There are nearly 14.5 million cancer survivors in the United States, and each year more than 1 million people join this population. Unfortunately, most cancer patients are not adequately prepared for the considerable changes they face in their daily lives, which they often refer to as their new normal. 1 These challenges may include pain, depression, lymphedema, swallowing difficulties, neuropathy, reduced range of motion, weakness, and cancer-related fatigue.2

Cancer prehabilitation identifies a patient’s physical and psychological deficits prior to beginning cancer treatment. Identifying these deficits allows for the use of targeted interventions to help decrease future impairments. Such interventions, therefore, can help decrease readmission rates, length of hospital stays, and direct and indirect healthcare costs.3 Cancer rehabilitation — occurring during and after treatment — is therapy for the deficits that occur as a result of treatment. Rehabilitation is defined as “an effort to maintain or restore function, reduce symptom burden, maximize independence, and improve quality of life [QOL] in this medically complex population.”4 Rehabilitation can occur during treatment, shortly after it, or even years later.2 Oncology rehabilitation programs use a multidisciplinary approach to assess each survivor and provide evidence-based therapies to address and decrease short- and long-term impairments related to cancer and its treatments, while working to improve survivors’ level of disability.5

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Local Needs Assessment

Unfortunately, although “functional problems are prevalent among outpatients with cancer, [they] are rarely documented by oncology clinicians.”6 This finding is congruent with what was happening at our project’s setting: a rural oncology clinic in northern Michigan. Many clinic patients were experiencing treatment toxicities, but few were being referred to the oncology rehabilitation program adjacent to the clinic. The researchers hypothesized that increasing referrals to the oncology rehabilitation program could help reduce this gap in care.


The purpose of this quality improvement project was to implement an evidence-based staff education program about the need to refer patients to the oncology rehabilitation program. The goals were to improve clinic staff knowledge about an oncology rehabilitation program and to increase patient referrals for treatment- or cancer-related toxicities or impairments.

A chart review was conducted to document and compare the referral rates during the 3 months before and after the education program. The oncology clinic staff took pretests and posttests to document their oncology rehabilitation knowledge before and after participating in the education program.

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Literature Review

A literature search of several databases was conducted: PubMed, CINAHL, Up-to-Date, and Medline. The search date range was 2000 to present using the following keywords: oncology rehabilitation, cancer rehabilitation, cancer care, and survivorship rehabilitation.

Economic Burden

Cancer-related healthcare costs — including costs related to treatment and treatment-related impairments — are expected to reach $155.77 billion by 2018. This amount does not reflect indirect costs such as lost wages, caregiver burden, transportation, and adaptive equipment. In addition, cancer survivors are at increased risk for unemployment and early retirement, and are less likely to be re-employed.7 One study showed that 26% to 53% of survivors lost or quit their jobs in the 72 months post treatment.7 In some cases, survivors’ precancer employment was physically demanding, and they were no longer able to meet these job requirements.8 Cancer site, clinical prognosis, treatment modality, socioeconomic status, and the job itself are factors that affect survivors’ ability to return to work. In 1960, the 5-year breast cancer survival rate was 63%; today it is 90%. This significant increase in the survival rate means that there could be a larger number of unemployed breast cancer survivors.9 Silver and Gilchrist noted that 26.5% of the population treated for head and neck cancers drive less or not at all after treatment, a fact that could reduce their employability.10