Cancer Rehabilitation: Opportunities and Challenges

Each year, thousands of Canadians are told they have cancer. Most of us know someone—a friend, colleague, or family member—who has been diagnosed with the disease. The word “cancer” can provoke an emotional reaction that includes fear, anxiety and sadness. Today, however, the majority of cancer survivors can expect to pass the 5-year mark.^1,2 To quote Lynn Gerber, MD, cancer has been transformed from “an acute lethal illness” to “a complex, chronic and common disorder.”^3(p.xiv)

Physiotherapy Canada will be running a special series on oncology, including at least one article in each of the next few issues. The series will highlight the diversity in needs among cancer types, explore new treatment interventions and approaches, and provide both information on the state of the research evidence and insight into the availability of specialized services and programmes offered in Canada.

BACKGROUND

An estimated 177,800 Canadians were diagnosed with cancer in 2011.¹ Based on current incidence rates, 40% of women (1 in 2.5) and 45% of men (1 in 2.2) will develop cancer during their lifetime,¹ and current mortality rates indicate that approximately one in every four Canadians will die from cancer.¹ Despite declines in smoking rates, our growing and ageing population, and the current obesity epidemic will contribute to an increase in the number of individuals diagnosed with cancer.⁴ Moreover, as the absolute number of Canadians with cancer grows and survival improves, the prevalence of cancer will rise.

Cancer is largely a disease of older adults: the risk of developing cancer greatly increases with age,¹ and approximately 70% of all cases and 72% of all deaths will occur in Canadians aged 60 years or older.¹ Cancer and its treatments can exacerbate age-related declines in physical functioning, which can significantly affect the older adult's independence.⁵ Another 29% of cancer cases will occur in those between 19 and 59 years of age; for these younger and middle-aged adults, ongoing symptoms may compromise return to work and lifestyle activities. Cancer is even less prevalent in those under age 19 (accounting for only 1% of new cases), and survival rates for childhood cancers exceed 80%.¹ Many survivors of childhood cancers have a normal life expectancy, and must deal with ongoing or late-onset side effects of their cancer treatment.^6,7 The need for cancer rehabilitation services to address symptoms and functional limitations thus extends across the age spectrum.⁸

THE IMPACT OF CANCER TREATMENT

The impact of cancer treatment on overall quality of life is often the result of a complex interaction of physical and psychosocial factors, many of which are disease specific.⁹

Unlike other disease states, “cancer” includes more than 100 different diseases, each with its own distinctive disease and treatment profiles. Treatments of cancer include surgery, radiation therapy, chemotherapy, hormonal therapy, and biotherapy. There are many well-known effects associated with cancer treatment, such as pain, nausea, and hair loss, as well as less recognized effects such as myalgias and arthralgias, peripheral neuropathy, and cardiotoxicity. Cancer and its treatment can also take a toll on the individual's psychosocial and emotional well-being.¹⁰

In an attempt to identify effects of cancer treatments by their onset, definitions have been proposed for acute, late, and long-term effects experienced by cancer survivors.¹¹ Acute effects are those complications or toxicities associated with cancer treatment, such as immunosuppression, that occur or present during treatment and generally subside over time. Long-term effects are complications or toxicities of treatment, such as fatigue, that begin during treatment and persist beyond the end of treatment. Late effects are unrecognized complications or toxicities that are absent or sub-clinical at the end of therapy, such as lymphedema, but become apparent months or years after the completion of treatment.¹¹ Research evidence suggests that survivors are not prepared to manage many of the late and long-term chronic effects that arise as a result of treatment of cancer.^12,13

THE ROLE OF ONCOLOGY REHABILITATION

“I came in [to this programme] a bent-over old man; I am leaving an upright, middle-aged gentleman.”

—Mr. T., cancer survivor

The most vital issue for most cancer survivors is “getting back to normal.”^10(p.841) Rehabilitation needs vary greatly across tumour groups and individuals, as the medical effects depend on both the cancer type and the treatment regimen chosen.⁹ Moreover, the goals of treatment are often influenced by the survivor's own personal life roles and values.³ Most cancer survivors experience a reduction in physical functioning as a result of the impact of cancer treatment on overall activity level. At present, there is convincing evidence in favour of physical exercise as an intervention, both during and following cancer treatments, to improve outcomes including physical functioning. Moreover, there is compelling evidence to suggest benefits from physical exercise for both cancer-related and overall survival.^14–16

“What you have done for my husband's mind and soul by assisting him in getting back [physically] cannot be measured or graded and for that I am so very grateful.”

—Mrs. D., spouse of cancer survivor

In the clinical setting, many survivors present with symptoms including pain, anxiety, and fatigue, and physical conditions such as lymphedema. Some survivors may be undernourished and cachexic; some may be in advanced stages of the disease. The emotional toll associated with declining physical function and increasing dependency is profound.¹⁷ The road to recovery can be long, and the rehabilitation process overwhelming. This is where, as physical therapists, our expertise in areas such as pain and edema management and therapeutic exercise prescription is most valuable. By improving physical functioning, we can also positively influence the survivor's social and emotional functioning.¹⁸ In some cases, a patient-centred approach with an individualized comprehensive treatment plan may need to be developed for the survivor. This is best accomplished by means of an interdisciplinary rehabilitation team that also includes expertise in, for example, occupational therapy, nutrition, speech–language pathology and exercise physiology.

Physical therapists are well positioned to work as leaders in researching and developing cancer rehabilitation services and programmes. Our challenge is to develop and implement evidence-based interventions to assist cancer survivors in their transition from illness to wellness. Specifically, research is needed to evaluate preventive interventions, prospective surveillance programmes, and commonly used physical therapy interventions such as manual therapy and electrophysical modalities (e.g., TENS, acupuncture). It is critical for us to establish the efficacy of our interventions and to share this evidence with the larger medical community.

In this special series, you will get a glimpse of the diverse area of cancer rehabilitation and the excellent work being done in Canada and abroad. The role of physical therapy is well established in some areas (e.g., post-mastectomy exercises, lymphedema management), and it is exciting to see the services and programmes that are emerging across the country and the breadth of involvement of our discipline across cancer types and through the continuum of cancer care.