REP 24: WE KNOW IT WORKS: SO WHERE ARE THE CANCER REHABILITATION SERVICES IN CANADA?
Every year over 190,000 Canadians are diagnosed with cancer and today there are more than 800,000 cancer survivors living in Canada (i.e. those who have had a cancer diagnosis). While cancer encompasses more than 100 distinct diseases, there are many common threads regarding the treatments and related side effects. Physical rehabilitation is a mainstay of many health conditions, from cardiac rehabilitation programs to physiotherapy after a joint replacement. However, the physical rehabilitation needs of cancer survivors in Canada have received little attention and few services.
The Big Idea
In 2011, a survey of Canadian facilities offering cancer treatment reported that only 30% of the facilities who responded reported having an oncology rehabilitation program. Furthermore, the majority felt the programming was not meeting the patient needs.
How can we improve the access to physical rehabilitation services for cancer survivors in Canada?
My take on things…
Improving this situation is a big job. However, as 5-year survival rates continue to climb for many cancer types, there is growing recognition of the need for strategies to improve the quality of life, physical function and health of cancer survivors.
First, is there really a need?
The prevalence and severity of physical impairment related to cancer treatments, such as surgery, chemotherapy, radiation and emerging novel therapies, continues to be documented for a variety of cancer types. Specific to breast cancer, an entire issue of the journal Cancerexamines the prevalence of various cancer-related physical impairments and the potential of physical rehabilitation to address these issues. Furthermore, there is good evidence for the role of physical rehabilitation/exercise to improve cancer-related fatigue, physical function and pain, as well as to improve return to work.
Why are people not getting services?
There are many reasons why services are not available and this likely differs by province, region, and cancer-type. However, in the survey by Canestraro et al., 71% of respondents stated lack of funding as the main reason. Lack of available resources or space, along with lack of support from administration were also reported as key barriers.
With limited funding, perhaps priority should be placed on supporting physical rehabilitation at least within the large regional cancer centers and then work to develop strategies to grow capacity in smaller centres or on-line resources.
Is there a need to raise the awareness of other health care providers?
In a cross-sectional study of 254 consecutive community-dwelling outpatients in the US who attended a large cancer centre* over a 1 week period, patients were asked about their physical symptoms and function over the two weeks prior. The researchers compared this patient-reported information to physician notes in the patients’ electronic medical record. While functional problems were reported by over 65% of patients, only 6% were noted in the medical chart and this resulted in only 2 referrals to physical rehabilitation services! As cost of services is commonly reported as a key barrier to provision of oncology rehabilitation, , so more research in this area is needed.
It is time to ensure that all members of the health care team are aware that many of the physical side effects of cancer treatment can be effectively addressed by physical therapy and provide opportunities for patients to receive those services.
*Of note, this particular centre has out-patient rehabilitation service providers available.
What can physiotherapists do?
First, as the survey by Canestraro et al. reported, a lack of experience in oncology on the part of physiotherapists was a barrier to oncology rehabilitation programming. This behooves the physical therapy programs across Canada to ensure training in oncology is provided and thatcontinuing education opportunities for physiotherapists in oncology are available in Canada.
Second, a tangible next step could be to ensure that evidence-based patient education materials on physical rehabilitation are more easily accessible to cancer survivors. One idea may be tocurate the most appropriate and up-to-date resources and ensure this information is available via web links at your local cancer centre. That way, all members of the health care team can point cancer survivors toward this information.
For example, the Canadian Cancer Society worked with the Canadian Physiotherapy Association to produce a patient guide entitled Exercise after breast cancer surgery. Not only does this guide provide instruction about general range of motion exercises and exercise progressions, it also provides guidance to cancer survivors on how to safely undertake resistance training after breast cancer surgery. This type of resource can directly help to counter the myriad of contradictory information that women encounter from friends, family, and other healthcare providers around contraindications to lifting and upper extremity exercise following surgery and treatment for breast cancer.
Finally, physiotherapists need to advocate for the development multi-disciplinary care teams within oncology. This will require the coordinated support of practice leaders within health regions or health authorities, our national and provincial professional associations, and key stakeholders, such as patient advocates, in order to address access to services in public healthcare settings and reimbursement from providers of extended healthcare benefits.
As physiotherapists, let’s be the leaders in the effort to find ways to follow in the footsteps of cardiac and pulmonary rehabilitation programs, and ensure that oncology rehabilitation takes its rightful place as part of standard patient care across Canada.
Did you enjoy this topic? Want to read more? Here are the full citations for the papers I referred to in this Rep. Unless otherwise noted, all are open access:
Canadian Cancer Statistics 2014. Toronto: Canadian Cancer Society; 2014.
Canestraro A, Nakhle A, Stack M, Strong K, Wright A, Beauchamp M, et al. Oncology Rehabilitation Provision and Practice Patterns across Canada. Physiotherapy Canada. Physiotherapie Canada 2013;65(1):94-102.
Cheville AL, Beck LA, Petersen TL, Marks RS, Gamble GL. The detection and treatment of cancer-related functional problems in an outpatient setting. Supportive Care in Cancer2009;17(1):61-7. (NOT open access)
Egan MY, McEwen S, Sikora L, Chasen M, Fitch M, Eldred S. Rehabilitation following cancer treatment. Disability and Rehabilitation 2013;35(26):2245-58.
Mewes JC, Steuten LM, Ijzerman MJ, van Harten WH. Effectiveness of multidimensional cancer survivor rehabilitation and cost-effectiveness of cancer rehabilitation in general: a systematic review. The Oncologist 2012;17(12):1581-93.
Schmitz KH, Stout NL, Andrews K, Binkley JM, Smith RA. Prospective evaluation of physical rehabilitation needs in breast cancer survivors: A call to action. Cancer 2012;118(8 Suppl):2187-90.
Do you have ideas to share on ways to break down the inter-professional barriers in oncology to improve referrals to physiotherapy services (where available)?
Are there any success stories out there? Examples of how access to physiotherapy services for oncology patients has been improved in your practice setting or community?
About Kristin Campbell
Dr. Kristin Campbell is a physical therapist, research scientist, and an Associate Professor in the Department of Physical Therapy at the University of British Columbia in Vancouver, BC. Her research interests are focused on the role of physical activity across the cancer experience, namely in prevention, rehabilitation from cancer treatments, and cancer survivorship. Dr. Campbell is the author of over 60 peer reviewed articles and academic book chapters, and she participates on national and international advisory boards and grant review panels on cancer prevention, rehabilitation and survivorship. Dr. Campbell also has several professional memberships, including in the Oncology Division of the Canadian Physiotherapy Association, and she is a licenced physiotherapist with the College of Physical Therapy of British Columbia.