Editorial
Cancer Rehabilitation and Prehabilitation May Reduce Disability and Early Retirement Julie K. Silver, MD1,2,3,4
There is no doubt that cancer places an enormous financial burden on individuals and societies throughout the world. Although some patients are symptomatic from their disease at diagnosis, screening tests such as mammography, colonoscopy, and prostate-specific antigen blood studies can detect malignancies even in those who generally feel healthy. Regardless of presentation, therapy protocols frequently include multiple interventions that may be offered sequentially or even simultaneously, increasing both the risk and the severity of treatment-related, short-term and long-term side effects. Therefore, unfortunately, many of these symptomatic and asymptomatic patients then become increasingly ill as they progress through treatment. In the end, it is not only the cancer, but also its treatment, that may cause disability and a subsequent financial burden. In recent reviews that I wrote with colleagues, we demonstrated that cancer prehabilitation1 (assessments and interventions that are conducted in anticipation of an upcoming stressor such as surgery or chemotherapy) and rehabilitation2 can increase function in survivors and may improve employment rates, thereby positively impacting both direct and indirect health care costs.3 Early retirement is an important financial issue that impacts individuals, families, and society, limiting income and depleting accumulated resources. Recent reviews have confirmed that cancer survivors are at a significantly increased risk of early retirement and unemployment.4,5 For example, a 2013 German study by Noeres et al indicated that, 1 year after primary surgery, female breast cancer survivors were nearly 3 times more likely to have discontinued working than their counterparts in the reference group.6 Thus, as efforts to lessen the financial impact associated with cancer continue, it has become necessary to understand the root cause(s) leading to cancer-related disability, inability to work, and resultant early retirement. In cancer survivors, early retirement may be related to physical and/or emotional health. Although the impact of physical issues on employment is typically discernable, mental health issues that interfere with work may be less obvious. Certainly the distress, anxiety, and/or depression often associated with an oncology diagnosis and/or treatment may contribute to early retirement, particularly in vulnerable patient populations like those with comorbid mental health conditions. It is important first to identify individuals who may be at risk for early retirement and then to provide appropriate interventions that support current and future employment. In this issue of Cancer, Singer et al7 report on their investigation into whether a consecutive sample of German oncology inpatients were at higher risk of early retirement if they presented with comorbid mental health disorders than those presenting without psychiatric symptoms. The researchers interviewed and assessed 491 patients (age range, 18-55 years) using the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders to evaluate comorbid mental health disorders. Participants were excluded if they had metastatic disease or if they had already retired from work. Patients who consented to participate in the study were interviewed at the beginning of their hospitalization and were followed for 15 months after baseline. In their study, 150 patients (30.6%) were diagnosed with mental health disorders at baseline; and, during the subsequent 15-month follow-up period, in total, 41 patients (8.4%) retired. Of the participants who had a mental health disorder, 18 (12%) retired. In contrast, of the participants who did not have a comorbid psychiatric diagnosis, only 23 (7%) retired. The researchers observed that the incidence of early retirement was 9.3 per 100 person-years (py) (95% CI, 5.7-
Corresponding author: Julie K. Silver, MD, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA 02115; Fax: (508) 718-4036; julie_silver@hms.harvard.edu I acknowledge and thank Julie A. Poorman, PhD, for her assistance with manuscript preparation. See related original article on pages 000-000, this issue. 1 Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts; 2Spaulding Rehabilitation Hospital Network, Boston, Massachusetts; 3Massachusetts General Hospital, Boston, Massachusetts; 4Brigham and Women’s Hospital, Boston, Massachusetts
DOI: 10.1002/cncr.28713, Received: February 20, 2014; Revised: March 6, 2014; Accepted: March 11, 2014, Published online Month 00, 2014 in Wiley Online Library (wileyonlinelibrary.com)
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14.8 per 100 py) in those with mental health disorders versus 6.1 per 100 py (95% CI, 4.0-9.1 per 100 py) in those without psychiatric diagnoses. Thus, Singer et al concluded that mental health comorbidity is indeed a predictor of early retirement. Moreover, they concluded that patients who had lower incomes were at greater risk of early retirement when they presented with poor mental health than those who had higher incomes. With regard to specific psychiatric diagnoses, Singer et al observed that participants who were diagnosed with anxiety retired more frequently than those who had good mental health; participants with depression were at greater risk of retirement only if they had an income level above the poverty threshold; and participants with adjustment disorders, which was the most frequent diagnosis in cancer survivors, seemed to exhibit no predictable correlation to early retirement. Alcohol dependence was associated with a 3 times increased risk of early retirement, but the researchers believed that this effect could be largely explained by confounding factors, including employment status before the cancer diagnosis. In summary, Singer et al concluded that, whereas the effect differs according to type of psychiatric disorder and income level, mental health conditions are risk factors for early retirement in cancer patients. Although their study focused on the impact of mental health issues, both psychological and physical impairments, either independently or in combination, may reduce a survivor’s ability to function, potentially leading to work-related disability and early retirement. For example, in a recent study of breast cancer survivors, researchers observed that poor physical quality of life was associated with both early retirement and other nonemployment after cancer and that the nonemployed survivors also rated their mental quality of life as lower—experiencing more anxiety and fatigue than other survivors.8 There are many ways in which mental illnesses like depression can influence physical outcomes, and vice versa. Regardless of whether a mental health condition reaches the threshold for a formal diagnosis, it is clear that physical and emotional problems in survivors tend to influence each other—for better or worse. Moreover, several recent studies have demonstrated a clear link between cancerinduced disability and distress, and 1 investigation even went so far as to conclude that the leading cause of distress in cancer survivors was physical disability.9-12 As patients progress through treatment and/or as their cancer advances, they are more likely to develop symptom clusters—combinations of symptoms that are present simultaneously, such as distress, pain, insomnia, 2
anxiety, and fatigue.13 Furthermore, there is substantial evidence to support the finding that symptom clusters have an impact on function and, in fact, that a “sentinel” symptom may predict other symptoms.14 To better understand the impact of cancer-related physical impairments, mental health comorbidity, and disability, consider the hypothetical case of a female software engineer who was diagnosed with early stage breast cancer. For background, note that research has demonstrated that shoulder and arm morbidity is a significant problem, even in early stage breast cancer, that may last for years15; breast and arm symptoms are strongly associated with being on sick leave among breast cancer survivors16; and, early rehabilitation may improve glenohumeral joint mobility, reduce pain, and improve quality of life.17 In this hypothetical case, the patient has completed her acute treatments and is now left with untreated shoulder pain because of rotator cuff impingement on the affected side. Whereas rotator cuff impingement may lead to disability in some workers, especially in those holding jobs that involve repetitive arm motion such as a hair stylist or construction worker, this diagnosis usually would not result in disability for someone, like this patient, who works in an office setting. Yet, when this diagnosis presents in the oncologic setting, there may be a psychoneuromusculoskeletal symptom cluster, with functional limitations and subsequent disability resulting even in those whose daily job duties are not affected by the shoulder pain itself. In this case, shoulder pain has caused the patient to have difficulty falling asleep and/or staying asleep. The patient has now developed considerable anxiety, either because she is worried that her cancer has returned or simply because she cannot sleep comfortably. Reduced ability to function and subsequent disability may be caused by fatigue and poor concentration at work. In fact, insomnia is an excellent predictor of daytime fatigue, and it is well documented that poor sleep has a negative impact on work performance and productivity.18 Not only can poor sleep affect job performance, but even driving to work can be difficult. In a convenience sample of head and neck cancer survivors, self-restricted driving was associated, among other factors, with perceived impaired cognition and cancer-related distress.19 Selfrestricted driving may further increase symptoms of anxiety and depression.20 In addition, there is substantial evidence to suggest that “drowsy driving” is dangerous.21 The diagnosis and rehabilitative treatment of the patient’s shoulder presumably would reduce or eliminate her pain at night and, in turn, would improve her sleep. Daytime fatigue probably would be less problematic, and her Cancer
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ability to concentrate at work would be positively impacted. Simultaneously addressing her anxiety, which may significantly improve once she has less pain and sleeps better, is important. Clearly, this case demonstrates why addressing only the mental health condition—anxiety—may not be as effective as identifying the patient’s cluster of physical and emotional symptoms and recommending treatment that is designed to improve her health and function in a more comprehensive manner. Because cancer patients typically are complex and have a high likelihood of developing physical, mental health, and functional issues, cancer rehabilitation should be seamlessly integrated into the oncology care continuum. In a recent review of impairment-driven cancer rehabilitation, we discussed that a critical first step in the treatment of cancer survivors is screening.2 Although distress screening has received considerable attention, it does not make sense to screen cancer patients only for emotional issues. Instead, it is important to recognize that the disease and its treatments may cause both emotional and physical issues in survivors; therefore, we recommended dual screening for physical and psychological impairments. Furthermore, because it is essential to understand a patient’s baseline health status, we recommended that the first dual screening ideally should occur shortly after diagnosis—postdiagnosis but pretreatment—to help them maintain or return to the highest level of function possible in the coming weeks, months, and years. With such an early understanding of the patient’s physical, psychological, and likely functional impairments, the value of early intervention, or prehabilitation, becomes evident. We have defined prehabilitation as “a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments.”2 Then, in the first ever review on the subject, we discussed how cancer prehabilitation provides an opportunity to obtain baseline assessments and improve outcomes.1 Ideally, cancer prehabilitation immediately follows early dual screening and includes multimodal interventions. For example, in 1 pilot study, a prehabilitation protocol included nutritional counseling with protein supplementation, anxiety reduction, moderate exercise, and an evaluation in patients who were scheduled for colorectal cancer surgery.22 Forty-two consecutive patients were enrolled in that prehabilitation program, Cancer
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and their results were compared with 45 patients who were assessed before the intervention program was offered. The median duration of the prehabilitation protocol was 33 days. Although the postoperative complication rates and hospital lengths of stay were similar for both groups, the prehabilitation group had better postoperative walking capacity both at 4 weeks and at 8 weeks. Moreover, at 8 weeks, 81% of the patients who underwent prehabilitation had recovered compared with only 40% of the control group. Using the time between diagnosis and the beginning of cancer treatment can be advantageous for a survivor’s physical and emotional health outcomes. Although by definition prehabilitation assessments and interventions are performed before the beginning of acute oncology treatment, often these same interventions, such as therapeutic exercise programs, can carry over into the treatment phase, possibly increasing patient comfort and compliance. Indeed, as suggested by the Prospective Surveillance Model for the female breast oncology population that was described in an earlier supplement to Cancer, assessments and interventions may be woven seamlessly into the entire care continuum.23 Obviously, it is important to consider the timing of prehabilitation in relation to acute cancer treatment, because delays in treatment may increase the risk of poor oncologic outcomes. In the United States, prehabilitation interventions (eg, smoking cessation, anxiety reduction, and treatment of physical impairments discovered at screening) may be covered by third-party payors. Rehabilitation interventions also usually are covered by third-party payors, including Medicare, as long as they are provided as “skilled care.” Medicare defines skilled care as the kind of health care received when a patient requires skilled nursing or rehabilitation staff to manage, observe, and evaluate their care; Medicare classifies nursing, physical therapy, occupational therapy, and speech therapy as skilled care.24 Therefore, interventions that can be safely overseen by professionals and are not classified as skilled care (eg, fitness professionals or trainers) or that may be performed independently by the patient without the supervision of designated health care professionals (eg, a health club exercise class) are not considered skilled care and generally are not covered by Medicare or other third-party payors, meaning that exercise that promotes general health and well being is not the same as therapeutic exercise designed to treat physical impairments. Thus, it is important to note that cancer survivors, like survivors of strokes and other serious illnesses and injuries, should be screened first for physical impairments and then prescribed and treated 3
Editorial
with appropriate rehabilitation interventions before they are given recommendations for more general exercise regimens. In the future, cancer prehabilitation and rehabilitation will become increasingly important in the prevention and/or reduction of physical and psychological sequelae that may lead to disability and early retirement in survivors. I predict that research will continue to demonstrate significant support for these interventions and that more oncologists and survivors will insist on this care. The “oncology-rehabilitation disconnect”25 will be replaced with rehabilitation as a standard part of the oncology care continuum. Cancer rehabilitation care will include dualscreening procedures to identify both physical and emotional problems early in the course of treatment when these issues are most easily addressed. Physical space in cancer centers and oncology departments will be allocated to rehabilitation—just as there is increasingly space in these facilities for integrative medicine. More health care professionals will recognize the important difference between general exercise intended to improve overall health and, in some cases, prevent cancer recurrence and therapeutic exercise designed to treat impairments. Rehabilitation clinicians will receive more and better training in oncology,26 and health care professionals in general will develop an increasingly sophisticated understanding of rehabilitation interventions. In addition to the important interventions that physical therapists can provide, we will witness the development of interdisciplinary cancer rehabilitation service lines, which will lead to better use of other clinical experts such as physiatrists, occupational therapists, and speech-language pathologists—health care professionals with unique skill sets that are critical to improving outcomes. In the future, hospitals and cancer centers will be held more accountable for dual screening as well as the services offered and the outcomes achieved. Access to and reimbursement for this care will evolve as evidenced by a 2013 court ruling in Jimmo versus Sebelius27 that clarified the “improvement standard” for Medicare reimbursement and paved the way—even for patients who are not expected to improve—to receive rehabilitation care.28 Moreover, I firmly believe that third-party payors will increasingly recognize that cancer prehabilitation and rehabilitation are essential components of high-quality cancer care and will provide financial incentives and disincentives accordingly. The future likely will bring about further inclusion of myriad other clinicians, including, but not limited to, primary care providers, nurse navigators, and mental health professionals, who will significantly contribute to better physical and 4
psychological health outcomes in survivors. Indeed, prehabilitation and rehabilitation undoubtedly will become essential components of high-quality cancer care. FUNDING SUPPORT No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES Dr. Silver is cofounder of Oncology Rehab Partners, LLC, which developed the Survivorship Training and Rehabilitation (STAR) Program, a best-practices model for cancer rehabilitation care.
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23. Stout NL, Binkley JM, Schmitz KH, et al. A prospective surveillance model for rehabilitation for women with breast cancer. Cancer. 2012;118(8 suppl):2191-2200. 24. Centers for Medicare and Medicate Services. Glossary: Skilled Care. Available at: http://www.medicare.gov/homehealthcompare/Resources/Glossary.html. Accessed February 17, 2014. 25. Vargo MM. The oncology-rehabilitation interface: better systems needed. J Clin Oncol. 2008;26:2610-2611. 26. Raj VS, Balouch J, Norton JH. Cancer rehabilitation education during physical medicine and rehabilitation residency: preliminary data regarding the quality and quantity of experiences [published online ahead of print February 6, 2014]. Am J Phys Med Rehabil. 2014. 27. Centers for Medicare and Medicaid Services. Jimmo v. Sebelius Settlement Agreement Fact Sheet. Available at: http://www.cms.gov/ Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/ Jimmo-FactSheet.pdf. Accessed February 19, 2014. 28. Kanach FA, Brown LM, Campbell RR. The role of rehabilitation in palliative care services. Am J Phys Med Rehabil. 2014;93:342-345.
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