Julie Silver, MD
Assistant Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
Dr Silver is a rehabilitation physician and observed that cancer rehabilitation research is outpacing all other fields of rehabilitation research. She defined the following terms:
- Impairment: what is seen on a physical exam, eg, injured muscle or nerves
- Disability: what the patient can’t do because of the impairment
- Handicap: societal and other prejudices that come along with disability
Dr Silver spoke about rehab and a little about “prehab.” She noted that unlike survivorship care, which may not be covered by insurance, cancer rehab is reimbursable (like that for a stroke or accident). According to CoC guidelines, accreditation requires offering cancer rehab services right now (not in 2015), and there are national mandates for offering real cancer rehab services. It is not acceptable to tell survivors to accept more pain and disability than they have to. Their insurance has to cover these rehab services. Survivors are vocal and will mention where they are being treated and how they feel about not being offered rehab. They are not happy to accept disability as the “new normal.” Rehab is not a posttreatment service, it is medical treatment. In a study of patients with breast cancer, physical performance and activity level are the only 2 things that correlate with quality of life in these patients.
Rehab includes occupational therapy, physical therapy, physiatry, and speech/language therapy, and all of these are reimbursable if performed by trained, licensed, and/or board certified professionals. Exercise classes are important but are not “real” rehab. She presented case studies to illustrate the use of rehab in patient care. She also made the point that palliative care is not the same as rehab. She presented evidence that 60% to 95% of patients should be referred for cancer rehab based on the presence of impairments. Although rehab may not remove impairments, it will be associated with improvements. Although most patients with breast cancer may have lymphedema, it is not their only problem. Other problems that rehab should address include chemo therapy-induced peripheral neuropathy, cancerrelated fatigue, chemo brain, and cognitive impairment.
Dr Silver recommended keeping the future of accountable care in mind. Accountable care means standardized training, implementing protocols, then tracking outcomes. Prehabilitation is the precursor to rehabilitation and includes evaluations and interventions that are designed to obtain a baseline status and improve pain or functional limitations prior to beginning oncology treatments. Examples include smoking cessation, alcohol reduction or cessation, nutrition, a supervised exercise program, and other services. She also discussed strategies to relieve psychosocial symptoms and distress. She concluded by saying that cancer rehabilitation is the next frontier in survivorship care.
