September 23, 2014

Dedicated Cancer Rehabilitation: Lessons in Promoting QOL Throughout the Course of Care

Insights on meeting cancer patients’ unique rehab needs

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By Sree Battu, MD

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Individuals with cancer are unique rehabilitation patients because their impairments are remarkably complex and their personal goals can vary greatly at each stage of their disease process.

Cleveland Clinic has recently enhanced its specialized rehabilitation services for patients with cancer through a dedicated Cancer Rehabilitation Program. This article shares lessons learned from our recent experience with the program, which focuses primarily on breast cancer patients and survivors.

Why cancer makes for unique rehabilitation patients

At the heart of our program is the recognition that patients with cancer often have physical, psychological and social needs that go beyond their cancer diagnosis and cancer-specific treatments.

Accordingly, the program’s overriding objective is to develop patient-oriented functional goals throughout the cancer care continuum and provide tailored services at each of the following stages, as needed:

  • Diagnosis
  • Treatment
  • Post-treatment and long-term follow-up
  • Survivorship
  • End-of-life care

An early and enduring role for rehabilitation

Cancer rehabilitation encompasses a range of therapies, educational interventions and support services. Our goal is to integrate rehabilitation early in the care process and ensure that it is considered by oncology specialists in patients’ overall treatment plans. This early integration can be key to averting or ameliorating the significant physical loss of function that cancer surgery and treatments can cause.

Well-designed research studies in breast cancer patients are limited, but they show that effective rehabilitation services can improve the following:

  • Upper and lower body strength
  • Flexibility
  • Body image
  • Bone density
  • Symptoms of fatigue, dyspnea, pain, anxiety and depression

Collaboration is crucial

The Cancer Rehabilitation Program is a collaboration among the Department of Physical Medicine and Rehabilitation and the following partners across Cleveland Clinic:

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  • Taussig Cancer Institute
  • Ob/Gyn & Women’s Health Institute
  • Breast Center
  • Cleveland Clinic Rehabilitation and Sports Therapy

Physiatrists and therapists in the Department of Physical Medicine and Rehabilitation work in conjunction with the patient’s cancer team to provide an extra layer of support and comprehensive care. We have found educational programming on the importance of rehabilitation at each stage of cancer management to be invaluable in securing the cooperation and support of our oncology specialist colleagues (surgeons, oncologists, hematologists, radiation oncologists and hospice/palliative care providers) and the oncology support staff.

Likewise, formal educational programming on common medical issues and impairments among breast cancer patients has been critical to enabling our rehabilitation clinicians (occupational and physical therapists) to design therapy programs that are patient-centered and appropriate to the patient’s stage in the care continuum.

Two essentials: An individualized approach and regular evaluations

Effective rehabilitation in this setting recognizes that cancer can profoundly change a patient’s sense of personhood. Our program assesses the whole patient in designing an individualized, patient-centered rehabilitation plan to help achieve the highest level of function possible within the limits of the patient’s disease and in keeping with personal goals. We strive to enhance quality of life for patients living with cancer and the effects of cancer treatments.

Another key to our program design is having consistent functional evaluations for every patient before surgery, after surgery and at appropriate intervals. This is a collaborative effort. Surgical nurses perform preoperative functional measurements that can be referenced postoperatively by surgeons or rehabilitation professionals. When patients start rehabilitation after surgery, they undergo more detailed evaluations that include functional measurements and quality-of-life questionnaires. These evaluations are continued periodically to track changes in progress.

Direct referrals to therapists encouraged

Though physiatrists play an integral role in the program, access to a broad network of talented cancer rehabilitation physical and occupational therapists is not restricted, as these disciplines have collaborated from the start in designing therapy programming. In fact, direct referrals to therapists by surgeons and oncologists is encouraged.

As a result, hundreds of patients benefit from contact with specialized rehabilitation providers, and physiatric consultations become more meaningful as the therapy team identifies and routes patients with compelling diagnostic and management needs.

Ongoing program refinements

Our program is developing a prospective surveillance model to evaluate how physical impairment develops in patients with breast cancer and how best to treat and allocate resources to reduce disability and suffering.

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We have also developed a unique algorithm to help patients find the most appropriate therapist for their needs at a location near home. There is strong interest in treating breast cancer patients among rehabilitation clinicians across the Cleveland Clinic Rehabilitation and Sports Therapy network, yet some clinicians have more experience than others. Our algorithm accounts for the patient’s needs and the experience and comfort of the clinician when matching patients with therapists. Patients with more complex medical issues that require a neuromuscular workup or symptom control with medication management will see a rehabilitation physician with specialty training in cancer rehabilitation.

Dr. Battu is a physiatrist in the Department of Physical Medicine and Rehabilitation within Cleveland Clinic’s Neurological Institute. Her specialty interests include cancer rehabilitation.

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Therapy session for a breast cancer patient.

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