Does rehabilitation have a place in oncology management?

Robert P. Cole1 and Salvatore J. Scialla2

1Allied Services Rehabilitation Hospital; 2Hematology and Oncology Associates of Northeastern PA, Scranton, PA, USA

During the past 20 years, the treatment of cancer has evolved. Current surgical procedures are often less extensive than those used previously, and are frequently combined with adjuvant chemotherapy and radiation treatment. Indeed, the use of multiple cytotoxic treatments has become commonplace in the treatment of many cancers. This more prevalent use of multiple cytotoxic management strategies has prolonged the primary treatment period and increased the toxic effects of treatment. Ultimately, these advances in treatment along with improved detection and diagnosis have been a boon for cancer patients. As we move into the 21st century, individuals diagnosed with cancer are living longer than ever before. Approximately 60% of patients newly diagnosed with cancer are expected to survive more than 5 years [1]. Proximally, however, the effects of cancer itself, along with longer, more toxic treatment, can adversely effect all areas of function (physical, cognitive, social, vocational and economic).

The physical and psychosocial impairments encountered by cancer patients are numerous [2, 3]. Physically, impairments of the nervous system, musculoskeletal system and internal organs are common consequences of cancer and its management. Psychosocially, depression and anxiety are frequently encountered. Asthenia, a chronic, pathological fatigue, is the most common problem reported by cancer patients [4]. These impairments, either singly or collectively, may diminish function and quality of life (QOL). Despite the prevalence of functional impairment in cancer patients, rehabilitation is not a common component of cancer treatment throughout most of the world.

One factor contributing to rehabilitation’s lack of favor in the medical management of cancer may be the relative scarcity of quantitative research examining its efficacy. Although several recent reports have documented functional improvement in cancer patients following treatment in a comprehensive, multidisciplinary, physician-led rehabilitation program [57], such reports are relatively uncommon in the oncology literature. Given the increased survival rates for individuals diagnosed with cancer, increased emphasis on the maintenance of function and QOL are paramount. To that end, examinations of the effectiveness of rehabilitation in promoting function and QOL in individuals with cancer are necessary.

In this issue of Annals of Oncology, Hensel et al. report the results of an examination of long-term QOL variables (e.g. physical, cognitive, social function, profession reintegration) in over 300 patients following autologous stem cell transplantation (ASCT) [8]. Special emphasis is placed on the relationship between post-transplant rehabilitation and the QOL variables examined. The authors ultimately conclude that there are no differences in QOL and profession reintegration between those receiving and those not receiving rehabilitation. This retrospective study had several notable limitations. Importantly, there is no pre-rehabilitation measure of QOL. The reported lack of differences in the study’s outcome variables could suggest that rehabilitation did not impact long-term QOL. On the other hand, the null result could represent lower pre-rehabilitation QOL in those patients receiving rehabilitation relative to those who did not receive rehabilitation. Owing to the use of a retrospective design and the lack of a baseline measure of QOL, it is difficult to evaluate the lack of differences in QOL variables.

A related issue is the study’s lack of an objective (e.g. physician’s) determination of a patient’s disability and rehabilitation potential. Candidates for ASCT are typically screened so that only those patients with the best performance status are selected for transplant. Typically, the chosen candidates have few other debilities or co-morbidities. In this study, long-term survivors were examined, many of which were employed prior to ASCT. Both of these factors indicate that the study’s patients were relatively high functioning prior to ASCT. The patients may have suffered only from temporary toxicity and weakness from treatment, and experienced full physical recovery. It would have been interesting to note if patients receiving and not receiving rehabilitation services differed with respect to a physician’s evaluation of disability. This, and the aforementioned QOL baseline, would have been invaluable in evaluating the current QOL and profession reintegration data.

Another important shortcoming of the study is that the rehabilitation treatments evaluated are not specified. The authors state that no standard program of rehabilitation was employed, as the observed sample received rehabilitation services at a variety of locations. Without a standardized definition of rehabilitation, possible differences in treatment types and treatment intensity confound the evaluation of rehabilitation and limit the generalization of the results.

Finally, it is important to note the nature of the professional reintegration data. The featured research examines a return to the patient’s previous occupation following ASCT. Cancer type and treatment type may influence or preclude a patient’s return to their previous occupation. However, a patient unable to return to a previous occupation may still be gainfully employed. Future investigations of professional reintegration should consider both a patient’s return to a prior occupation and a return to any occupation.

Despite the aforementioned points, the authors should be commended for their investigation of cancer rehabilitation and long-term QOL in cancer patients. They acknowledge several of the shortcomings of the current retrospective study and allude to a future prospective study that would address some of the concerns outlined above. As survival rates for individuals with cancer continue to increase, it is important that future research evaluate the role of rehabilitation in cancer treatment and how it impacts both short- and long-term QOL. As previously noted, rehabilitation is not a common component of oncology management. However, several studies published in the last 5 years have examined the benefit of rehabilitation as a part of the medical management of the cancer patient [57]. Ideally, these studies would serve as seeds for more rigorous examinations of the impact of rehabilitation as a component of cancer treatment. There is a need for randomized prospective trials that examine how rehabilitation impacts short- and long-term function and QOL across a wide variety of cancer diagnoses and functional impairment levels.

Robert P. Cole1 and Salvatore J. Scialla2

1Allied Services Rehabilitation Hospital; 2Hematology and Oncology Associates of Northeastern PA, Scranton, PA, USA

References

1. American Cancer Society Home Page. [On-line.] http://www3.cancer.org (October 2001, date last accessed).

2. Loescher LJ, Welch-McCaffery D, Leigh SA et al. Surviving adult cancers. Part 1: physiologic effects. Ann Intern Med 1989; 3: 411–429.

3. Welch-McCaffery D, Hoffman B, Leigh SA et al. Surviving adult cancers. Part 2: phychosocial implications. Ann Intern Med 1989; 3: 517–524.

4. Theologides A. Ashtenia in cancer. Am J Med 1982; 73: 1–3.

5. Cole RP, Scialla SJ, Bednarz L. Functional recovery in cancer rehabilitation. Arch Phys Med Rehabil 2000; 81: 623–627.[ISI][Medline]

6. Sabers SR, Kokal JE, Girardi JC et al. Evaluation of consultation-based rehabilitation for hospitalized cancer patients with functional impairment. Mayo Clin Proc 1999; 74: 855–861.[ISI][Medline]

7. Marciniak CM, James JA, Spill G, Heinemann AW. Functional outcome following rehabilitation of the cancer patient. Arch Phys Med Rehabil 1996; 77: 54–57.[ISI][Medline]

8. Hensel M, Egerer G, Schneeweiss A et al. Quality of life and rehabilitation in social and professional life after autologous stem cell transplantation. Ann Oncol 2002; 13: 209–217.[Abstract/Free Full Text]





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