Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services

Cancer survivors maintain health benefits 6 to 12 months after exercise-based rehabilitation: a systematic review and meta-analysis

PURPOSE

To determine if the effects of exercise-based cancer rehabilitation on physical functioning, activity (including physical activity) and participation (including quality of life) are maintained at 6 to 12 months.

METHODS

Electronic databases CINAHL, Embase, MEDLINE, PsycINFO and PubMed were searched from the earliest available time to August 2021. Randomised controlled trials examining the long-term effects (≥ 6 months post-intervention) of exercise-based rehabilitation were eligible for inclusion. Outcome data (e.g. fitness, physical activity, walking capacity, fatigue, depression, quality of life) were extracted and the methodological quality assessed using PEDro. Meta-analyses using standardised mean differences were used to synthesise data and Grades of Recommendation, Assessment, Development and Evaluation criteria were applied.

RESULTS

Nineteen randomised controlled trials including 2974 participants were included. Participants who underwent exercise-based rehabilitation had improved physical activity (SMD 0.30, 95% CI 0.09 to 0.51, I2 = 0%), cardiorespiratory fitness (SMD 2.00 ml/kg/min, 95% CI 0.56 to 3.45, I2 = 0%), walking capacity (SMD 0.62, 95% CI 0.33 to 0.92, I2 = 0%), depression (SMD 0.71, 95% 0.05 to 1.37, I2 = 90%), quality of life (physical functioning component SMD 0.56, 95% CI 0.11 to 1.01, I2 = 62%) and sleep (MD 0.69 points, 95% 0.46 to 0.92, I2 = 0%) at 6 to 12 months follow-up. There was no data available on cancer-related mortality or recurrence.

CONCLUSION

Health outcomes of cancer survivors after exercise-based rehabilitation can be maintained after rehabilitation completion.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors can maintain health benefits achieved through exercise-based rehabilitation.

Survivorship in Advanced Lung Cancer: Understanding a New Landscape and Opportunities

People with advanced lung cancer represent a distinct group whose needs remain understudied, especially compared with people diagnosed with limited-stage disease. Fortunately, novel treatments such as tyrosine kinase inhibitors and immune checkpoint inhibitors are leading to significant advances in prognosis and survival, even among those with advanced disease at the time of diagnosis. However, there are known gaps in symptom management, psychosocial and nutritional support, complex care coordination, health behavior coaching, and health care delivery efforts among patients living with advanced lung cancer. Many of these patients would benefit from survivorship and palliative care approaches. In particular, survivorship care may include health care maintenance, treatment of immune-related adverse events and late- or long-term effects, frailty assessment and rehabilitation, and care coordination. Palliative care may be best suited to discuss ongoing symptom management, advanced care planning, and end-of-life considerations, as well as psychosocial well-being. To this end, we share a review of the current status of the palliative and survivorship care infrastructure for patients with advanced lung cancer and provide suggestions across the care continuum for this diverse group of patients and families.

A path to recovery for overlooked populations and their unique challenges: integrating rehabilitation in palliative care for patients with substance use disorders

Palliative care is a growing medical specialty focusing on providing compassionate and holistic management for those facing life-threatening diseases. These patients frequently present with physical, functional, emotional, and psychosocial problems that require comprehensive interdisciplinary management. However, there is a substantial opportunity to improve care for patients in palliative care who also have a substance use disorder (SUD). These opportunities include direct provision of SUD treatments by specialist palliative care providers and the integration of physical medicine and rehabilitation services. The purpose of this article is to examine the misunderstood and underutilized interaction between palliative care and SUDs, as well as describing the unique opportunities provided by physical medicine and rehabilitation providers to achieve a patient's palliative care goals and optimize overall quality of life. Substance Use Disorder is a chronic, often relapsing, illness that is relevant to palliative care practice due to the potential for significant morbidity and mortality through organ failure, chronic infections, and overdose syndromes. In traditional palliative care practice, it has been observed that past or current SUD diagnoses are often left untreated, resulting in increased distress, and exacerbating an already complex medical situation. Furthermore, many of these patients also experience physical, functional, or psychosocial changes that, when left untreated, will worsen distress and quality of life. To provide more comprehensive and successful palliative care for patients with SUD, the authors recommend an increased emphasis on specialist palliative care training in SUD management, proactive integration of rehabilitation services into the palliative care team, and consistent advocacy for these steps in various arenas. Combined, these actions can improve the care team's ability to provide a holistic, patient-centered approach that can have substantial positive outcomes for patients, health systems, and society.

Using Performance Status to Identify Risk of Acute Care Transfer in Inpatient Cancer Rehabilitation

OBJECTIVE

To identify patient factors associated with acute care transfer (ACT) among cancer survivors admitted for inpatient medical rehabilitation.

DESIGN

An exploratory, observational design was used to analyze retrospective data from electronic medical records.

SETTING

Data were obtained from 3 separate inpatient rehabilitation hospitals within a private rehabilitation hospital system in the Northeast.

PARTICIPANTS

Medical records were reviewed and analyzed for a total of 416 patients with a confirmed oncologic diagnosis treated in 1 of the inpatient rehabilitation hospitals between January and December 2020.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of an ACT. Covariates included the adapted Karnofsky Performance Scale (KPS) for inpatient rehabilitation, demographic information, admission date, re-admission status, discharge destination, and cancer-related variables, such as primary cancer diagnosis and presence/location of metastases.

RESULTS

One in 5 patients (21.2%) were transferred to acute care. Patients with hematologic cancer had a higher risk of ACT compared with those with central nervous system (CNS) cancer. Lower functional status, measured by the adapted KPS, was associated with a higher likelihood of ACT. Patients with an admission KPS score indicating the need for maximum assistance had the highest transfer rate (59.1%).

CONCLUSIONS

These findings highlight the medical complexity of this population and increased risk of an interrupted rehabilitation stay. Considering patients' performance status, cancer type, and extent of disease may be important when assessing the appropriateness of IRF admission relative to patient quality of life. Earlier and improved understanding of the patient's prognosis will allow the cancer rehabilitation program to meet the patient's unique needs and facilitate an appropriate discharge to the community in an optimal window of time.

Using Multiphase Optimization Strategy and Human-Centered Design to Create an Integrated Model of Palliative Care Skills in Home-Based Physical Therapy for Advanced Heart Failure

Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.

The Development of a Multi-Modal Cancer Rehabilitation (Including Prehabilitation) Service in Sheffield, UK: Designing the Active Together Service

Cancer patients undergoing major interventions face numerous challenges, including the adverse effects of cancer and the side effects of treatment. Cancer rehabilitation is vital in ensuring cancer patients have the support they need to maximise treatment outcomes and minimise treatment-related side effects and symptoms. The Active Together service is a multi-modal rehabilitation service designed to address critical support gaps for cancer patients. The service is located and provided in Sheffield, UK, an area with higher cancer incidence and mortality rates than the national average. The service aligns with local and regional cancer care objectives and aims to improve the clinical and quality-of-life outcomes of cancer patients by using lifestyle behaviour-change techniques to address their physical, nutritional, and psychological needs. This paper describes the design and initial implementation of the Active Together service, highlighting its potential to support and benefit cancer patients.

Assessment of Integrative Therapeutic Methods for Improving the Quality of Life and Functioning in Cancer Patients-A Systematic Review

Background: Cancer rehabilitation represents a series of measures adopted for the recovery of psychological, emotional, social, and financial functioning in the case of cancer patients. The purpose of this study is to identify the main elements of therapeutic management in the field of medical rehabilitation, as well as integrative, complementary medicine and holistic approaches that can be performed on the oncological patient. Methods: This systematic literature review follows the methodology outlined in the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" ("PRISMA") statement, which is an internationally recognized and widely accepted standard. Results: Active rehabilitative therapies offer therapeutic options for improving the functioning and quality of life of oncological patients; these therapies comprehensively address both the physical and psychological aspects of the disease. This review also includes the latest novelties and nanotechnologies applied in oncological rehabilitation, for example, drugs (or supplements) inspired by nature. Conclusions: Physical and rehabilitation medicine, mostly using stimulating therapeutic methods, was recently added to the list of contraindications in the management of oncological patients, both as an approach to the pathological concept itself and as an approach to the main clinical consequences and functional aspects of oncological therapies. Integrative, complementary medicine presents an important therapeutic resource in the case of oncological patients. Advanced studies are needed in the future to further ascertain the role of these therapies.

Advanced Cancer in Young Adults (YAs): Living in a Liminal Space

Young adults (YAs), defined as individuals between the ages of 18 and 39 years, experience unique challenges when diagnosed with advanced cancer. Using the social constructivist grounded theory approach, we aimed to develop a theoretical understanding of how YAs live day to day with their diagnosis. A sample of 25 YAs (aged 22-39 years) with advanced cancer from across Canada participated in semi-structured interviews. Findings illustrate that the YAs described day-to-day life as an oscillating experience swinging between two opposing disease outcomes: (1) hoping for a cure and (2) facing the possibility of premature death. Oscillating between these potential outcomes was characterized as living in a liminal space wherein participants were unsure how to live from one day to the next. The participants oscillated at various rates, with different factors influencing the rate of oscillation, including inconsistent and poor messaging from their oncologists or treatment team, progression or regression of their cancer, and changes in their physical functioning and mental health. These findings provide a theoretical framework for designing interventions to help YAs adapt to their circumstance.

The importance of a continuum of rehabilitation from diagnosis of advanced cancer to palliative care

PURPOSE

Identifying the evidence found in the international scientific literature, referring to the concept of rehabilitation in the setting of oncologic palliative care.

METHODS

Integrative literature review based on articles published in indexed journals on the electronic databases: LILACS, CINAHL and PubMed/MEDLINE, WEB OF SCIENCE, OTSEEKER and PEDRO, following the PRISMA criteria. The quantitative articles were evaluated using the McMaster form for quantitative studies and the qualitative studies were assessed by the Critical Appraisal Skills Program. The studies were inserted in the Rayyan™ application.

RESULTS

The final sample was composed of 21 qualitative and quantitative articles published in the period from 2004 to 2021, in nine different countries. Three thematic units were defined addressing the interface between palliative care and rehabilitation, the concept of palliative rehabilitation and the barriers to its implementation. The quality of the articles reviewed varied from 31% to 100% of the criteria met.

CONCLUSION

The international scientific production reinforces the importance of including rehabilitation in care in oncologic palliative care, highlighting the concept of palliative rehabilitation, but there is a need for expanding and divulging new research on the theme and the results.IMPLICATIONS FOR REHABILITATIONPalliative care services and rehabilitation services should take and create opportunities to promote rehabilitation for people living with incurable cancer.Palliative rehabilitation has an important role in the treatment of people with advanced cancer, helping increase the quality of life, relief of pain, symptoms, and distress.It is considered an integral part of palliative care, given that rehabilitation and palliative care are related to the continuum of care.It is important to understand this gap in the international literature on the continuum between rehabilitation and palliative rehabilitation to improve the provision of this approach in both rehabilitation and palliative care services.

Moving Forward With Telehealth in Cancer Rehabilitation: Patient Perspectives From a Mixed Methods Study

BACKGROUND

The COVID-19 pandemic accelerated the use of telehealth in cancer care and highlighted the potential of telehealth as a means of delivering the much-needed rehabilitation services for patients living with the side effects of cancer and its treatments.

OBJECTIVE

This mixed methods study aims to explore patients' experiences of telehealth and their preferences regarding the use of telehealth for cancer rehabilitation to inform service development.

METHODS

The study was completed in 2 phases from October 2020 to November 2021. In phase 1, an anonymous survey (web- and paper-based) exploring the need, benefits, barriers, facilitators, and preferences for telehealth cancer rehabilitation was distributed to survivors of cancer in Ireland. In phase 2, survivors of cancer were invited to participate in semistructured interviews exploring their experiences of telehealth and its role in cancer rehabilitation. Interviews were conducted via telephone or video call following an interview guide informed by the results of the survey and transcribed verbatim, and reflexive thematic analysis was performed using a qualitative descriptive approach.

RESULTS

A total of 48 valid responses were received. The respondents were at a median of 26 (range 3-256) months after diagnosis, and 23 (48%) of the 48 participants had completed treatment. Of the 48 respondents, 31 (65%) reported using telehealth since the start of the pandemic, 15 (31%) reported having experience with web-based cancer rehabilitation, and 43 (90%) reported a willingness for web-based cancer rehabilitation. A total of 26 (54%) of the 48 respondents reported that their views on telehealth had changed positively since the start of the pandemic. Semistructured interviews were held with 18 survivors of cancer. The mean age of the participants was 58.9 (SD 8.24) years, 56% (10/18) of the participants were female, and 44% (8/18) of the participants were male. Reflexive thematic analysis identified 5 key themes: telehealth improves accessibility to cancer rehabilitation for some but is a barrier for others, lived experiences of the benefits of telehealth in survivorship, the value of in-person health care, telehealth in cancer care and COVID-19 (from novelty to normality), and the future of telehealth in cancer rehabilitation.

CONCLUSIONS

Telehealth is broadly welcomed as a mode of cancer rehabilitation for patients living with and beyond cancer in Ireland. However, issues regarding accessibility and the importance of in-person care must be acknowledged. Factors of convenience, time savings, and cost savings indicate that telehealth interventions are a desirable patient-centered method of delivering care when performed in suitable clinical contexts and with appropriate populations.

The views and experiences of people with myeloma referred for autologous stem cell transplantation, who declined to participate in a physiotherapist-led exercise trial: a qualitative study

BACKGROUND

Recruitment rates to rehabilitation trials are variable among cancer survivors, and deeper investigation into the causes for declining participation is needed. The aim of this study was to qualitatively explore the experiences of people with myeloma referred for autologous stem cell transplant who were approached to take part in a physiotherapist-led exercise trial but declined.

METHODS

Participants were asked to participate in this qualitative study after declining to participate in a trial conducted at a UK tertiary cancer center. Semi-structured interviews were conducted. Data was analyzed inductively using reflexive thematic analysis.

RESULTS

Interviews from 18 myeloma patients (56% male, mean age 62 years) were analyzed. Four themes were identified: 1) Traveling to the specialist center is challenging, not just logistically; 2) Individualized approach valued but recall of research information variable; 3) Being less active has profound impact yet ameliorative support is lacking; and 4) Common side-effects of treatment are expected and endured but personal impact underestimated and unaddressed.

CONCLUSION

A number of barriers to participation were identified. Travel, a commonly cited reason for declining research participation, is more than a logistical issue for cancer survivors experiencing side-effects and the time burden of clinical appointments. Expectation or knowledge of the typical side-effects from myeloma and its treatment may lead to under-reporting of concerns to care providers, despite their impact upon daily activities and quality of life. Approaches used for research recruitment should consider the timing and consequences of ongoing cancer treatment to reduce potential barriers to participation.

Effect of Telerehabilitation and Outpatient Rehabilitation in Women with Breast Cancer

Telemedicine was shown to be indispensable during the SARS-CoV-2 pandemic to ensure continuity of care for fragile patients. We compared a telerehabilitation program versus an outpatient rehabilitation program in women with breast cancer undergoing quadrantectomy surgery. There were 56 women with breast cancer divided into two groups: the treatment group (TG), made up of 24 patients undergoing a remote rehabilitation project program; and the control group (CG), composed of 32 patients subjected to the same rehabilitation project program in an outpatient setting. At the time of enrollment (T0) and the end of the 8 weeks of treatment (T1), the following questionnaire scores were considered: numerical rating scale (NRS), Disabilities of the Arm, Shoulder and Hand questionnaire (Quick-DASH), Piper fatigue scale (PFS)m and Breast Cancer Therapy Functional Rating Scale (FACT-B). We observed that the CG showed greater improvements than the TG in upper limb function (7.8 ± 4.2 vs. 10.9 ± 4.9; p < 0.05) and quality of life (27.9 ± 7.2 vs. 40.0 ± 3.3; p < 0.05). No difference in efficacy between the two groups was observed for pain (2.2 ± 0.6 vs. 2.3 ± 0.9; p = 0.64) and fatigue (3.2 ± 1.1 vs. 3.2 ± 0.6; p = 0.66). Telerehabilitation is a valid tool in the management of women with breast cancer in the postoperative phase. However, face-to-face rehabilitation treatment may be preferred because it is more effective as it allows the construction of a specific, personalized, and targeted rehabilitation program.

Impact of an Accelerated Diagnostic Assessment Program on the Timeliness of Cancer Diagnosis and Treatment

PURPOSE

The Accelerated Diagnostic Assessment Program (ADAP) manages patients with imaging abnormalities, with or without concomitant symptoms, where cancer is suspected. The ADAP is offered to primary care practitioners and emergency departments with cases triaged by a medical oncologist.

METHODS

We performed a retrospective patient chart review of electronic medical records from January 2019 until June 2021 to validate the program. We collected information on the referral pathways, patient demographics, wait-times, and diagnostic results. The control group consisted of outpatients who were referred for biopsy over a 1-year period outside the ADAP stream. Statistical analyses were performed using IBM SPSS software.

RESULTS

Of the 97 patients included, 54% were female, with ages ranging from 18 to 96 years. Twenty-nine percent (n = 20) of the malignant cases were incidental findings. Most patients referred to the ADAP were diagnosed with a malignancy (71%; n = 69), comprising hematologic (45%; n = 31), GI (26%; n = 18), or other cancers (29%; n = 20). The ADAP had decreased wait-times from referral to biopsy collection (17.6 days ± 10.7 [standard deviation (SD)]; n = 43) when compared with the control group (41.2 days ± 40.0 [SD]; n = 67; P < .001). ADAP patients with malignancies saw a treating specialist 7.6 ± 7.6 days [SD] after their follow-up appointment at the ADAP.

CONCLUSION

The ADAP accelerated time to biopsy in a statistically significant manner when compared with age-, referring physician-, and biopsy site-matched controls. It also outperformed national and provincial standards, suggesting that its model addresses a gap in care by providing an underserved population timely access to diagnosis and treatment.

Effects of virtual reality on physical, cognitive, and psychological outcomes in cancer rehabilitation: a systematic review and meta-analysis

PURPOSE

To systematically examine and summarize the current evidence regarding the effects of virtual reality (VR) on physical, cognitive, and psychological outcomes in cancer rehabilitation.

METHODS

Six bioscience and engineering databases were searched. Two independent reviewers screened the titles and abstracts of 2397 records and retrieved 25 full-text articles. Inclusion criteria included patients with a current or previous diagnosis of cancer; VR was used as an intervention for physical, cognitive, or psychological impairments and functional limitations; and clinical trials with at least two arms and with both pre- and post-intervention assessments. Reviewers assessed methodological quality using the Physiotherapy Evidence Database scale.

RESULTS

Seventeen studies including 799 patients with cancer were identified. Within-group pooled analysis indicated that patients demonstrated significant improvement in pain (P < 0.001), fatigue (P < 0.001), anxiety (P < 0.001), upper extremity function (P < 0.001), and quality of life (P = 0.008) after VR intervention. Between-group pooled analysis indicated significant improvements with VR in pain (P = 0.004), anxiety (P < 0.001), and upper extremity function (P < 0.001) compared with the control. Three studies reported the positive effects of VR on cognition.

CONCLUSIONS

VR demonstrates promising effects in physical, cognitive, and psychological aspects of patients with cancer. VR can be incorporated into a comprehensive cancer rehabilitation program to alleviate impairments and functional limitations.

Physiatrists’ Attitudes and Knowledge About Cancer Rehabilitation

Objective

We aim to assess the awareness and evaluation pattern among physiatrists regarding cancer rehabilitation and associated barriers to access.

Design

The present study is a cross-sectional study in the Physical Medicine and Rehabilitation (PMR) Association Annual Meeting in Puerto Rico that used a 10-item questionnaire to summarize physiatrists’ clinical patterns with their persons diagnosed with cancer (PDWCs).

Results

Thirty-eight (66.7%) participants answered they received minimal to no education about cancer rehabilitation benefits. Cancer patients represented 10% or less of the weekly patient load for 47 (82.5%) physiatrists surveyed. The most common type of cancer encountered was breast cancer for the management of adverse effects. Twenty-nine (50.9%) physiatrists answered that a multifactorial barrier was the cause for limited services within this population group. All participants agreed that rehabilitation is at least sometimes beneficial for cancer patients, and 54 (94.7%) believed these services are needed.

Conclusion

Although rehabilitation specialists learn about the benefits of rehabilitation for PDWCs, there continues to be a limited number of PDWCs evaluated, mainly due to poor access, lack of information about cancer rehabilitation, and economic difficulties. Further efforts should be made to emphasize the importance of integrating rehabilitation techniques in the care of PDWCs.

Australian inpatient cancer rehabilitation as seen by patients receiving care pre and post intervention: Insights into unmet needs in the cancer and rehabilitation journey

OBJECTIVE

The objective of this study is to explore both the negative and positive lived experiences of cancer survivors during specialist inpatient rehabilitation programmes.

METHODS

This phenomenological study explored the negative and positive perspectives of cancer survivors with residual disability, during their inpatient rehabilitation. Semi-structured interviews conducted with 22 inpatients on admission and discharge were analysed using the protocols of Interpretative Phenomenological Analysis.

RESULTS

Experiences of inpatient cancer rehabilitation were not independent of the whole cancer trajectory. Rather, for these inpatients, processing and ruminating upon challenges to self from the moment of cancer diagnosis and throughout treatments indicated that more emotional and psychosocial support may be useful throughout cancer rehabilitation and the whole cancer trajectory.

CONCLUSION

Understanding the concurrent sources of psychological distress and growth in these cancer survivors as they recover from life changing events provides a unique consumer evaluation of an inpatient cancer rehabilitation service and the overall cancer experience. This study has implications for developing insight into the impact that the cancer trajectory has on the individual and reinforces the importance of a holistic approach to rehabilitation that includes a supported mind, body and spirit appreciation of healing.

Early integration of palliative care into oncological care: a focus on patient-important outcomes

BACKGROUND

Globally, cancer remains one of the leading causes of mortality. Palliative care is designed to meet a range of cancer patients' priority issues, including the management of pain and other cancer-associated symptoms. Routine palliative care envisages the provision of not just medical therapy, but also psychological support, social support and spiritual assistance. What constitutes the best model for palliative care remains a matter of debate.

AIM

This review was undertaken with the aim to discuss different aspects of early integration of palliative care into oncological care, with a focus on patient-important outcomes.

METHODS

A comprehensive search of publications was conducted with a focus on integrative palliative care for incurable cancer patients. For this purpose, the following databases and search engines were used: Scopus, PubMed, Cochrane Library, Research Gate, Google Scholar, eLIBRARY and Cyberleninka.

RESULTS

A comprehensive approach with early integration of different medical services appears to be the most promising. Integrative palliative care is best provided via specialised interdisciplinary teams, given that all members maintain systemic communications and regularly exchange information. This model ensures that timely and adequate interventions are provided to address the needs of patients.

CONCLUSION

Further research is needed to pinpoint the most optimal strategies to deliver palliative care and make it as tailored to the patient's demands as possible.

Developing an mHealth App for Empowering Cancer Survivors With Disabilities: Co-design Study

Background

The transition from active treatment to long-term cancer survivorship leaves the needs of many cancer survivors unaddressed as they struggle with physical, cognitive, psychological, and social consequences of cancer and its treatment. The lack of guidance after treatment has forced cancer survivors to manage long-term effects on their own, which has an impact on their overall health, quality of life, and social participation. Mobile health (mHealth) interventions can be used to promote self-management and evidence-informed education.

Objective

This study aims to design an mHealth app for cancer survivors with disabilities that will offer interventions to improve their quality of life and increase their self-efficacy to manage cancer as a chronic condition.

Methods

We organized 3 co-design workshops with cancer survivors (n=5). These workshops included persona development based on data from 25 interviews with cancer survivors with disabilities; prototype ideation, where we sketched ideas for the prototype; and prototype development, where participants critiqued, and suggested improvements for, the wireframes.

Results

These workshops helped us to define the challenges that cancer survivors with disabilities face as well as important considerations when designing an mHealth app for cancer survivors with disabilities, such as the need for including flexibility, engagement, socialization, and a minimalistic design. We also outline guidelines for other researchers to follow when planning their own co-design workshops, which include allowing more time for discussion among participants, having small participant groups, keeping workshops engaging and inclusive, and letting participants dream big.

Conclusions

Using a co-design process aided us in developing a prototype of an mHealth app for cancer survivors with disabilities as well as a list of guidelines that other researchers can use to develop their own co-design workshops and design their app. Furthermore, working together with cancer survivors ensured that the design team had a deeper sense of empathy toward the target users and kept the focus on our ultimate goal: creating something that cancer survivors would want to use and benefit from. Future work will include usability testing of a high-fidelity prototype based on the results of these workshops.

Identification of socially vulnerable cancer patients - development of a register-based index (rSVI)

BACKGROUND

Social vulnerability is a complex construct which is beyond relying on single measures. If socially vulnerable patients should be identified, we need a composite measure capturing the patient's overall circumstances. This study presents the development of a social vulnerability index (rSVI) for cancer patients based on administrative data from population-based registers.

METHODS

All patients, who died from cancer within 5 years after the cancer diagnosis during 2013-2018 (n = 44,187), were identified and divided in four subcohorts according to survival; index cohort surviving 3-5 years (n = 3044 surviving 3-5 years), cohort 1 (n = 27,170 surviving < 1 year), cohort 2 (n = 9450 surviving 1-2 years), and cohort 3 (n = 4523 surviving 2-3 years). Variables from ten registries on health and social issues were linked to each individual patient. Variables of interest were weighted to construct the rSVI using the index-cohort. rSVI was subsequently tested on the three other cohorts for validation.

RESULTS

The rSVI included weighted values for marital status, ethnicity, education, income, unemployment, psychiatric comorbidity, and somatic comorbidity. The validity of the rSVI was supported by the expected trend in proportions of vulnerable patients when applied on the other cohorts. Single social measures appeared insufficient in identification of vulnerable patients when compared with the rSVI.

CONCLUSION

The rSVI provides a tool for identification of socially vulnerable cancer patients using administrative data. The index requires further validation in other patient groups and is tested against other measures of vulnerability. Future perspectives are to use the rSVI as predictor of advanced cancer patients' use of healthcare services.

Trajectories of disability in activities of daily living in advanced cancer or respiratory disease: a systematic review

INTRODUCTION

Advanced cancer and/or respiratory disease threaten a person's independence in activities of daily living (ADL). Understanding how disability develops can help direct appropriate and timely interventions.

AIM

To identify different trajectories and associations of disability in ADL and appraise its measurement.

METHODS

Medline, Embase, PsychINFO, and CINAHL databases were searched for cohort studies with measures of disability in ADL in advanced cancer or respiratory disease at three or more timepoints. Data were narratively synthesized to produce a typology of disability trajectories and a model of factors and outcomes associated with increasing disability.

RESULTS

Of 5702 publications screened, 11 were included. Seventy-four disability trajectories were categorized into typologies of unchanging (n = 20), fluctuating (n = 21), and increasing disability (n = 33). Respiratory disease did not predict any particular disability trajectory. Advanced cancer frequently followed trajectories of increasing disability. Factors associated with increasing disability included: frailty, multi-morbidity, cognitive impairment, and infection. Increased disability led to recurrent hospital admissions, long-term care, and/or death. Methodological limitations included use of non-validated measures.

CONCLUSIONS

Increasing disability trajectories in advanced cancer and/or respiratory disease is related to potentially modifiable personal and environmental factors. We recommend future studies using validated disability instruments.Implications for rehabilitationDisability in activities of daily living (ADL) is a common unmet need in advanced cancer or respiratory disease and represents an important outcome for patients, caregivers and health and social care services.Trajectories of ADL disability can be categorized into increasing, fluctuating, and unchanging disability, which could help planning of rehabilitation services in advanced cancer or respiratory disease.Increasing disability in advanced cancer or respiratory disease relates to personal and environmental factors as well as bodily impairments, which can all be modifiable by intervention.This review highlights implications for the measurement of ADL disability in advanced cancer or respiratory disease and recommends use of validated measures of ADL to understand what factors can be modified through rehabilitation interventions.

Physical Therapists in Oncology Settings: Experiences in Delivering Cancer Rehabilitation Services, Barriers to Care, and Service Development Needs

OBJECTIVE

Physical therapist-delivered rehabilitation aims to manage the side effects of cancer and its treatments. Although access to cancer rehabilitation is not yet a standard of care in many countries, physical therapists practice in many types of cancer services with different cancer populations. The purpose of this study was to explore the experiences of physical therapists in cancer care practice with regard to their role, the factors influencing service delivery and development, and physical therapists' professional development needs.

METHODS

In this qualitative study with semistructured interviews, physical therapists in cancer care settings in the Republic of Ireland were interviewed via telephone. Participants (n = 17) represented a variety of clinical settings and roles. Two researchers performed thematic analysis of transcriptions using a semantic, inductive approach. Key themes and codes were identified and illustrative quotes were selected.

RESULTS

Six main themes were found: the need for more services, barriers to service development and delivery, a lack of awareness of the role of physical therapy, facilitators to service development, goals for the future of oncology physical therapy, and training needs of staff.

CONCLUSIONS

Physical therapists provide valuable interventions across the spectrum of cancer care but experience barriers to the delivery and development of services. Investment in oncology physical therapy and developing international standards of care will allow physical therapists to meet the rehabilitation needs of survivors of cancer.

IMPACT

As international guidelines increasingly recommend development of cancer rehabilitation programs, it is important to understand physical therapists' experiences of working in cancer care to assist in the development of effective oncology physical therapy services. This study demonstrates that physical therapist-led cancer rehabilitation services need investment and public promotion to enable the provision of optimal services to all patients with cancer and to meet standards of care.

Experiences and perceptions of social eating for patients living with and beyond head and neck cancer: a qualitative study

Purpose

Patients with head and neck cancer (HNC) describe eating as more than a physical activity for nutrition and calories. After treatment for HNC, patients report a changed social experience around food, with eating and drinking in front of family and friends depicted as a challenge. However, there is limited research exploring how patients with HNC adapt and cope with social eating difficulties. This study aims to explore patients’ experiences and perceptions of social eating and drinking following treatment for HNC.

Methods

A qualitative research design using semi-structured interviews was employed to understand the experiences of social eating of patients living with and beyond HNC. Reflexive thematic analysis was used to inductively develop key themes from the data.

Results

Fourteen interviews were conducted with patients, and two key themes were identified: (1) “Social eating became a conscious process” and (2) “Strategies to maximise social eating participation”. To maximise social eating enjoyment, patients attempted to minimise the attention on their eating function and the fuss created around food. Patients with HNC established psychological and cognitive adaptations to manage expectations and promote positive participation in social eating.

Conclusion

This paper identifies key barriers limiting or diminishing social eating for patients with HNC; including being self-conscious, lack of understanding from others and functional issues with eating and drinking. This research highlights the need to raise awareness of social eating challenges and for the social dimensions of eating to be addressed through family-centred, supportive holistic interventions implemented early in the patient’s cancer journey.

Cancer rehabilitation and palliative care for socially vulnerable patients in Denmark: an exploration of practices and conceptualisations

Background:

Despite a tax-funded, needs-based organisation of the Danish health system, social inequality in cancer rehabilitation and palliative care (PC) has been noted repeatedly. Little is known about how best to improve access and participation in cancer rehabilitation and PC for socio-economically disadvantaged and socially vulnerable patients.

Aim:

To gather, synthesise and describe practice-orientated development studies presented in Danish-language publications and examine the underpinning conceptualisations of social inequality and vulnerability; explore related views of stakeholders working in the field.

Methods:

The study comprised a narrative review of Danish-language literature on practice-orientated development studies which address social inequality and vulnerability in cancer rehabilitation and PC and an online stakeholder consultation workshop with Danish professionals and academics working in the field.

Results:

Two themes characterise the included publications (n = 8): types of interventions; conceptualisations of social inequality and vulnerability; three themes were identified in the workshop data: focus and type of interventions; organisation of cancer care; and vulnerability of the healthcare system. The publications and the workshop participants (n = 12) favoured approaches which provide additional individualised resources throughout the cancer trajectory for this patient group. The terms social inequality and social vulnerability are largely used interchangeably, and associated with low income and no or little education yet qualified with multiple descriptors, which reflect the diverse socio-economic situations professionals encounter in cancer patients and their psychosocial needs.

Conclusion:

Addressing social inequality and vulnerability in cancer rehabilitation and PC in Denmark entails practical and conceptual challenges. Of importance is individualised support and the integration of rehabilitation and PC into standardised care pathways. To conceive of social vulnerability as a layered, dynamic, relational and contextual concept reflects current practice in identifying the diversity of cancer patients who may benefit from additional support in accessing and participating in rehabilitation and PC.

Experiences of cancer rehabilitation among patients in rural areas in northern Iceland: physical and psychosocial well-being, coping, quality of life, and satisfaction with care. A qualitative study

Physical rehabilitation and psychosocial support are a part of cancer patients well-being and their ability to cope. Physical geography and healthcare provider barriers may have negative influences on patients' health outcomes. To explore the perceptions and experiences of cancer rehabilitation in a rural area in northern Iceland. A further aim was to explore patients' physical and psychosocial well-being, coping and satisfaction with care. A qualitative study using semi-structured interviews and thematic analysis was completed with a purposive sample of 21 patients at a tertiary hospital in northern Iceland. Three main themes emerged: 1) Rehabilitation - the need for improved access support and continuity; 2) Coping and quality of life - balancing life as it was before cancer against the present situation in order to achieve normality; 3) Satisfaction - encountering caring behaviours enhances satisfaction and well-being. Specifically targeted rehabilitation programmes need to be included in the treatment options for cancer patients. Survival instinct, coping mechanisms and a strong urge to maintain general functionality are of paramount importance intertwined with patients' ability to cope with the disease and treatment, and their satisfaction with care.

Exercise for individuals with bone metastases: A systematic review

BACKGROUND

Exercise has the potential to improve physical function and quality of life in individuals with bone metastases but is often avoided due to safety concerns. This systematic review summarizes the safety, feasibility and efficacy of exercise in controlled trials that include individuals with bone metastases.

METHODS

MEDLINE, Embase, Pubmed, CINAHL, PEDro and CENTRAL databases were searched up to July 16, 2020.

RESULTS

A total of 17 trials were included incorporating aerobic exercise, resistance exercise or soccer interventions. Few (n = 4, 0.5%) serious adverse events were attributed to exercise participation, with none related to bone metastases. Mixed efficacy results were found, with exercise eliciting positive changes or no change. The majority of trials included an element of supervised exercise instruction (n = 16, 94%) and were delivered by qualified exercise professionals (n = 13, 76%).

CONCLUSIONS

Exercise appears safe and feasible for individuals with bone metastases when it includes an element of supervised exercise instruction.

Limitations of Current Rehabilitation Practices in Pediatric Oncology: Implications for Improving Comprehensive Clinical Care

OBJECTIVE

To identify the proportion of hospitals/clinics in the United States (US) that have a comprehensive pediatric oncology rehabilitation program and characterize current practices.

DESIGN

Cross-sectional survey of rehabilitation providers in the US and internationally.

SETTING

Electronic or telephone survey.

PARTICIPANTS

Rehabilitation or supportive care practitioners employed at a hospital, outpatient clinic, or medical university.

INTERVENTIONS

Electronic and telephone survey. The full electronic survey contained 39 questions, provided opportunities for open-ended responses, and covered 3 main categories specific to pediatric cancer rehabilitation: service delivery, rehabilitation program practices, and education/training. The short telephone survey included 4 questions from the full survey and was designed to answer the primary study objective.

MAIN OUTCOME MEASURES

Proportion of hospitals/clinics with a comprehensive pediatric oncology rehabilitation program.

RESULTS

This cohort (N=241) includes rehabilitation providers from 191 hospitals/clinics, 49 states within the US, and 5 countries outside of the US. Of hospitals/clinics represented from the full and short survey, 145 (76%) do not have an established pediatric oncology rehabilitation program. Nearly half of full survey respondents reported no knowledge of the prospective surveillance model (PSM) and 65% reported no education was provided to them regarding pediatric cancer rehabilitation. Qualitative survey responses fell into three major themes: variability in approach to rehabilitation service delivery, program gaps, and the need for additional educational opportunities.

CONCLUSIONS

There is evidence of limited comprehensive rehabilitation programming for children with cancer as demonstrated by the lack of programs with coordinated interdisciplinary care, variability in long-term follow-up, and the absence of education and training. Research is needed to support the development and implementation of comprehensive pediatric oncology rehabilitation programs.

Evaluation of a multimodal rehabilitative palliative care programme for patients with high-grade glioma and their family caregivers

BACKGROUND

Patients diagnosed with high-grade glioma and their family caregivers often experience intense disease and treatment trajectories. Fluctuations in patient's symptoms lead to enormous burdens for caregivers and the risk of developing symptoms of stress, anxiety, and depression.

AIM

The study aim is to explore patient and caregiver experiences and evaluate the relevance of and satisfaction with a multimodal rehabilitative palliative care programme for patients diagnosed with a high-grade glioma and their family caregivers.

METHODS

In a longitudinal multi-methods study, adult patients with high-grade glioma (n = 17) and their family caregivers (n = 16) completed a 4-day residential programme and a 2-day follow-up programme 3 months later. Participants completed questionnaires after each programme, scoring relevance and satisfaction on a 5-point Likert scale. Qualitative data were collected during four evaluation group interviews with patients and caregivers.

RESULTS

The mean overall satisfaction score was 4.80 (standard deviation [SD], 0.55) for the initial 4-day programme and 4.28 (SD, 0.83) for the follow-up programme. Three themes emerged in the evaluation group interviews: (1) meeting peers strengthens social well-being, (2) the value of information and focusing on individual needs, and (3) accepting life as an unpredictable passage.

CONCLUSION

Participants found completing the REHPA-HGG programme feasible and rated all sessions highly for relevance and satisfaction. Qualitative findings confirm the value of individualised information, acceptance, and peer interactions.

IMPLICATION FOR PRACTICE

A multimodal rehabilitative palliative care programme addressed unmet patient and caregiver needs. Peer-to-peer interventions for family caregivers may address individual support needs. Similar programmes may maximise benefit by avoiding planned behaviour changes and enhancing palliative approaches.

The current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan

OBJECTIVE

This survey was conducted to clarify the current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan.

METHODS

A survey questionnaire was sent to 427 designated cancer hospitals in Japan. Information was sought regarding whether inpatient cancer rehabilitation was provided by the center, and if so, whether respondents regarded such provision as satisfactory.

RESULTS

Responses were obtained from 235/427 surveyed institutions (55.0%). Cancer rehabilitation was provided in inpatient settings by 97.4%. Two-thirds of respondents (67.7%) regarded inpatient cancer rehabilitation provision as still inadequate. The primary reasons claimed for this inadequacy were a lack of human resources, a lack of rehabilitation professionals with the requisite knowledge/skills and patients who would benefit from cancer rehabilitation present but not prescribed. The total number of rehabilitation staff was identified as associated factor of inadequate inpatient cancer rehabilitation in multivariate analysis (odds ratio = 0.979, 95% confidence interval = 0.96-1.00, P = 0.009).

CONCLUSIONS

In order to provide adequate cancer rehabilitation, a sufficient supply of rehabilitation staff, education and recognition of the need for cancer rehabilitation within oncology units are necessary.

Association between palliative care referral and burden of illness among cancers of the lip, oral cavity and pharynx

PURPOSE

To evaluate the burden of illness--length of stay (LOS), total charges, and discharge disposition--among cancers of the lip, oral cavity and pharynx (CLOP) patients with and without palliative care (PC) referral.

METHODS

This cross-sectional study utilized the 2017 National inpatient sample database to identify hospitalizations with a primary diagnosis of CLOP. Generalized linear models were used to assess the association between PC referral status and the outcomes-LOS, total charges, and discharge disposition while controlling for patients' characteristics.

RESULTS

There were 4165 PC referral among 52, 524 CLOP patients. The geometric mean of LOS for non-PC referral patients was 3.7 days, and for PC referral was 5.02 days, P < 0.001. In the adjusted analysis, CLOP patients with PC referral were more likely to have a higher LOS (Coefficient: 1.16; 95% CI, 1.01-1.25) compared to those without PC referral. The geometric mean of total charge among non-PC referral group was 48,308 USD, and CLOP-PC referral was 48,983 USD, P = 0.72. After adjusting for covariates, there was still no significant difference between the PC and non-PC referral groups. Discharge disposition were considerably different across the non-PC vs. PC referral groups. Compared to non-PC referral patients, PC referral patients were more likely to be discharge to skilled nursing facility, intermediate care, and another type of facility (aOR = 7.10; CIs, 5.51-9.12), or home health care (aOR = 4.13; CIs, 3.31-5.15).

CONCLUSION

During primary hospitalization, total charges was not different between patient non-PC and PC referral groups; however, the LOS and discharge dispositions were significantly different.

Palliative Rehabilitation Improves Health Care Utilization and Function in Frail Older Adults with Chronic Lung Diseases

OBJECTIVES

The Integrated Care for Advanced REspiratory Disorders (ICARE) service is a stay-in, post-acute care program for hospitalized patients with chronic, nonmalignant lung diseases. It provides palliative rehabilitation-a novel model integrating functional rehabilitation with early palliative care. We compare reduction of health care utilization among ICARE participants vs matched controls receiving usual care.

DESIGN

This is a prospective, propensity score-matched study. Primary outcomes were reduction in hospital readmissions and length of stay and emergency department (ED) visits, comparing the period 6 months before and after ICARE, or 6 months before and after hospital discharge (for controls). Secondary outcomes included 6-minute walking distance (6MWD) and Modified Barthel Index (MBI).

SETTING

Participants were matched 1:1 to controls by age, respiratory diagnosis, socioeconomic strata, index hospitalization length of stay, frailty, and recent admissions into intensive care unit or noninvasive ventilation units.

METHODS

Multidisciplinary interventions focused on symptom relief, functional rehabilitation, targeted comorbidity management, and postdischarge care coordination.

RESULTS

One hundred pairs of patients were matched. Participants were older adults (mean age 73.9 ± 8.2 years) with prolonged index hospitalization (median 12.0 days; interquartile range 7-18). Overall, 57% had high Hospital Frailty Risk Scores and 71% had overlapping respiratory diagnoses, the most common commonest being COPD (89%), followed by interstitial lung disease (54%) and bronchiectasis (28%). Small reductions in health care utilization were observed among controls. ICARE was associated with a further 9.1 ± 19.9 days' reduction in hospitalization length of stay (P < .001), 0.8 ± 1.9 lesser admission (P < .001), and 0.6 ± 2.2 fewer ED visits (P < .02). Participants with longest index hospitalization were observed to have greatest reduction in length of stay. 6MWD and MBI scores improved by 41.0 ± 60.2 m and 12.3 ± 11.6 points, respectively (both P < .001). Greater improvement was observed in patients with lower baseline 6MWD and MBI scores. Prescription of slow-release opioids rose from 9% to 49%. Treatment for anxiety and depression rose from 5% to 19%.

CONCLUSIONS AND IMPLICATIONS

Integrating palliative care with postexacerbation functional rehabilitation was associated with short-term reduction in health care utilization, improved functional capacity, and increased treatment of dyspnea, anxiety, and depression.

Disability in Basic Activities of Daily Living Is Associated With Symptom Burden in Older People With Advanced Cancer or Chronic Obstructive Pulmonary Disease: A Secondary Data Analysis

CONTEXT

Managing activities of daily living is important to people with advanced cancer or chronic obstructive pulmonary disease (COPD). Understanding disability in activities of daily living may inform service planning.

OBJECTIVE

To identify the prevalence of disability in activities of daily living, associations and change over time, in older people with advanced cancer or COPD.

METHODS

Secondary analysis of International Access, Rights and Empowerment (IARE) studies in adults aged ≥65 years with advanced disease in the United Kingdom, Ireland, and United States, using cross-sectional (IARE I & II) and longitudinal (IARE II, 3 timepoints over 6 months) data. Measures included disability in activities of daily living (Barthel Index), symptom severity (Palliative Outcome Scale), and assistive device use (self-reported). Logistic regression was used to identify relationships between disability and age, sex, living alone, diagnosis, and symptom burden; visual graphical analysis explores individual disability trajectories.

RESULTS

One hundred fifty-nine participants were included (140 cancer, 19 COPD). Sixty-five percent had difficulty climbing stairs, 48% bathing, 39% dressing, and 36% mobilizing. Increased disability was independently associated with increased symptom burden (odds ratio, 1.08 [95% CI:1.02-1.15], P = 0.01) and walking unaided (z = 2.35, P = 0.02), but not with primary diagnosis (z = -0.47, P = 0.64). Disability generally increased over time but with wide interindividual variation.

CONCLUSION

Disability in activities of daily living in advanced cancer or COPD is common, associated with increased symptom burden, and may be attenuated by use of assistive devices. Individual disability trajectories vary widely, with diverse disability profiles. Services should include rehabilitative interventions, guided by disability in individual activities of daily living.

Evidence Gaps in Cancer Survivorship Care: A Report from the 2019 National Cancer Institute Cancer Survivorship Workshop

Today, there are more than 16.9 million cancer survivors in the United States; this number is projected to grow to 22.2 million by 2030. While much progress has been made in understanding cancer survivors needs and in improving survivorship care since the seminal 2006 Institute of Medicine report From Cancer Patient to Cancer Survivor: Lost in Transition, there is a need to identify evidence gaps and research priorities pertaining to cancer survivorship. Thus, in April 2019, the National Cancer Institute convened grant-funded extramural cancer survivorship researchers, representatives of professional organizations, cancer survivors, and advocates for a one-day in-person meeting. At this meeting, and in a subsequent webinar aimed at soliciting input from the wider survivorship community, evidence gaps and ideas for next steps in the following six areas, identified from the 2006 Institute of Medicine report, were discussed: surveillance for recurrence and new cancers, management of long-term and late physical effects, management of long-term and late psychosocial effects, health promotion, care coordination, and financial hardship. Identified evidence gaps and next steps across the areas included the need to understand and address disparities among cancer survivors, to conduct longitudinal studies as well as longer-term (>5 years post-diagnosis) follow-up studies, to leverage existing data, and to incorporate implementation science strategies to translate findings into practice. Designing studies to address these broad evidence gaps, as well as those identified in each area, will expand our understanding of cancer survivors' diverse needs, ultimately leading to the development and delivery of more comprehensive evidence-based quality care.

Conventional supportive cancer care services in Australia: A national service mapping study (The CIA study)

AIM

Cancer and its treatment produce significant acute and long-term adverse effects in cancer survivors, resulting in a range of supportive cancer care needs across the disease trajectory. To enhance supportive cancer care in Australia, this study sought to understand and describe conventional services offered nationwide, specific to their structure (ownership, setting, duration), process (participants, delivery mode, referral pathways), and outcomes (evaluation).

METHODS

A survey canvassing 13 conventional supportive cancer care interventions was electronically distributed to 265 cancer organizations in all Australian states and territories over 2019 and 2020. Cancer organizations were invited to participate if they provided at least one cancer-directed treatment (ie, surgery, radiation therapy, or systemic therapies); or clinical cancer care to adults, adolescents, or children; or conventional supportive care interventions to cancer survivors.

RESULTS

A response rate of 46% (n = 123/265) was achieved, with 72% of cancer organizations (n = 88) delivering at least one intervention. Most were provided as outpatient or inpatient services, with few at home (<13%) or via telehealth (<10%). Psychological therapy (90%), self-care (82%), exercise (77%), healthy eating (69%), and lymphedema (69%) services were most common. Fatigue management (51%) and pelvic health (32%) were less common. Services offering massage, return-to-work, cognitive therapy, sleep hygiene, and leisure were underrepresented (<31%).

CONCLUSION

Provision of conventional supportive cancer care services continues to evolve in Australia. Multiple areas of care require development of dedicated services to address supportive cancer care intervention shortfalls across the country. Online resources and telemedicine are currently underutilized modalities that are available for further development.

A systematic review of rehabilitation and exercise recommendations in oncology guidelines

Guidelines promote high quality cancer care. Rehabilitation recommendations in oncology guidelines have not been characterized and may provide insight to improve integration of rehabilitation into oncology care. This report was developed as a part of the World Health Organization (WHO) Rehabilitation 2030 initiative to identify rehabilitation-specific recommendations in guidelines for oncology care. A systematic review of guidelines was conducted. Only guidelines published in English, for adults with cancer, providing recommendations for rehabilitation referral and assessment or interventions between 2009 and 2019 were included. 13840 articles were identified. After duplicates and applied filters, 4897 articles were screened. 69 guidelines were identified with rehabilitation-specific recommendations. Thirty-seven of the 69 guidelines endorsed referral to rehabilitation services but provided no specific recommendations regarding assessment or interventions. Thirty-two of the 69 guidelines met the full inclusion criteria and were assessed using the AGREE II tool. Twenty-one of these guidelines achieved an AGREE II quality score of ≥ 45 and were fully extracted. Guidelines exclusive to pharmacologic interventions and complementary and alternative interventions were excluded. Findings identify guidelines that recommend rehabilitation services across many cancer types and for various consequences of cancer treatment signifying that rehabilitation is a recognized component of oncology care. However, these findings are at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked. Considering that functional morbidity negatively affects a majority of cancer survivors, improving guideline concordant rehabilitative care could have substantial impact on function and quality of life among cancer survivors.

Subspecialty Training: Hospice and Palliative Medicine

ABSTRACT

Physiatrists care for patients and families with complex medical needs, and primary palliative care is an important part of the comprehensive rehabilitation care plan. Palliative care improves patient and family quality of life and reduces healthcare costs. Clinical care guidelines for several physiatry patient populations now include the provision of palliative care.Current Accreditation Council for Graduate Medical Education physiatry residency program requirements include foundational palliative care skills. Similarly, current clinical palliative care practice guidelines enumerate standards that apply to the rehabilitation setting. However, there is a dearth of literature on the current state of palliative care training within physiatry programs, and hospice and palliative medicine remains one of the least subscribed physiatry subspecialties.In this article, we describe palliative care, highlight existing literature on palliative care needs within physiatry patient populations, and identify a core physiatry-palliative care skillset. We look both within physiatry and across other specialties to guide recommendations for palliative care education within physiatry residency programs. We also describe opportunities for post-residency fellowship training in hospice and palliative medicine.

Cancer Rehabilitation Providers and Oncology Patient Expectations for Functional Outcomes after Inpatient Rehabilitation

BACKGROUND

Cancer rehabilitation is a valued resource for patients and oncologists. Cancer rehabilitation providers are seeing increasing numbers of referrals for inpatient rehabilitation as the number of cancer survivors grows. However, cancer rehabilitation providers, oncologists, therapists, patients, and caregivers may not always clearly communicate the goals of care, which can lead to different expectations for inpatient rehabilitation.

OBJECTIVE

To determine the difference in expectations of function after an acute inpatient rehabilitation stay between cancer patients and cancer rehabilitation providers and how they align with achieved goals after treatment.

DESIGN

Prospective survey study.

SETTING

Quaternary academic medical center inpatient rehabilitation unit.

PARTICIPANTS

Out of 194 eligible patients, 132 were enrolled and completed admission surveys, and 110 completed the discharge survey. Twelve cancer rehabilitation providers completed the surveys.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Barthel Index.

RESULTS

Patients estimated their expected functional status as a median (interquartile range) score of 19 points (18, 20) using the Barthel Index, compared to cancer rehabilitation providers, who estimated a median score of 17 points (15, 19) (P < .001). Actual functional status upon discharge was a median score of 16 points (13, 18) using the Barthel Index, which was three points lower than expected by patients (P < .001).

CONCLUSIONS

Oncology patients and cancer rehabilitation providers significantly overestimate functional goals for acute inpatient rehabilitation. This overestimation was clinically significant for oncology patients and statistically but not clinically significant for cancer rehabilitation providers. Increased communication may allow for a more realistic expectation of functional status upon discharge.

Prehabilitation in head and neck cancer patients: a literature review

Background

Dysphagia is one consequence of head and neck cancer that has a significant impact on quality of life for head and neck cancer survivors. While survival rates continue to improve, focus has shifted to maximizing long-term function, with prevention or prehabilitation programs becoming more common. Prehabilitation programs typically include an exercise regime that specifies the exercise type, the number of repetitions to complete per set, the number of sets of each exercise to complete per day, as well as the length of the treatment block. Ideally, exercise programs are designed with principles of neuromuscular plasticity in mind.

Methods

Twenty-nine original research articles published between 2006 and 2020 were included in this state-of-the-art review and examined for program timing and details.

Results

Two definitions for prehabilitation were noted: one third of the studies defined prehabilitation as preventative exercises prior to the start of acute cancer treatment; the remaining two thirds defined prehabilitation as treatment concurrent prehabilitation. Exercises prescribed ranged from general stretching and range of motion exercises, to trismus and swallowing specific exercises. The most common swallowing specific exercise was the Mendelsohn’s maneuver, followed by the effortful swallow, Shaker, and Masako maneuver. The most common dose was 10 repetitions of an exercise, three times per day for the duration of radiation therapy. The most common measures were questionnaires, followed by g-tube dependence, mouth opening, and MBS reports.

Conclusion

This review of the literature has shed light on the variability of prehabilitation timing, exercise type, dose, duration of treatment, and outcomes associated with prehabilitation, making the selection of an optimal prehabilitation program difficult at this time.

Oncologists' Attitude and Knowledge about Cancer Rehabilitation

INTRODUCTION

Cancer survivors may experience multiple comorbidities related to the disease itself and adverse effects from treatment. Rehabilitation specialists could provide treatment options; however, oncologic rehabilitation services are underutilized.

OBJECTIVE

To assess oncologists' awareness of the benefits of rehabilitation for cancer care patients and to identify barriers to rehabilitation referrals in adult cancer patients in Puerto Rico.

DESIGN

Cross-sectional study.

SETTING

Regional Annual Meeting of the Association of Medical Hematology and Oncology of Puerto Rico, 4-7 September 2015.

PARTICIPANTS

Forty-two oncologists.

INTERVENTIONS

Participants completed a 10-item questionnaire focused on demographics, knowledge, and clinical practices over the previous 12 months related to rehabilitation in cancer patients.

MAIN OUTCOME MEASURES

Frequency, reasons, and timing for oncologist referral of cancer patients to rehabilitation. Perceived risks and benefits of rehabilitation in cancer patients and their correlation to patient referrals, prognosis, type of cancer, and type of symptoms.

RESULTS

Thirty-seven oncologists (88.1%) received minimal or no education about cancer rehabilitation, its benefits, and indications. This resulted in 31 oncologists (73.8%) referring less than 15% of their patients for rehabilitation, with almost a third of participants referring less than 5%. However, 39 (92.9%) agreed that rehabilitation is always or frequently beneficial for their patients. Fifteen (35.7%) said they did not refer patients if prognosis was less than 6 months, and 16 (38.0%) avoided referring patients with life expectancy of less than 3 months.

CONCLUSIONS

Although medical oncologists have some knowledge that rehabilitation is beneficial for their patients, there is a low referral rate. This could be due to lack of information about cancer rehabilitation and limited access to cancer rehabilitation specialists. Further efforts should be made to improve access to rehabilitation care for cancer patients and survivors.

Multidisciplinary, exercise-based oncology rehabilitation programs improve patient outcomes but their effects on healthcare service-level outcomes remain uncertain: a systematic review

QUESTION

What is the effect of multidisciplinary, exercise-based, group oncology rehabilitation programs on healthcare service outcomes and patient-level outcomes, including quality of life and physical and psychosocial function?

DESIGN

Systematic review with meta-analysis of randomised controlled trials.

PARTICIPANTS

Adults diagnosed with cancer.

INTERVENTION

Multidisciplinary, group-based rehabilitation that includes exercise for cancer survivors.

OUTCOME MEASURES

Primary outcomes related to health service delivery, including costs, hospitalisations and healthcare service utilisation. Secondary outcomes were patient-level measures, including: the European Organisation for Research and Treatment of Cancer Quality-of-life Questionnaire, 30-second timed sit to stand and the Hospital Anxiety and Depression Scale. The evidence was evaluated using the PEDro Scale and the Grades of Research, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Seventeen trials (1,962 participants) were included. There was uncertainty about the effect of multidisciplinary, exercise-based rehabilitation on healthcare service outcomes, as only one trial reported length of stay and reported wide confidence intervals (MD 2.4 days, 95% CI -3.1 to 7.8). Multidisciplinary, exercise-based rehabilitation improved muscle strength (1RM chest press MD 3.6 kg, 95% CI 0.4 to 6.8; 1RM leg press MD 19.5 kg, 95% CI 12.3 to 26.8), functional strength (30-second sit to stand MD 6 repetitions, 95% CI 3 to 9) and reduced depression (MD -0.7 points, 95% CI -1.2 to -0.1) compared to usual care. There was uncertainty whether multidisciplinary rehabilitation programs are more effective when delivered early versus late or more effective than exercise alone. Adherence was typically high (mean weighted average 76% sessions attended) with no major and few minor adverse events reported.

CONCLUSION

Multidisciplinary, exercise-based oncology rehabilitation programs improve some patient-level outcomes compared with usual care. Further evidence from randomised trials to determine their effect at a healthcare service level are required if these programs are to become part of standard care.

TRIAL REGISTRATION

PROSPERO CRD42019130593.

Rehabilitation and palliative care for socioeconomically disadvantaged patients with advanced cancer: a scoping review

BACKGROUND

Rehabilitation and palliative care may play an important role in addressing the problems and needs perceived by socioeconomically disadvantaged patients with advanced cancer. However, no study has synthesized existing research on rehabilitation and palliative care for socioeconomically disadvantaged patients with advanced cancer. The study aimed to map existing research of rehabilitation and palliative care for patients with advanced cancer who are socioeconomically disadvantaged.

MATERIAL AND METHODS

A scoping review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A systematic literature search was performed in CINAHL, PubMed and EMBASE. Two reviewers independently assessed abstracts and full-text articles for eligibility and performed data extraction. Both qualitative and quantitative studies published between 2010 and 2019 were included if they addressed rehabilitation or palliative care for socioeconomically disadvantaged (adults ≥18 years) patients with advanced cancer. Socioeconomic disadvantage is defined by socioeconomic position (income, educational level and occupational status).

RESULTS

In total, 11 studies were included in this scoping review (138,152 patients and 45 healthcare providers) of which 10 were quantitative studies and 1 was a qualitative study. All included studies investigated the use of and preferences for palliative care, and none focused on rehabilitation. Two studies explored health professionals' perspectives on the delivery of palliative care.

CONCLUSION

Existing research within this research field is sparse. Future research should focus more on how best to reach and support socioeconomically disadvantaged people with advanced cancer in community-based rehabilitation and palliative care.

Safety, Precautions, and Modalities in Cancer Rehabilitation: an Updated Review

PURPOSE OF REVIEW

Providing rehabilitation to patients with cancer can be challenging due to the medical complexity associated with the illness and its treatments. This article provides the reader with a summary of frequently encountered medical conditions in the cancer population and associated safety considerations and precautions. An update on treatment modalities commonly used for symptom management is also presented.

RECENT FINDINGS

Cancer and cancer treatments can cause changes in multiple organ systems. Special considerations and precautions are necessary to provide safe and effective rehabilitation. Physical modalities can be used as monotherapy or adjunct to treatment for common cancer-related side effects with recent studies noting benefit with a variety of modalities.

SUMMARY

Detailed assessment of the cancer patient is necessary before implementing a rehabilitation program. Understanding cancer and side effects of treatments, including newer options, are necessary to provide safe care.

Cancer Rehabilitation and Palliative Care-Exploring the Synergies

With perpetual research, management refinement, and increasing survivorship, cancer care is steadily evolving into a chronic disease model. Rehabilitation physicians are quite accustomed to managing chronic conditions, yet, cancer rehabilitation remains unexplored. Palliative care physicians, along with rehabilitationists, are true generalists, who focus on the whole patient and their social context, in addition to the diseased organ system. This, together with palliative care's expertise in managing the panoply of troubling symptoms that beset patients with malignancy, makes them natural allies in the comprehensive management of this patient group from the moment of diagnosis. This article will explore the under-recognized and underused parallels and synergies between the two specialties as well as identifying potential challenges and areas for future growth.

Analysis of palliative care treatment among head and neck patients with cancer: National perspective

BACKGROUND

To analyze the characteristics and survival patterns of patients with head and neck squamous cell carcinoma (SCC) who received palliative treatment during their first course of treatment.

METHODS

Cohort analysis utilizing the National Cancer Data Base (NCDB) of patients with a diagnosis of oral cavity/oropharyngeal, hypopharyngeal, and laryngeal SCC. Statistical analysis included multivariate logistic regression and Cox Hazard ratio modeling, and Kaplan-Meier survival analysis.

RESULTS

165 081 patients were included, of which 2747 patients received palliative treatment. Patients who received palliative treatment tended to be ≥65 years old, black, Charlson/Deyo score ≥3, hypopharyngeal cancer, stage (III-IV), with Medicaid insurance (P < .05). Patients were more likely to be treated with palliative intent if they underwent chemotherapy/radiotherapy and declined surgery (P < .001) compared to patients who underwent surgery and declined chemotherapy/radiotherapy (P = .006).

CONCLUSIONS

Palliative care use in head and neck oncology is associated with older patients, non-whites, Medicaid patients, and nonsurgically treated patients.

The efficacy of specialised rehabilitation using the Op-reha Guide for cancer patients in palliative care units: protocol of a multicentre, randomised controlled trial (JORTC-RHB02)

BACKGROUND

Although rehabilitation is recommended for terminal cancer patients, the specific components and methods of such programs are poorly documented. No studies to date have examined the effectiveness of rehabilitation for terminal cancer patients. This study aims to evaluate the efficacy of a new intervention for rehabilitation therapists, using the Op-reha Guide (Guide to Optimal and Patient-Centred Rehabilitation Practice for Patients in Palliative Care Units [PCUs]) in rehabilitation practice. This guide consists of recommended actions and attitudes for rehabilitation therapists and aims to optimise therapists' actions according to the patient's needs and condition. It shares goals with terminal cancer patients to maintain their activities of daily living (ADL).

METHODS

This study uses a multicentre, prospective, randomised controlled trial (RCT) design with two parallel groups in PCUs where specialised rehabilitation will be routinely performed for terminal cancer patients by rehabilitation therapists. Participants will be randomised (1:1) to intervention (the Op-reha Guide) and control groups (usual rehabilitation). We will then conduct an observational study in PCUs that do not perform specialised rehabilitation for terminal cancer patients; this will be considered the usual care group, and the efficacy of usual rehabilitation will be quantitatively evaluated. Inclusion criteria are hospitalisation in PCU, European Cooperative Oncology Group Performance Status of 2 or 3, and clinical estimation of life expectancy of 3 weeks or more. Patients with severe symptom burden will be excluded. We hypothesise that the Op-reha Guide will be more effective in maintaining the ADL of terminal cancer patients hospitalised in PCUs than usual rehabilitation. The primary endpoint is defined as the change in (total) modified Barthel Index from baseline to Day 22. Quality of life will be a secondary endpoint. In total, 135 patients will be recruited from 16 Japanese sites between July 2019 and December 2021.

DISCUSSION

This will be the first trial to evaluate the efficacy of specialised rehabilitation for terminal cancer patients hospitalised in PCUs, and will contribute to the evidence on the efficacy of implementing rehabilitation for terminal cancer patients.

TRIAL REGISTRATION

UMIN-CTR, UMIN000037298 R000042525 (date of registration 7 July 2019).

Managing employment among pre-retirement aged cancer survivors

Introduction

Successfully maintaining (managing) paid employment can be a challenge as people negotiate the cancer care pathway and survivorship. Little research explores the influence of age on this situation. The purpose of this project was to explore the role of age in managing employment for survivors from age 45 to 64 years.

Method

A qualitative descriptive design was conducted to explore the intersection of age and managing employment for cancer survivors. In-depth semi-structured interviews were conducted with 19 United States cancer survivors (lung, breast, colorectal). Interviews were conducted in person or by phone. Verbatim transcripts were analyzed using thematic analysis. Codes were grouped by categories, incorporated into separate topical files, and then aggregated into broader emergent themes.

Findings

Survivors are not just “returning” to work after treatment. They are often managing work both during and after treatment. Age may have benefits but can also provide barriers to positive survivorship and employment experiences. Fulfilling the role of employee and maintaining a worker identity was a strong driver for many participants. Again, this was potentially both a support and a barrier. It was discovered that health care providers provided little support to facilitate employment.

Conclusion

Age is a factor that is poorly understood but influences both health and personal aspects of the experience of managing paid employment during and after cancer treatment. Occupational therapy practitioners should acknowledge this important role in addressing cancer survivorship.

Thirteen-year analyses of medical oncology outpatient day clinic data: a changing field

Background

Novel treatment modalities like targeted therapy and immunotherapy are currently changing treatment strategies and protocols in the field of medical oncology.

Methods

Numbers of patients and patient contacts admitted to medical oncology day clinics of a large European academic cancer centre in the period from 2006 to 2018 were analysed using our patient administration system.

Results

A patient cohort of 9.870 consecutive individual patients with 125.679 patient contacts was descriptively and retrospectively characterised. Mean age was 59.9 years. A substantial increase in both individual patients treated per year (+45.4%; 2006: 1.100; 2018: 1.599) and annual patient contacts (+63.3%; 2006: 8.857; 2018: 14.467) between 2006 and 2018 was detected. Hence and most interestingly, the ratio of visits per patient increased by approximately one visit per patient per year over the last 12 years (+12.4%; 2006: 8.0; 2018: 9.0). Further, a decrease of patient contacts in more prevalent entities like breast cancer was found, while contacts for orphan diseases like myeloma and sarcoma increased substantially. Interestingly, female patients showed more per patient contacts as compared with men (13.5 vs 11.9). Lastly, short-term safety data of outpatient day clinic admissions are reported.

Conclusions

We present a representative and large set of patient contacts over time that indicates an increasing load in routine clinical work of outpatient cancer care. Increases observed were highest for orphan diseases, likely attributed to centralisation effects and increased treatment complexity.

Occupational therapy and physiotherapy interventions in palliative care: a cross-sectional study of patient-reported needs

INTRODUCTION

An interdisciplinary team approach to patients in specialised palliative care is recommended; however, the composition of the professionals tends to vary, and the roles of physiotherapists and occupational therapists may be underestimated. We aimed to investigate patient-reported unmet needs, which potentially could benefit from physiotherapy and occupational therapy interventions in a specialised palliative care team.

METHODS

Adult patients with chronic advanced diseases referred to the Specialised Palliative Care Team at Copenhagen University Hospital, Rigshospitalet were enrolled in the study. The Three-Levels-of-Needs Questionnaire was used as primary outcome to assess symptom/problem intensity, symptom/problem burden and felt needs for 12 commonly reported symptoms/problems for patients referred to a specialised palliative care team. Furthermore, participants' level of distress, fatigue and physical activity, symptoms of anxiety and depression, and barriers towards the rehabilitation programme were registered with other measures.

RESULTS

In total, 43 of 67 (64%) patients participated. The majority of participants reported severe symptoms/problems concerning fatigue (81%), impaired physical activities (77%), carrying out work and daily activities (77%), pain (72%), and worries (58%). Furthermore, need for help was expressed concerning physical activities (79%), work and daily activities (77%), fatigue (70%), pain (65%), concentration (58%) and worries (51%). On average the patients characterised 6 (out of 12) symptoms/problems as severe.

CONCLUSION

Patients referred to a specialised palliative care team reported extensive unmet needs concerning physical activities, work and daily activities, fatigue, pain, concentration and worries. Unmet needs that potentially could be alleviated by physiotherapists or occupational therapists implemented in the interdisciplinary team.