Toward a National Initiative in Cancer Rehabilitation: Recommendations From a Subject Matter Expert Group

Physical decline, falls, and hospitalization among vulnerable older patients in the trajectory of colorectal cancer treatment

INTRODUCTION

Resilience to anticancer treatment for colorectal cancer (CRC) among older patients varies. Many experience weight loss, physical decline, falls, and hospitalization during treatment, often leading to early discontinuation of otherwise effective chemotherapy. Screening for vulnerability might help to identify patients at risk of these adverse outcomes in older adults.

MATERIALS AND METHODS

This is a secondary analysis from the GERICO trial. Patients aged ≥70 years assessed for chemotherapy for CRC were screened for eligibility for the GERICO trial with the geriatric-8 (G8) frailty screening tool. The present study population comprised patients who were (1) screened with G8 but for reasons not included in the GERICO study and (2) patients who were randomized to the GERICO control group. We evaluated whether patients identified as vulnerable with G8 (≤14/17) or retrospectively constructed mG8 (≥6/35) had higher risk of experiencing decline in performance status (PS), falls, and unplanned hospitalization during treatment. The association between frailty status and the adverse outcomes was analyzed with univariate and multivariate logistic regression. The discriminative ability of G8/mG8 to predict outcomes was analyzed using the area under the curve for receiver operating characteristics curves.

RESULTS

In total, 238 patients (median age 74 years [range 70-91]) were included in this analysis. More vulnerable than fit patients experienced decline in PS (G8: 41% vs. 14%, p = 0.006 and mG8: 28% vs. 17%, p = 0.04) during treatment. Furthermore, more vulnerable than fit patients experienced falls (G8 14% vs. 6% p = 0.04) and unplanned hospitalization (G8: 31% vs. 14%, p = 0.009 and mG8: 34% vs. 13%, p < 0.001). Multivariate analyses showed an association between G8 vulnerability and decline in PS, falls, and hospitalization.

DISCUSSION

Patients with G8 or mG8 vulnerability were more likely to experience decline in PS and unplanned hospitalization during chemotherapy for CRC than fit patients. More G8 vulnerable patients experienced falls compared with fit patients. Appropriate interventions should be offered to older patients with CRC assessed as vulnerable with G8 or mG8 to maintain PS during chemotherapy.

Telephone consultation for cancer survivors with unclarified need for rehabilitation in a primary healthcare setting: a mixed methods process evaluation

PURPOSE

To evaluate the implementation of telephone consultations to assess cancer patients' needs for rehabilitation, with focus on patients' acceptance, health professionals' experience and contextual factors.

METHODS

A mixed methods process evaluation was conducted at a primary healthcare rehabilitation clinic. Cancer survivors above 18 years of age with an unclarified rehabilitation need at discharge from hospital, was offered a telephone consultation provided by health professionals. Data on implementation and acceptability were collected using medical records systems, data collection forms and semi-structured interviews with six patients and two health professionals.

RESULTS

Eighty-one cancer survivors were referred to the intervention, and 54% continued to further rehabilitation. The telephone consultations were executed approximately eight days after referral and took on average 44 min to deliver. Overall, the patients found that the telephone consultation addressed what they considered the most important topics, and the health professionals found the intervention to be acceptable. Both patients and health professionals reported challenges regarding the referral process.

CONCLUSION

Patient acceptance of the intervention was high, and the telephone consultation was implemented to a high degree, resulting in more than half of the patients continuing to further rehabilitation. Patients' and health professionals' perspectives provided valuable insights about contextual factors.

Evidence-based rehabilitation medicine: definition, foundation, practice and development

To determine the definition, foundation, practice, and development of evidence-based rehabilitation medicine (EBRM) and point out the development direction for EBRM. Retrieve the database of PubMed, Cochrane Library, Embase, China national knowledge infrastructure (CNKI), Wanfang, and China science and technology journal database (CSTJ). The search was conducted from the establishment of the database to June 2023. The key words are "rehabilitation medicine and evidence based" in Chinese and English. After reading the abstract or full text of the literature, a summary analysis is conducted to determine the definition, foundation, practice, and development of EBRM. A total of 127 articles were included. The development of 14 sub majors in EBRM are not balanced, evidence-based musculoskeletal rehabilitation medicine (EBMRM) (31 articles, mainly focuses on osteoarthritis, osteoporosis and musculoskeletal pain), evidence-based neurorehabilitation medicine (EBNM) (34 articles, mainly concentrated in stroke, traumatic brain injury and spinal cord injury) and evidence-based education rehabilitation medicine (EBEDRM) (17 articles, mainly focuses on educational methodology), evidence-based nursing rehabilitation medicine (EBNRM) (2 articles), evidence-based engineering rehabilitation medicine (EBENRM) (7 articles), evidence-based traditional Chinese rehabilitation medicine (EBTCRM) (3 articles), evidence-based internal rehabilitation medicine (EBIRM) (11 articles), evidence-based intensive care rehabilitation medicine (EBICRM) (4 articles), evidence-based oncology rehabilitation medicine (EBORM) (6 articles), evidence-based physical therapy medicine (EBPTM) (3 articles), evidence-based cardiopulmonary rehabilitation medicine (EBCRM) (6 articles), evidence-based speech therapy medicine (EBSTM)/evidence-based occupation therapy medicine (EBOTM)/evidence-based geriatric rehabilitation medicine (EBGRM) (1 article). The EBMRM, EBNM and EBEDRM are relatively well developed. The development of EBNRM, EBENRM, EBTCRM, EBIRM, EBICRM, EBGRM, EBORM, EBCRM, EBPTM, EBSTM and EBOTM is relatively slow, indicating these eleven fields should be pay more attention in future.

Neurorehabilitation for Adults with Brain and Spine Tumors

Central nervous system (CNS) malignancies (i.e. brain and spine tumors) and their treatments can result in a multitude of neurologic deficits. Patients with CNS malignancies experience physical, cognitive, and psychosocial sequelae that can impact their mobility and quality of life. Neurorehabilitation can play a critical role in maintaining independence, preventing disability, and optimizing safety with activities of daily living. This review provides an overview of the neurorehabilitation approaches for patients with CNS malignancies, neurologic impairments frequently treated, and rehabilitation interventions in various health care settings. In addition, we will highlight rehabilitative outcomes between patients with nononcologic neurologic conditions compared to brain and spine tumors. Finally, we address medical challenges that may impact rehabilitation care in these medically complex cancer patients.

Utilization and Cost of Outpatient Rehabilitation Services for Pediatric Patients Treated for Acute Lymphoblastic Leukemia Using a Commercial Claims Database

OBJECTIVE

To investigate the temporal trends and factors associated with outpatient rehabilitation utilization and costs for pediatric acute lymphoblastic leukemia (ALL).

DESIGN

Deidentified administrative claims data and longitudinal health information on patients representing a mixture of ages, ethnicities, and geographic regions across the United States were accessed using Optum Labs Data Warehouse. Regression models were constructed to assess associations of outpatient rehabilitation with age, sex, race and ethnicity, year of diagnosis, and region.

SETTING

Outpatient rehabilitation.

PARTICIPANTS

1000 Patients aged 1-30 years with a new diagnosis of ALL between 1993 and 2017 and continuous insurance coverage (N=1000).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Outpatient rehabilitation service utilization and cost based on reimbursed charge codes, summarized over 36 months after cancer diagnosis.

RESULTS

In 1000 patients, utilization of outpatient rehabilitation services increased from 20% in 1993-2002 to 55% in 2013-2017. In the earliest era examined, physical and/or occupational therapy was provided to 18% and increased to 54% in the latest years. Speech service utilization remained between 5%-8% across timepoints. Inflation-adjusted cost for provision of services did not change significantly across time and remained low, accounting for a median of 1.3% (Q1, Q3 0.3, 3.4) of total treatment cost in 1993-2002 and decreasing to a median 0.4% (Q1, Q3, 0.1, 1.0) in 2013-2017. Age 1 to 5 years at ALL diagnosis was associated with increased rehabilitation visit number and cost, and treatment in the Midwest was associated with increased likelihood of outpatient rehabilitation service utilization compared to other geographic regions.

CONCLUSIONS

Outpatient rehabilitation services are being increasingly provided to patients with ALL at a relatively low cost per patient, yet geographic variability in care utilization is evident. These services do not add excessively to the overall cost of leukemia care and thus cost containment should not be an excuse to limit access.

Integrated Short-term Palliative Rehabilitation to improve quality of life and equitable care access in incurable cancer (INSPIRE): a multinational European research project

Background

Disability related to incurable cancer affects over a million Europeans each year and people with cancer rank loss of function among the most common unmet supportive care needs.

Objectives

To test the clinical and cost-effectiveness of an integrated short-term palliative rehabilitation intervention, to optimise function and quality of life in people affected by incurable cancer.

Design

This is a multinational, parallel group, randomised, controlled, assessor blind, superiority trial.

Methods

The INSPIRE consortium brings together leaders in palliative care, oncology and rehabilitation from partner organisations across Europe, with complementary expertise in health service research, trials of complex interventions, mixed-method evaluations, statistics and economics. Partnership with leading European civil society organisations ensures citizen engagement and dissemination at the highest level. We will conduct a multinational randomised controlled trial across five European countries, recruiting participants to assess the effectiveness of palliative rehabilitation for people with incurable cancer on the primary outcome - quality of life - and secondary outcomes including disability, symptom burden and goal attainment. To support trial conduct and enhance analysis of trial data, we will also conduct: comparative analysis of current integration of rehabilitation across oncology and palliative care services; mixed-method evaluations of equity and inclusivity, processes and implementation for the intervention, at patient, health service and health system levels. Finally, we will conduct an evidence synthesis, incorporating INSPIRE findings, and a Delphi consensus to develop an international framework for palliative rehabilitation practice and policy, incorporating indicators, core interventions, outcomes and integration methods.

Scientific contribution

If positive, the trial could produce a scalable and equitable intervention to improve function and quality of life in people with incurable cancer and reduce the burden of care for their families. It could also upskill the practitioners involved and motivate future research questions. The intervention could be adapted and integrated into different health systems using existing staff and services, with little or no additional cost.

Analysing outpatient care access for planning purposes: The Basilicata Region experience

The delivery of healthcare services at regional level should be modeled on population needs, stemming from patients' consumption pattern and trying to include unexpressed needs and exclude excesses of demand due to both moral hazard behaviors and inducements from the supply side. We propose a model able to estimate the frequency of access in outpatient care (OC) based on the characteristics of the population. According to empirical evidence, among the determinants of outpatient access we include variables addressing health, socioeconomic status and place of residence, plus variables related to the supply of services. We run generalized linear models for counting data of the Poisson family with the aim of both identifying the determinants of OC utilization and quantifying the related effects. We use the regional administrative database of Basilicata region, year 2019. Results are consistent with literature findings and provide new insights into the analysis of OC, suggesting that our model could easily be implemented by regional policymakers to plan the supply of ambulatory services on population needs.

Self-Employed Canadians' Experiences with Cancer and Work: A Qualitative Study

Self-employed individuals with cancer face unique challenges that have not been fully explored in previous research. For example, while some studies conducted in Europe have suggested that self-employed workers with cancer experience more adverse health and work-related outcomes compared to salaried workers, the specific manners in which cancer affects the health, work, and businesses of self-employed individuals remain inadequately understood. This lack of understanding represents a crucial gap in the literature, as self-employed individuals make up a significant portion of the workforce in many countries, including Canada. To address this gap, a qualitative interpretive description study was undertaken to explore the experiences of 23 self-employed Canadians diagnosed with cancer from six provinces, with the aim of generating insights into the unique challenges faced by this population. The interviews were conducted in the language chosen by the participants from the two official languages of Canada, namely English and French. Using reflexive thematic analysis, four major themes and twelve subthemes were generated from the participants' shared accounts that reflected the impact of cancer on self-employed Canadians' physical, cognitive, and psychological function, affecting their work ability and their ability to maintain their business and financial well-being. Participants in the study also shared strategies they used to continue working and maintain their business during their cancer experience. This study sheds light on the impact of cancer on self-employed individuals and provides insight into the experiences of self-employed individuals with cancer that can inform the development of interventions to support this population.

Implementation of a Cancer Rehabilitation Navigation Program: a qualitative analysis of implementation determinants and strategies

BACKGROUND

Cancer rehabilitation navigation (CRNav) is a care delivery model that expedites identification and management of symptom-related functional morbidity for individuals undergoing cancer treatment. A CRNav program is unique in that it embeds a cancer rehabilitation professional in the cancer center for patient screening and assessment. The implementation of CRNav programs has not been studied and doing so could facilitate greater uptake of these programs.

METHODS

Using implementation science frameworks, we conducted a qualitative, post-implementation analysis of a CRNav program that was implemented in 2019. Semi-structured, 1:1 interviews were guided by the Consolidated Framework for Implementation Research (CFIR) and a combination of deductive and inductive analyses, using a priori established codes, was used to assess the implementation context, and identify emergent themes of barriers and facilitators to implementation. Participant described implementation strategies were characterized and defined using the Expert Consensus Recommendations for Implementing Change (ERIC) taxonomy.

RESULTS

Eleven stakeholders including physicians, administrators, clinical staff, and patients, involved with program development and the implementation effort, participated in interviews. Predominant barriers to implementation included developing the program infrastructure, and lack of awareness of rehabilitation services among oncology professionals, predominant facilitators of implementation included; physical co-location of the navigator in the cancer center, individual characteristics of the navigator, and unique characteristics of the program. Strategies described that supported implementation included developing stakeholder interrelationships, evaluating and iteratively adapting the program, creating infrastructure, training and education, and supporting clinicians.

CONCLUSION

This analysis uses implementation science to methodically analyze and characterize factors that may contribute to successful implementation of a CRNav program. These findings could be used alongside a prospective context-specific analysis to tailor future implementation efforts.

IMPLICATIONS FOR CANCER SURVIVORS

Implementing a CRNav program expedites a patient's direct contact with a rehabilitation provider complementing the cancer care delivery team, and providing an additive and often missing service.

Implementing and sustaining a breast cancer prospective surveillance rehabilitation program: an institutional perspective

BACKGROUND

The prospective surveillance model (PSM) is an evidence-based rehabilitation care delivery model that facilitates functional screening and intervention for individuals undergoing cancer treatment. While PSM is empirically validated and feasible in practice, implementation into cancer care delivery has languished. The purpose of this manuscript is to characterize the barriers and facilitators to implementing PSM in a breast cancer center and to share policy and process outcomes that have sustained the model in practice.

METHODS

The PSM implementation was undertaken as a quality improvement initiative of our cancer center. We retrospectively assessed barriers to implementation and define those according to the Consolidated Framework for Implementation Research (CFIR). Implementation strategies are defined based on the Expert Recommendations for Implementation Change (ERIC) taxonomy. Breast center policy changes and stakeholder-reported process improvement outcomes at the clinic and system level are described.

RESULTS

PSM implementation facilitation was driven primarily by adapting the model to align with the cancer center workflow, engaging interdisciplinary stakeholders as program champions, enhancing knowledge and awareness among cancer care providers, and changing infrastructure to support the model. System and clinic-level policy and process changes included the development of clinical pathways, EHR order sets and automated referrals, new staffing models, and adapted clinical workflows.

CONCLUSION

Our report provides insight on implementing the PSM at a single institution in a cancer care delivery setting. Successful implementation strategies addressed individual, clinic, and system-level barriers and facilitated process and policy changes that have enabled PSM sustainment. Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity.

IMPLICATIONS FOR CANCER SURVIVORS

Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity.

Predictors of cancer rehabilitation medicine referral and utilization based on the Moving Through Cancer physical activity screening assessment

PURPOSE

Cancer survivors experience high rates of physical inactivity that often go unaddressed. The My Wellness Check program (MWC) is an EHR-integrated screening and referral system that includes surveillance of physical activity and triage to cancer rehabilitation medicine services. This study examined assessment of physical activity and subsequent referrals to cancer rehabilitation medicine.

METHODS

A secondary analysis was performed for survivors who completed the MWC between April 2021 and January 2022. Univariable and multivariable logistic regression modeled determinants of qualification for a physical activity referral and provider completion of referral to cancer rehabilitation medicine. Referral was based on responses to the Moving Through Cancer questionnaire. Adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI) were calculated.

RESULTS

There were 1,174 survivors who completed the assessment, of which 46% (n = 540) reported physical inactivity. After controlling for group differences, individuals with moderate-severe physical dysfunction (aOR: 1.750; 95% CI: 1.137, 2.693) had higher odds, and self-reporting Hispanic or Latino ethnicity (aOR: 0.720; CI: 0.556, 0.932) had lower odds of physical inactivity. Only 31% (n = 168) received a completed physician referral to cancer rehabilitation medicine following identification of physical inactivity. No patient-level factors were associated with receiving a physician referral. Following referral, 8% (n = 13) utilized cancer rehabilitation medicine services.

CONCLUSIONS

Patient-level and clinical factors may predict qualification for physical activity referrals; however, they don't appear to predict referral completion to cancer rehabilitation medicine. Future research should focus on potential provider- and organization-level factors that interact and influence access to cancer rehabilitation medicine services.

Trajectories of participation in daily life among individuals newly diagnosed with cancer: A 5-month longitudinal study

PURPOSE

To determine how participation in daily life is impacted during the first six months following a new cancer diagnosis and to identify risk factors for participation restrictions. Patient-reported outcomes (PROs) were used to suggest referrals to rehabilitation services.

METHODS

Participants (n = 123) were adults (> 18 years) with the newly diagnosed primary brain, breast, colorectal, or lung cancer. PROs were collected at baseline (within 30 days of diagnosis/treatment initiation), two and five months post baseline. Daily life participation was assessed through the community participation indicators (CPI) (score range: 0-1) and patient-reported outcome measurement information system (PROMIS) ability to participate, (score range: 20-80; mean: 50, SD: 10). PROMIS-43 profile was also completed. Linear mixed-effect models with random intercept evaluated change in participation over time.

RESULTS

The baseline total sample mean CPI score was 0.56; patients reported mildly impaired participation based on PROMIS scores (baseline: 46.19, 2-month follow-up: 44.81, 5 months: 44.84). However, no statistically significant changes in participation were observed over the study period. Risk factors for lower participation included receiving chemotherapy, lower physical function, higher anxiety and fatigue, and reduction in employment, p < 0.05. PROs indicated that roughly half of the participants may benefit from physical or occupational therapy or mental health support, but only 20-36% were referred by their medical team.

CONCLUSION

People newly diagnosed with cancer experience impaired participation, but they are infrequently referred to supportive services such as rehabilitation. The use of PROs to assess participation, physical function, and mental health can promote access to supportive care services by identifying patients who may benefit from rehabilitation beyond those identified through routine clinical care.

Physiotherapy and Exercise Management of People Undergoing Surgery for Lung Cancer: A Survey of Current Practice across Australia and New Zealand

Background: Moderate- to high-certainty evidence supports the benefits of pre- and post-operative exercise for people undergoing surgical resection for lung cancer. Despite this, exercise programs are not commonly provided. Previous data regarding exercise practices are a decade old. Therefore, this study aimed to understand current exercise practices in surgical lung cancer care in Australia and New Zealand. Methods: An online cross-sectional survey of Australian and New Zealand allied health professionals specialising in exercise-based interventions was carried out. Survey development and reporting adhered to CHERRIES and CROSS checklists. Institutions with thoracic surgery departments were invited to participate via email, and additional responses were sought via snowballing. Results: The response rate was 81%, with a total of 70 health services responding. A total of 18 (26%) pre-operative services, 59 (84%) inpatient post-operative services, and 39 (55%) community/outpatient post-operative services were identified. Only eight (11%) services provided a pre-operative exercise program. Half of the respondents referred less than 25% of patients to community/outpatient exercise programs on hospital discharge. Respondents reported that their clinical management was predominantly influenced by established workplace practices and personal experience rather than evidence. Conclusions: The availability and uptake of pre- and post-operative exercise remain low, and work should continue to make pre/post-operative exercise training usual practice.

Translation of Karnofsky Performance Status (KPS) for use in inpatient cancer rehabilitation

BACKGROUND

Better tools are needed to predict functional decline and oncologic prognosis in inpatient cancer rehabilitation. The Karnofky Performance Status (KPS) is a widely used scale of functional performance in oncology, although the scale differs from current rehabilitation terminology. Use of the KPS in inpatient rehabilitation may support a shared method of communication between cancer rehabilitation providers and the primary oncology teams.

OBJECTIVE

To establish interrater reliability for translation of the KPS for use in inpatient cancer rehabilitation.

DESIGN

Retrospective interrater reliability review.

SETTING

A large inpatient rehabilitation hospital system.

PARTICIPANTS

Fifty randomized charts were chosen for review from a larger database of all patients admitted to an inpatient cancer rehabilitation program in 2020.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The KPS scale was translated into common inpatient rehabilitation grading consistent with the Continuity and Assessment Record and Evaluation (CARE) Item Set to support its use in this specialty area. Additionally, a list of best practice guidelines and scoring instructions were created to assist raters in determining appropriate levels within the scale. Members of the inpatient cancer rehabilitation team scored all patients within the larger database (n = 424) throughout 2020. A blinded rater completed retrospective chart reviews to score the 50-chart sample. A two-way random effects model was used to calculate an intraclass correlation coefficient (ICC) for the KPS scores at each of three time points (premorbid, admission, and discharge).

RESULTS

The KPS interpretation for rehabilitation proved to be statistically reliable for the 50-chart sample. The premorbid KPS interrater reliability was acceptable (ICC = 0.67; 95% confidence interval [CI]: 0.40-0.82), admission KPS reliability was good (ICC = 0.88, 95% CI: 0.78-0.93), and discharge reliability was excellent (ICC = 0.96; 95% CI: 0.91-0.98).

CONCLUSION

The KPS translation at three time points (premorbid, admission, and discharge) during the inpatient rehabilitation continuum has acceptable interrater reliability.

Physical exercise program to older frail patients receiving chemotherapy for colorectal cancer - feasibility and experiences from the GERICO study

INTRODUCTION

Older and frail patients with cancer are at high risk of physical and functional decline during chemotherapy. Exercise interventions can often counteract chemotherapy related toxicity and may help patients to improve or retain physical function and quality of life. Studies evaluating feasibility and the effect of exercise in older patients are lacking. The aim of this study was to investigate the feasibility and effect of an exercise intervention in older frail patients during chemotherapy for colorectal cancer (CRC).

MATERIALS AND METHODS

This is a secondary analysis from the GERICO study investigating the effect of geriatric interventions in frail patients ≥70 years receiving chemotherapy for CRC. All patients in the present analysis were patients randomized to geriatric interventions and who were found physically frail (low handgrip strength or slow 10 m gait speed) and therefore offered referral to the exercise program for twelve weeks. We evaluated reasons for dropping out and feasibility of an individually tailored exercise program twice a week for twelve weeks. Each 60 min session comprised warm-up followed by progressive resistance training and cool-down followed by an oral protein supplement. Baseline characteristics and the effect of exercise for patients with high and low adherence (attendance of <50% of exercise sessions) were compared.

RESULTS

Of 71 patients in the intervention group, 47 (66%) were found physically frail and were offered referral to the exercise program. Seven patients were referred to municipal physiotherapy before study start. In the remaining population (N = 40) 19 had exercise adherence >50% and 21 had no or low exercise adherence. Baseline characteristics were similar between patients with high and low/no adherence, except for sex (68% and 33% were men in high and low/ no adherence group, respectively). Patients with >50% attendance had significant improvements in physical tests after twelve weeks of exercise.

DISCUSSION

Low adherence to the exercise program was seen due to lack of energy and/or treatment related adverse events. Patients with high adherence benefitted from exercise during chemotherapy but did not differ from patients with low adherence at baseline. Consequently, exercise should be offered to all older frail patients receiving chemotherapy for CRC.

The Effects of Multimodal Prehabilitation Interventions in Men Affected by Prostate Cancer on Physical, Clinical and Patient Reported Outcome Measures: A Systematic Review

OBJECTIVES

To synthesize existing evidence on the effects of multimodal prehabilitation interventions in men affected by prostate cancer on physical, clinical, and patient-reported outcome measures.

DATA SOURCES

A systematic review was conducted according to the PRISMA 2020 Statement Guidelines. Electronic databases (ie, Medline, Embase, CINAHL and Cochrane CENTRAL, and clinicaltrials.gov) were searched using key search terms. Articles were assessed according to prespecified eligibility criteria. Data extraction and quality appraisal was conducted. The findings were integrated in a narrative synthesis.

CONCLUSION

Of the 5863 publications screened, 118 articles were assessed in full text and 17 studies met the prescreening eligibility criteria. There were a range of study designs that included randomized controlled clinical trials (n = 11), quasi experimental (n = 4), cohort (n = 1), and case series (n = 1), covering a total of 1739 participants. The prehabilitation interventions included physical activity, peer support, pelvic floor muscle training, diet, nurse-led prehabilitation, psychological, and prehabilitation administration of phosphodiesterase-5 inhibitors.

IMPLICATIONS FOR NURSING PRACTICE

Significant heterogeneity existed in the prehabilitation intervention programs for men affected by prostate cancer in terms of the composition, duration, method of administration, and the outcomes measured to quantify their impact. This systematic review has identified that multimodal prehabilitation interventions are an emerging area for practice and research among men affected by prostate cancer. Importantly, there has been a lack of focus on the inclusion of partners as critical companions during this distressing phase of the cancer care continuum. For the moment, all members of the multidisciplinary team caring for people affected by prostate cancer are encouraged to use the findings in this review to inform holistic models of care.

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.

Development of an intervention influencing activity limitations in older breast cancer survivors: A modified Delphi study

INTRODUCTION

Older breast cancer survivors have difficulty accessing rehabilitation interventions addressing activity limitations. Stakeholder input may improve accessibility of interventions. We sought expert consensus on intervention content and delivery features (e.g., where, mode, duration) to inform development of more accessible interventions for this population.

MATERIALS AND METHODS

We conducted a modified Delphi process with patient, clinical, administrative, and research experts. In Round 1, experts evaluated content and delivery features according to domains of feasibility and prioritization. In Round 2, panelists were asked to re-rank or confer agreement of content and delivery features that met Round 1 consensus. Ranking was based on median score. Consensus was defined as a percentage of panelists that ranked an option within one unit of the median. For nominal data, consensus was defined as percent agreement.

RESULTS

Panelists (n = 20) prioritized physical activity strategies (Median Rank: 2; Consensus: 85%) and adaptive skills training (3; 65%). Panelists also prioritized delivery through outpatient services (1; 100%), post-treatment (1; 100%), combination mode of delivery (100%), duration of three months or less (100%) and occurring one to two days per week (100%).

DISCUSSION

Cancer rehabilitation interventions should be designed with input from stakeholders. The stakeholder intervention priorities identified in this study (e.g., content, setting, and mode) may improve relevance and accessibility of future cancer rehabilitation interventions. Interventions delivered in outpatient clinics and post-treatment using virtual and in-person visits may improve accessibility. Future research should examine the effectiveness and implementation of these intervention characteristics.

Long-term resource utilisation and associated costs of exercise during (neo)adjuvant oncological treatment: the Phys-Can project

BACKGROUND

Exercise during oncological treatment is beneficial to patient health and can counteract the side effects of treatment. Knowledge of the societal costs associated with an exercise intervention, however, is limited. The aims of the present study were to evaluate the long-term resource utilisation and societal costs of an exercise intervention conducted during (neo)adjuvant oncological treatment in a randomised control trial (RCT) versus usual care (UC), and to compare high-intensity (HI) versus low-to-moderate intensity (LMI) exercise in the RCT.

METHODS

We used data from the Physical Training and Cancer (Phys-Can) project. In the RCT, 577 participants were randomised to HI or to LMI of combined endurance and resistance training for 6 months, during oncological treatment. The project also included 89 participants with UC in a longitudinal observational study. We measured at baseline and after 18 months. Resource utilisation and costs of the exercise intervention, health care, and productivity loss were compared using analyses of covariance (RCT vs. UC) and t test (HI vs. LMI).

RESULTS

Complete data were available for 619 participants (RCT HI: n = 269, LMI: n = 265, and UC: n = 85). We found no difference in total societal costs between the exercise intervention groups in the RCT and UC. However, participants in the RCT had lower rates of disability pension days (p < .001), corresponding costs (p = .001), and pharmacy costs (p = .018) than the UC group. Nor did we find differences in resource utilisation or costs between HI and LMI exercise int the RCT.

CONCLUSION

Our study showed no difference in total societal costs between the comprehensive exercise intervention and UC or between the exercise intensities. This suggests that exercise, with its well-documented health benefits during oncological treatment, produces neither additional costs nor savings.

Association of the Extent of Cancer Patients’ Internet Use with Social Support among Patients and Change in Patient-reported Treatment Outcomes during Inpatient Rehabilitation: Cross-Sectional and Longitudinal Study. (Preprint)

BACKGROUND

Given the increasing number of cancer survivors and their rising survival rates, rehabilitation plays an increasingly important role. Social support among patients is an essential element of inpatient and day care rehabilitation. The internet can empower patients with cancer to become more active health care consumers and facilitate information and supportive care needs. By contrast, therapists suspect that high internet use during rehabilitation may severely limit social interactions between patients, thus interfering with the patients' rehabilitation program and jeopardizing treatment success.

OBJECTIVE

We hypothesized that the extent of internet use would be negatively related to social support among patients with cancer during their clinical stay as well as fewer improvements in patient-reported treatment outcomes from the first to the last day of their clinical stay.

METHODS

Patients with cancer participated during their inpatient rehabilitation. Cross-sectional data, such as the extent of participants' internet use and perceived social support among patients, were collected during the last week of their clinic stay. The treatment outcomes, that is, participants' levels of distress, fatigue, and pain, were collected on the first and last day of the clinic stay. We used multiple linear regression analysis to study the association between the extent of internet use and social support among patients with cancer. We used linear mixed model analyses to study the association between the extent of internet use by patients with cancer and the change in patient-reported treatment outcomes.

RESULTS

Of the 323 participants, 279 (86.4%) participants reported that they used the internet. The extent of the internet use (t₃₁₅=0.78; P=.43) was not significantly associated with the perceived social support among the participants during their clinical stay. In addition, the extent of participants' internet use during their clinical stay was not associated with changes in participants' levels of distress (F_1,299=0.12; P=.73), fatigue (F_1,299=0.19; P=.67), and pain (F_1,303=0.92; P=.34) from the first to the last day of their clinical stay.

CONCLUSIONS

The extent of internet use does not seem to be negatively associated with the perceived social support among patients with cancer or with the change in patients' levels of distress, fatigue, or pain from the first to the last day of their clinical stay.

Telerehabilitation programmes for patients with cancer and survivors: a protocol for a systematic review

INTRODUCTION

The global cancer burden is a major public health problem. Cancer rehabilitation is an essential component of survivorship care for preventing complications, decreasing symptoms and improving functional quality of life (QOL). In addition to pre-existing challenges, the COVID-19 pandemic has greatly affected cancer rehabilitation programmes and their delivery to patients. This comprehensive systematic review will assess the efficacy and safety of telerehabilitation on functional outcomes and QOL in patients with cancer and survivors.

METHODS AND ANALYSIS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. The following key electronic bibliographic databases will be searched from their inception to April 2021: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials and Physiotherapy Evidence Database (PEDro). We will include randomised controlled trials (RCTs) published in English that examine the effects of telerehabilitation programmes on patients with cancer and survivors. The terms 'telerehabilitation', 'neoplasm', 'RCT' and their analogous terms will be used in our search strategy. Two reviewers will independently complete the study screening, selection, data extraction and quality rating. The PEDro scale will be used to assess the methodological quality of the included studies. Narrative or quantitative synthesis will be conducted on the basis of the final data. The planned start and end dates for the study are 1 March 2021 and 1 May 2022, respectively.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this review, and the results will be disseminated in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021243467.

Short- and long-term effect of high versus low-to-moderate intensity exercise to optimise health-related quality of life after oncological treatment-results from the Phys-Can project

Purpose

This study aimed to evaluate the effect of high intensity (HI) vs low-to-moderate intensity (LMI) exercise on health-related quality of life (HRQoL) up to 18 months after commencement of oncological treatment in patients with breast, colorectal or prostate cancer. In addition, we conducted a comparison with usual care (UC).

Methods

Patients scheduled for (neo)adjuvant oncological treatment (n = 577) were randomly assigned to 6 months of combined resistance and endurance training of HI or LMI. A longitudinal descriptive study (UC) included participants (n = 89) immediately before the RCT started. HRQoL was assessed by EORTC QLQ-C30 at baseline, 3, 6 and 18 months (1 year after completed exercise intervention) follow-up. Linear mixed models were used to study the groups over time.

Results

Directly after the intervention, HI scored significant (P = 0.02), but not clinically relevant, higher pain compared with LMI. No other significant difference in HRQoL was found between the exercise intensities over time. Clinically meaningful improvements in HRQoL over time were detected within both exercise intensities. We found favourable significant differences in HRQoL in both exercise intensities compared with UC over time.

Conclusion

This study adds to the strong evidence of positive effect of exercise and shows that exercise, regardless of intensity, can have beneficial effects on HRQoL during oncological treatment and also for a substantial time after completion of an exercise intervention. In this study, for one year after.

Implications for cancer survivors

Patients can be advised to exercise at either intensity level according to their personal preferences, and still benefit from both short-term and long-term improvements in HRQoL.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07016-3.

Prospective Surveillance for Breast Cancer-Related Arm Lymphedema: A Systematic Review and Meta-Analysis

PURPOSE

The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of the condition. We offer a critical evaluation of the literature on prospective surveillance and early management for cancer-related lymphedema and evaluate the effect of such programs in preventing chronic lymphedema (CRD42019137965).

METHODS

Five databases and two registries were searched for randomized controlled trials or observational studies that assessed the incidence or prevalence of lymphedema associated with participation in a prospective surveillance program, published until February 26, 2021. Numbers triggered for early lymphedema management, resolved, and chronic lymphedema were extracted. Pooled relative risk (trials) and pooled rate (cumulative incidence; observational studies) of chronic lymphedema was calculated. Subgroup analyses assessed the effect of study design, length of follow-up, and extent of axillary surgery.

RESULTS

Twenty-three studies were included, of which 21 studies evaluated breast cancer-related arm lymphedema (BCRaL). Participation in prospective surveillance with early management reduced the risk of chronic BCRaL versus usual care (relative risk 0.31; 95% CI, 0.10 to 0.95; two randomized controlled trials; N = 106). The pooled rate of chronic BCRaL was 4% (95% CI, 3 to 6; 15 observational studies; N = 3,545), and 6% (95% CI, 4 to 9) when restricted to participants with axillary lymph node dissection (12 studies; N = 1,527).

CONCLUSION

The findings suggest that participation in prospective surveillance with early management reduces the risk of chronic BCRaL. Only a minority of patients at high risk of lymphedema because of axillary surgery developed chronic lymphedema. More robust research is needed to determine whether prospective surveillance with early management can reduce the risk of chronic lymphedema, particularly among cancer survivors other than breast cancer.

Clinical Outcome Assessment in Cancer Rehabilitation and the Central Role of Patient-Reported Outcomes

Simple Summary

After completion of acute cancer treatment, it is important to support patients in recovering physically and psychologically and to help them regain their social life. This is the goal of cancer rehabilitation. If we want to know which rehabilitation interventions are helpful, we must measure their effects. This can be done by asking clinicians, testing patients’ performance, observing their behaviors, or by asking patients directly about their experience. This paper focuses on reports from the patients. We give an overview of available questionnaires and offer advice regarding their use. Furthermore, we discuss how to integrate them into clinical practice and research. The most promising way to collect such data are electronic systems, which offer many advantages. The goal of assessing the patient perspective is to help patients, clinicians, and health insurance providers to decide which rehabilitation interventions suit patients’ needs, and therefore, which ones should be chosen and reimbursed.

Abstract

The aim of cancer rehabilitation is to help patients regain functioning and social participation. In order to evaluate and optimize rehabilitation, it is important to measure its outcomes in a structured way. In this article, we review the different types of clinical outcome assessments (COAs), including Clinician-Reported Outcomes (ClinROs), Observer-Reported Outcomes (ObsROs), Performance Outcomes (PerfOs), and Patient-Reported Outcomes (PROs). A special focus is placed on PROs, which are commonly defined as any direct report from the patient about their health condition without any interpretation by a third party. We provide a narrative review of available PRO measures (PROMs) for relevant outcomes, discuss the current state of PRO implementation in cancer rehabilitation, and highlight trends that use PROs to benchmark value-based care. Furthermore, we provide examples of PRO usage, highlight the benefits of electronic PRO (ePRO) collection, and offer advice on how to select, implement, and integrate PROs into the cancer rehabilitation setting to maximize efficiency.

Factors influencing utilization of cancer rehabilitation services among older breast cancer survivors in the USA: a qualitative study

PURPOSE

Many older breast cancer survivors experience long-term disability due to cancer and cancer-related treatments. However, less than 20% of older breast cancer survivors utilize cancer rehabilitation services to address cancer-related disability. Further understanding of survivor experiences may reveal strategies to improve uptake cancer rehabilitation services in the USA.

METHODS

Older breast cancer survivors were recruited from university-based registries, previous breast cancer research studies at our institution, community support groups, and geriatric oncology clinics. Participants completed a brief online survey to capture demographic and clinical characteristics. Semi-structured telephone-based interviews were recorded, transcribed, and thematically analyzed. Interviews facilitated conversation about access to rehabilitation and indications for cancer rehabilitation.

RESULTS

Participants (n = 14) were, on average, 71 years old, primarily White, and an average of 36.5 months post-diagnosis. Five participants had formally received rehabilitation for a cancer-related concern. Participants described seven factors that influenced utilization of cancer rehabilitation services: (1) emerging awareness of disability; (2) coping styles; (3) comparison of cancer experience with others; (4) provider interaction; (5) perceptions of cancer diagnosis; (6) social support; and (7) cost of rehabilitation.

CONCLUSIONS

Older breast cancer survivors consider multiple factors when determining utilization of cancer rehabilitation services. Development of shared decision-making tools addressing the seven described factors may enhance communication and referral to cancer rehabilitation services. Intervention research should adopt frameworks that enhance healthcare accessibility to improve relevance of intervention content and delivery features for older breast cancer survivors.

A Randomized Controlled Trial Using Automated Technology for Improving Ototoxicity Monitoring in VA Oncology Patients

Purpose Determine the efficacy of ototoxicity monitoring (OM) administered as automated protocols with the Oto-ID mobile audiometer (automated ototoxicity monitoring [A-OM]), compared with usual care (UC) OM in cancer patients receiving cisplatin. Method Participants were patients (n = 46, mean age 64.7 years; range: 30-78 years) receiving cisplatin-based chemotherapy at the Department of Veterans Affairs Portland Health Care System. A randomized controlled trial contrasted A-OM and UC at up to three program evaluations (PEs) conducted by the study audiologist who was blinded to arm through PE1. PE1 occurred before randomization or oncology treatment; PE2 and PE3 occurred during and/or after treatment at 35 and 365 days postrandomization. The A-OM group (n = 24) used Oto-ID to screen their hearing before each cisplatin dose. Oto-ID results were sent to the study audiologist for interpretation, follow-up, and care coordination. The UC group (n = 22) received a consult for OM services through the audiology clinic. Outcomes included hearing shift near each patient's high-frequency hearing limit, revised hearing-handicap inventory score, and survival time from the start of treatment. Adherence to OM protocols, patients' use of aural rehabilitation services, and oncologists' treatment decisions were also examined. Results Ototoxicity was identified at a high overall rate (46% and 76% at 35 and 365 days, respectively, postrandomization). Adherence to monitoring prior to each cisplatin dose was 83.3% for those randomized to A-OM compared with 4.5% for UC. Randomization to A-OM was not associated with reduced ototoxic hearing shifts or self-reported hearing handicap relative to UC; neither did it compromise participants' survival. Half of participants in each arm accessed aural rehabilitation services. One in each arm had a documented ototoxicity-related cisplatin dose reduction. Conclusions Auditory impairment was an actionable concern for the participants and their oncology providers. A dedicated surveillance program using the Oto-ID's automated protocols improved adherence to OM recommendations over a traditional UC service delivery model. Supplemental Material https://doi.org/10.23641/asha.16649602.

Prehabilitation services for people diagnosed with cancer in Scotland - Current practice, barriers and challenges to implementation

BACKGROUND

Prehabilitation is the practice of enhancing a patient's functional and psychological capacity before treatment commences. It is of interest in the cancer context because of the impact of treatments on quality of life and cancer survivorship. This work aims to document current practice, barriers and challenges to implementing prehabilitation to inform the development of a national framework.

METHODS

A mixed-methods approach was applied: an on-line survey was sent to stakeholders in cancer care across Scotland, supplemented by in-depth interviews. Key domains explored were the perceived importance of prehabilitation, availability, delivery and content of services, outcome measures, referral processes and funding.

FINDINGS

A total of 295 survey responses were obtained and 11 interviews completed. Perceived importance of prehabilitation was rated highly. There was uncertainty over the definition of prehabilitation and most respondents did not know if local services were available. Where services were described, a range of health professionals were involved, different outcome measures were utilised and frequency of referrals varied. Respondents highlighted short time frames between referral and treatment, concerns about patient engagement, the evidence base for action and funding priorities. Respondents also commented on which context a referral should be made and to whom, and the need for equity of service across the country.

CONCLUSIONS

The current work found clear evidence of the perceived importance of prehabilitation in cancer patients. However, issues and key gaps were identified within current services (including issues arising from COVID-19) which must be addressed to enable wide-spread development and implementation of equitable programmes.

Evaluation of two strategies to implement physical cancer rehabilitation guidelines for survivors of abdominopelvic cavity tumors: a controlled before-and-after study

Purpose

This study evaluates the effectiveness and feasibility of two strategies to implement physical cancer rehabilitation (PCR) guidelines for patients who have survived abdominopelvic cavity malignancies.

Methods

We tested and compared two tailored strategies to implement PCR guidelines for survivors of gastrointestinal, female organ and urogenital organ malignancies, in a clustered controlled before-and-after study. A patient-directed (PD) strategy was tested in five cancer centers, aiming to empower survivors. A multifaceted (MF) strategy was tested in four cancer centers, aiming additionally to influence healthcare professionals and the healthcare organization. Data were collected from existing registration systems, patient questionnaires and professional questionnaires. We measured both implementation- and client outcomes. For insight into the effectiveness we measured indicators related to PCR guidelines: (1) screening with the Distress Thermometer (DT) (=primary outcome measure), (2) information provision concerning physical activity (PA) and physical cancer rehabilitation programs (PCRPs), (3) advice to take part in PA and PCRPs, (4) referral to PCRPs, (5) participation in PCRPs, (6) PA uptake (PAU); and patient reported outcomes (PROs) such as (7) quality of life, (8) fatigue, and (9) empowerment. Furthermore, survivor and center determinants were assessed as possible confounders. Multilevel analyses were performed to compare the scores of the indicators of the PD and MF strategies, as well as the differences between the characteristics of these groups. The use of and experiences with both strategies were measured using questionnaires and Google Analytics to assess feasibility.

Results

In total, 1326 survivors participated in the study, 673 in the before- and 653 in the after-measurement. Regarding our primary outcome measure, we found a significant improvement of screening with the DT between the before- and after-measurement for both strategies, respectively from 34.2 to 43.1% (delta=8.9%; odds ratio (OR)=1.6706; p=0.0072) for the PD strategy and from 41.5 to 56.1% (delta=14.6%; OR=1.7098; p=0.0028) for the MF strategy. For both the primary and secondary outcomes, no statistically significant effect of the MF strategy compared to the PD strategy was observed. We found good use of and positive experiences with both strategies.

Conclusion

Implementation strategies containing tools enhancing patient empowerment seem to be effective in increasing the systematic screening with the DT for survivors of abdominopelvic cavity malignancies. Further research is needed to assess the additional effectiveness of strategies that stimulate compliance among healthcare professionals and healthcare organizations.

Implications for Cancer Survivors

Using implementation strategies containing tools enhancing patient empowerment seem to be effective in increasing the systematic screening with the DT and might improve the quality of care of patients who have survived abdominopelvic cavity malignancies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01045-3.

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.

A Qualitative Study of Cancer Survivors' Experienced Outcomes of a Multidimensional Rehabilitation Program in Primary Healthcare

BACKGROUND

Cancer survival rates are increasing, but survival is often followed by several late effects. Cancer survivors' need for complex rehabilitation is well documented, but this is mostly missing in primary healthcare.

OBJECTIVE

The aim of this study was to explore cancer survivors' experienced outcomes of a multidimensional rehabilitation program in primary healthcare.

METHODS

The study used a qualitative method with a descriptive research design. Fifty-six cancer survivors completed a 12-week rehabilitation program built upon the 5 elements of goal setting, physical exercise, psychoeducation, individual follow-up, and peer support. Data were collected at the end of the program via 8 focus group interviews, and systematic text condensation was used to analyze the data.

RESULTS

"Increased coping and participation" was identified as the overarching theme of the participants' experienced outcomes from the program, and this was elaborated by 3 main themes: (1) "increased energy and capacity," (2) "acceptance and understanding," and (3) "structure and hope."

CONCLUSION

The multidimensional rehabilitation program seemed to address cancer survivors' multiple challenges in survivorship. Proximity and accessibility to a local rehabilitation program and professionals' competence seemed to be essential factors for the participants' experienced outcomes of the program.

IMPLICATION FOR PRACTICE

A multidimensional rehabilitation program integrated in a Healthy Life Centre in primary healthcare may be beneficial for cancer survivors' coping and participation in everyday life. Cancer nurses play a crucial role in initiating and facilitating such programs.

Factors associated with unplanned transfers among cancer patients at a freestanding acute rehabilitation facility

BACKGROUND

Cancer patients undergoing inpatient rehabilitation often have high risk of complications leading to unplanned transfer to acute care. Prior studies have identified factors associated with these transfers but have been limited to examining factors that pertain to initial admission to rehabilitation and were not conducted in a freestanding inpatient rehabilitation facility.

OBJECTIVE

The study aimed to include these prerehabilitation factors in addition to factors upon initial assessment in rehabilitation. It was hypothesized that specific factors from each of these periods would be associated with unplanned transfer to acute care.

DESIGN

Retrospective cohort study.

SETTING

Freestanding academic inpatient rehabilitation facility affiliated with an academic tertiary care facility with a comprehensive cancer center.

PATIENTS

Retrospective review of 330 specific encounters unique to 250 patients from March 2017 to September 2018.

MAIN OUTCOME MEASURES

The outcome measure was unplanned transfer to acute care. A binary logistic regression model was used to examine the relationship between factors from oncologic history, acute care course, and factors upon admission to rehabilitation to unplanned transfer to acute care.

RESULTS

From 330 encounters, there were 111 unplanned transfers (34%). Unplanned transfer to acute care was independently associated with gastrointestinal malignancy (odds ratio [OR] 4.4, p = .01), 6-minute walk test less than 90 m (OR 4.6, p = .003), and prior unplanned transfer (OR 3.5, p = .007).

CONCLUSIONS

The study suggests that oncologic and functional prerehabilitation markers are associated with an increased likelihood of unplanned transfer during inpatient cancer rehabilitation. These findings will provide a framework for creating predictive tools for unplanned transfers in cancer rehabilitation patients.

Daily living and rehabilitation needs in patients and caregivers affected by myeloproliferative neoplasms (MPN): A qualitative study

AIMS AND OBJECTIVES

To explore experiences of daily living and identify rehabilitation needs in patients and caregivers living with myeloproliferative neoplasms.

BACKGROUND

Myeloproliferative neoplasms are chronic haematological cancers. Studies report a high symptom burden but little is known about supportive care and rehabilitation for this patient group.

DESIGN

Qualitative study with a phenomenological approach using focus group interviews to gather knowledge about the participants' lived experiences.

METHODS

Forty-eight patients and seven caregivers attending a 5-day rehabilitation course were interviewed in 12 focus groups. Systematic Text Condensation was used to analyse the interviews. Reporting adhered to COREQ.

RESULTS

Two main themes for patients were found: The loss of choice and identity due to the need to prioritise energy and The schism of being a person but also a patient. Patients described how living with myeloproliferative neoplasms meant having to prioritise energy and, therefore, losing freedom to choose activities. This changed their identity and impaired their quality of life. Patients of working age seemed to struggle the most in balancing the disease, family, social relationships and work. One main theme was found for caregivers: Influence of the disease. Caregivers reported how the disease limited their social lives, that the disease brought psychological strain, extra work, and that communication between couples was impaired. When both patients and caregivers participated in rehabilitation courses, they reported better understanding between couples and more open conversations. Rehabilitation needs identified were mainly in relation to psychosocial support and patient education, although needs varied across patients and caregivers.

CONCLUSIONS

Patients and caregivers expressed difficulties in adjusting to the lives the disease enforced upon them. Our findings indicate that myeloproliferative neoplasms patients and their caregivers would benefit from a combined model of psychosocial support, patient education, peer support and rehabilitation interventions based on an individual needs assessment.

RELEVANCE TO CLINICAL PRACTICE

Nurses can be responsible for individual needs assessments and refer patients and caregivers to suitable supportive care and rehabilitation interventions.

TRIAL REGISTRATION DETAILS

The study was approved by the Danish Data Protection agency (J.nr. 2008-58-0035).

Bridging the gap: a pre-post feasibility study of embedding exercise therapy into a co-located cancer unit

PURPOSE

To establish the feasibility of embedding a flexible, exercise-based rehabilitation program into a cancer treatment unit to allow cancer survivors early exercise support.

METHOD

A pre-post study was conducted using Bowen's Framework to describe key domains of feasibility: demand (referrals), acceptability (uptake, attendance, satisfaction), implementation (resources), practicality (adverse events, costs) and limited-efficacy (function, quality of life, self-efficacy). Participants were medically stable, adult cancer survivors receiving curative or palliative treatment for cancer at the health service. Participants completed an 8-week home or hospital-based exercise program. Data were analysed descriptively. Standardised mean differences (Hedge's g) and mean differences were calculated to determine effect size and clinical significance.

RESULTS

The exercise-based rehabilitation service received 155 referrals over 6 months. Of those eligible, 73/119 (61%) commenced. Participants opting for twice-weekly, hospital-based exercise attended 9/16 (56%) sessions. Participants reported high satisfaction and there were no major adverse events. The program utilised existing resources, with the predominant cost being staff. The average health service cost per participant was AUD $1,104. Participants made clinically significant gains in function (6-min walk distance; + 73 m, 95% confidence interval 49 to 96) and quality of life (EORTC QLQ-C30 Global quality of life; + 8 units, 95% confidence interval 3 to 13).

CONCLUSION

Implementation of exercise-based rehabilitation in a co-located cancer unit was safe and feasible. Access, patient and staff education and establishing funding streams are important implementation considerations. Implications for cancer survivors Access to exercise in a cancer unit provides opportunity for early intervention to optimise function during treatment.

The effect of geriatric intervention in frail older patients receiving chemotherapy for colorectal cancer: a randomised trial (GERICO)

BACKGROUND

Older patients with colorectal cancer (CRC) experience chemotherapy dose reductions or discontinuation. Comprehensive geriatric assessment (CGA) predicts survival and chemotherapy completion in patients with cancer, but the benefit of geriatric interventions remains unexplored.

METHODS

The GERICO study is a randomised Phase 3 trial including patients ≥70 years receiving adjuvant or first-line palliative chemotherapy for CRC. Vulnerable patients (G8 questionnaire ≤14 points) were randomised 1:1 to CGA-based interventions or standard care, along with guideline-based chemotherapy. The primary outcome was chemotherapy completion without dose reductions or delays. Secondary outcomes were toxicity, survival and quality of life (QoL).

RESULTS

Of 142 patients, 58% received adjuvant and 42% received first-line palliative chemotherapy. Interventions included medication changes (62%), nutritional therapy (51%) and physiotherapy (39%). More interventional patients completed scheduled chemotherapy compared with controls (45% vs. 28%, P = 0.0366). Severe toxicity occurred in 39% of controls and 28% of interventional patients (P = 0.156). QoL improved in interventional patients compared with controls with the decreased burden of illness (P = 0.048) and improved mobility (P = 0.008).

CONCLUSION

Geriatric interventions compared with standard care increased the number of older, vulnerable patients with CRC completing adjuvant chemotherapy, and may improve the burden of illness and mobility.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02748811.

How to implement routine electronic patient-reported outcome monitoring in oncology rehabilitation

BACKGROUND

Implemenation of patient-reported outcomes (PRO) like quality of life can add the patient's perspective to traditional clinical outcomes of cancer rehabilitation in a structured and standardized way.

AIM

To present useful steps for a successful implementation of routine electronic patient-reported outcomes (ePRO) monitoring. The presented steps are exemplified by describing the procedure applied in an Austrian inpatient cancer rehabilitation centre.

METHODS

The suggested implementation steps are presented based on the structure of the replicating effective programmes framework, which was used for developing a pragmatic implementation strategy.

RESULTS

We scheduled alternating trainings and process evaluations for audit and enhancement of procedures. In this way, the ePRO participation rates could be improved. Stakeholder involvement led to initiatives that included the integration of ePRO data into the medical discharge letter and the implementation of follow-up assessments.

DISCUSSION

Tailored changes in assessment procedures enabled the successful implementation of ePRO, which has been shown to be feasible before and after cancer rehabilitation. The continuous involvement of stakeholders paved the way for further projects initiated by medical staff as users themselves (inclusion of PRO data in the discharge letter and a comprehensive ePRO follow-up using a versatile online patient portal).

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.

The Cancer Rehabilitation Medicine Metrics Consortium: A Path to Enhanced, Multi-Site Outcome Assessment to Enhance Care and Demonstrate Value

Purpose

A primary objective stated at the Cancer Rehabilitation Symposium at the National Institutes of Health was to improve outcome measurement. The purpose of this project was for the Cancer Rehabilitation Medicine Metrics Consortium (CRMMC) to develop an assessment tool to evaluate function in cancer patients via a data-driven and methodologically sound process. There is no agreed-upon measure of physical and cognitive function for cancer patients, making it difficult to demonstrate the value of rehabilitation interventions. Cancer patients are a particularly challenging population, with many tumor- and treatment-related variables impacting function.

Methods

Investigators from nine different cancer rehabilitation programs participated in a modified-Delphi process to delineate necessary aspects of an ideal patient assessment tool, including instrument type, domains evaluated, applicability across a range of patient traits, clinical feasibility, and item response characteristics. This involved numerous meetings, data review, and analysis of items involved in patient assessment.

Results

The CRMMC developed a 21-item patient-reported outcome measure based on item response theory. The process by which the short form was developed was documented and provides a framework for other clinicians to follow.

Conclusion

This document provides a framework for rehabilitation providers to follow when developing an assessment tool. This process is described in a stepwise fashion for reproducibility even in different, non-cancer populations.

Prehabilitation is the Gateway to Better Functional Outcomes for Individuals with Cancer

Prehabilitation is a clinical model that introduces components of rehabilitation to patients prior to undergoing intensive medical interventions, such as surgery, in order to optimize function and improve tolerability to the intervention. Cancer care introduces a continuum of sequential or concurrent intensive anti-neoplastic medical interventions that are known to be detrimental to a patient's function. Prehabilitation evidence has grown across several areas of oncology care delivery demonstrating that a multi-modal rehabilitative intervention, delivered prior to oncology-direct therapies, leads to better functional outcomes and improves important endpoints associated with surgery and cancer treatment. This commentary article provides a brief history of the emergence of prehabilitation in cancer care delivery, reviews the current evidence base and guidelines for prehabilitation, and offers insights for future implementation of this model as a standard in oncology care. A prehabilitation program is an optimal starting point for most patients undergoing anti-neoplastic therapy as it serves as a gateway to improving functional outcomes throughout the cancer continuum. Future research in prehabilitation should aim to reach beyond measuring functional outcomes and to explore the impact of this model on important disease treatment endpoints such as tumor response to oncology-directed treatment, impact on treatment-related toxicities, and disease progression.

Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management

Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.

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.

The Italian consensus conference on the role of rehabilitation for children and adolescents with leukemia, central nervous system, and bone tumors, part 1: Review of the conference and presentation of consensus statements on rehabilitative evaluation of motor aspects

Because of increasing survival rates in pediatric oncology, attention is focusing on cancer and its treatment-related side effects. Rehabilitation may reduce their impact. However, the literature does not provide strong evidence regarding rehabilitation pathways. Therefore, the Italian Association of Pediatric Hematology and Oncology organized a consensus conference on the role of rehabilitation of motor impairments in children/adolescents affected by leukemia, central nervous system, and bone tumors to define recommendations for daily practice. The grading of recommendation assessment, developing and evaluation (GRADE) method was used in order to formulate questions, select outcomes, evaluate evidence, and create recommendations. This paper includes the results on the rehabilitation assessment.

Efficacy and efficiency of a new therapeutic approach based on activity-oriented proprioceptive antiedema therapy (TAPA) for edema reduction and improved occupational performance in the rehabilitation of breast cancer-related arm lymphedema in women: a controlled, randomized clinical trial

BACKGROUND

Breast cancer (BC) is a major public health issue. More than one out of five women treated for breast cancer will develop lymphedema in an upper extremity. Current evidence advocates transdisciplinary oncological rehabilitation. Therefore, research in this area is necessary since limited consensus having been reached with regard to the basic essential components of this rehabilitation. Consensus has, however, been reached on the use of decongestive lymphedema therapy (DLT), but due to a lack of tests, the necessary dosages are unknown and its level is moderately strong. This study attempts to verify both the efficacy of activity-oriented proprioceptive antiedema therapy (TAPA), as compared to conventional treatments such as DLT or Complex Physical Therapy (CPT), as well as its efficiency in terms of cost-effectiveness, for patients affected by breast cancer-related arm lymphedema.

METHODS

Controlled, randomized clinical trial with dual stratification, two parallel arms, longitudinal and single blind. 64 women with breast cancer-related arm lymphedema will take part in the study. The experimental group intervention will be the same for stage I and II, and will consist of neuro-dynamic exercises oriented to the activity, proprioceptive neuromuscular facilitation activities and proprioceptive anti-edema bandaging. The control group intervention, depending on the stage, will consist of preventive measures, skin care and exercise-prescribed training in the lymphedema workshop as well as compression garments (Stage I) or conservative Complex Decongestive Therapy treatment (skin care, multi-layer bandaging, manual lymphatic drainage and massage therapy) (Stage II).

RESULTS

Sociodemographic and clinical variables will be collected for the measurement of edema volume and ADL performance. Statistical analysis will be performed on intent to treat.

DISCUSSION

It has been recommended that patient training be added to DLT, as well as a re-designing of patient lifestyles and the promotion of health-related aspects. In addition, clinical trials should be undertaken to assess neural mobilization techniques and proprioceptive neuromuscular facilitation should be included in the therapy. Cohesive bandaging will also be performed as an early form of pressotherapy. The proposed study combines all of these aspects in order to increased comfort and promote the participation of individuals with lymphedema in everyday situations.

LIMITATIONS

The authors have proposed the assessment of the experimental treatment for stages I and II. One possible limitation is the lack of awareness of whether or not this treatment would be effective for other stages as well as the concern for proper hand cleansing during use of bandages, given the current COVID-19 pandemic situation.

TRIAL REGISTRATION

This trial was registered in ClinicalTrials.gov ( NCT03762044 ). Date of registration: 23 November 2018. Prospectively Registered.