Cancer treatment is a constantly evolving challenge to deliver the right treatment at the right time to rid a patient of cancer. Treatment involves a process that is coordinated by a team of oncologists and other oncology providers to ensure that treatment modalities are as effective as prescribed. Cancer rehabilitation is also a process, which ideally is coordinated and monitored by a board-certified physician, trained in physical medicine and rehabilitation.
Together, the patient’s primary oncologist and the cancer rehabilitation physician (or physiatrist) work to ensure that cancer survivors maintain the highest possible level of function and quality of life.
Cancer rehabilitation is most effective when coordination between the oncology team and the cancer rehabilitation doctors starts early. Physiatrists have a comprehensive understanding of the predictable side effects of treatment and the changes that will likely occur over time.
How Will Cancer Rehabilitation Help Me?
“Very few people go through cancer treatment and come out completely unscathed,” Michael D. Stubblefield, MD, Medical Director for Cancer Rehabilitation, Kessler Institute for Cancer Rehabilitation, and Clinical Professor of Rehabilitation Medicine, Rutgers University, and National Medical Director, ReVital Cancer Rehabilitation, New Jersey, and author of Cancer Rehabilitation, Principles and Practice, said in an interview.
“The field of rehabilitation is about identifying issues you have now, so we can better predict the impacts of your treatment. Then, we continue to evaluate you at regular intervals throughout your treatment. We know what to look for at every stage in the process,” Dr. Stubblefield said. “If these things start developing, we find them early. When we start early, we are much more effective at resolving them, and we take less of your time,” he added.
“The cancer rehabilitation physician is taking care of the whole patient,” Dr. Stubblefield explained, which enables the oncologists to focus on eliminating the cancer. “Because there are so many cancer sites, and numerous complications associated with the various treatment modalities, an oncologist may not know what to watch for, or when or where to send patients when impairments start to develop,” he pointed out.
The physiatrist supports the oncology team by identifying the physical impairments that are most likely to arise, and initiating a rehabilitation program tailored to the patient’s specific needs. The physiatrist may order imaging tests such as MRIs or PET scans to identify the cause of pain and functional impairments, and to guide the design of a comprehensive, individualized cancer rehabilitation plan.
This may include pain management with medications and injections, referrals to nutritionists or to psychosocial services, and prescribing and monitoring therapy with cancer-trained physical therapists, occupational therapists, and speech and language therapists (see Figure).
“It’s a culture change,” Dr. Stubblefield said. “Survivorship issues and oncology are separate things. There is an overlap, but they are very different in focus. Cancer rehabilitation promotes quality of life despite the patient’s quantity of life.”
Managing Cancer-Related Physical Impairment
“Early detection and intervention are key to optimal functional outcomes, and improved quality of life,” Dr. Stubblefield emphasized. Ongoing surveillance by the cancer rehabilitation team also enables therapists to detect early signs of recurrence, which are rare.
“We focus on taking care of emerging functional issues,” he said, regardless of whether physical impairments surface during treatment, or years after treatment ends.
“Cancer rehabilitation therapists, when trained properly, systematically identify the issues that come along with certain courses of cancer treatment. They know what the issues are, and they know how to screen for them,” he explained. “Cancer rehabilitation therapists are extremely effective at restoring functional loss, because they understand the factors that caused it.”
Exercise is one of several modalities that cancer rehabilitation therapists use, but the activities that people usually identify as exercise, such as walking on a treadmill or resistance training, are a small part of the therapists’ repertoire.
To restore functional loss, cancer rehabilitation physical therapists may use stretches to prevent deficits in range of motion; engage in posture and balance training for fall prevention and complications from peripheral neuropathy; and perform manual interventions, such as myofascial work for radiation fibrosis, and treatments for swelling or scar mobilizations.
For example, common physical impairments from breast cancer treatment include shoulder dysfunction, chemotherapy–induced peripheral neuropathy, aromatase inhibitor-induced joint pain, chronic tendon inflammation, axillary cording, and lymphedema, all of which may develop during cancer treatment, or during long-term survivorship.
Similarly, patients with head-and-neck cancer may experience physical impairments during cancer treatment or over time, including carotid artery stenosis, dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and trismus (reduced mouth opening). All these complications are addressed by the cancer rehabilitation physiatrist and the team of the rehabilitation therapists.
A Well-Kept Secret
Research has shown that cancer rehabilitation services can help in the management of pain, reduce fatigue, reduce visits to the emergency department, reduce complications from lymphedema, and improve the likelihood of survivors returning to work.1
The bottom line, Dr. Stubblefield said, is improving the quality of life for each cancer survivor to the greatest extent possible, throughout survivorship.
“When I talk to survivors, what I hear is, ‘You have treatments for this?’ They are astonished, because nobody ever talked to them about the options. They just thought they had to live with (the impairments). There are options, but not everywhere, not yet,” Dr. Stubblefield said. His mission is to change that.
- Stubblefield MD, Kendig TD, Khanna A. ReVitalizing cancer survivors—making cancer rehabilitation the standard of care. MD Advis. 2019;12:30-33.
Q&A with Physiatrist Sara C. Parke, MD
Sara C. Parke, MD, is a board-certified physician in Physical Medicine and Rehabilitation at the Department of Physical Medicine and Rehabilitation at the Mayo Clinic in Arizona.
“My role here at the Mayo Clinic is multifaceted,” Dr. Parke explained. “I diagnose problems that may be limiting my patient’s overall function, coordinate care among the core rehabilitation care team, and consult with the patient’s primary oncologist and other physicians to ensure patient safety as we work toward their functional goals.”
Answering questions about the breadth and reach of cancer rehabilitation is a large part of Dr. Parke’s responsibilities. She is one of the leaders in a wave of young physicians who are changing the status quo.
Currently, only 9% of survivors who could benefit from cancer rehabilitation services receive them,1 but cancer rehabilitation providers like Dr. Parke are working hard to improve access to these services. Dr. Parke provided answers to some common questions she gets from patients with cancer and from oncology providers.
Q: “My treatment was several years ago, but I still have poor balance, and pain and tightness in places. After so long, can cancer rehabilitation really reduce my symptoms?”
Dr. Parke: “It’s common to have these problems after cancer treatment, and many of them can be improved with the right diagnosis and treatment. Your cancer rehabilitation provider typically would start with a comprehensive history, perform a detailed physical exam, discuss your overall goals, and then order any diagnostic testing needed to determine the best way to treat these concerns. Sometimes, treatment includes medication, injections, or physical therapy, among others. The role of the cancer rehabilitation physician is to diagnose the cause of your ailment, design a treatment plan, and then monitor your progress over time.”
Q: “I don’t exercise, because when I do, I have pain in my knees and back. I take medicine for hypertension. What would you suggest for me?”
Dr. Parke: “Our goal is to design a rehabilitation program to help you improve functionally within the context of your limitations. Your cancer rehabilitation provider would do their best to accurately diagnose your knee and back problems, and treat them effectively, possibly with a combination of medications, injections, therapy, and other modalities. Your rehabilitation providers would also coordinate care with your other physicians to make sure that your blood pressure is taken into consideration when designing your rehabilitation program.”
Q: “I joke about ‘chemo-brain’ and having trouble remembering things, but I am afraid to go back to work feeling this way. Can rehabilitation address chemo-brain?”
Dr. Parke: “Yes, there are treatment options for ‘chemo-brain,’ but first it is important to rule out other causes of memory loss, such as brain injury from primary tumor, metastatic disease, vascular problems, nutritional issues, medical concerns such as obstructive sleep apnea, and psychological changes such as depression, among others. Often ‘chemo-brain’ is secondary to fatigue, so treatment may start with energy conservation strategies, nutrition and exercise recommendations, and medications to address fatigue. Again, your cancer rehabilitation provider could help diagnose and treat the cause of your concern.”
Q: “I want to be more active. There is a Silver Sneakers program in a gym near me. Should I start there?”
Dr. Parke: “Your cancer rehabilitation provider would take a comprehensive history and perform a physical exam to determine if you are safe to participate in an unsupervised exercise program such as Silver Sneakers. For many survivors, a supervised exercise program is a better option, at least initially. However, some cancer survivors do very well in unsupervised programs.
For those who would benefit from supervision, your rehabilitation provider may recommend a session with a cancer-trained exercise physiologist or physical therapist to provide you with an exercise program that you can perform safely—typically insurance will cover these appointments, but you may need to have a prescription from your doctor.”
Q: “When should I ask to see a physiatrist like you?”
Dr. Parke: “Ideally, if you have just been diagnosed with cancer and are planning to undergo treatments such as chemotherapy, radiation, or surgery, a cancer rehabilitation physician can develop a prehab plan to prepare you to maintain or improve your function prior to treatment. This type of care is also often referred to as ‘prospective surveillance,’ which means that your rehabilitation provider will follow your case over time and help you with any functional concerns that arise during or after treatment. If you are already getting treatment and have side effects that limit your comfort or function, or if you have completed treatment and have residual limitations or functional concerns, rehabilitation providers can also help. There is no issue that is too small if it is impacting your quality of life.”
Q: “Do I need a referral to see a physiatrist? Where do I find cancer rehabilitation therapists? How much of rehabilitation is covered by insurance?”
Dr. Parke: “These answers depend on where you live and your insurance provider. Some states allow patients to self-refer for physical therapy, and others require a doctor’s order. Your insurance provider may also have requirements regarding self-referral or physician referral. Typically, coverage depends on your diagnosis, the severity of impairments, and your goals and preferences. Insurance will usually cover a visit with a physician, that is, a rehabilitation physician who is board-certified in Physical Medicine and Rehabilitation. If you require therapy with an oncology-specific physical, occupational, or speech therapist, your insurance typically will be billed, since this is part of standard care. However, again, this depends on your particular coverage plan and location.”
- Pergolotti M, Alfano CM, Cernich AN, et al. A health services research agenda to fully integrate cancer rehabilitation into oncology care. Cancer. 2019;125:3908-3916.