Context: Gap in Care
Adrienne Hill, DO
Physical Medicine and Rehabilitation
Comprehensive Cancer Center
at Wake Forest Baptist Health
Cancer is one of the leading causes of death in the United States, and is one of the most common, impairmentcausing, and costly diseases affecting Americans. The good news is that more people are surviving as a result of diagnostic and therapeutic advancements.1
The cancer patient’s journey is an intense fight on two fronts: (1) overcoming and managing disease and,(2) coping with often debilitating and even disabling adverse effects and impairments. Cancer- and treatment-related impairments may include profound fatigue, chronic pain, decreased physical and cognitive function, as well as many others. Many times, impairments exist long after treatment. Few patients are prepared for the discouraging and devastating toll that is taken as a result of cancer and its treatment.
Survivors are commonly told to expect a “new normal” before having received rehabilitation services that may facilitate higher level functioning. The lack of comprehensive rehabilitation services is a profound source of unnecessary suffering for survivors. Evidence suggests that 65% to 90% of patients with cancer have functional impairments with fewer than 30% who actually get referred for rehabilitation services. Excluding inpatient consults, less than 2% of patients receive rehabilitation care.2,3
Solution: Impairment-Driven Cancer Rehab
Figure 1. Survivorship Care Continuum
Impairment-driven cancer rehabilitation can provide a solution by focusing on screening and treating physical and psychosocial impairments simultaneously and across the continuum of care. If patients with cancer are routinely screened for impairments and then appropriately referred to trained rehabilitation professionals, it is reported that patients will experience significant improvements in function, decreased disability, and increased health-related quality of life.4
One model of cancer rehabilitation is the Survivorship Training and Rehabilitation program (STAR). The program provides a framework for the development of a multidisciplinary cancer rehab team. The STAR program incorporates training for clinicians, nurses, therapists, and support staff, and provides protocols to ensure the highest quality of cancer care. The model consists of the following: patient screening prior to undergoing acute cancer treatments, early identification of impairments, prehabilitation(if indicated), outcomes tracking, and treatment of functional deficits throughout the survivorship continuum.
Prehabilitation is a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment. It includes physical and psychological assessments that establish a baseline functional level, impairment identification, and interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments (Figures 1 and 2)
Figure 2. Cancer Prehabilitation vs Usual Care and Education
Four outcomes should be monitored and include clinician education, patient function, patient satisfaction, and referrals/revenue to the institution.
Impairment driven cancer rehabilitation is a critical part of high-quality care. The American Cancer Society, Institute of Medicine, and the Commission on Cancer mandate that cancer rehabilitation and survivorship care must be a distinct and well-developed part of cancer treatment.