Evaluation of a Comprehensive Rehabilitation Program for Post-Treatment Patients With Cancer

Experiences of Forest Healing Instructors Who Met Cancer Patients in Forest Healing Programs: FGI Research

BACKGROUND

Demand for urban forest programs for the healing of cancer survivors is increasing. To develop a forest healing program for the integrated care of cancer patients, it is necessary to analyze the experiences of forest healing instructors who have conducted programs for cancer patients.

METHODS

This qualitative study applied focus group interviews (FGIs; four interviews with sixteen participants) to describe and understand the experiences of forest healing instructors who run forest healing programs for cancer patients.

RESULTS

Four themes were identified: "prepared encounters and unexpected encounters," "yearning for healing," "people who need special care," and "things to prepare for cancer patient programs."

CONCLUSION

Forest healing instructors had difficulty facilitating programs for cancer patients owing to prejudice and a lack of knowledge about the characteristics of cancer patients. Moreover, differentiated programs and places that align with the specific needs of cancer patients are needed. It is necessary to develop an integrated care forest healing program for cancer patients and educate forest healing instructors about the needs of cancer patients.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

Evaluation of the Structure and Health Impacts of Exercise-Based Cardiac and Pulmonary Rehabilitation and Prehabilitation for Individuals With Cancer: A Systematic Review and Meta-Analysis

Exercise-based, multimodal rehabilitation programming similar to that used in the existing models of cardiac or pulmonary rehabilitation or prehabilitation is a holistic potential solution to address the range of physical, psychological, and existential (e.g., as their diagnosis relates to potential death) stressors associated with a cancer diagnosis and subsequent treatment. The purpose of this study was to systematically evaluate the structure and format of any type of exercise-based, multimodal rehabilitation programs used in individuals with cancer and the evidence base for their real-world effectiveness on metrics of physical (e.g., cardiorespiratory fitness, blood pressure) and psychological (e.g., health-related quality of life) health. Very few of the 33 included exercise-based, multimodal rehabilitation programs employed intervention components, education topics, and program support staff that were multi-disciplinary or cancer-specific. In particular, a greater emphasis on nutrition care, and the evaluation and management of psychosocial distress and CVD risk factors, with cancer-specific adaptations, would broaden and maximize the holistic health benefits of exercise-based rehabilitation. Despite these opportunities for improvement, exercise-based, multimodal rehabilitation programs utilized under real-world settings in individuals with cancer produced clinically meaningful and large effect sizes for cardiorespiratory fitness (VO2peak, ±2.9 mL/kg/min, 95% CI = 2.6 to 3.3) and 6-minute walk distance (+47 meters, 95% CI = 23 to 71), and medium effect sizes for various measures of cancer-specific, health-related quality of life. However, there were no changes to blood pressure, body mass index, or lung function. Overall, these findings suggest that exercise-based, multimodal rehabilitation is a real-world therapy that improves physical and psychological health among individuals with cancer, but the holistic health benefits of this intervention would likely be enhanced by addressing nutrition, psychosocial concerns, and risk factor management through education and counselling with consideration of the needs of an individual with cancer.

Distress Screening: Evaluating a Protocol for Gynecologic Cancer Survivors

BACKGROUND

A gynecologic cancer diagnosis and subsequent treatment may cause significant morbidity, leading to increased distress levels and poorer quality of life (QOL) for survivors. Clinicians have explored opportunities to integrate comprehensive distress management protocols into clinical settings using existing supportive care resources.
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OBJECTIVES

The aims were to improve multidisciplinary management of distress using a clinical pathway for gynecologic cancer survivors and to improve patient satisfaction with distress management.
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METHODS

This study is phase II of a quality improvement initiative to assess distress using the National Comprehensive Cancer Network Distress Thermometer and Patient Related Outcome Measures Information Systems QOL tool and to evaluate the use of a clinical pathway to identify and link gynecologic cancer survivors to multidisciplinary supportive care resources. The data were compared to results from phase I of this study with data triangulation that included medical record audits.
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FINDINGS

Thirty-five percent of survivors reported distress scores of 5 or greater. The use of a clinical pathway model for universal distress screening increased referrals to multidisciplinary service teams from 19 to 34, with a 32% increase in social work referrals. Patients appreciated the comprehensive approach the healthcare team used to treat cancer and help improve QOL.

Systematic Review of Occupational Therapy and Adult Cancer Rehabilitation: Part 2. Impact of Multidisciplinary Rehabilitation and Psychosocial, Sexuality, and Return-to-Work Interventions

This article is the second part of a systematic review of evidence for the effectiveness of cancer rehabilitation interventions within the scope of occupational therapy that address the activity and participation needs of adult cancer survivors. This article focuses on the use of multidisciplinary rehabilitation and interventions that address psychosocial outcomes, sexuality, and return to work. Strong evidence indicates that multidisciplinary rehabilitation benefits cancer survivors and that psychosocial strategies can reduce anxiety and depression. Moderate evidence indicates that interventions can support survivors in returning to the level of sexuality desired and help with return to work. Part 1 of the review also appears in this issue.

Cancer rehabilitation: outcome evaluation of a strengthening and conditioning program

BACKGROUND

Cancer treatments can lead to detriments in patients' health and declines in quality of life (QOL). Cancer rehabilitation programs may improve functional status, symptom control, and QOL.

OBJECTIVE

The objective of this study was to determine if an outpatient, physical therapy-supervised Cancer Rehabilitation Strengthening and Conditioning (CRSC) program improved patients' conditioning level, functional status, QOL, and symptoms.

METHODS

This was a prospective study of oncology patients participating in CRSC program. Measurements included conditioning level (6-minute walk test [SMWT], metabolic equivalent level, grip strength), functional status (Physical Component Summary of Short Form 36), QOL (Mental Component Summary of Short Form 36), and symptoms (M. D. Anderson Symptom Inventory). Paired t tests were conducted to determine significant changes between pre- and post-CRSC program measures, and regression methods identified predictors of change from baseline.

RESULTS

One hundred fifteen patients with cancer were enrolled in the study; 75 patients completed pre- and post-CRSC program measures. Significant improvements were noted in SMWT by 186.4 ft, SMWT speed by 0.35 mph, treadmill time (3.5 minutes longer), metabolic equivalent level (by 0.87 units), QOL, symptom severity, symptom interference with daily life, fatigue, shortness of breath, and sadness.

CONCLUSIONS

In a pretest-posttest design, significant improvements were noted in conditioning level, functional status, QOL, and symptoms. Greater improvements were noted in participants who were most deconditioned at baseline.

IMPLICATIONS FOR PRACTICE

Further research should be conducted to provide additional support for CRSC programs. Cancer rehabilitation strengthening and condition programs may benefit patients across the continuum of care, including deconditioned patients.

Update on research-based interventions for anxiety in patients with cancer

Anxiety may begin at the moment a person is diagnosed with cancer and may fluctuate throughout the cancer trajectory as physical illness improves or declines. The purpose of this article is to present current evidence for nurses to implement interventions to reduce anxiety in patients who have cancer. The PubMed and CINAHL® databases were searched to identify relevant citations addressing interventions that treat or prevent anxiety symptoms in patients with cancer. Based on available evidence, the interventions addressed herein are categorized according to the Putting Evidence Into Practice (PEP®) rating schema. Interventions include pharmacologic and nonpharmacologic approaches to care, and meet criteria for three PEP categories: likely to be effective, effectiveness not established (the largest category of results), or effectiveness unlikely.

Putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment

Cancer-related fatigue (CRF) has deleterious effects on physical, social, cognitive, and vocational functioning, and causes emotional and spiritual distress for patients and their families; however, it remains under-recognized and undertreated. This article critically reviews and integrates the available empirical evidence supporting the efficacy of pharmacologic and nonpharmacologic treatment approaches to CRF, highlighting new evidence since 2007 and 2009 Putting Evidence Into Practice publications. Interventions that are recommended for practice or likely to be effective in improving fatigue outcomes include exercise; screening for treatable risk factors; management of concurrent symptoms; yoga; structured rehabilitation; Wisconsin ginseng; cognitive-behavioral therapies for insomnia, pain, and depression; mindfulness-based stress reduction; and psychoeducational interventions such as anticipatory guidance, psychosocial support, and energy conservation and activity management. This information can be applied to improve the management of CRF, inform health policy and program development, shape the design of clinical trials of new therapies for CRF, and drive basic and translational research.

Screening, evaluation, and management of cancer-related fatigue: Ready for implementation to practice?

Answer questions and earn CME/CNE Evidence regarding cancer-related fatigue (fatigue) has accumulated sufficiently such that recommendations for screening, evaluation, and/or management have been released recently by 4 leading cancer organizations. These evidence-based fatigue recommendations are available for clinicians, and some have patient versions; but barriers at the patient, clinician, and system levels hinder dissemination and implementation into practice. The underlying biologic mechanisms for this debilitating symptom have not been elucidated completely, hindering the development of mechanistically driven interventions. However, significant progress has been made toward methods for screening and comprehensively evaluating fatigue and other common symptoms using reliable and valid self-report measures. Limited data exist to support the use of any pharmacologic agent; however, several nonpharmacologic interventions have been shown to be effective in reducing fatigue in adults. Never before have evidence-based recommendations for fatigue management been disseminated by 4 premier cancer organizations (the National Comprehensive Cancer, the Oncology Nursing Society, the Canadian Partnership Against Cancer/Canadian Association of Psychosocial Oncology, and the American Society of Clinical Oncology). Clinicians may ask: Are we ready for implementation into practice? The reply: A variety of approaches to screening, evaluation, and management are ready for implementation. To reduce fatigue severity and distress and its impact on functioning, intensified collaborations and close partnerships between clinicians and researchers are needed, with an emphasis on system-wide efforts to disseminate and implement these evidence-based recommendations.

Putting evidence into practice: evidence-based interventions for depression

Depression is a distressing emotion that occurs during various times of the cancer trajectory. Depression often goes unrecognized and untreated, which can significantly affect cost, quality of life, and treatment adherence. The Oncology Nursing Society's Putting Evidence Into Practice depression project team reviewed current literature to identify evidence-based interventions to reduce depression in people with cancer. Pharmacologic and nonpharmacologic interventions were evaluated, and opportunities for nurses to integrate recommendations into practice are offered in this article.

Distribution of abdominal obesity and fitness level in overweight and obese korean adults

Background. Abdominal obesity and its relative distribution are known to differ in association with metabolic characteristics and cardiorespiratory fitness. This study aimed to determine an association between fitness level and abdominal adiposity in overweight and obese adults. Methods. 228 overweight and obese individuals were classified as either cardiorespiratory unfit or fit based on their recovery heart rate. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), the visceral-to-subcutaneous adipose tissue ratio (VAT/SAT ratio), and cardiometabolic characteristics were analyzed to examine the relationship between recovery heart rate and abdominal adiposity components. Results. After adjustments for age and sex, significant relationships of recovery heart rate and VAT, SAT, and VAT/SAT ratio were found; however, SAT was not significantly associated after further adjustment for body mass index (BMI) (r = 0.045, P = 0.499), whereas VAT (r = 0.232, P < 0.001) and VAT/SAT ratio (r = 0.214, P = 0.001) remained associated. Through stepwise multiple regression analyses after adjustment for age, sex, BMI, lifestyle factors, mean blood pressure, fasting glucose, HOMA-IR, lipid profiles, and hsCRP, recovery heart rate was identified as an independent variable associated with VAT (β = 0.204, P < 0.001) and VAT/SAT ratio (β = 0.163, P = 0.008) but not with SAT (β = 0.097, P = 0.111). Conclusions. Cardiorespiratory fitness level is independently associated with VAT and the VAT/SAT ratio but not with SAT in overweight and obese adults.

Impact of a psycho-oncological rehabilitation intervention on psychological distress: the experience of CeRiOn (Oncological Rehabilitation Centre) Florence 2007-2010

BACKGROUND

Combining medical and psychological knowledge and accompanying patients in an individualised path, the Oncological Rehabilitation Centre of Florence (CeRiOn) aims at offering effective integrated rehabilitation interventions and at reducing psychological distress in cancer patients. In the present observational study, we measured the psychological distress at baseline and at the end of the completed rehabilitation processes.

METHODS

A total number of 627 cancer patients were treated by the psycho-oncological service at CeRiOn in 2007-2010. Among them, 99 (all women) participated in more than or equal to three sessions, were followed up for clinical and life status for at least 1 year and had a formal conclusion of their psychological rehabilitation process. For 98 cases, both a baseline and a follow-up measure of distress, by the Psychological Distress Inventory (PDI) and the Distress Thermometer (DT), were available.

RESULTS

Relevant before-after amelioration in this selected group of psychologically, highly suffering cancer patients has been shown. Almost all the patients (except 20%) received both group and individual psychological support. The average rehabilitation process lasted 1.7 years. Average distress evaluation decreased from a baseline of 34.7 to 26.4 (P < 0.001) according to PDI and from 5.9 to 2.2 according to DT (P < 0.001).

CONCLUSIONS

On average, quite a long psychological support time was necessary to complete the rehabilitation process. During this period, patients who had a formal conclusion of the psychological support received at CeRiOn showed a significant reduction of their distress.

Effectiveness of multidimensional cancer survivor rehabilitation and cost-effectiveness of cancer rehabilitation in general: a systematic review

INTRODUCTION

Many cancer survivors suffer from a combination of disease- and treatment-related morbidities and complaints after primary treatment. There is a growing evidence base for the effectiveness of monodimensional rehabilitation interventions; in practice, however, patients often participate in multidimensional programs. This study systematically reviews evidence regarding effectiveness of multidimensional rehabilitation programs for cancer survivors and cost-effectiveness of cancer rehabilitation in general.

METHODS

The published literature was systematically reviewed. Data were extracted using standardized forms and were summarized narratively.

RESULTS

Sixteen effectiveness and six cost-effectiveness studies were included. Multidimensional rehabilitation programs were found to be effective, but not more effective than monodimensional interventions, and not on all outcome measures. Effect sizes for quality of life were in the range of -0.12 (95% confidence interval [CI], -0.45-0.20) to 0.98 (95% CI, 0.69-1.29). Incremental cost-effectiveness ratios ranged from -€16,976, indicating cost savings, to €11,057 per quality-adjusted life year.

CONCLUSIONS

The evidence for multidimensional interventions and the economic impact of rehabilitation studies is scarce and dominated by breast cancer studies. Studies published so far report statistically significant benefits for multidimensional interventions over usual care, most notably for the outcomes fatigue and physical functioning. An additional benefit of multidimensional over monodimensional rehabilitation was not found, but this was also sparsely reported on. Available economic evaluations assessed very different rehabilitation interventions. Yet, despite low comparability, all showed favorable cost-effectiveness ratios. Future studies should focus their designs on the comparative effectiveness and cost-effectiveness of multidimensional programs.