Angelina Jolie and Others Who Don’t Have Cancer Still Need Cancer Rehab

Julie Silver, MD

Angelina Jolie just wrote about her mastectomies with breast implant reconstruction. As a mother with young children, she’ll need cancer rehabilitation in order to provide the love and caretaking that her kids depend on. Even lifting a small child or strapping her into a car seat is a challenge after this type of surgery. This means that you don’t need to have cancer to need cancer rehab. Women who elect to undergo preventative mastectomies should receive cancer rehabilitation services from a well-trained team of healthcare professionals. Despite the fact that research shows that physical and emotional outcomes are closely linked–the better someone feels physically after a mastectomy, the better she will likely feel emotionally–many people who need cancer rehab don’t get it at all (or only receive a little bit that doesn’t help them as much as it could if it was offered in a best practices team approach like in stroke care). Nearly 100 hospitals and cancer centers in the U.S. that have adopted the STAR Program® – a best practices model for cancer rehab—are currently participating in a campaign called Strength in Numbers that is designed to help decrease the gap between the need for these services and the delivery of them to patients. This 12 week “boot camp” campaign started in late April and will run through July 2013 to improve outcomes for anyone who has surgery or other treatments in a cancer center.

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Complementary Models of Cancer Rehabilitation Care

This video covers the important concepts of the Prospective Surveillance Model and the Impairment Driven Model in cancer rehabilitation care. These models, though distinct, have significant overlap and are complementary. Watch the video to learn more about these models.

Cancer Prehab for Head & Neck Survivors Improves Swallowing

Julie Silver, MD

A new study published in the journal Archives of Otolaryngology—Head & Neck Surgery suggests that patients who begin swallowing exercises prior to undergoing chemoradiation may have better swallowing outcomes after treatment.[1] Kotz and colleagues studied twenty-six patients who were going to receive chemoradiation for head and neck cancer. The intervention group performed five targeted swallowing exercises and participated in weekly swallowing therapy sessions to encourage accurate technique and adherence to the daily exercises. The control group had no prophylactic exercises but was referred after the completion of chemoradiation for swallowing treatment if needed.

In this study, the patients who performed the pre-treatment exercises had improved swallowing function at the 3-month and 6-month mark compared to the control group. It is important to note that statistically significant differences were not evident immediately after chemoradiation or after longer time periods than 6 months.

This small cancer prehabilitation study suggests that prophylactic swallowing exercises may “fast-track” healing after chemoradiation in head and neck survivors.

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[1]Kotz T, Federman AD, Kao J, Milman L, Packer S, Lopez-Prieto C, et al. Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: a randomized trial. Archives of otolaryngology–head & neck surgery. 2012;138(4):376-82. Epub 2012/04/18. doi: 10.1001/archoto.2012.187. PubMed PMID: 22508621.

Fast Track Cancer Rehabilitation Decreases Hospital Length of Stay

Julie Silver, MD

Multimodal “fast track” or “enhanced recovery after surgery” inpatient peri-operative studies have been demonstrating impressive results when it comes to getting patients out of the hospital faster and healthier.

Interventions for this fast track inpatient cancer rehabilitation may include such strategies as preoperative counseling, intraoperative fluid restriction, use of a laparoscopic approach, immediate initiation of clear fluids after surgery, early discontinuation of urinary catheters and early physical mobilization.

In a new study coming out of Canada that retrospectively evaluated 336 consecutive colorectal patients at seven hospitals, researchers found that in hospitals that had utilized enhanced recovery after surgery strategies found that of the strategies they studied, all were independently associated with shortened length of stay.[1]

As accountable care continues to be a key part of the healthcare dialogue and Medicare fines hospitals for high readmission rates, it’s important to pay close attention to the new studies that are coming out on fast track peri-operative cancer rehabilitation interventions.

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[1]Aarts MA, Okrainec A, Glicksman A, Pearsall E, Victor JC, McLeod RS. Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surgical endoscopy. 2012;26(2):442-50. Epub 2011/10/21. doi: 10.1007/s00464-011-1897-5. PubMed PMID: 22011937.

New Study on Fast Track Inpatient Rehabilitation in Liver Cancer

Barry Kraynack, MD

Multimodal rehabilitation, also known as “fast track” or “enhanced recovery”, has been shown to hasten recovery, decrease medical complications and reduce the time that patients spend in the hospital for cancer surgery.

Liver resection is a high risk, major surgery that has a median hospital stay in Denmark of 9 days for liver resection and 15 days after right hemi-hepatectomy . In a new study that was just released in the British Journal of Surgery, Schultz and colleagues investigated the effect of introducing fast track principles for patients undergoing open or laparoscopic liver resection. [1]They removed catheters and drains early, mobilized patients and began feeding patients immediately after surgery. Pain control (analgesia) was optimized and provided for the first week after surgery.

In this study, the researchers found that the introduction of this multimodal fast track rehabilitation care accelerated postoperative recovery, achieving a shorter hospital stay of 2 days for laparoscopic resection to 6 days following open surgery. There was no observed mortality and readmission rate was acceptably low. The authors concluded, “Open liver resections, even right and left hemi-hepatectomies, can be carried out safely and provide shorter hospital says. Fast-track liver surgery is safe, and has a low readmission rate.” Their results are similar to those reported by others for different types of cancer. With cost containment a major concern for medicine, it’s important to consider implementing fast track cancer rehabilitation care.

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[1]Schultz NA, Larsen PN, Klarskov B, Plum LM, Frederiksen HJ, Kehlet H, Hillings JG. Evaluation of a fast-track programme for patients undergoing liver resection. Br J Surg. 2013; 100(1):138-43.

Review of Cancer Rehabilitation Shows it is Cost-Effective

Julie Silver, MD

The Oncologist recently published a systematic review of cancer rehabilitation and determined that it is cost-effective.[1] In this study that evaluated the current research and was titled “Effectiveness of Multidimensional Cancer Survivor Rehabilitation and Cost-Effectiveness of Cancer Rehabilitation in General”, there were 16 effectiveness and 6 cost-effectiveness studies—22 studies in all–that were reviewed. The individual studies were performed in many different countries, including the United States and Canada. The researchers noted that despite the fact that the individual studies assessed different rehabilitation interventions, they all showed favorable cost-effectiveness ratios. This is an exciting new evidence-based review of the current research that strongly supports cancer rehabilitation as cost-effective.

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[1]Mewes JC, Steuten LM, Ijzerman MJ, van Harten WH. Effectiveness of Multidimensional Cancer Survivor Rehabilitation and Cost-Effectiveness of Cancer Rehabilitation in General: A Systematic Review. The oncologist. 2012. Epub 2012/09/18. doi: 10.1634/theoncologist.2012-0151. PubMed PMID: 22982580.

New Study Reveals that Cancer Survivors have Worse Health-Related Quality of Life than Others

Julie Silver, MD

There have been many studies published looking at health-related quality of life (HRQOL) in cancer survivors, but for the first time a new study compared people with and without a cancer history.[1] Not surprisingly but nevertheless very concerning is that cancer survivors reported a much worse HRQOL for both physical and emotional health compared to population norms.

In this new study published in the journal Cancer Epidemiology Biomarkers & Prevention, Wake Forest lead researcher, Kathryn Weaver, used the PROMIS® Global Health Scale to assess HRQOL in 1,822 adults with a history of cancer and 24,804 people who had never been diagnosed with cancer.

Weaver and colleagues found that poor physical health was reported by 24.5% of cancer survivors and only 10.2% of those without a history of cancer. Poor mental health was reported by 10.1% of cancer survivors compared with 5.9% of adults without a cancer diagnosis.

This study suggests that 3.3 million cancer survivors in the United States have poor physical health and 1.4 million have poor mental health.

Other recent studies have shown the close relationship between physical and emotional health with several studies citing disability as the most common reason for distress in cancer survivors.[2] This research documents an important opportunity for evidence-based cancer rehabilitation interventions to improve both physical and emotional HRQOL in cancer survivors.

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[1] Weaver KE, Forsythe LP, Reeve BB, Alfano CM, Rodriguez JL, Sabatino SA, et al. Mental and Physical Health-Related Quality of Life among U.S. Cancer Survivors: Population Estimates from the 2010 National Health Interview Survey. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2012. Epub 2012/11/01. doi: 10.1158/1055-9965.EPI-12-0740. PubMed PMID: 23112268.

[2] Banks E, Byles JE, Gibson RE, Rodgers B, Latz IK, Robinson IA, et al. Is psychological distress in people living with cancer related to the fact of diagnosis, current treatment or level of disability? Findings from a large Australian study. The Medical journal of Australia. 2010;193(5 Suppl):S62-7. Epub 2011/05/06. PubMed PMID: 21542449.

New Concerns About Safety in Cancer Rehabilitation

Julie Silver, MD

Cancer rehabilitation is offered in many different settings and by many different types of healthcare providers. Although cancer rehabilitation may include exercise programs recommended by trained fitness professionals, there is concern about the safety of referring patients directly to people who are not trained specifically in rehabilitation medicine. Recent articles are highlighting important safety concerns in cancer survivors. For example, a new article titled “Patient Safety in Cancer Rehabilitation” was published in May 2012 by Cristian and colleagues in the Physical Medicine and Rehabilitation Clinics of North America.[1]

In a recent study evaluating weightlifting in breast cancer survivors who had lymphedema or were at risk to develop it, researchers found that approximately 21% of the participants in the weightlifting group reported a problem—such as a new injury–that required them to see their doctors or other healthcare providers and this resulted in stopping or changing their exercise regimen.[2] In this study published in The Oncologist, Brown and colleagues stated, “Despite the demonstrated efficacy of weightlifting, musculoskeletal injuries and other health problems did occur. Therefore, for the successful translation of this rehabilitative intervention into clinical practice, health and fitness professionals working with breast cancer survivors need the knowledge, skills and abilities that clarify their scope of practice to address these needs.”

In order to clarify the scope of practice in rehabilitation medicine, it is important to identify those healthcare professionals who have completed the appropriate training in order to be able to identify and treat cancer survivors’ impairments. Only professionals who are licensed and/or board certified in rehabilitation medicine should be treating patients for physical impairments. These healthcare professionals include physicians (e.g., physiatrists), rehabilitation nurses and physical, occupational and speech therapists. The training of fitness professionals is not sufficient to qualify these individuals to treat survivors’ impairments. Therefore, this is beyond their scope of practice. Moreover, sending survivors to fitness professionals without first identifying and treating their impairments is dangerous. In the cancer care continuum, the goal must be to screen all survivors for physical impairments and then appropriately triage those with identified problems to licensed and/or board certified rehabilitation professionals prior to referring them to fitness professionals.

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[1] Cristian A, Tran A, Patel K. Patient safety in cancer rehabilitation. Physical medicine and rehabilitation clinics of North America. 2012;23(2):441-56. Epub 2012/04/28. doi: 10.1016/j.pmr.2012.02.015. PubMed PMID: 22537705.

[2] Brown JC, Troxel AB, Schmitz KH. Safety of weightlifting among women with or at risk for breast cancer-related lymphedema: musculoskeletal injuries and health care use in a weightlifting rehabilitation trial. The oncologist. 2012;17(8):1120-8. Epub 2012/07/04. doi: 10.1634/theoncologist.2012-0035. PubMed PMID: 22752068; PubMed Central PMCID: PMC3425531.

Research Demonstrates that Multidisciplinary Cancer Rehabilitation is Effective

Julie Silver, MD

A recent systematic review of twenty-two studies on cancer rehabilitation that was published in the prestigious medical journal The Oncologist demonstrated that multidisciplinary cancer rehabilitation is effective.[1] In this review that evaluated the current research and was titled “Effectiveness of Multidimensional Cancer Survivor Rehabilitation and Cost-Effectiveness of Cancer Rehabilitation in General”, there were 16 effectiveness and 6 cost-effectiveness studies—22 studies in all–that were included. The individual studies were performed in many different countries, including the United States and Canada. The researchers noted that despite the fact that the individual studies assessed different rehabilitation interventions, they demonstrated statistically significant benefits for multidimensional rehabilitation over usual care. This is an important new evidence-based review of the current research that supports multidisciplinary cancer rehabilitation.

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[1]Mewes JC, Steuten LM, Ijzerman MJ, van Harten WH. Effectiveness of Multidimensional Cancer Survivor Rehabilitation and Cost-Effectiveness of Cancer Rehabilitation in General: A Systematic Review. The oncologist. 2012. Epub 2012/09/18. doi: 10.1634/theoncologist.2012-0151. PubMed PMID: 22982580.