Download Cancer Rehabilitation and Physical Impairment from cancer treatment

MinnesotaCancerPlanUpdate:SurvivorshipWorkGroup
IssueAnalysis
Issue#3:CancerRehabilitationandPhysicalImpairmentfromcancertreatment
ISSUESTATEMENT&RATIONALE/EVIDENCEBASEDRESEARCH:
Physicalimpairmentsaftercancertreatmentincreasedistress,morbidityandmortality.Targeted,cancer-specificphysicalrehabilitationand
cancer-specificexercisehasbeenshowntoreducephysicalfrailty,reducedisability,lengthensurvivalandimprovequalityoflifeincancer
survivors.Partofrequireddistressscreeningistheimperativetoutilizequalifiedprofessionalstoaddressthedistresscausedbyphysical
impairmentsimposedbycancer.Researchhasshownthatcancersurvivorsarenotbeingreferredforexistingrehabilitationandcancerexercise
servicesandthattherearenotenoughqualifiedrehabilitationprofessionalsandcancerexercisespecialiststomeettheneedsoftheincreasing
numbersofcancersurvivors,particularlywithincreasingelderlyandfrailsurvivors.Additionally,minoritypopulationsandpopulationswhodo
notaccesstraditionalmedicalservicesareexcludedfromthiscare.
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“CancerRehabilitationismedicalcarethatshouldbeintegratedthroughouttheoncologycarecontinuumanddeliveredbytrainedrehabilitation
professionalswhohaveitwithintheirscopeofpracticetodiagnoseandtreatpatients’physical,psychological,cognitiveandfunctional
impairmentsinanefforttomaintainorrestorefunction,reducesymptomburden,maximizeindependenceandimprovequalityoflifeinthis
medicallycomplexpopulation.”SilverJK,RajVS,FuJB,WisotzkyEM,SmithSR,KirchRA.Cancerrehabilitationandpalliativecare:criticalcomponentsinthe
deliveryofhigh-qualityoncologyservices.SupportCareCancer.2015Dec;23(12):3633-43.
Cancertreatmentinducesastateofphysicalimpairmentthatcanleadtopoortreatmentoutcomesthatcouldbeamelioratedwithrehabilitation.
Jack,S.Theeffectofneoadjuvantchemotherapyonphysicalfitnessandsurvivalinpatientsundergoingoesophagogastriccancersurgery.EJSOxx(2014)1e8.Kilgour
R.Handgripstrengthpredictssurvivalandisassociatedwithmarkersofclinicalandfunctionaloutcomesinadvancedcancerpatients.SupportCareCancer(2013)
21:3261–3270.Koelwyn,G.RunningonEmpty:CardiovascularReserveCapacityandLateEffectsofTherapyinCancerSurvivorship.JournalofClinicalOncology,Vol
30,No36(December20),2012:pp4458-4461.Okumura,S.Impactofpreoperativequalityaswellasquantityofskeletalmuscleonsurvivalafterresectionof
pancreaticcancer2015.Surgery.doi.org/10.1016/j.surg.2015.02.002.Silver,Jet.ImpairmentDrivenCancerRehabilitation:anessentialcomponentofqualitycare
andsurvivorship.CACancerJ2013May17.doi:10.1002/caac.21186.
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Distressincancersurvivorsishighlycorrelatedwithphysicallimitationsimposedbycancertreatment.Bornbaum,K.Adescriptiveanalysisofthe
relationshipbetweenqualityoflifeanddistressinindividualswithheadandneckcancer.SupportCareCancer.2011.DOI10.1007/s00520-011-1326.Pentinnen,H.
QoLandPhysicalperformanceandactivityofbreastcancerpatientsafteradjuvanttreatment.Psycho-Oncology2011.20:1211–1220.Banks,E.Ispsychological
distressinpeoplelivingwithcancerrelatedtothefactofdiagnosis,currenttreatmentorlevelofdisability?FindingsfromalargeAustralianstudy.MJA2010;193:
S62–S67.Holm,L.Influenceofcomorbidityoncancerpatients’rehabneeds,participationinrehabactivitiesandunmetneeds:apopulation-basedcohortstudy.
SupportCareCancer2014.22:2095-2105.Hayes,SLymphedemaAfterBreastCancer:Incidence,RiskFactors,andEffectonUpperBodyFunction.2008JClinOncol28,
3536-3542
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25%ofcancersurvivorshavepoorphysicalhealthand10%havepoormentalhealthcomparedwith10%and6%ofadultswithoutahistoryof
cancerrespectively.Weaver,K.MentalandPhysicalHealth-RelatedQualityofLifeamongUSCancerSurvivors:PopulationEstimatesfromthe2010NationalHealth
InterviewSurvey.CancerEpidemiolBiomarkersPrev;2012.21(11);2108-1.
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Inspiteofresearchshowingrehabilitationimprovesfunctionaloutcomes,cancersurvivorsreceivefewreferralstoqualifiedrehabilitation
professionalsrelativetotheburdenofremediablephysicalimpairment.Cheville,A.Thedetectionandtreatmentofcancer-relatedfunctionalproblemsinan
MinnesotaCancerPlanUpdate:SurvivorshipWorkGroup
IssueAnalysis
outpatientsetting”SupportiveCareinCancer.2009Jan;17(1):61.Cheville,A.AnExaminationoftheCausesfortheUnderutilizationofRehabilitationServicesAmong
PeoplewithAdvancedCancer.AmJPhysMedRehabil2011;90(suppl):S27YS37.Cheville,A,etal.Prevalenceandtreatmentpatternsofphysicalimpairmentsin
patientswithmetastaticbreastcancer.2008JClinOnc.26(16):2621-9.Cheville,A.BarrierstoRehabilitationFollowingSurgeryforPrimaryBreastCancer.JSurg
Oncol2007;95:409-18.Thorsen,Letal.CancerPatientsNeedsforRehabilitationServices.ACTAOncologica.201150:212-222.Vargo,M.TheOncologyRehabilitationInterface:bettersystemsneeded.JClinicalOncol.2008.(16)2610.SpillGR,HlubockyFJ,DaughertyCK(2012)Oncologists’andphysiatrists’attitudes
regardingrehabilitationforpatientswithadvancedcancer.PMR4(2):96–108.PergolottiM,(2015)Theprevalenceofpotentiallymodifiablefunctionaldeficitsandthe
subsequentuseofoccupationalandphysicaltherapybyolderadultswithcancer.JGeriatrOncol.doi:10.1016/j.jgo.2015.01.004.SalakariMREffectofrehabilitation
amongpatientswithadvancedcancer:asystematicreview.(2015)ActaOncol54(5):618–628.ChevilleAL,Roleofrehabilitationmedicineandphysicalagentsinthe
treatmentofcancer-associatedpain.JClinOncol(2014)32(16):1691–1702.
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Medicalfrailtyanduntreatedphysicalimpairmentincancersurvivorsincreasesthecostofcare,institutionalization,caregiverburden,
hospitalizations,inabilitytoreturntoworkanddistress.Thisisaloomingcrisisincancercarethatmustbeaddressed.Winters-Stone,K.Preventing
FrailtyinOlderCancerSurvivors.TopicsinGeriatricRehabilitation.2015.31(4),241-245.Schmitz,Ketal.Theintersectionofcancerandageing:establishingtheneed
forbreastcancerrehabilitation.2007.CancerEpidemiologyBiomarkersandPrevention.2007;16:866-872.Hoppe,S.FunctionalDeclineinOlderpatientsreceiving
firstlinechemotherapy.2013.JClinOncol.31;3877-3882.Bentley,Jetal.Functionalstatus,life-spacemobility,andqualityoflife:alongitudinalmediationanalysis.
QualLifeRes.2013September;22(7):1621–1632.Cetal.OlderPeople’sQualityofLife(OPQOL)scoresandadversehealthoutcomes.HealthandQualityofLife
Outcomes2011,9:72.Prado,CM.SarcopeniaandPhysicalFunctioninOverweightPatientswithAdvancedCancer.Canadianjournalofdieteticpracticeandresearch
(2013)74(2):69.Silver,J.CancerRehabilitationmayimprovefunctionincancersurvivorsanddecreasetheeconomicburdenofcancertoindividualsandsociety.
Work.(2013)46(4):455-72.PearceAM,Productivitylossesassociatedwithheadandneckcancerusingthehumancapitalandfrictioncostapproaches.ApplHealth
EconHealthPolicy.(2015)doi:10.1007/s40258-015-0155-8
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AnadequateworkforceofPhysicalMedicineandRehabilitationspecialistswithexpertiseincancerrehabilitationisnecessarytomeettheneeds
forfuturecancersurvivorsinMinnesota.Alfano,Cetal.CancerSurvivorshipandCancerRehabilitation:RevitalizingtheLink.JournalofClinicalOncology.2012.
30:9.904-906.ChevilleAL(2014)Postacutecare:reasonsforitsgrowthandaproposalforitscontrolthroughtheearlydetection,treatment,andpreventionof
hospital-acquireddisability.ArchPhysMedRehabil95(11):1997–1999.NationalInstitutesofHealthClinicalCenter(2015)Cancerrehabilitationconference
http://www.cc.nih.gov/rmd/crc/presentations.html.MukaiAThefutureofphysiatry:withchallengescomeopportunities.2011.PMR3(3):189–192.RajVSCancer
rehabilitationeducationduringphysicalmedicineandrehabilitationresidency:preliminarydataregardingthequalityandquantityofexperiences.(2014)AmJPhys
MedRehabil.doi:10.1097/PHM.0000000000000060.SmithSR,Cancersurvivorship:agrowingroleforphysiatriccare.(2014)PMR.doi:10.1016/j.pmrj.2014.12.004
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Exerciseforcancersurvivorsrequiresspecificexerciseprescriptionsfromqualifiedprofessionalsinrehabilitationandcancerexercisephysiology
whoareabletoevaluatesafetyandcomorbitiesbeforeprescribingcorrectindividualexerciseprotocolforsurvivorship.LakoskiSG.Exercise
rehabilitationinpatientswithcancer.NatRevClinOncol.2012;9(5):288–96.Sasso,JP.Aframeworkforprescriptioninexerciseoncologyresearch.JCachexia,
Sarcopenia,Muscle.(2015)6:115-124.Brown,J.Theprescriptionorproscriptionofexerciseincolorectalcancercare.MedSciSportsEx.(2014)46(12):2202-2209.
Betof,A.Effectsandpotentialmechanismsofexercisetrainingoncancerprogression:atranslationalperspective.BrainBehavImmun.(2013)30(0):S75S87.Midtgaard,J.Efficacyofmultimodalexercise-basedrehabilitationonphysicalactivity,cardiorespiratoryfitness,andpatientreportedoutcomesincancer
survivors:arandomized,controlledtrial.(2013)AnnalsofOncology.24:2267-2273.Brown,J.Developmentofarisk-screeningtoolforcancersurvivorstoparticipate
inunsupervisedmoderatetovigorous-intensityexercise:resultsfromasurveystudy.(2015)PMR.7:113-122.Campbell,K.Reviewofexercisestudiesinbreastcancer
survivors:attentiontoprinciplesofexercisetraining.(2012)BrJSportsMed.46:909-916.Martin,E.Higherintensityexercisehelpscancersurvivorsremainmotivated.J
CaSurvivorship(2016)10(3):524-533.Devin,J.Theinfluenceofhigh-intensitycomparedwithmoderateintensityexercisetrainingoncardiorespiratoryfitnessand
bodycompositionincolorectalcancersurvivors:arandomizedcontrolledtrial.JCaSurvivorship(2016)10(3):467-479.Jones,LW.PrecisionOncology:Frameworkfor
investigationofexerciseastreatmentforcancer.(2015)JClinOncol33:1-4.Schmitz,K.ConsensusStatement:AmericanCollegeofSportsMedicineRoundtableon
MinnesotaCancerPlanUpdate:SurvivorshipWorkGroup
IssueAnalysis
ExerciseGuidelinesforCancerSurvivors.(2010)MedSciSportsEx1409-1426.Wolin,K.ImplementingtheExerciseGuidelinesforCancerSurvivors.(2012)JSupport
Oncol.10(5):171-177
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Currentmodelsofmedicalcare,paymentsystemsandinaccuratecoveragedeterminationsworkagainsttheclinicalintegrationofeffective
rehabilitationintooncologytothedetrimentofpatientoutcomes,healthandwellnessaftercancertreatment.Minnesotaneedstobeatthe
forefrontofresearchandpolicydevelopmentthatfacilitateseffective,coveredrehabilitationcareforMinnesotacancersurvivors.Round,J.Acostutilityanalysisofarehabilitationserviceforpeoplelivingwithandbeyondcancer.BMCHealthServRes.2014.14(1):558.InstituteofMedicine(2013)Deliveringhighqualitycancercare:chartinganewcourseforasystemincrisis.NationalAcademiesPress,Washington,DC.StubblefieldMD.Currentperspectivesandemerging
issuesoncancerrehabilitation.Cancer2013.119(Suppl11):2170–2178.MewesJCEffectivenessofmultidimensionalcancersurvivorrehabilitationandcosteffectivenessofcancerrehabilitationingeneral:asystematicreview.Oncologist(2012)17(12):1581–1593.PalacioA,Oncologyandphysicalmedicineand
rehabilitation.AnnPhysRehabilMed(2009)52(7–8):568–578.ShinKY,Inpatientcancerrehabilitation:theexperienceofanationalcomprehensivecancercenter.Am
JPhysMedRehabil(2011)90(5Suppl1):S63–68.StoutNL.Aprospectivesurveillancemodelforrehabilitationforwomenwithbreastcancer.Cancer(2012)
118(8Suppl):2191–2200.AlfanoCM,Anactionplanfortranslatingcancersurvivorshipresearchintocare.(2014)JNatlCancerInst106(11).doi:10.1093/jnci/dju287.
GladieuxJE.Jimmoandtheimprovementstandard:implementingmedicarecoveragethroughregulations,policymanualsandotherguidance.(2014)AmJLawMed
40(1):7–25
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Racial/ethnicdisparitiesinaccesstoaccurateinformationaboutcancertreatmentthataffectstreatmentrelatedmorbidityaswellasreduced
accesstorehabilitationinterventionsplacesthesepopulationsatgreaterriskofpooroutcomesfromcancertreatment.Hair,B.Racialdifferencesin
physicalactivityamongbreastcancersurvivors:implicationsforbreastcancercare.(2014).Cancer.120(14):2174-2182.Black,D.Racialdisparitiesinadoptionof
axillarysentinellymphnodebiopsyandlymphedemariskinwomenwithbreastcancer.(2014)JAMASurg149(8):788-796.Morehead-Gee,A.Racialdisparitiesin
physicalandfunctionaldomainsinwomenwithbreastcancer.(2012)SupportiveCareCancer.20(8):1839-47.Owasu,C.Racialdisparitiesinfunctionaldisabilityamong
olderwomenwithnewlydiagnosednon-metastaticbreastcancer.(2013)119(21):3839-46
Whatfactors&barrierscontributetothisissue?
-Oncologydepartments/programslackintegrationwithrehabilitation,especiallyPhysiatry
-ASCO,NCCNandCommissiononCancerintheirpublicationsandguidelinesdonotidentifyorpartnerwiththequalifiedprofessionalsfrom
PMR,PT,OTandCancerexercisephysiologyinpolicyinitiatives
-Inadequatemedicaltraininginmedicalschoolsandoncologyresidencyprogramsregardingthetypesandeffectivenessofrehabilitation
interventions
-PM&Rresidencytrainingprogramsnotdevotingadequatetime/resourcestotrainingincancerrehabilitation
-PT,OT,SLPtrainingprogramsnotdevotingadequatetimeto/resourcestotrainingincancerrehabilitation
-PaymentsystemsthathavesilosversusACOmodels
-Poorunderstandingofmedicalprofessionalsregardingthespecificsofmedicalexerciseprescriptionsandhowtheymustbeadministeredto
havebeneficial/safeeffectsoncancersurvivors(generallyhavebeenrelegatedtosportsmedicineprofessionals)
-Lackofunderstandingofrehabilitationcareascoveredmedicalcareasopposedtocommunityexercise/wellness
-LackofscreeningforphysicalimpairmentssinceCommissiononCancerimplementedDistressScreeningGuidelinebutnophysicalimpairment
screeningguideline
MinnesotaCancerPlanUpdate:SurvivorshipWorkGroup
IssueAnalysis
-Healthcaresystemsthatdonotinterfacewithracialandethniccommunitiesonculturaldifferenceswithdietandexerciseaswellas
survivorshipcareingeneral
-Lackofpartnershipswithqualifiedcommunitycancerexerciseprofessionalsinaffordable,accessiblesettings
-LackoftrainingforCancerExercisespecialists
-Survivorsuneducatedoncancerexercisespecialistsversuscommunityfitnesstrainersandsafetyconcerns
WhatarethePOLICYopportunitiestoaddresstheidentifiedfactors,andracial,economic,geographic,andotherbarriersthatcontributeto
thisissue?WhatarethePOLICYopportunitiestoaddresstheidentifiedgaps?
WorkwithASCO(MN)andACStodevelopstandardsforSurvivorshipProgramsutilizingexpertsincancerrehabilitationandcancerexercise
physiologytosetpolicyfortrainingandimplementationofcancerrehabilitationandcancerexercise.
Advancepolicyinmajorcancerorganizationstorequirephysicalimpairmentscreeningforcancersurvivorswithreferraltoqualified
rehabilitationandexerciseprofessionalsfollowingrecommendationsoftheNIHExpertTaskForceonCancerRehabilitation.
Requiremedicalschools,PMRresidenciesandOncologyresidencesinMNtohavetraininginevidencebasedcancerrehabilitation
Developtelemedicineopportunitiesandpaymentmechanismsforcancerrehabilitation.
Pilot/grantprojectstodevelopmodelsofcareforcancerrehabilitationandcancerexerciseinMinnesotamedicaltraininginstitutions.
Requireoncologysurvivorshipprogramstotrackpercentageofminoritiesundertheircarereceivingscreeningforphysicalimpairmentand
referralstoservices.
WorkwithinsurancecompaniesinMinnesotatoevaluatecompliancewithstandardsofcarecoverageforphysicalimpairmentsasmedicalcare.
Advancepolicystatementsfrommajoroncologyinstitutionstorequirecommunityprogramsstatingthattheyarea“CancerExerciseProgram”
todisclosequalificationsofclassinstructors,certifyinstructorsascancerexercisetrainedifoffering“cancerexerciseclasses.”
WhataretheSTRATEGYopportunitiestoaddressboththebarriersandthegapsrelatingtothisissue?
MCAworkwithMNbranchofASCOandACStocreatepolicyonscreeningforphysicalimpairmentandreferraltoqualifiedrehabilitation
professionals(PMR,PT,OT)andcertifiedcancerexercisespecialists.
ReachouttoMedicaltrainingprogramleadersinOncologyandPMRinMNtodevelopcancerrehabilitationcurriculum.
MinnesotaCancerPlanUpdate:SurvivorshipWorkGroup
IssueAnalysis
ReachouttoPT,OT,SLPtrainingprogramleadersinMNtodevelopcancerrehabilitationcurriculum.
SeekgrantfundingforpilotmodelsofcancerrehabilitationembeddedinOncologySurvivorshipClinics.
1. Whoaretheexistingpartners/organizationsalreadyworkingonthisissue?
AmericanCancerSociety
AmericanAcademyofPhysicalMedicineandRehabilitation
AmericanPhysicalTherapyAssociation
AmericanOccupationalTherapyAssociation
AmericanCollegeofSportsMedicine
AmericanCongressofRehabilitationMedicine
OncologyRehabPartners
2. Whichpartners/organizationsshouldworktogethertoaddressthisissue?
Thoselistedaboveandinaddition:
AmericanSocietyofClinicalOncology
MNMedicalSchoolsandmedicalprofessionaltrainingprograms
CancerHealthEquityNetwork
Whichstrategiespromotehealthequity?
MCAworkwithMNbranchofASCOandACS,alongwithCHENtocreatepolicyonscreeningforphysicalimpairmentandreferraltoqualified
cancerrehabilitationprofessionals(PMR,PT,OT)andcertifiedcancerexercisespecialists.