Surviving cancer takes more than surgery, chemotherapy, and radiation. It takes rehabilitation, and ideally, include prehabilitation, according to Julie Silver, MD, an associate professor at Harvard Medical School.1,2 Silver learned about the importance of oncology prehabilitation and rehabilitation the hard way—by having cancer herself in 2003. Recovering from grueling treatment for breast cancer at 38 years old, she was surprised at how ill she was. There was no aftercare in place, and with no mention of cancer rehabilitation she really struggled to recover and go back to work. She said, “I did some exercise testing, and I tested out as a woman in her 60s. So I had aged three decades in a matter of months through cancer treatment.”3
BUILDING A STAR PROGRAM
Silver realized there was a sizeable gap in oncology services available to patients. Utilizing her training as a physiatrist, a physician specializing in nonoperative treatment of musculoskeletal problems, she initiated a program of prehabilitation before cancer treatment as well as rehabilitation therapy after treatment. Launched in 2009, STAR Program (Survivorship Training and Rehabilitation) certified rehabilitation is offered by many facilities throughout the United States. Cancer rehabilitation addresses the findings of the 2010 National Health Interview Survey. The survey results demonstrated that many of the health-related quality-of-life (HRQOL) difficulties experienced by cancer survivors are physical.4 In that study, investigators evaluated 1,822 cancer survivors and 24,804 persons who had never received a cancer diagnosis.4 Although almost 25% of survivors reported being in poor physical health, only 10.2% of those with no history of cancer said their health was poor.4 When asked about mental health, 10.1% of survivors reported being in poor mental health, while only 5.9% of persons who had no cancer diagnosis said their mental health was poor.4 Silver noted that there is often a significant overlap between the physical and psychological components of distress experienced by cancer survivors, creating a real need for rehabilitation that is rarely delivered.1,2
THE NUMBERS ARE ASTONISHING
In a study of 163 women with metastatic breast cancer, more than 90% of the participants needed rehabilitation after their cancer treatments.5 However, fewer than 30% of them actually received it.5 Many similar studies show that cancer survivors continue to suffer for many reasons after their treatment ends, and this leads to further problems. As Silver wrote, “A leading cause, or perhaps even the leading cause, of emotional distress in cancer survivors is physical disability.”1 Study after study finds patients experiencing psychological distress that is disproportionate to their cancer diagnosis or physical state.
The physiatrist provides multidisciplinary care that addresses the physical, vocational, and rehabilitation needs of a cancer patient. Patients’ actual functionality should be assessed, not simply their quality of life. Activities of daily living are, of course, important. However, they require a low level of functionality, and most survivors can accomplish them quite readily. Silver recommends rehabilitation focus on the impairments that affect other activities. For example, can the patient use her arm well enough to handle a car or use public transportation? Can the patient eat in a normal manner so he can each lunch in a public place without being embarrassed?
If the patient cannot perform tasks beyond basic activities of daily living, physical, occupational, and speech rehabilitative therapies plus targeted exercise programs are essential. The STAR Program helps hospitals and other health care facilities develop cancer rehabilitation service lines that coordinate care among diverse providers. The programs are specific for each person’s cancer. The therapist identifies the problem, sets realistic goals for the patient, and then applies specific modalities to treat the impairment.