A Framework for Ensuring Competence and Credibility in Cancer Rehabilitation Services

The Growing Need for Cancer Rehabilitation Services in Canada

Two in five Canadians will develop cancer in their lifetime.¹ The risk of cancer increases dramatically with age, and the Canadian population is both growing and ageing. While the number of Canadians diagnosed with cancer is on the rise, more effective diagnostic and treatment methods have resulted in earlier detection and treatment and improved disease-free and overall survival.¹ Today, there are approximately 1 million survivors of cancer in Canada.

But while survival is improving, cancer treatments are invasive, and survivors experience side effects that can influence any system of the body. Many experience acute side effects that subside over time, but others develop persistent and/or late-appearing effects that can progress to disability.² The rehabilitation needs of cancer survivors span all ages and the full spectrum of rehabilitation fields, including musculoskeletal, neurological, cardiopulmonary, and chronic pain.

There is now a wealth of research evidence available on the benefits of rehabilitation as part of cancer care, yet this has not translated into access to these important services for patients. Patients and families often have to advocate for themselves in order to access the patchwork of services that may or may not be available.

—Kristin Campbell, PT, PhD (Assistant Professor, Exercise Physiology and Oncology, Department of Physical Therapy, University of British Columbia)

Impairment-based cancer rehabilitation is a niche area of practice that falls within the domain of physical therapy and encompasses preventive, restorative, supportive, and palliative interventions and strategies to prevent or minimize the impact of impairments and optimize function and life participation. While many cancer-related impairments are responsive to rehabilitation intervention, because health care practitioners and survivors themselves are often unaware of the benefits, many impairments go untreated.^2,3 Research evidence supports timely and appropriate cancer rehabilitation intervention to optimize the survivors' recovery after cancer and to bridge the gap between illness and wellness.

To meet the needs of people battling the disabling sequelae of cancer and its treatment, and to hasten recovery following surgical, radiation therapy and chemotherapeutic interventions, cancer rehabilitation services are in demand. Access to rehabilitation for people with cancer is the exception, not the norm, despite a growing body of evidence for effectiveness of rehabilitation interventions in improving impairments, quality of life, and even survival. As a result, people with cancer suffer needlessly the burden of preventable and remediable disabilities.

—Nancy Mayo, PhD (Professor, School of Physical & Occupational Therapy, McGill University and Cancer Rehabilitation)

Around the world, cancer rehabilitation is being recognized as a core component of cancer medical care,⁴ and a growing awareness of the need for cancer rehabilitation services has come to the fore in Canada as well. In a recent article in Physiotherapy Canada, Canestraro and colleagues⁵ reported the results of a cross-sectional online survey of current practice patterns and provision of oncology rehabilitation in Canada. Their results suggest that formal oncology rehabilitation programmes in Canada are scarce, leading them to highlight the need to create and expand programmes to meet the needs of the growing numbers of Canadians surviving and living with cancer.

Development of Cancer Rehabilitation Standards

In July 2014, the Commission on the Accreditation of Rehabilitation Facilities (CARF) released its Cancer Rehabilitation Specialty Program Standards to guide organizations toward sustained excellence in cancer rehabilitation business practices, service processes, and program-specific standards. These newly developed standards are timely and may prove useful in guiding the development of cancer rehabilitation programmes across Canada.

CARF, founded in 1966, is an independent non-profit accreditor of health and human services; more than 8.4 million people in 18 countries are served by CARF-accredited organizations. CARF Canada is a member of the CARF International family that accredits close to 50,000 health and human service programmes in ageing services, behavioural health, child and youth services, employment and community services, medical rehabilitation, and vision rehabilitation. CARF develops, reviews, and revises international consensus standards based on input from experts in the area, front-line service providers, and the people served. In this way, CARF aims to promote person-centred evidence-based care.

In 2012, CARF conducted a market analysis in collaboration with rehabilitation specialists working in cancer rehabilitation. This initiative resulted from a growing interest from hospitals, outpatient facilities, treatment centres, and other facilities in developing sector-specific standards to improve the quality of patient care in various cancer-related rehabilitation programmes, including those focused on prevention, early diagnosis, pre-treatment evaluation, staging, optimal treatment, surveillance for recurrent disease, support services, and end-of-life care. While practitioners providing cancer rehabilitation treatment realize the need to promote integration of services in the cancer care pathway, many acute-care and oncology specialists do not have the necessary rehabilitation knowledge and expertise.⁴ Thus, the CARF organization decided that this was a critical juncture to become engaged in the cancer field.

In summer 2013, CARF convened an International Standards Advisory Committee (ISAC) consisting of international and national leaders in cancer rehabilitation, survivors, family members of survivors, health care providers, academics, and researchers and administrators from National Institute of Cancer at the National Institute of Health and the American Cancer Society. Following the 3-day ISAC working sessions, CARF produced a draft Cancer Rehabilitation Specialty Program standards document. This document then went through two robust field reviews, and the new Cancer Rehabilitation Specialty Program standards were finalized in the January 2014.⁶ As of July 2014, organizations may be surveyed using these standards.

Cancer Rehabilitation Quality Framework

The CARF standards define cancer rehabilitation as a “specialty programme that focuses on strategies to optimize outcomes from the time of diagnosis through the trajectory of cancer in an effort to prevent or minimize the impact of impairments, reduce activity limitations, and maximize participation” for survivors of cancer.^6(p.1)

A Cancer Rehabilitation Specialty Program is defined as one that addresses the unique rehabilitation needs of cancer survivors using a holistic interdisciplinary team approach. The ISAC noted that a Cancer Rehabilitation Specialty Program may be provided in a variety of settings, including hospitals, outpatient clinics, or community-based programmes.

The standards highlight the need to establish partnerships and enhance communication with acute-care oncology, radiology, and other care providers along the continuum to deliver coordinated care and promote seamless transitions in health care. Features of a cancer rehabilitation programme include a focus on evidence-based practices and person-centred care, incorporation of self-management strategies, and promotion of health and wellness among survivors. CARF also endorses the use of performance indicators to measure the effectiveness and efficiency of services, access to services, and satisfaction among programme participants. Beyond meeting programmatic requirements, a CARF Cancer Rehabilitation Specialty Program must demonstrate efforts to advocate on behalf of survivors to regulators, legislators, educational institutions, research funding organizations, public and private payers, and the community at large. The programme is also expected to take an active role in translating current research evidence into practice and supporting future improvements in care by advocating for or participating in cancer research.

People diagnosed with cancer are regularly challenged with acute and chronic conditions that can be managed well by interdisciplinary rehabilitation teams. The standards for Cancer Rehabilitation Specialty Programs developed by CARF provides a tool for physiotherapists, and other health care professionals, and a method to promote high standard interdisciplinary care for cancer survivors.

—Oren Cheifetz, PhD (Clinical Specialist—Oncology, Hematology/Oncology Program, Hamilton Health Sciences; Past Chair, Oncology Division, Canadian Physiotherapy Association; founding member, Canadian Cancer Rehabilitation and Education Institute)

While the CARF framework provides the basis on which individual practitioners, clinics, and organizations can develop a Cancer Rehabilitation Specialty Program, the joint efforts of clinicians, cancer experts and researchers, professional organizations, and academic institutions in Canada will be needed to maximize the potential of this quality framework. Importantly, physical therapists will need specialized training and education in the nuances of cancer care. Efforts to this end are underway in Canada. The Canadian Physiotherapy Association's Oncology division actively provides leadership and offers oncology-related courses for clinicians. Moreover, in 2013 a Pan-Canadian Cancer Rehabilitation Meeting entitled “Preparing the New Generation of Physical, Occupational, and Speech–Language Therapists and Researchers to Meet the Demands for Cancer Rehabilitation in Canada” was hosted by McGill University in Montreal, Quebec. Dr Nancy Mayo chaired this 2-day meeting, which included academics and cancer rehabilitation researchers from across Canada; the group reached consensus on the need to expand cancer rehabilitation content in the physical therapy curriculum.

For further information on the new CARF Cancer Rehabilitation Specialty Program standards, please contact Chris MacDonell (cmacdonell@carf.org) at CARF International.