Download Prehab - Rackcdn.com

Prehab for Cancer Survivors:
Concepts and Evidence for
Impairment Driven Rehabilitation
Julie K. Silver, MD
Associate Professor, Harvard Medical School
Department of Physical Medicine & Rehabilitation
Disclosures
Founder, Oncology Rehab Partners which has developed the STAR
Program® (Survivorship Training and Rehabilitation) certifications
for hospitals and cancer centers in the United States that provide a
comprehensive model for cancer prehabilitation and rehabilitation.
Author/editor of several books on cancer rehabilitation & recovery.
Objectives
These are for the entire session, and this talk will provide an
overview of all of them:
• Learning Objective: Describe tenants of impairment driven cancer
rehabilitation.
• Learning Objective: Describe key components of effective cancer
prehab programs and how to overcome barriers to implementation.
• Learning Objective: Discuss evidence for effectiveness of early
rehabilitation interventions for cancer survivors.
• Learning Objective: Describe neuro-musculoskeletal impairments
in cancer survivors and how to ameliorate and prevent them.
Objective #1
• Learning Objective: Describe tenants of impairment driven cancer
rehabilitation.
This review has helped to
educate oncologists about
evidence based cancer
rehabilitation
Published in 2013
in the ACS’s journal
CA that has a high
impact factor
ACS’s New Facts & Figures (2014-2015)
Objective #2
• Learning Objective: Describe key components of effective cancer
prehab programs and how to overcome barriers to implementation.
Barriers
•
•
•
•
•
•
•
•
Evidence base
Clinical education
Clinical outcomes
Cost/Value analysis
Time to implement
Time for patients to receive services
Disconnect between oncology & rehabilitation
Etc.
Often there is a window of time for prehab!
Delays May Impact Prognosis
A meta-analysis published in 2011 in the Journal of the American
Medical Association (JAMA) evaluated treatment outcomes in 10
studies involving 15,410 patients who had colorectal resections
followed by adjuvant chemotherapy.
A four-week increase in the time between surgery and
chemotherapy was associated with a significant decrease in both
overall survival and disease-free survival.
Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM. JAMA. 2011 Jun 8;305(22):2335-42.
PMID:21642686.
Cancer Incidence Rates by Year
Disease Incidence Rates
“Rehabilitation programs are probably the
single most underappreciated service
among cancer survivors right now.”
Kevin Oeffinger, MD, MSKCC
Chair of ASCO’s survivorship committee
Washington Post (July 29, 2013—How to Get Healthy After the Cancer Treatments are
Done)
Cancer rehabilitation is not optional
Commission on Cancer
Institute of Medicine Report
2013
All Clinicians
Trained Multidisciplinary Team
Institute for Healthcare Improvement
Triple Aim in Cancer Care
Can you make your patients happier and
healthier--with fewer visits, fewer
unnecessary tests (e.g. metastatic
workups for musculoskeletal problems)
and less cost?
YES! IF, you identify impairments early
and treat them efficiently and effectively.
Objective #3
• Learning Objective: Discuss evidence for effectiveness of early
rehabilitation interventions for cancer survivors.
“During the years before the fighting
was resumed, recruitment for the
regular Army was hindered by the
high incidence of physical and mental
imperfection among those who
presented themselves for enlistment.
Large numbers were rejected, not on
account of gross defect or
derangement, but because their
general development was so
wretchedly poor. It was reasonable to
assume that these were not
constitutional weaklings, but were the
victims of poverty, malnutrition,
insanitation, incomplete and faulty
education, having lacked the
opportunities for normal growth and
development of mind and body.”
Prehabilitation is distinct from rehabilitation in that it is designed to
increase one’s ability to function in “anticipation of an upcoming
stressor.”
Mayo NE, et al. Impact of preoperative change in physical function on postoperative recovery:
argument supporting prehabilitation for colorectal surgery. Surgery. 2011;150(3):505-14.
Definition of Cancer Prehabilitation
“[Prehabilitation is] a process on the cancer continuum of
care that occurs between the time of cancer diagnosis and
the beginning of acute treatment and includes physical and
psychological assessments that establish a baseline
functional level, identify impairments, and provide
interventions that promote physical and psychological health
to reduce the incidence and/or severity of future
impairments.”
Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential
component of quality care and survivorship. CA Cancer J Clin. 2013;63(5):295-317.
Do you agree that
nurses (navigators,
etc.) can provide basic
18%
screening and
interventions for
prehabilitation if they 7%
receive appropriate
training and
demonstrate
competency?
75%
Yes
No
Not Sure
Knowlton SE, Silver AJ, Silver JK, McKitrick L. Can nurses provide assessments and interventions for prehabilitation? A
survey study of cancer rehabilitation service line coordinators. Journal of Oncology Navigation & Survivorship.
2014;5(4):44.
Objective #4
• Learning Objective: Describe neuro-musculoskeletal impairments
in cancer survivors and how to ameliorate and prevent them.
Silver JK, Baima J. Cancer prehabilitation: an opportunity
to decrease treatment-related morbidity, increase cancer
treatment options, and improve physical and
psychological health outcomes. Am J Phys Med Rehabil.
2013 Aug;92(8):715-27.
Cancer Survivor Health & Function Trajectory
Yes Prehab
7
Great health/function
Above baseline?!
6
Yes Rehab
5
At baseline
4
3
Below baseline
“New normal”
2
No Prehab
1
Poor health/function
No Rehab
0
Diagnosis
Before Tx
Acute Tx
Survivorship
High-Quality Cancer Care
“Cancer rehabilitation before, during and after therapy is the
largest unaddressed need in oncology. No oncologist should allow
patients to suffer needlessly. Routine referrals to cancer
rehabilitation are not optional—they are absolutely essential to high
quality care.”
Barry Brooks, MD
Medical Oncologist
US Oncology Network
“It is time that oncologists engage with experts in cancer
rehabilitation to better predict which impairments might
arise, or alternatively have occurred, from their cancer or
planned cancer therapy and develop strategies to reduce
disability and maximize the physical and psychological health
outcomes of survivors.”
Michael Seiden, MD, PhD
Chief Medical Officer
McKesson Specialty Health
& the US Oncology Network
Former President and CEO,
Fox Chase Cancer Center
Next on the Horizon
1.
2.
3.
4.
5.
6.
7.
8.
9.
More and better studies on cancer prehab/rehab
More sophisticated understanding by oncology healthcare professionals
of the difference between general exercise vs therapeutic exercise to
prevent and treat impairments
Huge increases in survivors demanding cancer prehab/rehab
Huge increases in oncologists wanting prehab/rehab care for their
patients (high-quality cancer care)
Hospitals and cancer centers being held accountable for cancer
prehab/rehab care--including demonstrating appropriate screening,
tracking of referrals to prehab/rehab (what is the gap in care compared
to new cancer cases), and physical/psychological outcomes
More inclusion of primary care providers, nurse navigators, mental
health professionals & others
Better reimbursement
Cancer prehab/rehab is part of bundles
Prehab/rehab is not optional—it’s a standard part of high-quality cancer
care
Prehab is protection against the coming storm
Email: [email protected]