With goals of maximizing function and improving quality of life, rehabilitation is a key component of cancer care. Cancer and its treatment impact function in patients, with functional loss occurring in a slow, gradual manner that is difficult to detect in its early stages. Asserting that physical function should be treated as a vital sign in patients with cancer, Adrian Cristian, MD, and Joy C. Cohn, PT, discussed the importance of rehabilitation medicine, including prehabilitation, with a focus on managing lymphedema.
Different cancers and their treatments are accompanied by varied impairments, which share the common ground of impeding function and often affecting patients’ ability to work. Although 63.5% of cancer survivors return to work, patients with cancer miss an average of 151 workdays and 26% to 53% of cancer survivors lose their jobs or stop working over a 72-month period after diagnosis. Affecting patients’ ability to work are physical symptoms, poor sleep, daytime fatigue, and decreased job performance.
“That’s where rehabilitation medicine can improve an individual’s ability to return to work,” Dr Cristian said.
Occurring between a cancer diagnosis and the start of treatment, prehabilitation is aimed at reducing the incidence and severity of future impairments and promoting physical and psychological health. It involves establishing patients’ baseline functional level, as well as identifying and treating impairments through nutritional counseling, anxiety reduction, smoking cessation, and exercise.
“Early intervention is key,” Dr Cristian said.
Barriers to rehabilitation include lack of patient and caregiver education about cancer-specific impairments and rehabilitative interventions, along with geographic and insurance-related issues. For some patients, childcare, work obligations, and other life demands get in the way of receiving necessary rehabilitation. Navigators, however, can help topple these barriers through early identification of impairments and by advocating for patients to receive this care, according to Dr Cristian.
As cancer-related impairments vary by cancer site, identification of these impairments varies accordingly. The presenters offered recommendations on areas to examine in patients, depending on their cancer type. For head and neck cancers, navigators should focus on swallowing, opening the mouth, neck swelling, and shoulder problems, along with weight loss. For breast cancer, the focus should be on shoulder pain and restriction of movement, arm swelling, hand pain, nerve-related symptoms, memory loss, spine pain, and weight gain. Gastrointestinal, genitourinary, and gynecologic cancer call for identification of incontinence, sexual dysfunction, leg swelling, nerve pain, impaired balance, and weakness, and decreased use of hands. For lung cancer, shortness of breath, nerve pain, balance issues, spine pain, and memory loss are significant issues. In brain and spine cancer, navigators should watch for weakness in limbs, balance issues, memory loss, impaired attention, and incontinence. Hematologic malignancies should be monitored for spine and nerve pain. In all cases, the impact of symptoms on work and social roles should be evaluated, the presenters advised.
In determining whom to refer for rehabilitation, navigators should identify those who cannot raise their arm overhead, stand on one leg for 10 seconds, or get up out of a chair 10 times in 30 seconds. Others to refer include patients who would benefit from a clinical trial but are considered too frail to participate, and all patients with stage IV cancer.
Lymphedema
Playing an important role in overall health, the lymphatic system recycles proteins, drains the interstitial space, conducts immune surveillance, and transports digested fats. Often caused by cancer and its treatment, secondary lymphedema has the greatest incidence in patients with head and neck cancers, reaching 75%, although it can occur in cancers of any type. Risk factors include nodal dissections, radiation to nodal regions, obesity, extensive surgeries, and preexisting venous disease in lower extremities.
“Differential diagnosis is really a key for me when a patient comes in with edema,” Ms Cohn said. “Lymphedema is only one of many things it could be.”
Occurring in 4 stages, lymphedema comes with symptoms that include numbness, tightness, stiffness, pain consisting of aching or heaviness, infection, redness, heat, and the signature swelling. Malignant lymphedema can be the first sign of cancer recurrence, and is characterized by rapid onset, significant edema, among other signs. In such cases, clinicians must ask for input from the oncology team before treatment.
“This may represent a recurrence,” she advised, adding, “The gold standard here in the United States is complete decongestive therapy.”
This consists of manual lymphatic drainage, multilayer compression bandaging, exercise, and meticulous skin care in the intensive phase, along with garment wear, compression at night, and exercise in the maintenance phase.
Key Points
- Early intervention is key
- Navigators can help topple barriers to rehabilitation through early identification of impairments and by advocating for patients to receive this care
- In determining whom to refer for rehabilitation, navigators should identify those who cannot raise their arm overhead, stand on one leg for 10 seconds or get up out of a chair 10 times in 30 seconds
