Cancer Rehabilitation: A Key for Successful Survivorship

1. Cancer Rehabilitation:A Key for Successful Survivorship MARGARET pLACEK, PT,CLT-LANA, Oncology Rehabilitation PALOS hEALTH

2. Objectives • Discuss the benefits of cancer rehab for patient and provider • Present supporting evidence for cancer rehabilitation • Describe the differences between traditional and cancer rehabilitation assessment and interventions. • Discuss the beneficial effects of cancer rehab for cancers other than breast cancer. • Know what to expect from cancer rehab in regards to interventions, outcomes & communication

3. Why Cancer Rehab as a Standard of Care • Without cancer treatments such as chemotherapy, surgery and radiation, mortality would likely be the result for most survivors. • Yet, cancer treatments very often involve unwanted side effects that negatively impact quality of life for surviors. • Cancer Rehabilitation is a specialized branch of therapy designed to minimize or eliminate these negative effects.

4. What is Cancer Rehabilitation? • A functionally based rehab model that is similar to other forms of rehab after serious illness or injury • Focuses on interventions that improve Quality of Life and/or physical and emotional function. • Our goal – Oncology Rehabilitation will one day be to Oncologists what Cardiac Rehab is to Cardiologists. • Can include consultations with various rehabilitation experts based on needs: • Physiatrists • Physical Therapists • Occupational Therapists • Speech Therapists

5. How is Cancer Rehab Different? • Similar model to traditional rehab • ROM, strengthening, endurance exercises • Manual techniques (scar tissue, lymphedema mgmt) • Patient education – a major component! • What sets cancer rehab apart? • Therapists with specialized training to better understand the effects of cancer and it’s treatments in order to holistically evaluate the needs of cancer survivors. • Assessment of the patient is both current & prospective and emphasizes quality of life. • May be involved with survivor across continuum of care for minimal visits.

6. Is Cancer Rehab New? • 1970’s Finnish Model of Cancer Rehabilitation • Services cover period from symptoms to post-tx follow-up • Rehab is an integral part of cancer treatment & recovery • The need for rehab is considered for all patients with cancer • Effective rehab involves multidisciplinary teamwork • 1990’s Netherlands’ Comprehensive Cancer Center Care Plan • 12 week program • Physical Training 2x/week • Psychological Education 1x/week

7. Cancer Rehab Recognition • Commission on Cancer (CoC) • 1 of 12 required services in the 2018 Program Standards publication. • Institute of Medicine (IoM) report From Cancer Patient to Cancer Survivor • Recommended greater education and specialization of rehabilitation professionals to better manage the side effects of toxic treatments including: • Pain • Profound Fatigue & Deconditioning • Loss of Range of Motion

8. Benefits of Oncology Rehabilitation for the Survivor • Improved endurance / strength / ROM • Decreased Pain • Lessened Fatigue • Assist with surgical recovery • Improve immune function • Increase bone density • Manage lymphedema • Improve function/balance & coordination • Improve quality of life • Decrease psychological distress • Education

9. Benefits of Oncology Rehab to Physician • Assist in obtaining optimal pain control • Bridging communication between team members • Therapy sessions generally 45-60 minutes • Optimize efficient physician office resources by improving functional deficits • Potential impact to decrease the need for unnecessary diagnostic testing and long-term pain medicine by improving musculoskeletal pain • Identifying early tissue restrictions or muscular imbalances and correcting before they develop into chronic conditions, such as tendonitis.

10. Evidence Supports the Need • Movsas SB, Chang VT, Tunkel RS, Shah VV, Ryan LS, Millis SR. Rehabilitation needs of an inpatient medical oncology unit. Arch PhysMed Rehabil 2003;84:1642–6. • In this study, 87% of patients surveyed here in the US reported the presence of rehabilitation needs during the initial phase of cancer treatment. • Cheville et al (2008), Prevalence and treatment patterns of physical impairment with metastatic breast cancer. Journal of Clinical Oncology. 26 (16):2621-2629. • 163 patients with metastatic breast cancer were examined . Physical impairments were identified in 92%. Only 21% received PT/OT services.

11. What does the evidence say? • Kim, et al. Cancer Rehabilitation: Experience, Symptoms and Needs. J Korean Med. 2011; 26: 619-624. • Of 402 patients with a cancer diagnosis admitted to a medical center in Seoul Korea, only 8.5% were recommended for therapy. Yet, 83.8% presented with one or more symptom associated with rehabilitation and 71.6% of those desired to have rehabilitation.

12. Side Effects of Treatment? Common effects but not all encompassing • Profound Fatigue - Most Common • Pain • Deconditioning • Loss of Range of Motion from Surgery, Chemo and Radiation • Impaired Mobility • Impaired Balance • Memory & Concentration Issues • Swallowing & Speech Problems • Lymphedema • Scarring/Fibrosis - deep tissue restrictions that don’t necessarily respond to simple stretching provided by return to normal daily activities.

13. Why Cancer Rehab? • More people are being diagnosed with cancer than ever before. Projections indicate that nearly 40% of those born today will develop cancer in their lifetime. Surveillance Epidemiology and End Results [SEER] Program cancer stat facts: Cancer of any site. National Cancer Institute. • As well, survival rates continue to improve - In fact, in the past 10 years the cancer death rate has dropped 1.8% per year for men, and 1.4% per year for women. In fact, the overall 5 year survival rate is currently around 67%. Surveillance Epidemiology and End Results [SEER] Program cancer stat facts: Cancer of any site. National Cancer Institute.

14. Why Cancer Rehab? • Cancer is one of the few diseases where a patient often begins treatment feeling relatively well, and emerges from “successful” treatment feeling awful. • Nearly 100% of cancer survivors experience negative side effects from cancer treatments. Many of these individuals will not return to their pre-morbid baseline.

15. Why Cancer Rehab? • Instead of being expected to accept a “new norm”, survivors deserve an opportunity to heal optimally thereby increasing their quality of life, as well as physical and emotional function. • Many studies have demonstrated a connection between physical and functional problems in survivors and psychological sequelae. Deficits in providing cancer rehab services to appropriate individuals equates to unnecessary physical and psychological suffering. Silver, J.K., MD. PM&R. 2017; Vol 9: s291-s296

16. Who Would Benefit from Cancer Rehab? • All survivors should have the opportunity to optimize their quality of life; whether they are currently undergoing treatment, living with cancer as a chronic condition, or still impacted by deficits resulting from treatment many years ago. • Recent review of studies from 2009-2014 revealed that rehabilitation/physical activity significantly improved general well-being and quality of life in patients with advanced disease and in palliative care. Salakari,M. et al. Effects of rehabilitation among patients with advanced cancer; doi.org, pages 618-628.

17. Who is Appropriate? • Listen for survivor or caretaker reports of side effects (pain, fatigue, falls, etc) • Facilitate safe and efficient return to work. • Julie Silver, MD & Assistant Professor at Harvard estimate 60% or more of survivors are appropriate for referral.

18. Appropriate Referral Examples • Inability to return to a previous activity level (work, home, recreation or social) • Pain that is not due to a tumor/malignancy • Difficulty lifting the arm overhead • Fatigue that interferes with function • Falls/subtle balance problems • Uncertainty about how to exercise or participate in other activities • Untreated or worsening lymphedema

19. Barriers to Care • But, isn’t their plate full enough? • Yes, it is full which is why we need to provide them with the tools to efficiently and effectively accomplish their tasks. • We place a high priority on working with our patients to schedule them at an appropriate frequency, and not overtax their resources. Our program has a heavy emphasis on education and developing home program skills, for long term carryover.

20. Does Cancer Rehab Work? • There is a growing body of evidence that supports cancer rehab. • Improved fatigue • Benefits of exercise • Psychosocial benefits • Holmes MD, Chen WY, Feskanich D, et al: JAMA 293: 2479-2486,2005 Study of 3,000 Women with breast cancer who performed aerobic exercise 3-5 hrs/week improved their survival rate from breast cancer and overall mortality from other causes by 28-40% compared to less active breast cancer patients - independent of their previous activity level.

21. Cancer Rehab Referral • Yet, it is common to not be referred to cancer rehab for many reasons: • Programs not available • Physicians/Providers unaware of benefit, or have misunderstanding of what cancer rehabilitation actually may consist of. • Patients not voicing concerns to Physicians/Providers. -they are not aware that they have limitations because they are not moving due to fear, or they do not realize that their deficit can be treated and improved. - some feel that they “shouldn’t” complain about anything, they should just be grateful that they are alive

22. Example: Referral of the Breast Cancer Survivor AJCC Stage I, II & III Possible Treatments Why cancer rehab? • Surgery: lumpectomy or mastectomy with sentinel or axillary lymph node dissection • Reconstruction • Chemotherapy • Radiation • Hormone Therapy • 1x Post-Surgical Evaluation to emphasize education, prescribe ROM HEP & discuss functional expectations • 1-2 visit follow-up may be indicated to advance strengthening ex’s • If needed, to work on fatigue, deconditioning, CIPN, cognition • Follow-up anytime following may be indicated to manage radiation fibrosis, fatigue and any chest wall or UE lymphedema that may develop • Assist in managing painful side effects from AI’s

23. Example: Referral of the Breast Cancer Survivor AJCC Stage IV • All of the previous may still be applicable • Metastasis may promote need for more supportive therapies such as: • Adaptive equipment issue and training • Assistive device issue and training / Fall risk reduction • Caregiver training

24. Heightened Risk Factors for Referral for all stages • Co-morbidities • Obesity • BMI 30 or greater =3.6 increased risk of lymphedema development • Likely more deconditioned at start of treatment • Scar tissue development • Depression • Physically strenuous work requirements

25. Cancer Rehab…It Goes Beyond Breast Cancer • Cancer Rehab is appropriate for survivors of ALL types of cancers. • Previous interventions could be applied for survivors of various cancers • Additional interventions could include: • Speech and swallow evaluation and treatment • Cognitive therapy for mild cognitive impairments • Lymphedema for any area of involvement • Pelvic floor therapy for incontinence

26. Cancer Rehab at Palos Health • Services are available Home Health and Outpatient • Palos Diagnostic Center - Private Oncology Only Treatment • Services Include: • Physiatry • Physical Therapy • Occupational Therapy • Speech Therapy • Physician Referral Required

27. What You Can Expect • Evaluation and treatment by a cancer specialist and member of our cancer rehab team. • Individualized, compassionate and holistic care • Timely communication to oncology team • Respect for survivor’s finances and insurance limitations. • Home management program

28. True Survivor Testimony “You would be so impressed to see where I am now because of the program. I am experiencing such a better quality of life with the exercises, the massages and the home program. I am almost at full range of motion to my right arm, my posture is so much better and the pain is about 80-90% under control….I wish this program was in existence years ago…..I pray that every breast cancer patient will have the opportunity to participate in a life changing program like this.”