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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]