The oncology-rehabilitation interface: better systems needed.

The enormous discrepancy between the incidence of disabling physical impairments among individuals with cancer and the provision of medical rehabilitation services to address these problems has once again been documented by Cheville et al in this issue of Journal of Clinical Oncology. In particular, the difference between receipt of rehabilitation care during acute hospitalization and the extremely low rate for outpatients is impressive, but hardly surprising. The extent to which presence of advanced cancer has accentuated the magnitude of the differences between inpatient and outpatient rehabilitation service delivery is unclear, because similar trends would likely be found even among those with less extensive disease. In the inpatient setting, rehabilitation services such as physical and occupational therapy are often readily available, and are integral to the discharge-planning process to attain basic function sufficient for homegoing and avoid costly prolonged hospitalization. On the other hand, rehabilitation goals among outpatients are typically more varied and focused on specific impairments, such as lymphedema, contracture, motor-sensory deficits, deconditioning, and musculoskeletal pain syndromes. Active recognition of the impairments as remediable issues is required. Additional barriers not seen during inpatient care may be present, such as insurance authorization obstacles and inconvenience. The main problem, however, is that more effective systems are needed to recognize rehabilitation needs, provide rehabilitation care, and facilitate evidencebased outcomes of rehabilitation in the cancer population. Multiple studies have documented increased levels of disability among cancer patients and survivors. Yet, many gaps exist in our knowledge of how this broad-based information can be applied clinically. Which impairments justify vigilant screening? In which situations are the problems most remediable? What are best practices for treatment? How does the presence of advanced cancer affect appropriate rehabilitation management? Some cancer-related impairments, such as amputation, and conditions affecting the brain or spinal cord produce obvious and devastating clinical care needs. A wide range of treatable musculoskeletal disorders can also occur in the setting of cancer, a fact that is probably underappreciated, including among many rehabilitation practitioners. There is a need to more closely examine the extent of rehabilitation needs in historically elusive, yet common, cancer subpopulations, including those with advanced cancer. In depicting a model of rehabilitation care that has worked in a major cancer hospital, Grabois described “lessons learned,” including the need for a core triad of strong administrative support, a physiatrist as medical director of rehabilitation services, and effective marketing. Clinical service lines including inpatient, consultative, and outpatient rehabilitation should be present, as well as an emphasis on scientific productivity, and educational dimensions including medical student and resident rotations, sponsorship of seminars, and development of cancer rehabilitation fellowships. Significantly, Grabois also spoke of the real-world importance of having adequate staff capacity to minimize patient waiting times, and of maintaining a convenient location. Such a model immerses rehabilitation in the culture and workings of the facility. Despite examples such as this, integration of rehabilitation into cancer care remains problematic. In a survey of National Cancer Institute–designated cancer centers, 70% of facilities reported services to treat lymphedema, but there was little discussion of other mainstream rehabilitation services. Challenges are even greater in institutions that are not dedicated cancer hospitals, where the majority of cancer patients are treated, and where rehabilitation services simultaneously need to meet the needs of other patient populations. What specific strategies can be employed to improve rehabilitation access for oncology patients? Lehmann, O’Toole, and Mosvas describe consultative models to screen oncology patients for rehabilitation needs, such as assigning rehabilitation personnel to meet regularly with the oncology team or using information such as the Karnofsky score to trigger rehabilitation assessment. However, data on long-term results of such screening systems are highly limited. Among inpatients, including those with advanced cancer, gains in functional status have been reported with both traditional acute rehabilitation and with interdisciplinary rehabilitation provided on a consultative basis, suggesting that future efforts at optimizing the rehabilitation screening process among oncology inpatients would be highly worthwhile. Among outpatients, screening presents even greater challenges. For example, do best care outcomes and cost effectiveness happen when a physiatrist sees all at-risk patients and triages the rehabilitation interventions, or when the patients go directly to other rehabilitation disciplines such as physical or occupational therapy, with physiatrist care reserved for those with the most complicated needs? Empirically, successful outpatient programs have cultivated specific service lines and consistent processes. Historically, many programs have been directed towards lymphedema and postmastectomy management, or other postsurgical issues. But there are other problems, often more global, to which there is a need to respond, especially as the evidence grows stronger. For example, because multiple studies have shown that individuals with cancer benefit from exercise programs, processes that routinely expedite exercise are needed. Areas JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 26 NUMBER 16 JUNE 1 2008