Post-acute Care Needs and Benefits of Inpatient Rehabilitation Care for the Oncology Patient

Abstract

Purpose of Review

This study aims to assess recent literature published on the post-acute care needs of cancer patients, specifically focusing on the acute inpatient rehabilitation setting.

Recent Findings

The neurologic cancer population appears to be the most studied oncologic population in acute inpatient rehabilitation studies within the past 5 years. This finding is consistent with prior findings from the past several decades. Recent trends in inpatient cancer rehabilitation note a population with lower admission functional status and shorter lengths of stay compared to prior studies. Despite these findings, the percentage discharged to the community remains high.

Summary

With new treatments yielding improved survival, cancer patients may live longer and risk accumulating more functional impairments. Physicians involved in their care must understand post-acute care needs and work in a multidisciplinary group to best determine post-acute disposition. This decision remains very individualized and should consider both oncologic and functional needs.

Introduction

In 2020, an estimated 19.3 million new cancer cases were diagnosed worldwide, with projections suggesting an increase to 28.4 million in 2040 [1]. The increasing incidence of cancer in the USA likely reflects “the growth and aging” of the US population [2]. In addition to the increasing number of cancer diagnoses, there is also a trend of improved mortality in high-income countries thought to be related to improved early diagnosis and treatment [3]. With this trend of increased survival, physiatrists who treat cancer patients may encounter older patients who have accumulated more functional impairments and debility. There will likely be a growing need for rehabilitation services and post-acute care for patients with cancer in the future [4].

Patients may develop several functional impairments related to cancer or cancer treatment throughout their course of illness. After acute care hospitalization, patients may be screened for admission to acute inpatient rehabilitation to optimize their functional status. Acute rehabilitation is generally reserved for patients with medical complexity requiring physician oversight, who can tolerate 3 h of therapy/day at least 5 days/week, and who are expected to make measurable functional gains within a relatively short length of stay [5]. A growing body of research highlights the functional improvements in cancer patients admitted to inpatient rehabilitation, and that patients find acute rehabilitation valuable [6,7,8•,9].

Gallegos-Kearin et al. noted a trend in decreasing admission Functional Independence Measure (FIM) scores in their 13-year review of adult cancer patients receiving inpatient rehabilitation [10••]. This finding has been highlighted in several recent studies, indicating that inpatient rehabilitation facilities (IRFs) have been accepting more debilitated cancer patients in recent years [11–13]. Several recent studies which have specifically examined patients with advanced, metastatic, and recurrent cancer and have found that these patients demonstrate functional gains and benefit from inpatient rehabilitation [11–14].

Though studies show inpatient rehabilitation benefits cancer patients, it is essential to note the medical complexity involved in treating this population. Cancer patients in IRF settings tend to have a higher transfer rate back to acute care hospitals than non-cancer acute rehabilitation populations. A recent study found that 96% of consecutive oncologic patients admitted to acute rehabilitation during a 6-month time period had at least one medical complication, and 19% necessitated transfer back to the acute care service [15••]. The most common complications were electrolyte abnormalities (50%) and musculoskeletal issues (43%). In another study, the 30-day readmission rate after inpatient cancer rehabilitation was 21%, which was higher than previously reported for other rehabilitation populations (5.8–18.8%), but within range for what has been found in patients with a diagnosis of cancer discharged from hospitals (< 3–34%) [16••].

In the USA, patients with tumors involving the brain and nervous system account for most of the cancer patients admitted to IRF (52.9%) [17••]. Accordingly, most of the research published on inpatient rehabilitation of cancer patients focuses on these patients [4, 6]. This review will primarily focus on the populations of brain and spine tumors and highlight relevant research on other less-studied groups. This review aims to provide an update on recent literature on post-acute cancer rehabilitation and highlight recent trends. All physicians involved in the care of cancer patients should have a basic understanding of post-acute care needs for their patients.

Barriers to Rehabilitation

Before examining the benefits of inpatient rehabilitation, a brief discussion on barriers to rehabilitation is relevant. Mix et al. found that patients with oncologic diagnoses comprised only 2.4% of total IRF patients in their 3-year retrospective study of all US acute IRFs [17••]. For Medicare reimbursement, 60% of patients admitted to an IRF must fall under one of 13 diagnoses [6]. Patients with brain tumors can be admitted under “brain injury,” and patients with metastatic spinal cord compression under “spinal cord injury.” As “cancer” is not one of the 13 diagnoses, those with other types of cancer may be less likely to be admitted to an IRF.

Another common barrier to inpatient rehabilitation is the inability of the IRF to provide specific treatment needs for cancer patients. These may include daily transportation to radiation therapy, blood transfusions, and chemotherapy administration. Post-acute care should not disrupt the oncologic treatment plan. A recent study examined acute care length of stay for brain tumor patients and found that those discharged to IRF had a median length of stay of 10 days and a longer waiting time to initiate outpatient treatment. Though this study did not find an association between wait time and overall survival, a delay in treatment in certain patients may have significant consequences [18••]. Multidisciplinary teams must work with the patients and caregivers to develop post-acute care plans that meet the priorities and needs of the patients (Fig. 1).

Fig. 1.

Patient and treatment-related factors in triaging post-acute disposition. (1) Is the patient amenable to post-acute rehabilitation and will it help them meet their goals? (2) Is the anticipated post-acute care disposition compatible with the oncology treatment plan? Will treatment be delayed if patient goes to rehabilitation? (3) Which level of post-acute care is most appropriate based on (a) functional needs, (b) medical needs, and (c) expected timeframe for improvement?

Aside from regulatory and treatment barriers, Smith and Zheng highlighted physician barriers to rehabilitation referrals, citing prior studies that found a lack of recognition and documentation of functional deficits and inadequate training on screening for symptoms as potential contributing factors [19]. Physician attitudes and prior experiences may also affect likelihood of referring or accepting patients with advanced cancer to rehabilitation [20]. Additionally, a lack of trained rehabilitation professionals and rehabilitation staff may affect the ability for an IRF to provide inpatient cancer rehabilitation [21].

Research on Post-acute Care Needs Based on Population

Brain Tumor

Patients with primary and metastatic brain tumors may develop significant functional impairments related to cancer and treatment with surgery and radiation. Mukand et al. found that nearly 75% of brain tumor patients admitted to inpatient rehabilitation had three or more concurrent neurologic deficits, and 39% of patients had five or more deficits [22]. Comparisons of functional gains made in inpatient rehabilitation settings between patients with brain tumors and those with traumatic brain injuries or strokes have been studied since the late 1990s [23–25]. Recent studies have reinforced the same findings from the 1990s: patients with brain tumors in IRF settings make significant functional gains [11–13]. The notable trends over the three decades are shorter lengths of stay and lower admission FIMs [12, 13]. Despite these changes, the percentage discharged to the community remains high.

There is a paucity of research on the long-term effects of inpatient rehabilitation for brain tumor patients. This data type may be more challenging to study in populations such as glioblastoma (GBM), as survival is often poor. Tang et al. found that greater functional improvement in inpatient rehabilitation was a significant predictor of more prolonged survival in patients with GBM and brain metastases [26]. Roberts et al. found that there was no significant survival difference in GBM patients discharged to IRF compared to those who were discharged to other locations and noted that perhaps, “a structured inpatient rehabilitation program may level the survival field in lower-functioning patients who otherwise may be faced with a dismal prognosis” [11]. Functional status remains an important variable in survival in this population as Warren et al. noted that patients discharged to rehabilitation facilities compared to home had worse survival, thought to be related to poorer functional status [18].

Over the past 5 years, only a few studies have been published on these populations (Table 1). Ayotte and Harro’s study is unique in evaluating a targeted aerobic component of exercise training during inpatient rehabilitation. This was achieved by using a cycle ergometer and having patients continuously cycle at moderate intensity for 5 days/week, measuring aerobic capacity and a 6-min walk test (6MWT) as primary outcomes. Though only 16 patients completed the inpatient phase of the study, there was a statistically significant improvement in all outcome measures, including aerobic capacity, 6MWT (median improvement 173.0 m), and FACIT-Fatigue score [27].

Table 1.

Inpatient brain tumor rehabilitation studies

Citation	Country	Design	Population	Measures	Findings
Ayotte and Harro (2017)	USA	Prospective, single cohort	Brain tumor (mixed)	Aerobic capacity- submaximal graded exercise test with cycle ergometer, 6MWT, FACIT-Fatigue, FIM, strength test-dynamometer	Statistically significant improvement in all outcomes measured
Yu (2019)	Korea	Retrospective chart review	Brain tumor (mixed), Stroke	FMA, BBS, K-MBI, K-MMSE, IQ, ECOG Caregiver questionnaire (1 year after discharge)	Similar functional gains between tumor and stroke patients Most family caregivers thought rehabilitation was effective and would recommend to patients in similar situations
Jie Tay (2022)	Singapore	Retrospective chart review	Brain tumor (mixed)	FIM, GOS during inpatient rehabilitation and at 1 year post-discharge	Patients with low-grade tumors had significantly improved functional gains in inpatient rehabilitation as compared to high-grade tumor group. Low grade group had better GOS at 1 year and improved survival at 1 year
Chowdhury (2022)	USA	Retrospective chart review	GBM (initial resection vs repeat resection)	Total FIM change, total FIM efficiency, motor and cognitive FIM efficiency, proportion discharged home	No significant differences between groups in any of the measures
Reilly (2020)	USA	Retrospective case-matched chart review	GBM (initial diagnosis vs recurrent diagnosis)	FIM gain, FIM efficiency	No difference in FIM measures between the two groups

6MWT 6-min walk test, FACIT-Fatigue Functional Assessment of Chronic Illness Therapy-Fatigue, FIM Functional Independence Measure, FMA Fugl-Meyer Assessment Index, BBS Berg Balance Scale, K-MBI Korean Modified Barthel Index, K-MMSE Korean Mini-Mental State Exam, IQ Wechsler Adult Intelligence Scale, ECOG Eastern Cooperative Oncology Group, GOS Glasgow Outcome Scale

Two studies attempted to provide long-term data on brain tumor patients discharged from IRF. Yu et al. compared functional gains in IRF between patients with brain tumors (benign and malignant) with patients with strokes and found no statistically significant difference between the groups. To address long-term effectiveness, this group surveyed family caregivers 1-year post-discharge from IRF, finding that most caregivers were satisfied with the program, thought rehabilitation improved functional status, and would recommend the program to patients with similar conditions [28].

The second study examined functional gains that primary brain tumor patients made in inpatient rehabilitation and collected data on function and disability one year after IRF discharge. Patients with low-grade tumors showed statistically significantly improved functional outcomes during inpatient rehabilitation and one-year post-discharge. The authors also noted that many functional improvements were sustained at the timepoints of 6 months and 1-year post-discharge. It is important to note that this study had a large percentage of low-grade tumors (79%) compared to high-grade tumors [29].

Two retrospective studies compared functional gains between patients with GBM admitted after initial diagnosis and after recurrent disease [12, 13]. Chowdhury et al. found no difference in functional gains between patients admitted to IRF after initial resection versus repeat resection for GBM. The percentage of patients discharged home was similar in both groups, with 75% in the initial resection group and 78.3% in the repeat resection group [13]. Similarly, a retrospective case-matched study found no difference in FIM gain or FIM efficiency between patients admitted to IRF after initial diagnosis of GBM versus recurrent diagnosis of GBM. Sixty-four percent of patients in both groups were able to be discharged home [12].

Spine Tumors

Patients with cancer may develop symptoms of spinal cord injury related to primary tumors of the spine or, more commonly, metastases to the spine [30]. The most common spine tumor is a metastatic extradural tumor, which can cause symptoms of metastatic epidural spinal cord compression (MESCC). Patients may also develop extramedullary metastases or leptomeningeal disease. Based on the location of the lesion, patients with disease affecting the spinal cord may have various symptoms, such as back pain, weakness, impaired sensation, and bowel and bladder dysfunction [31]. The goals of acute rehabilitation for a patient with a neoplastic spinal cord injury are similar to those for patients with traumatic spinal cord injuries — to provide education for patients and caregivers, to improve mobility and safety, to maximize independence, and to help facilitate a safe discharge to the community [32].

Comparison studies examining the functional gains made by those with neoplastic spinal cord injury and traumatic spinal cord injury have also found similar functional gains made per day of acute inpatient rehabilitation between the two groups and similar percentages discharged to the community [33, 34]. One study also found that patients with metastatic epidural spinal cord compression who participated in inpatient rehabilitation had improved life satisfaction, and less depression than those who did not [35]. As prior studies have demonstrated improved functional outcomes in IRFs with dedicated spinal cord injury units, patients with neoplastic SCI who are appropriate for acute inpatient rehabilitation should be recommended for acute rehabilitation in an SCI unit if possible [32].

Over the past 5 years, few articles have been published on neoplastic SCI; thus, the timeframe was expanded to also include a study from 2015 (Table 2). The most recent study was published in 2022, comparing functional gains made between 43 neoplastic SCI patients and 209 traumatic SCI patients. Like other studies, the neoplastic SCI group was significantly older than the traumatic group and had incomplete injuries. The FIM efficiencies were similar, though the neoplastic group showed a significantly shorter length of stay than the traumatic group. Interestingly, complications of urinary tract infections and decubitus ulcers were significantly more common in the traumatic group than in neoplastic group [36].

Table 2.

Inpatient spine tumor rehabilitation studies

Citation	Country	Design	Population	Measures	Findings
Afsar (2022)	Turkey	Retrospective chart review	43 neoplastic SCI, 209 traumatic SCI	FIM, FAC, LOS, bladder independence	No difference in admission FIM, discharge FIM, or FIM efficiencies between groups Neoplastic SCI had shorter lengths of stay (p < 0.01), were older than traumatic SCI (p < 0.01), and were more likely to have incomplete SCI (p < 0.01)
Knowlton (2017)	USA	Retrospective chart review	40 chordoma patients admitted after surgical resection	FIM, Hospital Transfer Rate	Mean total FIM gain was 33.7 and mean motor FIM gain 26.1. 62.5% developed post-operative complication and 32.5% were transferred to acute hospital
Fu (2020)	USA	Retrospective chart review	30 patients with a diagnosis of LMD	FIM, LOS, survival	Statistically significant functional gains were made by these patients. 66.7% were able to be discharged home. Median survival after admission to inpatient rehabilitation was 180 days
Fortin (2015)	Canada	Retrospective database review	143 MSCC, 1274 NT-SCI	FIM, LOS, survival, healthcare utilization	No difference in total admission or discharge-FIM between groups. NT-SCI had higher FIM efficiency (p < 0.001) and greater variability in FIM efficiency. Length of stay and discharge home were comparable between groups. NT-SCI had increased survival rates at 3 months, 1 year and 3 years(76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively)

FIM Functional Independence Measurement, FAC functional ambulation categories, LOS length of stay, MSCC malignant spinal cord compression, NT-SCI nontraumatic spinal cord injury

Fortin et al. compared outcomes in inpatient rehabilitation made between those admitted with malignant spinal cord compression (MSCC) versus those with other non-traumatic spinal cord injuries (NT-SCI). Though the NT-SCI group was noted to have a higher FIM efficiency, the MSCC cohort also made significant functional gains in inpatient rehabilitation. The authors note similar percentages of each group were able to be discharged home (65% MSCC, 69.7% NT-SCI) and met their rehabilitation goals (75.5% MSCC, 81.3% NT-SCI) [34].

A 2017 study evaluated functional gains made by patients with chordomas in inpatient rehabilitation. This retrospective study examined 40 patients admitted for inpatient rehabilitation and found that these patients made functional gains during admission. However, they demonstrated a higher acute transfer rate of 32.5% and a high postoperative complication rate [37].

In 2020, a retrospective study evaluated outcomes for patients with leptomeningeal disease receiving acute inpatient rehabilitation. Given that survival rates in this population are typically measured on the order of months, it also aimed to evaluate outcomes after rehabilitation. Of the 30 patients identified, nine were transferred back to the acute care service for additional chemotherapy needs, neurologic symptoms (neurologic decline, altered mental status), and fever. The 21 patients who completed inpatient rehabilitation made statistically significant functional gains, and 66.7% were able to be discharged home. At the time that the study was conducted, the median time from inpatient admission until death was 180 days [38].

Although prognosis may be poor for some patients if they meet the criteria for acute inpatient rehabilitation and if rehabilitation is consistent with their goals, acute inpatient rehabilitation can serve many purposes.

Other Notable Studies

Bilek et al. studied older patients with active cancer (OPAC) admitted to acute inpatient rehabilitation and found that in this group of 330 patients, with a mean age of 80.1, patients were able to make significant functional gains and 80.4% were able to be discharged to the community [8]. Scherer-Trame retrospectively studied 3704 colorectal cancer patients and noted that 43.6% attended inpatient rehabilitation. They found that those who underwent inpatient rehabilitation had better overall and disease-specific survival [39].

Conclusions

Though there are many barriers in admitting cancer patients to acute inpatient rehabilitation, there is a clear need for these patients to have access to this post-acute care setting. Though the specific goals for each patient in acute rehabilitation are different, the overarching themes are to improve function and optimize independence. There is a need to study various cancer populations in inpatient rehabilitation, as most studies have focused on those with neurologic cancers. More data on long-term outcomes and survival after acute inpatient rehabilitation is also necessary.

There appears to be growing interest in the use of multidisciplinary care for patients’ cancer [40–42]. As these patients have complex medical and functional needs, collaboration and discussion among multiple specialties are necessary to best treat these patients. Rehabilitation medicine physicians and rehabilitation specialists can help assist teams with post-acute care discharge plans and continued outpatient follow-up to address functional impairments.

Data Availability

The authors confirm that the data supporting the findings of this article are available within the article.