety of factors contribute to the current availability of comprehensive rehabilitation services in only a few cancer centers. In general, cancer patients are highly distressed by the loss of independent mobility and self-care. The majority of patients are amenable to receiving rehabilitation services. Reports describing the integration of rehabilitation specialists into the delivery of cancer care strongly suggest that patients’ independence can be optimized through established techniques. The provision of humane and effective rehabilitation requires the formulation of dynamic and clinically appropriate goals. Many goals are common to most malignancies, eg, reducing the functional impact of aerobic deconditioning and chemotherapeutic neuropathy. Others are highly disease-specific, such as scapular stabilization following cranial nerve IX sacrifice. The expectations of patients and clinicians must evolve in response to the progression of disease. Restorative, supportive, preventative, and palliative goals should be re-evaluated at critical points along the disease course. A rubric for the development and implementation of rehabilitation goals at different cancer stages is described and illustrated with examples from breast and head and neck cancers. Semin Oncol 32:219-224 © 2005 Elsevier Inc. All rights reserved.
T
he goals of cancer rehabilitation remain broad and holistic as defined by Cromes 1 in 1978. “Cancer rehabilitation aims to allow the patient to achieve optimal physical, social, physiological and vocational functioning within the limits imposed by the disease and its treatment.”1 This definition resonates in the current culture of 21st century oncology. Although cancer rehabilitation can address psychological concerns, its primary focus relates to maximizing patients’ physical functioning during cancer treatment, following completion of therapy, and during cancer survivorship. Mounting evidence suggests that the implementation of appropriate rehabilitation goals and the timely provision of comprehensive services can meaningfully enhance the level of functional autonomy enjoyed by cancer patients living with, and cured of their disease. Historically, cancer rehabilitation too often has been dismissed as an oxymoron. The widely held perception that cancer is an inevitably progressive and terminal disease has undermined the allocation of human and fiscal resources for the development of rehabilitation services. As a consequence, cancer rehabilitation remains clinically marginalized, and it
Department of Rehabilitation Medicine, University of Pennsylvania Health System, Philadelphia, PA. Address reprint requests to Andrea L. Cheville, MD, Department of Rehabilitation Medicine, University of Pennsylvania Health System, 5 West Gates, 2400 Spruce St, Philadelphia, PA 19104. E-mail: [email protected]
0093-7754/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.seminoncol.2004.11.009
has been inadequately represented in medical literature, research, and education. This is unfortunate since many reports demonstrate that cancer patients generally want to remain independent in self-care, vocational pursuits, and mobility.2,3 Depression associated with cancer is highly associated with patient perceptions of increasing dependency and caretaker burden.4,5 Much cancer-related impairment and associated suffering may be diminished through timely and appropriate rehabilitative interventions. The knowledge and skill required to preserve patients’ autonomy is widely available within the rehabilitation medicine community. However, few cancer centers offer comprehensive rehabilitative services for oncology patients, despite patients’ concerns about progressive disability, their interest in receiving services, and the availability of professional expertise. If rehabilitation is to become an integral part of comprehensive cancer care, the rehabilitation medical team has to be integrated into the care plan similar to the way multidisciplinary treatment approaches have integrated surgery, radiation, and chemotherapy. A redefinition of clinical norms and current standards of care must take place. The expectation that optimal function is both reasonable and possible must be cultivated across the spectrum of professionals caring for cancer patients. If this expectation is communicated to patients, they can become self-advocates and solicit services proactively when threats arise to their independence. Recently, there have been significant strides to integrate cancer 219
A.L. Cheville
220 services that support psychological and functional well-being. These advances reflect growing awareness that quality, as well as quantity, of life matters to cancer patients. Hopefully, this trend will continue and produce an environment that supports concurrent delivery of function-enhancing and disease-modifying therapies.
Epidemiology Cancer rehabilitation is a timely topic since the medico-economic burden associated with cancer-related functional impairments is expected to increase. This can be attributed to several trends. Demographic projections predict an increasing population of older Americans over the next half century.6 Cancer incidence is highest among the elderly and we can therefore expect significant expansion in the number of elderly cancer patients.7 These patients’ fragile premorbid functional status renders them most vulnerable to the development of cancerand treatment-related impairments. The increasing prevalence of such impairments is also due to growing survivorship.7 The 5-year survival rates of many cancers have been extended. However, many of the advances responsible for enhanced survivorship exact a significant functional toll. For example, taxanes can cause debilitating peripheral neuropathy, and trastuzumab-associated cardiotoxicity can undermine exertional tolerance.9 In addition, we are only beginning to appreciate the adverse longterm functional consequences of aggressive combined modality therapies. A final contribution to increasing cancer-related impairment is the extension of the advanced stages of disease, an interval highly associated with deteriorating function. Expansion of the chemotherapeutic arsenal has permitted this extension by providing more treatment options to patients with stage IV disease. Given these trends, we can anticipate that more and more Americans will have had cancer or be living with a cancer diagnosis. Many will experience costly and potentially remediable functional compromise.
Impairment-Associated Psychological Distress The fact that remediable functional decline engenders significant psychological distress among cancer patients offers a compelling argument for cancer rehabilitation. Axelsson and Sjoden found that patients with far advanced disease rated “the loss of the ability to do what one wants” highest among of end-of-life concerns.3 The vast majority of “terminal” cancer patients express a strong desire for enhanced and autonomous mobility.2 Compromised self-care behaviors, particularly those relating to bowel and bladder hygiene, correlate with depression.10,11 Activities of daily living (ADL) dependency was associated with lower quality-of-life ratings in cancer patients.10 When functional decline leads patients to perceive themselves as an increasing caretaker burden, the perception may be associated with a desire to hasten death. In fact, the perception of increasing dependency was a strong predictor of patient interest in physician-assisted suicide.4 In Holland, where euthanasia is incorporated into clinical prac-
tice, the “fear of becoming a burden” was among the most frequently cited reasons for euthanasia requests.12 Cancer patients are eager to access rehabilitation services. For example, the majority of stage IV breast cancer patients are highly distressed by their cancer-related functional deficiencies and amenable to receiving rehabilitative services.13 In a patient sample with Karnofsky performance status (KPS) scores ranging from 40 to 90, the most common impairments were generalized deconditioning, exertional intolerance due to pulmonary factors, motor deficits related to epidural disease, brachial plexopathies, lymphedema, and chemotherapeutic neuropathy.13 Patients’ levels of distress were tightly correlated with their KPS scores. Patients with KPS scores of 40 to 50 described themselves as being “quite a bit” distressed by their mobility status and their inability to independently perform ADLs. Virtually all patients with KPS scores between 40 and 70 expressed very strong interest in receiving physical therapy and other rehabilitative interventions to optimize their functional status.
Efficacy of Cancer Rehabilitation Given that patients are distressed by cancer-associated functional decline and amenable to receiving treatment to reduce their disability, the question arises whether and to what degree rehabilitative interventions are effective in cancer. In anticipation of the establishment of a cancer rehabilitation service, a prospective, descriptive study was designed to characterize the scope and nature of cancer patients’ rehabilitation needs.14 In a sample of more than 800 patients, the prevalence and severity of different rehabilitation problems were recorded and the adequacy and efficacy of available services assessed. Unfortunately, the amount of quantitative information in the publication is limited. There was a large gap between cancer patients’ rehabilitation needs and available services. The authors began a cancer rehabilitation initiative that included patient education, automatic screening for functional deficits, and the introduction of a physiatrist to the clinical oncology team. Subsequent to the implementation of this service, significantly enhanced functional qualityof-life status was documented among the patient population. Additional studies, largely published in the 1970s, suggest that cancer rehabilitation programs offer meaningful patient benefit. A 1977 study of patients with breast, head and neck, and gastrointestinal tract cancers by Mellette showed that 47% of 400 patients in the sample returned to “mainstream life.”15 In describing a rehabilitation program developed at Memorial Sloan-Kettering Cancer Center, Dietz reported that 80% of patients with unspecified malignancies measurably benefited from an interdisciplinary approach.16 More recently, in 1991, O’Toole described a series of 70 cancer patients admitted for inpatient rehabilitation. The proportion of those capable of independent ambulation increased from 10% to 56%.17 A case series of 115 cancer patients admitted for acute inpatient rehabilitation reported an increase in functional independence measure scores of 13.1%, P
Cancer rehabilitation ⬍.001.18 Importantly, there was no significant difference in the gains made by patients with limited and more advanced stages of disease. Collectively, these reports argue persuasively that cancer rehabilitation can functionally benefit a significant proportion of cancer patients. An important case series published by Yoshioka in 1994 described the effects of physical therapy on a cohort of 301 terminal cancer patients admitted to an inpatient hospice facility.2 Barthel mobility indices (BMIs) were recorded preand post-physical therapy and a nonvalidated satisfaction questionnaire was administered to the patients. There was a mean increase of 7.5 in BMI scores (P ⬍.0001) following completion of physical therapy. Seventy-three percent of patients found the therapy to be “useful,” and 63% of patients found the therapy to be “highly effective.” Forty-six of the 301 patients achieved sufficient functional gains for autonomous mobility, which permitted home discharge. The current literature, though needing more well-designed and adequately powered studies, strongly suggests that cancer rehabilitation has the capacity to enhance patients’ functional status irrespective of cancer stage or ongoing antineoplastic therapy.
Formulation of Rehabilitation Goals One of the most challenging dimensions of cancer rehabilitation is setting humane, realistic, and clinically appropriate goals. Goals should be determined by an aggregate of factors, including patient age, type and stage of cancer, comorbid medical conditions, baseline physical fitness, and socioeconomic background. A widely accepted scheme focuses on identification of four categories of rehabilitation goals: restorative, supportive, preventative, and palliative.16 Restorative rehabilitation refers to the effort to return patients to their premorbid functional status when little or no long-term impairment is anticipated. For example, impairments associated with cancer-related surgeries such as mastectomy and axillary lymph node dissection are common considerations. Following these procedures, breast cancer patients should recover full shoulder range of motion and upper extremity strength. If long-term deficits occur, with restorative rehabilitation, patients are expected to recover to their premorbid levels of flexibility and strength. An additional example that has been extensively studied is interval aerobic conditioning following bone marrow transplantation.19 Bone marrow transplant patients generally experienced decline in their oxidative capacity in association with transplantation. With the initiation of an appropriate restorative rehabilitation program involving structured, progressive aerobic conditioning, they can recover to their premorbid level of aerobic fitness. Supportive rehabilitation attempts to maximize function after permanent impairments caused by cancer and/or its treatment. Cancer patients often sustain irremediable impairments; however, those need not produce significant disability or handicap. Supportive measures enable patients to circum-
221 vent the impairment and preserve their mobility and independence. For example, following surgical limb salvage, pelvic and lower extremity biomechanics are adversely affected. A rehabilitation program geared toward the restoration of proprioception, balance, and normal ambulatory patterns will minimize lasting gait abnormalities.20 An additional example is cognitive remediation following the resection or irradiation brain tumors. Many patients experience cognitive deficits following definitive treatment, but remediation programs allow precise definition of these deficits and the provision of compensatory strategies to minimize their functional impact.21 A final example of supportive rehabilitation is physical therapy for head and neck cancer patients following neck dissection and sacrifice of cranial nerve XI.22 Therapeutic strengthening and flexibility activities can do much to mitigate long-term shoulder dysfunction. Many patients never experience complete reinnervation of their trapezius muscle. However, with strategic strengthening of alternate shoulder elevators and retractors, patients need not develop significant associated disability. Preventative rehabilitation attempts to preclude or mitigate functional morbidity caused by cancer or its treatment. This is perhaps the most unappreciated yet powerful strategy in cancer rehabilitation. It is always easier to preserve strength, flexibility, and aerobic conditioning than to restore them once compromised. For this reason, patient education in appropriate preventative approaches helps to reduce longterm functional morbidity. Prophylactic range of motion of irradiated soft tissue is an excellent example. Some degree of soft tissue and muscle contracture generally occurs following radiation therapy.23 This is common in breast cancer patients, whose pectoralis major and minor muscles progressively shorten following breast or chest wall irradiation. Pectoral muscle tightness produces an imbalance in shoulder biomechanics and may eventually lead to myofascial pain syndromes and rotator cuff tendonopathies. If patients are instructed in appropriate pectoral muscle stretching at the time of radiation therapy, these conditions can be minimized.24 Protection of insensate skin secondary to chemotherapy-related peripheral neuropathy is another example of preventive rehabilitation. For many stage IV cancer patients receiving serial neurotoxic chemotherapies, proprioceptive and sensory impairment is severe, particularly among elderly cancer patients.25 If these patients are provided with appropriate orthotics and instructed in close monitoring of dermal integrity, decubitus ulcers and other adverse effects can be prevented. Palliative rehabilitation applies equally to patients with advanced cancer. Its primary goal is reduction of dependence in mobility and self-care activities in association with the provision of comfort and emotional support. Enabling patients to remain independent with bowel and bladder management is a prime goal. Fecal and urinary incontinence, in particular, engender psychological distress.26 Through provision of assistive devices and instruction in compensatory strategies, patients maintain personal hygiene until the extremely advanced stages of disease. Education in energy conservation approaches is also helpful.27 Patients learn to pace
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For purposes of rehabilitation considerations, cancer can be divided into several distinct stages. This approach calls clinical attention to certain nodal points along the disease trajectory that should trigger revaluation of anticipated deficits, reinvolvement of rehabilitation services, and redefinition of functional goals. We define five distinct stages of malignant disease, including initial diagnosis and treatment, surveillance, recurrence, temporization, and advanced disease. This concept borrows liberally from the model outlined by Gerber,28 and the reader is referred to this work for a more extensive discussion. Each of these stages will be addressed in turn with attention directed to critical physiatric issues. It is important to note that goal setting in cancer rehabilitation must be as dynamic as the disease. Goals must be continuously reformulated in response to the progression of the disease and the choice of antineoplastic therapies. Attention to these stages will ensure that significant shifts in prognosis and treatment requirements inform rehabilitative efforts. Breast, and head and neck cancers offer useful models for illustrating possible rehabilitative contributions at each stage of disease. These malignancies will be described in the following discussion of cancer stages.
their proprioceptive acuity. Concurrent stretching with a therapy ball prevents tightness of the abdominal wall and the resultant premature thoracic kyphosis. Latissimus flap breast reconstruction may disrupt shoulder biomechanics and produce periscapular pain if care is not taken to restore muscle strength and flexibility.31 Head and neck cancer patients often have intense rehabilitative needs following surgical neck dissection and external beam radiation. They require instruction in progressive neck range of motion and isometric cervical strengthening. These interventions minimize the risk of permanent anterior cervical soft tissue contractures. Following glossectomy or laryngectomy, patients should be provided with a means of communication and encouraged in its use immediately following surgery. If the expectation of immediate communication is fostered in patients, the likelihood of long-term withdrawal, social isolation, and depression is minimized. Spinal accessory nerve (cranial nerve XI) palsy commonly follows neck dissection. Many patients experience gradual reinervation and recover sufficient trapezius strength for normal performance of activities of daily living. However, if shoulder flexibility and stability are not proactively preserved after surgery and prior to reinervation, recovery may be incomplete and suboptimal. For those patients who never recover normal spinal accessory nerve function, strengthening of the unaffected shoulder elevators and retractors (eg, levator scapulae, rhomboid, and residual trapezius muscles) ensures optimal function within the limits of the associated impairment. During initial cancer treatment, cancer rehabilitation also attempts to limit the functional impact of chemotherapeutic toxicity. This includes neuropathies, pulmonary and cardiac toxicity, as well as fatigue and deconditioning. Many studies have demonstrated the substantial benefits of aerobic exercise during adjuvant chemotherapy for breast cancer.32,33 In addition, those patients who experience peripheral neuropathy benefit from assistive devices for mobility and ADL performance, optimizing their safety and function.
Initial Diagnosis and Treatment
Surveillance
At the time of their initial cancer diagnosis, patients deemed curable are treated aggressively with a regimen of anticancer therapies designed to definitively eliminate disease. A primary rehabilitation goal during initial cancer treatment is attenuation of the acute functional impact of surgery, radiation, and chemotherapy. Primary breast cancer surgery often produces lasting, adverse anatomic changes in the absence of rehabilitation. Following mastectomy and axillary lymph node dissection, patients should be instructed in progressive shoulder range of motion and upper extremity strengthening.29 This approach is both preventative and restorative. It obviates the development of contractures and abnormal shoulder biomechanics, and ensures that patients will have sufficient shoulder abduction and external rotation to comfortably undergo radiation therapy. Transverse rectus abdominus flap breast reconstruction produces deficits in truncal stability and strength.30 Exercise is used in a supportive fashion to strengthen residual abdominal muscles and to enhance
Once primary cancer treatment has been completed, patients enter a potentially protracted period of surveillance. For most patients, this is an uneasy and indefinite interval. Patients’ discovery that their lives do not effortlessly revert to their premorbid status after treatment can be difficult. Cancer patients need to become acquainted with their altered anatomy, physiology, and functional status. Rehabilitation will facilitate patients’ gradual return to an active and integrated lifestyle through vocational counseling, intermittent functional assessment, and education in potential late toxicities of cancer treatment (eg, lymphedema and radiation fibrosis). A primary goal of cancer rehabilitation during the surveillance phase of disease is the prevention and mitigation of latent cancer treatment-related impairments. Delayed radiation fibrosis contributes to lymphedema, pulmonary toxicity, plexopathies, and soft tissue contractures. Supportive, preventive, and restorative interventions ensure that patients’ function is not adversely impacted. For example, deconges-
themselves and make ergonomic modifications. If mobility is significantly threatened, provision of aids such as wheelchairs or scooters to ensure continued community integration and to prevent social isolation is recommended. It is extremely useful when assessing patients’ rehabilitation needs to consider systematically what restorative, supportive, preventative, and palliative goals are appropriate. Since cancer is a dynamic disease, it is important to review rehabilitation goals on a regular basis. What follows is a discussion of how goal setting should evolve across the trajectory of cancer.
Cancer Stages and Rehabilitation Needs
Cancer rehabilitation tive physiotherapy has been shown to control lymphedema indefinitely when used with appropriate intensity and duration.34 Pulmonary rehabilitation programs that foster progressive interval aerobic conditioning reduce or eliminate the adverse functional sequelae of radiation pneumonitis. Soft tissue contractures can be prevented entirely through the timely prescription of strategic and frequent stretching. When contractures are left unaddressed, aberrant biomechanics generally develop. These produce secondary pain generators. An excellent example is the spasm, pain, and myofascial dysfunction seen in the scapular retractors of breast cancer patients with pectoral muscle contractures consequent to radiation therapy. For some patients, the adverse effects of cancer treatment emerge many years after completion. Osteoporosis and premature osteoarthritis may develop in patients with therapeutically induced hypogonadism and abnormal gait patterns, respectively.35 In addition to dietary and pharmacologic interventions for osteoporosis, rehabilitation can reduce fracture risk through spinal extension exercises, axial loading activities, and balance training. Abnormal gait patterns arise from persistent chemotherapeutic neuropathies and radiation-induced tightness of pelvic muscles. Premature osteoarthritis can be mitigated through gait training, resistive exercises, flexibility activities, and exercises to encourage normal, integrated movement patterns. Osteoporosis and osteoarthritis are but two of many clinical conditions for which critical diagnostic and therapeutic insight can be offered by cancer rehabilitation specialists. The appropriate diagnosis and management of delayed impairments related to cancer therapy can preserve patients’ function and quality of life.
Disease Recurrence For some patients, the phase of surveillance ends with a diagnosis of recurrent cancer. If cure is deemed achievable, patients are treated aggressively in a multimodal fashion to eliminate disease. If not, they enter the temporization phase discussed below. Patients treated for recurrent cancer are rendered extremely vulnerable to lasting functional impairment since tissue previously subject to anticancer therapies may be surgically manipulated and/or irradiated. Cumulative chemotherapeutic and radiation toxicities may become problematic. Preventative rehabilitative strategies to preserve tissue flexibility and suppleness, normalize biomechanics, optimize wound healing, and preserve aerobic capacity ensure patients’ functional viability. Breast cancer patients treated for local disease recurrence often develop shoulder dysfunction in the absence of appropriate rehabilitation. This may present as adhesive capsulitis, myofascial dysfunction, neuropathic pain, or rotator cuff tendonitis. These conditions can be obviated with appropriate and timely physical therapy. The adverse effects of chemotherapy on aerobic capacity are only beginning to be quantified. Measurement of maximal oxidative capacity (VO2max) before, during, and following adjuvant chemotherapy demonstrates a significant reduction that continues long after treatment is complete. This
223 reduction may be cumulative with the repeated or protracted chemotherapy administration required to eradicate recurrent cancer. For this reason, patients treated for recurrent disease stand to benefit most from the restorative and preventative use of interval aerobic conditioning strategies. Conditioning will reduce morbidity due to cardiac and pulmonary toxicity associated with chemotherapy and radiation therapy. Patients successfully treated for recurrent disease reenter the surveillance phase described above with its associated concerns. The probability of latent function-compromising toxicity is greater and mandates stringent and ongoing screening for treatment-related impairments.
Temporization Patients who present with stage IV disease at initial diagnosis or who are deemed incurable following disease recurrence enter a stage characterized by efforts to temporize progression of disease. Anticancer therapies during this interval are geared toward reducing tumor burden, metastasis, and the development of medical comorbidities. Rehabilitation goals are analogous in their efforts to reduce functional morbidity. Patients generally undergo serial chemotherapy trials, which may engender progressive impairment. One of the greatest challenges to function preservation during temporization is the potential for acute cancer-related medical problems requiring aggressive management and/or hospitalization, eg, ureteral obstruction, pathologic fractures, pleural effusions, malignant epidural cord compression, etc. Palliative surgery or radiation may be required for symptom control or to limit associated neurologic deficits. Involvement of rehabilitation is essential once patients are rendered medically stable and comfortable. The deleterious effects of immobility (eg, muscle atrophy, aerobic deconditioning, osteopenia, loss of autonomic vascular tone) in this population emerge rapidly and may be difficult to reverse once established. The temporization phase may be punctuated by many acute medical problems, each of which has the potential to be functionally devastating. Because cancer patients receiving ongoing antineoplastic therapy are precariously poised for abrupt functional decline, periodic evaluation by a cancer rehabilitation specialist is warranted. Early detection of functional decline permits the timely initiation of preventative rehabilitative strategies, reduces the impact of impairments, and limits caretaker dependency. Rehabilitative interventions during the temporization phase must remain sensitive to patients’ prognoses, commitment to anticancer therapy, socioeconomic constraints, and willingness to participate in the rehabilitation process. When patients’ functional goals are defined through ongoing dialogue with a cancer rehabilitation professional, they will generally commit the time and energy needed to ensure functional autonomy.16
Palliation As patients enter the final stages of cancer, rehabilitative goals focus on maximizing patient independence for mobility and ADL performance. Cancer patients are intensely disturbed at the prospect of becoming increasingly burdensome to their caretakers.12 This is particularly true in relation to toileting
224 and hygiene-related activities. Physical and occupational therapists can provide patients with assistive devices, educate them in compensatory strategies, and offer guidance in environmental modification. Often remarkably simple rehabilitative strategies coupled with good symptom control and psychological support will significantly enhance patients’ ADL autonomy. Caretaker education becomes a key focus during the palliative stage of cancer rehabilitation. Teaching caretakers how to properly utilize durable medical equipment and to protect themselves from musculoskeletal strain during patient transfers empowers them and allows them to provide better patient assistance. Preservation of community integration, if appropriate, is an important rehabilitative focus during palliation. This can be achieved through the provision of wheelchairs, scooters, or assistive devices such as walkers, canes, or crutches. Home modification may be required to ensure easy access. The effort to preserve patients’ community involvement is invaluable in preventing progressive isolation and depression.
Conclusion Functional morbidity can be expected to increase as the number of patients with a history of cancer or living with active disease grows. Proactive cancer rehabilitation can significantly diminish the prevalence and impact of cancer-related impairments. It is reasonable to assume that greater availability and utilization of cancer rehabilitation professionals can reduce the medico-economic burden of cancer and significantly enhance patients’ quality of life. At present, there is lack of productive interface between the rehabilitation and oncologic medical communities. This presents a limitation to future growth of cancer rehabilitation. In addition, rehabilitation training programs for therapists, nurses, and physicians need to focus greater attention on the unique dimensions of cancer rehabilitation. Hopefully these challenges will be met in the future so that all cancer patients may remain maximally functional across the entire disease trajectory.
References 1. Cromes GJ: Implementation of interdisciplinary cancer rehabilitation. Rehabil Counseling Bull 21:230-237, 1978 2. Yoshioka H: Rehabilitation for the terminal cancer patient. Am J Phys Med Rehabil 73:199-206, 1994 3. Axelsson B, Sjoden P: Quality of life of cancer patients and their spouses in palliative home care. Palliat Med 12:29-39, 1998 4. Emanuel E, Daniels ER, Fairclough DL, et al: The practice of euthanasia and physician-assisted suicide in the United States: Adherence to proposed safeguards and effects on physicians. JAMA 280:507-513, 1998 5. Longman A, Braden C, Mishel MH, et al: Side effects burden in women with breast cancer. Cancer Pract 4:274 –280, 1996 6. The Sex and Age Distribution of the World Populations: 1998 Revision, Vol. II: Sex and Age (United Nations publication, Sales No. E.99.XIII.8). New York, NY, United Nations, 1998 7. American Cancer Society: Cancer Facts and Figures 2004. Atlanta, GA, American Cancer Society, 2004 8. Kuroi K, Shimozuma K: Neurotoxicity of taxanes: Symptoms and quality of life assessment. Breast Cancer 11:92-99, 2004 9. Klein P, Dybdal N: Trastuzumab and cardiac dysfunction: update on preclinical studies. Semin Oncol 30:49-53, 2003 (suppl 16)
A.L. Cheville 10. Ulander K, Jeppsson B, Grahn G: Quality of life and independence in activities of daily living preoperatively and at follow-up in patients with colorectal cancer. Support Care Cancer 5:402-409, 1997 11. Broome B: The impact of urinary incontinence on self-efficacy and qualify of life. Health Qual Life Outcomes 1:35, 2003 12. van der Maas P, van der Wal G, Haverkate I, et al: Euthanasia, physicianassisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 335:1699-1705, 1996 13. Cheville A, Kornblith A: Impirment-associated distress in stage IV breast cancer. Presented at the 63rd Annual Assembly of the American Academy of Rehabilitation Medicine, Orlando, FL, November 21-24, 2002 14. Lehman J, DeLisa J, Warren C: Cancer rehabilitation: Assessment of need, development, and evaluation of a model of care. Arch Phys Med Rehabil 59:410-419, 1978 15. Mellette S: Development and utilization of rehabilitation and continuing care resources and services for cancer patients. (Final report, June 1974 to July 1977.) Contract NO1-CN-65287. Richmond, VA, Medical College of Virginia/Virginia Commonwealth University Cancer Center, 1977 16. Deitz JJ: Rehabilitation of the cancer patient: Its role in the scheme of comprehensive care. Clin Bull 4:104-107, 1974 17. Harvey R, Jellinek H, Habeck R: Cancer rehabilitation. An analysis of 36 program approaches. JAMA 15:2127-2131, 1982 18. Marciniak C, Sliwa JA, Spill G, et al: Functional outcome following rehabilitation of the cancer patients. Arch Phys Med Rehabil 77:54-57, 1996 19. Dimeo F, Bertz H, Finke J, et al: An aerobic exercise program for patients with haematological malignancies after bone marrow transplantation. Bone Marrow Transplant 18:1157-1160, 1996 20. King JC, Williams RP, McAnelly RD, et al: Rehabilitation of tumor amputees and limb salvage patients. Phys Med Rehabil State Art Rev 8:297-319, 1994 21. Butler R, Copeland D: Attentional processes and their remediation in children treated for cancer: A literature review and the development of a therapeutic approach. J Int Neuropsychol Soc 8:115-124, 2002 22. Hillel A, Patten C: Neck dissection: Morbidity and rehabilitation. Cancer Treat Res 52:133-147, 1990 23. Autio P, Saarto T, Tenhunen M, et al: Demonstration of increased collagen synthesis in irradiated human skin in vivo. Br J Cancer 77: 2331-2335, 1998 24. Johansson K, Ingvar C, Albertsson M, et al: Arm lymphedema, shoulder mobility and muscle strength after breast cancer treatment—A prospective 2-year study. Adv Physiother 3:55-66, 2001 25. Repetto L: Greater risks of chemotherapy toxicity in elderly patients with cancer. J Support Oncol 1:18-24, 2003 (suppl 2) 26. Smith D: Urinary continence issues in oncology. Clin J Oncol Nurs 3:180-182, 1999 27. Barsevick A: Energy conservation and cancer-related fatigue. Rehabil Oncol 20:14-17, 2002 28. Gerber L: Cancer Rehabilitation, in Devita V, Hellman S, Rosenberg S (eds): Cancer: Principles and Practice of Oncology. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 2925-2956 29. Lotze M, Duncan MA, Gerber LH, et al: Early versus delayed shoulder motion following axillary dissection: A randomized prospective study. Ann Surg 193:288-295, 1981 30. Field S, Knecht K, Schrodi D, et al: Functional limitations of women with transverse rectus abdominis (TRAM) flap breast reconstruction: Summary of presentation at CSM, Boston, MA. Rehabil Oncol 16:28-32, 1998 31. Carter A: Occupational therapy perspective: Breast cancer reconstructive rehabilitation. J Bodywork Movement Ther 3:19-23, 1999 32. Winningham M, MacVicar MG, Bondoc M, et al: Effect of aerobic exercise on body weight and composition in patients with breast cancer on adjuvant chemotherapy. Oncol Nurs Forum 16:683-689, 1989 33. Segal R, Evans W, Johnson D, et al: Structured exercise improves physical functioning in women with stages I and II breast cancer: Results of a randomized controlled trial. J Clin Oncol 19:657-665, 2001 34. Ko D, Lerner R, Klose G, et al: Effective treatment of lymphedema of the extremities. Arch Surg 133:452-458, 1998 35. Fontanges E, Fontana A, Delmas P: Osteoporosis and breast cancer. Joint Bone Spine 71:102-110, 2004
T
he goals of cancer rehabilitation remain broad and holistic as defined by Cromes 1 in 1978. “Cancer rehabilitation aims to allow the patient to achieve optimal physical, social, physiological and vocational functioning within the limits imposed by the disease and its treatment.”1 This definition resonates in the current culture of 21st century oncology. Although cancer rehabilitation can address psychological concerns, its primary focus relates to maximizing patients’ physical functioning during cancer treatment, following completion of therapy, and during cancer survivorship. Mounting evidence suggests that the implementation of appropriate rehabilitation goals and the timely provision of comprehensive services can meaningfully enhance the level of functional autonomy enjoyed by cancer patients living with, and cured of their disease. Historically, cancer rehabilitation too often has been dismissed as an oxymoron. The widely held perception that cancer is an inevitably progressive and terminal disease has undermined the allocation of human and fiscal resources for the development of rehabilitation services. As a consequence, cancer rehabilitation remains clinically marginalized, and it
Department of Rehabilitation Medicine, University of Pennsylvania Health System, Philadelphia, PA. Address reprint requests to Andrea L. Cheville, MD, Department of Rehabilitation Medicine, University of Pennsylvania Health System, 5 West Gates, 2400 Spruce St, Philadelphia, PA 19104. E-mail: [email protected]
0093-7754/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.seminoncol.2004.11.009
has been inadequately represented in medical literature, research, and education. This is unfortunate since many reports demonstrate that cancer patients generally want to remain independent in self-care, vocational pursuits, and mobility.2,3 Depression associated with cancer is highly associated with patient perceptions of increasing dependency and caretaker burden.4,5 Much cancer-related impairment and associated suffering may be diminished through timely and appropriate rehabilitative interventions. The knowledge and skill required to preserve patients’ autonomy is widely available within the rehabilitation medicine community. However, few cancer centers offer comprehensive rehabilitative services for oncology patients, despite patients’ concerns about progressive disability, their interest in receiving services, and the availability of professional expertise. If rehabilitation is to become an integral part of comprehensive cancer care, the rehabilitation medical team has to be integrated into the care plan similar to the way multidisciplinary treatment approaches have integrated surgery, radiation, and chemotherapy. A redefinition of clinical norms and current standards of care must take place. The expectation that optimal function is both reasonable and possible must be cultivated across the spectrum of professionals caring for cancer patients. If this expectation is communicated to patients, they can become self-advocates and solicit services proactively when threats arise to their independence. Recently, there have been significant strides to integrate cancer 219
A.L. Cheville
220 services that support psychological and functional well-being. These advances reflect growing awareness that quality, as well as quantity, of life matters to cancer patients. Hopefully, this trend will continue and produce an environment that supports concurrent delivery of function-enhancing and disease-modifying therapies.
Epidemiology Cancer rehabilitation is a timely topic since the medico-economic burden associated with cancer-related functional impairments is expected to increase. This can be attributed to several trends. Demographic projections predict an increasing population of older Americans over the next half century.6 Cancer incidence is highest among the elderly and we can therefore expect significant expansion in the number of elderly cancer patients.7 These patients’ fragile premorbid functional status renders them most vulnerable to the development of cancerand treatment-related impairments. The increasing prevalence of such impairments is also due to growing survivorship.7 The 5-year survival rates of many cancers have been extended. However, many of the advances responsible for enhanced survivorship exact a significant functional toll. For example, taxanes can cause debilitating peripheral neuropathy, and trastuzumab-associated cardiotoxicity can undermine exertional tolerance.9 In addition, we are only beginning to appreciate the adverse longterm functional consequences of aggressive combined modality therapies. A final contribution to increasing cancer-related impairment is the extension of the advanced stages of disease, an interval highly associated with deteriorating function. Expansion of the chemotherapeutic arsenal has permitted this extension by providing more treatment options to patients with stage IV disease. Given these trends, we can anticipate that more and more Americans will have had cancer or be living with a cancer diagnosis. Many will experience costly and potentially remediable functional compromise.
Impairment-Associated Psychological Distress The fact that remediable functional decline engenders significant psychological distress among cancer patients offers a compelling argument for cancer rehabilitation. Axelsson and Sjoden found that patients with far advanced disease rated “the loss of the ability to do what one wants” highest among of end-of-life concerns.3 The vast majority of “terminal” cancer patients express a strong desire for enhanced and autonomous mobility.2 Compromised self-care behaviors, particularly those relating to bowel and bladder hygiene, correlate with depression.10,11 Activities of daily living (ADL) dependency was associated with lower quality-of-life ratings in cancer patients.10 When functional decline leads patients to perceive themselves as an increasing caretaker burden, the perception may be associated with a desire to hasten death. In fact, the perception of increasing dependency was a strong predictor of patient interest in physician-assisted suicide.4 In Holland, where euthanasia is incorporated into clinical prac-
tice, the “fear of becoming a burden” was among the most frequently cited reasons for euthanasia requests.12 Cancer patients are eager to access rehabilitation services. For example, the majority of stage IV breast cancer patients are highly distressed by their cancer-related functional deficiencies and amenable to receiving rehabilitative services.13 In a patient sample with Karnofsky performance status (KPS) scores ranging from 40 to 90, the most common impairments were generalized deconditioning, exertional intolerance due to pulmonary factors, motor deficits related to epidural disease, brachial plexopathies, lymphedema, and chemotherapeutic neuropathy.13 Patients’ levels of distress were tightly correlated with their KPS scores. Patients with KPS scores of 40 to 50 described themselves as being “quite a bit” distressed by their mobility status and their inability to independently perform ADLs. Virtually all patients with KPS scores between 40 and 70 expressed very strong interest in receiving physical therapy and other rehabilitative interventions to optimize their functional status.
Efficacy of Cancer Rehabilitation Given that patients are distressed by cancer-associated functional decline and amenable to receiving treatment to reduce their disability, the question arises whether and to what degree rehabilitative interventions are effective in cancer. In anticipation of the establishment of a cancer rehabilitation service, a prospective, descriptive study was designed to characterize the scope and nature of cancer patients’ rehabilitation needs.14 In a sample of more than 800 patients, the prevalence and severity of different rehabilitation problems were recorded and the adequacy and efficacy of available services assessed. Unfortunately, the amount of quantitative information in the publication is limited. There was a large gap between cancer patients’ rehabilitation needs and available services. The authors began a cancer rehabilitation initiative that included patient education, automatic screening for functional deficits, and the introduction of a physiatrist to the clinical oncology team. Subsequent to the implementation of this service, significantly enhanced functional qualityof-life status was documented among the patient population. Additional studies, largely published in the 1970s, suggest that cancer rehabilitation programs offer meaningful patient benefit. A 1977 study of patients with breast, head and neck, and gastrointestinal tract cancers by Mellette showed that 47% of 400 patients in the sample returned to “mainstream life.”15 In describing a rehabilitation program developed at Memorial Sloan-Kettering Cancer Center, Dietz reported that 80% of patients with unspecified malignancies measurably benefited from an interdisciplinary approach.16 More recently, in 1991, O’Toole described a series of 70 cancer patients admitted for inpatient rehabilitation. The proportion of those capable of independent ambulation increased from 10% to 56%.17 A case series of 115 cancer patients admitted for acute inpatient rehabilitation reported an increase in functional independence measure scores of 13.1%, P
Cancer rehabilitation ⬍.001.18 Importantly, there was no significant difference in the gains made by patients with limited and more advanced stages of disease. Collectively, these reports argue persuasively that cancer rehabilitation can functionally benefit a significant proportion of cancer patients. An important case series published by Yoshioka in 1994 described the effects of physical therapy on a cohort of 301 terminal cancer patients admitted to an inpatient hospice facility.2 Barthel mobility indices (BMIs) were recorded preand post-physical therapy and a nonvalidated satisfaction questionnaire was administered to the patients. There was a mean increase of 7.5 in BMI scores (P ⬍.0001) following completion of physical therapy. Seventy-three percent of patients found the therapy to be “useful,” and 63% of patients found the therapy to be “highly effective.” Forty-six of the 301 patients achieved sufficient functional gains for autonomous mobility, which permitted home discharge. The current literature, though needing more well-designed and adequately powered studies, strongly suggests that cancer rehabilitation has the capacity to enhance patients’ functional status irrespective of cancer stage or ongoing antineoplastic therapy.
Formulation of Rehabilitation Goals One of the most challenging dimensions of cancer rehabilitation is setting humane, realistic, and clinically appropriate goals. Goals should be determined by an aggregate of factors, including patient age, type and stage of cancer, comorbid medical conditions, baseline physical fitness, and socioeconomic background. A widely accepted scheme focuses on identification of four categories of rehabilitation goals: restorative, supportive, preventative, and palliative.16 Restorative rehabilitation refers to the effort to return patients to their premorbid functional status when little or no long-term impairment is anticipated. For example, impairments associated with cancer-related surgeries such as mastectomy and axillary lymph node dissection are common considerations. Following these procedures, breast cancer patients should recover full shoulder range of motion and upper extremity strength. If long-term deficits occur, with restorative rehabilitation, patients are expected to recover to their premorbid levels of flexibility and strength. An additional example that has been extensively studied is interval aerobic conditioning following bone marrow transplantation.19 Bone marrow transplant patients generally experienced decline in their oxidative capacity in association with transplantation. With the initiation of an appropriate restorative rehabilitation program involving structured, progressive aerobic conditioning, they can recover to their premorbid level of aerobic fitness. Supportive rehabilitation attempts to maximize function after permanent impairments caused by cancer and/or its treatment. Cancer patients often sustain irremediable impairments; however, those need not produce significant disability or handicap. Supportive measures enable patients to circum-
221 vent the impairment and preserve their mobility and independence. For example, following surgical limb salvage, pelvic and lower extremity biomechanics are adversely affected. A rehabilitation program geared toward the restoration of proprioception, balance, and normal ambulatory patterns will minimize lasting gait abnormalities.20 An additional example is cognitive remediation following the resection or irradiation brain tumors. Many patients experience cognitive deficits following definitive treatment, but remediation programs allow precise definition of these deficits and the provision of compensatory strategies to minimize their functional impact.21 A final example of supportive rehabilitation is physical therapy for head and neck cancer patients following neck dissection and sacrifice of cranial nerve XI.22 Therapeutic strengthening and flexibility activities can do much to mitigate long-term shoulder dysfunction. Many patients never experience complete reinnervation of their trapezius muscle. However, with strategic strengthening of alternate shoulder elevators and retractors, patients need not develop significant associated disability. Preventative rehabilitation attempts to preclude or mitigate functional morbidity caused by cancer or its treatment. This is perhaps the most unappreciated yet powerful strategy in cancer rehabilitation. It is always easier to preserve strength, flexibility, and aerobic conditioning than to restore them once compromised. For this reason, patient education in appropriate preventative approaches helps to reduce longterm functional morbidity. Prophylactic range of motion of irradiated soft tissue is an excellent example. Some degree of soft tissue and muscle contracture generally occurs following radiation therapy.23 This is common in breast cancer patients, whose pectoralis major and minor muscles progressively shorten following breast or chest wall irradiation. Pectoral muscle tightness produces an imbalance in shoulder biomechanics and may eventually lead to myofascial pain syndromes and rotator cuff tendonopathies. If patients are instructed in appropriate pectoral muscle stretching at the time of radiation therapy, these conditions can be minimized.24 Protection of insensate skin secondary to chemotherapy-related peripheral neuropathy is another example of preventive rehabilitation. For many stage IV cancer patients receiving serial neurotoxic chemotherapies, proprioceptive and sensory impairment is severe, particularly among elderly cancer patients.25 If these patients are provided with appropriate orthotics and instructed in close monitoring of dermal integrity, decubitus ulcers and other adverse effects can be prevented. Palliative rehabilitation applies equally to patients with advanced cancer. Its primary goal is reduction of dependence in mobility and self-care activities in association with the provision of comfort and emotional support. Enabling patients to remain independent with bowel and bladder management is a prime goal. Fecal and urinary incontinence, in particular, engender psychological distress.26 Through provision of assistive devices and instruction in compensatory strategies, patients maintain personal hygiene until the extremely advanced stages of disease. Education in energy conservation approaches is also helpful.27 Patients learn to pace
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For purposes of rehabilitation considerations, cancer can be divided into several distinct stages. This approach calls clinical attention to certain nodal points along the disease trajectory that should trigger revaluation of anticipated deficits, reinvolvement of rehabilitation services, and redefinition of functional goals. We define five distinct stages of malignant disease, including initial diagnosis and treatment, surveillance, recurrence, temporization, and advanced disease. This concept borrows liberally from the model outlined by Gerber,28 and the reader is referred to this work for a more extensive discussion. Each of these stages will be addressed in turn with attention directed to critical physiatric issues. It is important to note that goal setting in cancer rehabilitation must be as dynamic as the disease. Goals must be continuously reformulated in response to the progression of the disease and the choice of antineoplastic therapies. Attention to these stages will ensure that significant shifts in prognosis and treatment requirements inform rehabilitative efforts. Breast, and head and neck cancers offer useful models for illustrating possible rehabilitative contributions at each stage of disease. These malignancies will be described in the following discussion of cancer stages.
their proprioceptive acuity. Concurrent stretching with a therapy ball prevents tightness of the abdominal wall and the resultant premature thoracic kyphosis. Latissimus flap breast reconstruction may disrupt shoulder biomechanics and produce periscapular pain if care is not taken to restore muscle strength and flexibility.31 Head and neck cancer patients often have intense rehabilitative needs following surgical neck dissection and external beam radiation. They require instruction in progressive neck range of motion and isometric cervical strengthening. These interventions minimize the risk of permanent anterior cervical soft tissue contractures. Following glossectomy or laryngectomy, patients should be provided with a means of communication and encouraged in its use immediately following surgery. If the expectation of immediate communication is fostered in patients, the likelihood of long-term withdrawal, social isolation, and depression is minimized. Spinal accessory nerve (cranial nerve XI) palsy commonly follows neck dissection. Many patients experience gradual reinervation and recover sufficient trapezius strength for normal performance of activities of daily living. However, if shoulder flexibility and stability are not proactively preserved after surgery and prior to reinervation, recovery may be incomplete and suboptimal. For those patients who never recover normal spinal accessory nerve function, strengthening of the unaffected shoulder elevators and retractors (eg, levator scapulae, rhomboid, and residual trapezius muscles) ensures optimal function within the limits of the associated impairment. During initial cancer treatment, cancer rehabilitation also attempts to limit the functional impact of chemotherapeutic toxicity. This includes neuropathies, pulmonary and cardiac toxicity, as well as fatigue and deconditioning. Many studies have demonstrated the substantial benefits of aerobic exercise during adjuvant chemotherapy for breast cancer.32,33 In addition, those patients who experience peripheral neuropathy benefit from assistive devices for mobility and ADL performance, optimizing their safety and function.
Initial Diagnosis and Treatment
Surveillance
At the time of their initial cancer diagnosis, patients deemed curable are treated aggressively with a regimen of anticancer therapies designed to definitively eliminate disease. A primary rehabilitation goal during initial cancer treatment is attenuation of the acute functional impact of surgery, radiation, and chemotherapy. Primary breast cancer surgery often produces lasting, adverse anatomic changes in the absence of rehabilitation. Following mastectomy and axillary lymph node dissection, patients should be instructed in progressive shoulder range of motion and upper extremity strengthening.29 This approach is both preventative and restorative. It obviates the development of contractures and abnormal shoulder biomechanics, and ensures that patients will have sufficient shoulder abduction and external rotation to comfortably undergo radiation therapy. Transverse rectus abdominus flap breast reconstruction produces deficits in truncal stability and strength.30 Exercise is used in a supportive fashion to strengthen residual abdominal muscles and to enhance
Once primary cancer treatment has been completed, patients enter a potentially protracted period of surveillance. For most patients, this is an uneasy and indefinite interval. Patients’ discovery that their lives do not effortlessly revert to their premorbid status after treatment can be difficult. Cancer patients need to become acquainted with their altered anatomy, physiology, and functional status. Rehabilitation will facilitate patients’ gradual return to an active and integrated lifestyle through vocational counseling, intermittent functional assessment, and education in potential late toxicities of cancer treatment (eg, lymphedema and radiation fibrosis). A primary goal of cancer rehabilitation during the surveillance phase of disease is the prevention and mitigation of latent cancer treatment-related impairments. Delayed radiation fibrosis contributes to lymphedema, pulmonary toxicity, plexopathies, and soft tissue contractures. Supportive, preventive, and restorative interventions ensure that patients’ function is not adversely impacted. For example, deconges-
themselves and make ergonomic modifications. If mobility is significantly threatened, provision of aids such as wheelchairs or scooters to ensure continued community integration and to prevent social isolation is recommended. It is extremely useful when assessing patients’ rehabilitation needs to consider systematically what restorative, supportive, preventative, and palliative goals are appropriate. Since cancer is a dynamic disease, it is important to review rehabilitation goals on a regular basis. What follows is a discussion of how goal setting should evolve across the trajectory of cancer.
Cancer Stages and Rehabilitation Needs
Cancer rehabilitation tive physiotherapy has been shown to control lymphedema indefinitely when used with appropriate intensity and duration.34 Pulmonary rehabilitation programs that foster progressive interval aerobic conditioning reduce or eliminate the adverse functional sequelae of radiation pneumonitis. Soft tissue contractures can be prevented entirely through the timely prescription of strategic and frequent stretching. When contractures are left unaddressed, aberrant biomechanics generally develop. These produce secondary pain generators. An excellent example is the spasm, pain, and myofascial dysfunction seen in the scapular retractors of breast cancer patients with pectoral muscle contractures consequent to radiation therapy. For some patients, the adverse effects of cancer treatment emerge many years after completion. Osteoporosis and premature osteoarthritis may develop in patients with therapeutically induced hypogonadism and abnormal gait patterns, respectively.35 In addition to dietary and pharmacologic interventions for osteoporosis, rehabilitation can reduce fracture risk through spinal extension exercises, axial loading activities, and balance training. Abnormal gait patterns arise from persistent chemotherapeutic neuropathies and radiation-induced tightness of pelvic muscles. Premature osteoarthritis can be mitigated through gait training, resistive exercises, flexibility activities, and exercises to encourage normal, integrated movement patterns. Osteoporosis and osteoarthritis are but two of many clinical conditions for which critical diagnostic and therapeutic insight can be offered by cancer rehabilitation specialists. The appropriate diagnosis and management of delayed impairments related to cancer therapy can preserve patients’ function and quality of life.
Disease Recurrence For some patients, the phase of surveillance ends with a diagnosis of recurrent cancer. If cure is deemed achievable, patients are treated aggressively in a multimodal fashion to eliminate disease. If not, they enter the temporization phase discussed below. Patients treated for recurrent cancer are rendered extremely vulnerable to lasting functional impairment since tissue previously subject to anticancer therapies may be surgically manipulated and/or irradiated. Cumulative chemotherapeutic and radiation toxicities may become problematic. Preventative rehabilitative strategies to preserve tissue flexibility and suppleness, normalize biomechanics, optimize wound healing, and preserve aerobic capacity ensure patients’ functional viability. Breast cancer patients treated for local disease recurrence often develop shoulder dysfunction in the absence of appropriate rehabilitation. This may present as adhesive capsulitis, myofascial dysfunction, neuropathic pain, or rotator cuff tendonitis. These conditions can be obviated with appropriate and timely physical therapy. The adverse effects of chemotherapy on aerobic capacity are only beginning to be quantified. Measurement of maximal oxidative capacity (VO2max) before, during, and following adjuvant chemotherapy demonstrates a significant reduction that continues long after treatment is complete. This
223 reduction may be cumulative with the repeated or protracted chemotherapy administration required to eradicate recurrent cancer. For this reason, patients treated for recurrent disease stand to benefit most from the restorative and preventative use of interval aerobic conditioning strategies. Conditioning will reduce morbidity due to cardiac and pulmonary toxicity associated with chemotherapy and radiation therapy. Patients successfully treated for recurrent disease reenter the surveillance phase described above with its associated concerns. The probability of latent function-compromising toxicity is greater and mandates stringent and ongoing screening for treatment-related impairments.
Temporization Patients who present with stage IV disease at initial diagnosis or who are deemed incurable following disease recurrence enter a stage characterized by efforts to temporize progression of disease. Anticancer therapies during this interval are geared toward reducing tumor burden, metastasis, and the development of medical comorbidities. Rehabilitation goals are analogous in their efforts to reduce functional morbidity. Patients generally undergo serial chemotherapy trials, which may engender progressive impairment. One of the greatest challenges to function preservation during temporization is the potential for acute cancer-related medical problems requiring aggressive management and/or hospitalization, eg, ureteral obstruction, pathologic fractures, pleural effusions, malignant epidural cord compression, etc. Palliative surgery or radiation may be required for symptom control or to limit associated neurologic deficits. Involvement of rehabilitation is essential once patients are rendered medically stable and comfortable. The deleterious effects of immobility (eg, muscle atrophy, aerobic deconditioning, osteopenia, loss of autonomic vascular tone) in this population emerge rapidly and may be difficult to reverse once established. The temporization phase may be punctuated by many acute medical problems, each of which has the potential to be functionally devastating. Because cancer patients receiving ongoing antineoplastic therapy are precariously poised for abrupt functional decline, periodic evaluation by a cancer rehabilitation specialist is warranted. Early detection of functional decline permits the timely initiation of preventative rehabilitative strategies, reduces the impact of impairments, and limits caretaker dependency. Rehabilitative interventions during the temporization phase must remain sensitive to patients’ prognoses, commitment to anticancer therapy, socioeconomic constraints, and willingness to participate in the rehabilitation process. When patients’ functional goals are defined through ongoing dialogue with a cancer rehabilitation professional, they will generally commit the time and energy needed to ensure functional autonomy.16
Palliation As patients enter the final stages of cancer, rehabilitative goals focus on maximizing patient independence for mobility and ADL performance. Cancer patients are intensely disturbed at the prospect of becoming increasingly burdensome to their caretakers.12 This is particularly true in relation to toileting
224 and hygiene-related activities. Physical and occupational therapists can provide patients with assistive devices, educate them in compensatory strategies, and offer guidance in environmental modification. Often remarkably simple rehabilitative strategies coupled with good symptom control and psychological support will significantly enhance patients’ ADL autonomy. Caretaker education becomes a key focus during the palliative stage of cancer rehabilitation. Teaching caretakers how to properly utilize durable medical equipment and to protect themselves from musculoskeletal strain during patient transfers empowers them and allows them to provide better patient assistance. Preservation of community integration, if appropriate, is an important rehabilitative focus during palliation. This can be achieved through the provision of wheelchairs, scooters, or assistive devices such as walkers, canes, or crutches. Home modification may be required to ensure easy access. The effort to preserve patients’ community involvement is invaluable in preventing progressive isolation and depression.
Conclusion Functional morbidity can be expected to increase as the number of patients with a history of cancer or living with active disease grows. Proactive cancer rehabilitation can significantly diminish the prevalence and impact of cancer-related impairments. It is reasonable to assume that greater availability and utilization of cancer rehabilitation professionals can reduce the medico-economic burden of cancer and significantly enhance patients’ quality of life. At present, there is lack of productive interface between the rehabilitation and oncologic medical communities. This presents a limitation to future growth of cancer rehabilitation. In addition, rehabilitation training programs for therapists, nurses, and physicians need to focus greater attention on the unique dimensions of cancer rehabilitation. Hopefully these challenges will be met in the future so that all cancer patients may remain maximally functional across the entire disease trajectory.
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