Implementing Standards of Care in Cancer Rehabilitation In Ireland’s Health Services
Proposal for Cancer Survivorship Surveillance Model (CSSM).
Original Article by:
Jill Binkley, PT, MSc(PT), CLT, FAAOMPT.
Siobhan O’Reilly Bracken, MISCP, MPA, CLT. MSc(Sports)
Tuesday, October 17, 2017
Treatment for cancer typically includes surgery, chemotherapy, radiation therapy and endocrine therapies, which introduce a variety of physiological effects known to adversely impact body structure and function.1-8 Treatment side effects have been most well documented in breast cancer patients, where effects may lead to physical impairments including lymphedema, pain, fatigue, weakness, restricted range of motion, joint arthralgia, neuropathy, and osteoporosis. Treatment is also known to adversely affect physical function, body weight, and cardiovascular health. These impairments may adversely affect patients’ participation in activities of daily living and employment, and negatively affect healthy lifestyle behaviors such as regular exercise.9 While there may be a clinical impression that these issues are uncommon, emerging evidence indicates that a majority of patients experience at least one or more of these physical impairments and suffer from the aggregate burden of impairments, co-morbidities and disease treatment.4,7-9
Lymphedema is a common, much-feared and deeply impactful side effect of cancer treatment.3,7,8,10,11 The risk factors for lymphedema in cancer patients include lymph node removal, radiation, primary involvement of the lymph system. Risk can be decreased through exercise and weight management. In the case of breast cancer, virtually all survivors are at risk for lymphedema and approximately 30% of patients will experience this much-feared side effect in their lifetime. The condition is progressive, chronic and costly to manage when it becomes moderate to severe. Research has demonstrated that patient education regarding risk reduction and provision of early detection and treatment is successful in preventing the impact and progression of lymphedema through less costly intervention.12-15
The Prospective Surveillance Model of Breast Cancer Rehabilitation
The Prospective Surveillance Model of Breast Cancer Rehabilitation (PSM) was developed by the American Cancer Society in collaboration with a team of experts in the field of cancer survivorship.14 The model aims to identify physical side effects early in order to reduce impact on patients and reduce costs in the healthcare system. In the model, baseline assessment that includes arm volume, shoulder range of motion, pain and strength are taken prior to surgery, which is typically the initial phase of breast cancer treatment. Measures are repeated at follow-up visits post-operatively in an effort to identify early signs of physical impairment. If impairments are detected, rehabilitation may be initiated. This proactive approach promotes early intervention to optimize recovery and return to pre-morbid levels of function.9,16-1
Lymphedema risk is reduced through the model through educating patients regarding risk factors, providing early detection as well as treatment of related impairments such as cording and limitation of motion that increase lymphedema risk. Education and reinforcement of health promoting behaviors such as exercise, weight control and physical activity is continued is woven throughout the model of care.
Perspectives of Cancer Patients
In Ireland and internationally, cancer patients’ unmet needs for education and support for cancer treatment side effects are widely documented. In general, cancer patients are seeking access to care that promotes understanding, prevention and treatment of cancer side effects through evidence-based education, lifestyle change, exercise and, when needed, rehabilitation for cancer treatment side effects.19,20 A prospective surveillance model of survivorship care meets patients’ needs.
The PSM as a Model of Survivorship Care in Other Cancers
The PSM serves as a template for a more general Cancer Survivorship Surveillance Model (CSSM) proposed here that will address survivorship issues commonly seen in other cancers. The focus of this proposal is on cancers where chronic side effects of treatment, such as lymphedema result in the need for ongoing care and cost to the health care system. As such, the focus initially is on breast cancer, head and neck cancers, skin cancer with either axillary or inguinal lymph node dissection and radiotherapy and abdominal and gynecological cancers, where lymphedema is a common side effect of treatment.
Implementation of a Cancer Survivorship Surveillance Model (CSSM) for Lymphedema Risk Reduction and Early Management in Ireland
The CSSM could be implemented for all cancer patients, or at different levels of intensity based on risk for chronic impairments such as lymphedema. It includes a pre-operative assessment by a physiotherapist or occupational therapist, including relevant range of motion, strength, limb volume assessment, education and exercise instruction, as applicable. This would be carried out in one of the Cancer Centers. These records and post-operative discharge notes will be sent to the patients’ family practitioners and community based physiotherapist for continuity of care and as a reference point for ongoing care and surveillance frequency, based on risk factors and co-morbidity. Post-operative follow-up assessments and management of survivorship issues, including lymphedema, would be carried out by community-based physiotherapists and occupational therapists trained in the model.
Three tracks of care have been identified to broadly demonstrate trajectories of care within the CSSM. Research suggests that implementation of a prospective model that facilitates early detection of issues, including lymphedema and that includes education and exercise may reduce patients in need of Track 3 care, which is more burdensome to the patient and significantly more expensive to provide.
Figure: Cancer Survivorship Surveillance Model
Current and Future Health Care Provider Capacity
Most aspects of the proposed CSSM relies on community physiotherapists already in place, with basic undergraduate education in oncology, including assessment of range of motion, pain, function and lymphedema risk factors, risk reduction and intervention for mild lymphedema. However, there will need to be clinically skilled leadership in each province to facilitate implementation of the model and train community-based physiotherapists. These trainers will be physiotherapists or occupational therapists who understand cancer rehabilitation, lymphedema risk and management and the proposed model of surveillance. We propose two trainers per province.
The CSSM trainers would be provided with advanced training related to the proposed model of surveillance through the HSE. The proposed training would be three 2-day workshops, taught by Siobhan O’Reilly Bracken, MISCP, PT, MPA, CLT. MSc-Sports and Jill Binkley, PT, MSc(PT), CLT, FAAOMPT.
Workshop One: Identify and train 2 nominated Chartered Physiotherapists and or Occupational Therapists as trainers and facilitators to pilot the program in each province. Once trained, the liaison would pilot the program in each of the provinces for 6 months.
Workshop Two: Follow-up training for 2 days at 6 months to identify successes, challenges and barriers, provide further training and develop report for the NCCP.
Workshop Three: In the third workshop, liaisons take what the executives agree to roll out and we do an advanced workshop and train the same trainers in the agreed approach.
Health Care Cost Reduction
When impairments and functional limitations are detected early, education and treatment measures can reduce the burden to cancer survivors as well as to the health-care system from a cost perspective. For example, studies have demonstrated that early detection, management and education regarding lymphedema can prevent progression of the condition and in fact, reduce the cost-burden of treating more advanced lymphedema.15 The reinforcement of health promoting behaviors such as exercise, weight control and physical activity is woven throughout the model of care not only decreases lymphedema risk, but also the risk of cancer recurrence, which may have an impact on recurrence, mortality and future costs to the health care system.15,21,22
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