THE NEXT EVOLUTION: HIGH-QUALITY CANCER PREHABILITATION CARE
Health care in the United States is constantly evolving and is very much focused on translating the evidence base that supports distinct interventions at specific times into clinical care. The translation of research into clinical care, however, is not enough. More and more, hospitals and individual clinicians are becoming responsible for reporting clinical outcomes and demonstrating that the care they provide is not only the standard of care, but also high-quality care. The bar has been raised, and what used to pass for good care is no longer good enough. Indeed, with the release of the Institute of Medicine’s 2013 report “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” every hospital and cancer center in the United States was given the undeniable message to step it up.3 With the focus squarely on improving every aspect of oncology care, offering evidence-based prehabilitation care by well-trained nurses who are tracking and reporting outcomes makes sense. After all, prehabilitation can impact outcomes including health-related quality of life, return to work, and physical function. As people begin to understand the role of prehabilitation in improving outcomes, there will be an increasing demand for these services—by doctors and patients alike.
Trained rehabilitation specialists, such as physiatrists and physical, occupational, and speech therapists, treat existing physical impairments in cancer survivors, and although nurses with specific training may work within the auspices of skilled care in rehabilitation settings, the typical oncology nurse would not provide rehabilitation care. For example, a patient with newly diagnosed breast cancer presents with a painful shoulder when she lifts her arm overhead would be referred to a physiatrist or orthopedist who can determine whether further diagnostic testing is warranted (eg, an MRI), make a diagnosis (eg, rotator cuff impingement or adhesive capsulitis), and decide on the next steps regarding treatment (eg, corticosteroid injection, physical therapy, etc).
In contrast, prehabilitation, technically a part of the rehabilitation care continuum but entails the period of time before cancer treatment begins, provides an opportunity to prevent or limit the development of future impairments. Prehabilitation interventions ideally engage a multimodal and interdisciplinary approach to preparation for cancer treatment by bringing in additional specialists such as mental health professionals, dieticians, nurses, and depending on the patient population, respiratory or other types of therapists. The ideal prehabilitation protocol involves an interdisciplinary team, with each health care professional performing assessments and interventions within his or her area of expertise. However, the reality is that prehabilitation care needs to be streamlined, and nurses with the appropriate training should be able to step in to perform certain early assessments and interventions efficiently and expertly.
Nurses, in particular, are uniquely positioned to participate in and even lead prehabilitation initiatives within their institutions. For example, consider the aforementioned case of newly diagnosed breast cancer. Two recent reviews highlighted an urgent need to better address upper body pain and dysfunction in patients with breast cancer, reporting that upper body impairments occur in up to 50% to 62% of breast cancer survivors.4,5 Undoubtedly, rehabilitation specialists should be involved in the care of these patients from diagnosis onward; however, if a physiatrist or a physical or occupational therapist is not available during a patient visit, a nurse-led prehabilitation protocol for screening shoulder problems could be employed (Figure 2).
(Click on Figure 2 to view at larger size.)
The screening assessment might include a validated patient-report instrument such as the QuickDASH6 and/or a brief physical examination of the upper extremities, range of motion, and other evaluations. The assessment should also include a validated measure of general physical conditioning, such as the 6-Minute Walk Test. If the patient demonstrates a problem during the screening, a referral to a rehabilitation specialist would be made for further evaluation and treatment. If no impairments are identified, the nurse could provide instruction on preoperative shoulder range-of-motion exercises. In this scenario, the patient has now been routed more efficiently through prehabilitation assessments and interventions that research has demonstrated may improve pain and dysfunction outcomes better than pretreatment education alone.7 In addition, the patient’s medical record now includes assessments that can be utilized during postoperative recovery and surveillance phases to facilitate earlier detection of impairments and referral for appropriate interventions.
Similarly, if a mental health specialist was not available during a patient visit, a nurse could conduct distress screening and refer the patient for specific stress reduction techniques, such as meditation or guided imagery. Preventing future impairments in patients with newly diagnosed cancer is something that oncology nurses can and should be trained to do. This may in fact be one of the most important contributions of nurse navigators in improving patient outcomes and the delivery of high-quality care.