The Status of Cancer Rehabilitation in the Late 1990s
1999; Elsevier BV; Volume: 74; Issue: 9 Linguagem: Inglês
10.4065/74.9.939
ISSN1942-5546
Autores Tópico(s)Cancer Treatment and Pharmacology
ResumoA quarter of a century ago, in the early days of Nixon's War on Cancer, the National Cancer Institute provided seminal funding for several cancer rehabilitation programs scattered across the country. These efforts documented the wide array of rehabilitation needs of cancer patients,1Lehmann JF DeLisa JA Warren CG deLateur BJ Bryant PL Nicholson CG Cancer rehabilitation: assessment of need, development, and evaluation of a model of care.Arch Phys Med Rehabil. 1978; 59: 410-419PubMed Google Scholar the failure of medical personnel to recognize these needs,2Habeck RV Blandford KK Sacks R et al.WCCC Cancer Rehabilitation and Continuing Care Needs Assessment Study Report. Wisconsin Clinical Cancer Center, Cancer Control Program, Madison1981Google Scholar and the feasibility of rehabilitation interventions for cancer patients.3Gordon WA Freidenbergs I Diller L et al.Efficacy of psychosocial intervention with cancer patients.J Consult Clin Psychol. 1980; 48: 743-759Crossref PubMed Scopus (141) Google Scholar By the early 1980s, a variety of models for delivery of cancer rehabilitation services had been identified.4Harvey RF Jellinek HM Habeck RV Cancer rehabilitation; an analysis of 36 program approaches.JAMA. 1982; 247: 2127-2131Crossref PubMed Scopus (42) Google Scholar Even though the survival rate from cancer was significantly poorer then than today, rehabilitation services were viewed as an important component of cancer care. Early work in cancer rehabilitation often focused on the problems of acutely hospitalized patients who frequently underwent physically disabling surgical procedures. Current perspectives on cancer rehabilitation see it as a field concerned with many broad areas of human function, including physical, psychological, social, and vocational activities. As suggested by Cullen,5Cullen JR Cancer rehabilitation in the 1980's.in: Cancer Rehabilitation: Proceedings of the Western States Conference on Cancer Rehabilitation. Bull Publishing Co, Palo Alto, Calif1982: 1-3Google Scholar the major goal of contemporary cancer rehabilitation is to help each patient achieve maximum function in all of these areas within the limitations imposed by the disease or its treatment. Furthermore, Melierte6Mellette S. Role of cancer rehabilitation. Workshop presentation at: National Cancer Institute; September 11, 1987; Bcthesda, Md.Google Scholar has suggested that “cancer rehabilitation is the process aimed at prevention of the physical and psychosocial dysfunction which may result from the disease or its treatment.” As part of this process, clinicians must anticipate sequelae and initiate preventive interventions. Since the early 1980s the treatment of cancer has increased in complexity leading to new kinds of rehabilitation problems. Surgical procedures are often less extensive than in preceding decades (eg, radical mastectomy vs modified radical mastectomy vs segmental mastectomy with radiation); however, to limit the extent of surgery, the patient receives adjunctive chemotherapy and/or radiation therapy, which increases both the duration and toxic effects of treatment. Multimodal therapy, combining 2 or 3 treatment approaches, is now standard for many curable cancers. The rehabilitation and recovery process is prolonged for these intensively treated patients compared with earlier times when surgery was the sole form of treatment. Primary treatment frequently extends from 6 months to a year, and the combined adverse effects of multimodal therapy can affect all areas of function (physical, psychosocial, vocational, and economic). Therefore, rehabilitation programs for cancer patients must address all of these potential problem areas. Who is a candidate for cancer rehabilitation services? Today, advances in detection, diagnosis, and treatment have increased survival for many individuals diagnosed as having cancer, with more than half of all patients with newly diagnosed cancers expected to survive for more than 5 years. Most patients with early-stage cancer can anticipate a normal life span. However, sequelae from cancer treatments can impair functioning even in these long-term survivors.7Schag CA Ganz PA Wing DS Sim MS Lee JJ Quality of life in adult survivors of lung, colon and prostate cancer.Qual Life Res. 1994; 3: 127-141Crossref PubMed Scopus (267) Google Scholar, 8Schag CA Ganz PA Polinsky ML Fred C Hirji K Petersen L Characteristics of women at risk for psychosocial distress in the year after breast cancer.J Clin Oncol. 1993; 11: 783-793PubMed Google Scholar Other patients live with active cancer for many years, with symptomatic problems controlled by surgery, hormone treatment, chemotherapy, or radiation therapy; for these individuals, cancer is truly a chronic disease. For individuals with advanced cancer at the time of diagnosis, pain and functional impairment are common presenting problems that are direct results of the disease. Attention to the functional and rehabilitation problems of cancer patients is important at any point in the disease continuum, with the goal of maximizing functional performance and quality of life. In this issue of Mayo Clinic Proceedings, Sabers et al9Sabers SR Kokal JE Girardi JC et al.Evaluation of consultation-based rehabilitation for cancer patients with functional impairment.Mayo Clin Proc. 1999; 74: 855-861Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar describe their experience evaluating the rehabilitation outcomes for almost 300 hospitalized patients referred to the Cancer Adaptation Team (interdisciplinary rehabilitation services) over an 8-month period. Functional status at enrollment and discharge was evaluated with observer-rated scales of functional performance. An attempt to gather quality-of-life outcome data from these patients was hampered by poor compliance (only 17% of forms were completed, and few by the patients themselves) as well as the use of a nonstandard questionnaire. This observational, nonrandomized study has some important limitations: the use of observer-rated scales that focus on physical functioning only, evaluation of outcome performed by the intervention team rather than by an unbiased observer, and a high rate of unevaluable patients due to their early discharge. In addition, this was a very disabled population of patients (mean ± SD Karnofsky Performance Status score was 34±13); thus, it is unclear how generalizable these results would be for patients with higher performance scores and less disability. Quality-of-life data might have been valuable in this study population, since measurement of this construct with a multidimensional instrument could have shed light on improvements in emotional and social well-being, as well as the physical dimension targeted by these investigators. The authors are mistaken in their statement that “no current instrument met all criteria for an ideal measure of quality of life in the cancer population. “Currently, many well-validated quality-of-life instruments are available to assess cancer patients.10Ganz PA Quality of life measures in cancer chemotherapy: methodology and implications.Pharmacoeconomics. 1994; 5: 376-388Crossref PubMed Scopus (13) Google Scholar, 11Cella DF Bonomi AE Measuring quality of life: 1995 update.Oncology (Huntingt). 1995; 9: 47-60PubMed Google Scholar However, as noted by the authors, self-administration of questionnaires is often difficult in severely ill, hospitalized patients. Under these circumstances, proxy ratings may be used, but they may also have some biases.12Sprangers MA Aaronson NK The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease: a review.J Clin Epidemiol. 1992; 45: 743-760Abstract Full Text PDF PubMed Scopus (680) Google Scholar Nevertheless, the authors should be commended for their attempt at programmatic evaluation of the Cancer Adaptation Team. This is an important first step that should be followed up with a more rigorous experimental design, including a comparison group, as well as evaluation of patient outcome by observers not involved in the clinical intervention. Use of the Cancer Adaptation Team approach in less disabled patients (eg, outpatients or patients with newly diagnosed cancer receiving surgery), as well as collection of data on longer-term outcomes (eg, return to work, less need for assistance), will be important for the medical and economic justification of this program. It is unfortunate that the rehabilitation community has largely abandoned its focus on the cancer patient since the early days of the National Cancer Act. The study by Sabers et al,9Sabers SR Kokal JE Girardi JC et al.Evaluation of consultation-based rehabilitation for cancer patients with functional impairment.Mayo Clin Proc. 1999; 74: 855-861Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar as well as a few others,13Yoshioka H Rehabilitation for the terminal cancer patient.Am J Phys Med Rehabil. 1994; 73: 199-206Crossref PubMed Scopus (118) Google Scholar, 14Marciniak CM Sliwa JA Spill G Heinemann AW Semik PE Functional outcome following rehabilitation of the cancer patient.Arch Phys MedRehabil. 1996; 77: 54-57Abstract Full Text PDF PubMed Scopus (131) Google Scholar suggests resurgence of interest in this area of research. Many tools are available to evaluate quality of life and rehabilitation outcomes in cancer patients, and these can be useful in rehabilitation program evaluation. Much work in geriatric assessment has emphasized improvement in functioning,15Siu AL Kravitz RL Kecler E et al.Postdischarge geriatric assessment of hospitalized frail elderly patients.Arch Intern Med. 1996; 156: 76-81Crossref PubMed Google Scholar and these efforts could be used as a model for the design of future studies in cancer rehabilitation. Well-designed controlled clinical trials are needed to reinvigorate this component of cancer care, as well as to evaluate the impact of this clinical care activity on patient outcomes. Evaluation of Consultation-Based Rehabilitation for Hospitalized Cancer Patients With Functional ImpairmentMayo Clinic ProceedingsVol. 74Issue 9PreviewTo evaluate prospectively the effect of consultation-based interdisciplinary rehabilitation in hospitalized cancer patients. Full-Text PDF
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