What are the attitudes and beliefs of oncologists regarding potential cancer rehabilitation in a tertiary cancer center?

Abstract

Cancer Rehabilitation (CR) is an emerging field in Physical Medicine & Rehabilitation. Current literature highlights the effectiveness of cancer rehabilitation in improving functional outcomes, shorter length of hospital stay, and improved quality of life. Despite this, there are very few formalized CR programs across all of North America. We conducted a survey at a tertiary cancer center without a formalized CR program to assess the perceived need of such a program and its potential development. This survey of medical, surgical, radiation and pediatric oncologists demonstrated that 92.3% of 39 respondents felt CR was somewhat to very important, particularly for their patients’ issues of fatigue, deconditioning, pain management and disposition planning. These findings highlight the value seen by oncologists in the need for further cancer rehabilitation access and formalized program development in order to meet patient needs for improving functional deficits, activities of daily living and quality of life.

Introduction

Cancer Rehabilitation (CR) involves providing rehabilitation to patients with any cancer diagnoses and at any stage of cancer, including physical, cognitive and psychological issues affecting function. CR is comprised of many disciplines including Physical Medicine & Rehabilitation (PM&R), Physical Therapy, Occupational Therapy, Speech Therapy, Vocational Rehabilitation, Recreational Therapy, Nutrition, Kinesiology and Psychology. CR improves functional outcomes via increasing functional scores (1), decreasing financial burdens to health care systems (2), improving ambulatory status (3), and increasing rates of patients being able to be discharged home rather than remaining in hospital or transferring to a skilled nursing facility (4).

While CR as a subspecialty of PM&R is relatively rare, it has steadily gained recognition internationally with a growing body of literature and the ability to rehabilitate cancer patients, as well as proposed models to identify functional impairments early on (5). Despite their benefits, CR programs with PM&R specialists have been slow to develop in Oncology. There are many reasons for this, one reason being the non-recognition of PM&R, rehabilitative issues and lack of referrals made by oncologists (6, 7). There are many centers that have a great need for CR; however, due to a lack of access and exposure to the benefits CR and PM&R provide, their need is poorly recognized (8).

While there is a breadth of literature investigating reasons for gaps in CR program development, there has been little consideration in the literature of oncology input as to what areas of rehabilitation they perceive to be needed, and how important it would be to develop a cancer rehabilitation program to address functional needs of their population.

To assess the perceived benefits of CR from the perspective of Physical Medicine & Rehabilitation, we developed a survey for oncologists and distributed it to a tertiary cancer center without a formalized CR program.

Methods

Study design.

This was a cross-sectional survey of medical, radiation, surgical and pediatric oncologists at the Tom Baker Cancer Centre in Calgary, Alberta, Canada – a center with no established CR program. Participants were required to understand English proficiently in order to complete the survey, and be at least 20% clinically oriented in order to have seen a sufficient volume of patients that may have functional deficits.

Survey.

The survey was composed and reviewed independently by both a PM&R CR Fellow and an experienced board certified PM&R specialist at MD Anderson Cancer Center within the CR program. Development of the survey was based on a thorough literature search of medical databases including MEDLINE (1950 to 2017) and EMBASE (1980 to 2017), cancer rehabilitation textbooks authored by cancer physiatrists from MD Anderson Cancer Center and Memoral Sloan Kettering Cancer Center, recommendations of physiatrists and oncologists involved in the care of patients requiring rehabilitation, and the authors’ knowledge of the literature in addition to their experience in CR.

The survey (see supplemental materials) was approved by the IRB Board at MD Anderson and distributed to oncologists at the Tom Baker Cancer Centre electronically. The survey was administered via RedCap (see footnotes) and online survey completion was automatically entered into an MD Anderson database. Given there was no patient involvement in the study and essentially zero-risk for adverse events, consent was implied electronically by respondents submitting the survey. The consent informed the oncologists about the nature of the survey and that it was assessing the importance of CR development from the perspective of PM&R, and Oncologists were made aware that PM&R or Physiatry was one component of the multidisciplinary nature of oncology rehabilitation. The link was sent via encrypted email to participants, including the information that the survey link was not to be shared outside of study participants. Following survey submissions, data collectors verified that all surveys were submitted by confirmed oncologists, which the study coordinators were blinded to. Submitted data was then stripped of any identifying information and kept confidentially in an electronic format.

Outcome measures.

The primary outcome of the survey was the proportion of oncologists perceiving that PM&R involvement in oncology is important. Respondents choosing “Very important” or “Somewhat important” for Question 10 were counted as a positive response. Secondary measures included identification of functional deficits that oncologists would refer for CR, at what stages of cancer referral would be considered, and any preference for referral to CR for inpatients versus outpatients.

Statistical analysis.

The survey was sent to all 74 oncology physicians at Tom Baker Cancer Centre. Oncologists’ information and survey responses were summarized by standard descriptive statistics where appropriate including percentage values and numerical values.

Results

Of the 74 oncologists who were sent the survey, 39 respondents completed the survey for a 53% response rate. Respondents (by frequency, percent) included adult medical oncologists (22, 56%), surgical oncologists (8, 21%), radiation oncologists (7, 18%), and pediatric oncologists (2, 5%). Respondents also noted if they treated exclusively adults (35, 90%), pediatric (2, 5%) or both populations (2, 5%). The importance of PM&R in oncology was ranked as very important (26, 66.7%), somewhat important (10, 25.6%), neutral (3, 7.7%), and somewhat or unimportant (0). Respondents answered CR would be very beneficial for the following populations: both inpatient and outpatient services (25, 64.1%); inpatients only (11, 28.2%) and outpatients only (4, 10.3%).

Tables 1 and 2 display the frequency of rehabilitative issues seen in cancer patients and likelihood of referral to PM&R, respectively. Issues affecting at least 50% of the respondents’ patient populations included fatigue (27, 69.2%), deconditioning or asthenia (17, 43.6%), and pain management (9, 23.1%). Respondents felt they would be most likely to refer to CR for deconditioning (18, 46.2%), mobility assistance or devices (18, 46.2%), paraplegia or hemiplegia (18, 46.2%), disposition planning (14, 35.9%), and management of spasticity or contractures (12, 30.8%).

Table I.

The frequency at which oncologists come across rehabilitation diagnoses and symptoms (by frequency, (percent)).^a

	Medical Oncology	Surgical Oncology	Radiation Oncology	Pediatric Oncology	Total
Fatigue	17 (77.3%)	3 (37.5%)	5 (71.4%)	2 (100%)	27 (69.2%)
Deconditioning/asthenia	10 (45.5%)	3 (37.5%)	2 (28.6%)	2 (100%)	17 (43.6%)
Pain management	5 (22.7%)	1 (12.5%)	2 (28.6%)	1 (50%)	9 (23.1%)
Discharge/disposition planning	1 (4.6%)	1 (12.5%)	0	1 (50%)	3 (7.7%)
Peripheral neuropathy	1 (4.6%)	0	0	1 (50%)	2 (5.1%)
Mobility training/devices	0	0	0	1 (50%)	1 (2.6%)

^aResponses of >50% frequency (oncologists selecting 50–75% or >75%) for the issues listed above were considered a positive response.

Table II.

The likelihood of oncologists referring to PM&R for functional issues (by frequency, (percent)).^a

	Medical Oncology	Surgical Oncology	Radiation Oncology	Pediatric Oncology	Total
Deconditioning/asthenia	10 (45.5%)	3 (37.5%)	3 (42.9%)	2 (100%)	18 (46.2%)
Paraplegia/hemiplegia	9 (40.9%)	4 (50%)	3 (42.9%)	2 (100%)	18 (46.2%)
Mobility training/devices	10 (45.5%)	4 (50%)	2 (28.6%)	2 (100%)	18 (46.2%)
Discharge/disposition planning	8 (36.4%)	5 (62.5%)	-	1 (50%)	14 (35.9%)
Spasticity/contractures	8 (36.4%)	2 (25%)	1 (14.3%)	1 (50%)	12 (30.8%)
Neurogenic bowel/bladder	5 (22.7%)	2 (25%)	1 (14.3%)	2 (100%)	10 (25.6%)
Fatigue	8 (36.4%)	-	1 (14.3%)	-	9 (23.1%)
Orthostasis	5 (22.7%)	-	1 (14.3%)	1 (50%)	7 (17.9%)
Pain management	4 (18.2%)	1 (12.5%)	1 (14.3%)	-	6 (15.4%)
Peripheral neuropathy	4 (18.2%)	-	-	-	4 (10.3%)

^aResponses of >50% likelihood for the issues listed above were considered a positive response.

With respect to patients’ stage of cancer, oncologists reported they would refer to CR at the time of diagnosis (8, 20.5%), early stages of cancer (13, 33%); mid stage or relapse of cancer (18, 46.2%) and late or palliative stage (19, 48.7%).

Discussion and Conclusions

Cancer rehabilitation is an important but underutilized service often due to a lack of CR program development and access (9). Nevertheless, oncologists still recognize rehabilitation as a vital component of patient care. In our survey, despite limited exposure to CR in their clinical practice, 92.3% of oncologists felt it was somewhat to very important.

All oncologists identified at least one rehabilitation issue affecting >50% of their patients. The issues that were identified as being most frequently seen in oncology patients – including fatigue, deconditioning and pain management – are consistent with literature regarding symptom frequency in cancer patients (10). These areas of potential referral are all areas that may be addressed by PM&R in a comprehensive CR program including evidence-based exercise programs (11), pharmacologic and interventional pain & spasticity management, bracing and education (12).

Surprisingly, our survey respondents reported a higher likelihood of referral for CR in later stages of cancer disease. This is contrary to previous literature, which suggests that both oncologists and PM&R physicians are less likely to provide rehabilitative services to patients with advanced cancer (13). This finding may be due to a lack of exposure to rehabilitation in the early stages of cancer, especially given recent evidence supporting prehabilitation (14, 15). As mentioned in the introduction, one reason CR programs are slow to develop is the lack of recognition of functional problems amenable to rehabilitation in cancer patients. While the oncologists in this survey recognized a need for cancer rehabilitation, they appeared to undervalue the impact of cancer rehabilitation in the earlier stages of disease, when optimal prevention and management of functional deficits result in the best outcomes (16).

This study and research is important to the field of oncology rehabilitation, as throughout cancer rehabilitation literature from several decades ago up to the present day, there continue to be many articles highlighting the need for further emphasis on rehabilitation in the field of oncology. In the United States, national accrediting bodies such as the Commission on Cancer; clinical practice guidelines such as the National Comprehensive Cancer Network; and survivorship care planning all support the implementation of rehabilitation into oncology care (17). However as mentioned, integration with oncology remains a challenge. Directly surveying the oncologists themselves establishes connections between oncology and rehabilitation, and thus the potential of developing oncology rehabilitation in partnership with oncologists through educating them on the importance of rehabilitation in improving cancer outcomes, while tailoring a rehabilitation program addressing the needs of their cancer population (18).

There are several limitations to our study. The small number of 39 respondents limits our ability to generalize the importance of CR beyond this center. Additionally, surveying cancer centers with established CR programs would help to provide a comparison of what rehabilitative needs are shared across multiple centers, focusing CR program development around common rehabilitative issues. Responder bias may also play a role in the survey results, as oncologists who have an indifferent perception of CR are less likely to fill out the survey and thus be omitted in our analysis. An important limitation to our survey is that it pertains primarily to impairments and services as treated from the perspective of PM&R. Given that CR is a multidisciplinary program involving many disciplines as previously mentioned, future surveys would look at the perceived and potential benefits of all disciplines involved in CR.

It is also important to note in our survey that the option of referring patients to CR at the time of diagnosis may overlap with any stage of cancer, depending on when the diagnosis is made. The presentation of impairments at any stage of cancer should warrant referral to rehabilitation services, both at the time of diagnosis as well as during subsequent time periods of treatment, restaging and surveillance (10).

While under-referral and under-recognition of CR benefits have long been issues for the sub-specialty, our survey of oncologists in a major cancer center with limited CR suggests that many value what CR can offer. This may be due to growth in the literature, as well as increasing recognition among the oncology community about CR’s potential benefits (19).

Future directions and research looking at oncology input into development of a CR program include a multicenter survey, as this would provide increased numbers of oncology-based feedback, and the observation of rehabilitation needs across several centers would provide more generalizable results. Additionally, a subsequent survey addressing more specific interventions in PM&R such as interventional pain management (20), as well as expanding on areas of patient rehabilitation needs, staffing and clinical and administrative support networks, may help oncologists identify particular needs that a CR program should develop to serve their population. Finally, the addition of services that many other rehabilitation specialists provide – including physical therapy, occupational therapy, speech language pathology, and many more as mentioned in our introduction – would help to further detail not only the importance of particular rehabilitation needs, but also the need of specific rehabilitation disciplines when developing CR programs.

Rehabilitation in the cancer population is an important but underutilized component of cancer care. Despite limited availability of CR, oncologists in our study generally acknowledge the potential of CR in their patients, though exposure and education are lacking with respect to the various benefits of CR at all stages of cancer. Further formalization of CR programs is important in helping patients recover from physical deficits resulting from cancer and/or its treatment, resulting in improved function, quality of life and well-being.