Hollywood, FL—Cancer rehabilitation is “the next frontier” in survivorship care, according to Julie K. Silver, MD, Assistant Professor of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA.
Dr Silver is the author of numerous books, including After Cancer Treatment: Heal Faster, Better, Stronger, & What Helped Get Me Through: Cancer Survivors Share Wisdom and Hope.
The main reasons for distress among cancer survivors pertain to physical disabilities and the inability to return to an expected functional level, studies show, said Dr Silver at the Third Annual Conference of the Association for Value-Based Cancer Care. An evidence-based cancer rehabilitation program led by board-certified rehabilitation health professionals can improve most common complaints, including fatigue, mild cognitive impairment, and chemotherapy-induced peripheral neuropathy, according to Dr Silver.
“Even when you can’t change the impairment—for instance, the nerve injury—you can often dramatically change the disability,” Dr Silver said.
She described the role of cancer rehabilitation, and how survivorship care is beginning to incorporate cancer rehabilitation and prehabilitation.
Diagnosed with cancer herself at age 38, Dr Silver felt strong going into treatment, but progressively became weaker as a result of it. “When I was sicker than I had ever imagined, out of work, couldn’t take care of my kids, when I couldn’t function, my oncologist said, ‘You’re done. Go home. Try to accept a new normal. Try to figure out how to heal. Go back to work if you’re able to,’” Dr Silver said.
“I’m a rehab doctor. I’m a physiatrist. I’ve been at Harvard Medical School my whole career. I can tell you I’ve never given anybody that advice,” she said. “I actually think that it’s not okay to tell someone to accept pain and fatigue and disability. I do not tell patients to accept a new normal.”
Thus began her crusade to develop and promote cancer rehabilitation medical services, to make evidence-based, impairment-driven cancer rehabilitation the standard of care to be offered to all cancer survivors who need it.
Rehabilitation Myths Although there is a near-universal agreement that these medical services are needed, there are still many myths to be debunked:
Identify, Then Treat Patients with Impairments The great majority of patients with cancer who need rehabilitation services do not receive them. One study of 163 patients with metastatic breast cancer showed that 92% of patients had at least 1 physical impairment, but only 30% received the care they needed; 88% of patients required physical or occupational therapy, but only 21% received this (Cheville AL, et al. J Clin Oncol. 2008;26:2621-2629).
“For patients with injuries, we don’t say that we are not going to bother recognizing them. We’re not going to figure out if they are treatable, or if insurance pays for them. We don’t do that in medicine,” Dr Silver emphasized.
The early identification of patients who need cancer rehabilitation is critical, not only for the good of the patient but also to avoid unnecessary workups for metastatic disease when musculoskeletal pain arises as a result of untreated impairment. “We have to screen every patient for physical impairments that are treatable,” she pointed out.
Dr Silver emphasized that exercise programs and lymphedema programs are not substitutes for cancer rehabilitation. The American College of Sports Medicine and the American Cancer Society have produced a Cancer Exercise Trainer program, but this is a fitness, not a cancer rehabilitation, model. Although exercise programs may be helpful at some point, they do not constitute rehabilitation for most patients with cancer, who have a variety of needs.
Cancer Rehab = Medical Treatment Dr Silver emphasized that a new standard of care within survivorship is an impairment-driven cancer rehabilitation program involving professionals delivering evidence-based services that are reimbursed by health plans (Figure).
“We need to identify impairments all along the continuum and refer those patients to licensed and board-certified rehabilitation healthcare professionals,” Dr Silver said. “The bottom line is that cancer rehabilitation equals medical treatment. It’s critical, but it is not often offered. When it is offered in an evidence-based, best practices manner, it will be reimbursed, and it will improve outcomes.”
“Prehabilitation” an Emerging Concept Research suggests that physical and emotional health outcomes of patients with cancer can be improved with interventions that occur in the time interval between the cancer diagnosis and treatment onset. Cancer “prehabilitation” programs maximize that window of time to prepare patients for cancer treatment physically and emotionally.
