Comprehensive Rehab Programs Beneficial in Advanced Cancer

Roxanne Nelson

July 23, 2014

Patients with advanced cancer can benefit from a rehabilitation program that combines exercise, nutritional counseling, and control of symptoms, which should be available from the point of diagnosis.

Evidence from nonrandomized studies indicates that "full-service" programs can improve the symptomatic course of the disease, according to a review published online July 21 in CMAJ.

Although there are numerous programs for patients with earlier-stage cancer that combine diet and exercise, few serve patients with advanced disease, explain lead author Martin Chasen, MD, from the division of palliative care at the Élisabeth Bruyère Hospital in Ottawa, Ontario, Canada, and colleagues.

Physicians generally embrace the concept of rehabilitation, but many think of it only in terms of restoring function through exercise. "We use a broader definition that applies to patients with advanced cancer," they point out.

Dr. Chasen and colleagues define cancer rehabilitation as "a process that assists a person with a cancer diagnosis to obtain optimal physical, social, psychological, and vocational functioning within the limits created by the disease and its treatment."

They describe successful rehabilitation programs at several Canadian hospitals in which patients showed improvement in fatigue, physical endurance, symptom alleviation, mood, and quality of life after beginning nutritional and exercise regimens.

"When caring for patients, we may limit our horizons if we fail to recognize the influence of their psychological state, nutrition, physical activity, symptoms, and functional status on their disease and response to therapy," write the authors. "A truly comprehensive care program will incorporate elements that address each of these aspects."

Forty Years in the Making

The rehabilitation approach to cancer treatment originated more than 40 years ago in the United States, with the National Cancer Act of 1971. "The aim was to combat cancer by ultimately eradicating it and to improve care for those suffering from it," said Dr. Chasen. "This legislation declared cancer rehab to be an objective, and it directed funds toward the development of training programs and research projects."

A year later, the National Cancer Institute sponsored the National Cancer Rehabilitation Planning Conference. "This was the first such conference to examine cancer-related rehabilitation," Dr. Chasen told Medscape Medical News. "At this conference, 4 recommendations were made for the rehabilitation of cancer patients."

Two of these were to provide the patient with psychosocial support and to optimize physical functioning. "The third recommendation proposed that patients be given support so that they could continue to work or fulfill other important roles, such as being a parent and taking care of a home," explained Dr. Chasen. "The final recommendation concerned social functioning, and aimed to reduce the disadvantages experienced by patients by educating the public about the effects of cancer through the use of advertising campaigns, such as explaining hair loss, and thus reduce patients' feelings of isolation."

Previous Data Supportive of Rehab

Most previous studies have looked at these factors, and the role they play in cancer and its management, individually.

For example, one study found an association between stress and the aggressiveness of breast cancer. In fact, patients who reported experiencing higher levels of stress were more likely to have high-grade, more aggressive tumors, and were more likely to have tumors that lack hormone receptors.

Because cancer therapy can lead to a loss of muscle mass and function, a number of researchers have evaluated the role of exercise in cancer care. "Observational studies and some randomized trials are starting to suggest that patients who exercise more and gain more muscle mass have better outcomes," explained David Kerr, MD, professor of cancer medicine at the University of Oxford in the United Kingdom, in a Medscape Kerr on Oncology video.

"Take the dog for a walk, making sure you that have 30 minutes of exercise every day," he said. "I might even consider rather more thoughtful exercise regimens, such as exercise programs that are tailored to the age category of patients.... It's something to think about."

Symptoms Better But Dropout Rates High

In their review, Dr. Chasen and colleagues evaluated results from prospective single-institution studies. Most described outcomes for single-modality programs or accounts of issues faced by patients and their families.

In addition, they identified 1 randomized and 5 nonrandomized trials that studied the outcomes of a program that combined exercise, nutritional counseling, and symptom control.

Four of the studies assessed rehabilitation interventions for patients with advanced cancer, with overall positive results. In 1 of the nonrandomized studies, patients who remained in the combined program for 2 months showed improved nutritional and functional status, endurance, and strength, and a decline in symptoms (Support Care Cancer. 2011;19:445-454).

In another study, appetite and weight increased significantly with a combination of simple pharmacologic and nonpharmacologic interventions that included dietary counseling from a dietician and standard exercise recommendations (J Palliat Med. 2011;14:1004-1008).

All of the programs reported a high dropout rate, which was most prevalent in patients with high levels of C-reactive protein. This indicates a chronic inflammatory state, and these patients tend to have a poor prognosis and a higher burden of symptoms, Dr. Chasen and colleagues explain.

"Dropout rates must be addressed," said Dr. Chasen. "Earlier referral of patients while they have a good performance status and reserve will address some of the dropout rate. Better selection of patients based on biological parameters and others not fully elucidated will also help."

He added that the dropout rate is not only caused by patient health factors, but also by factors such as the distance needed to travel and the availability of time in a busy physician appointment schedule.

"Creating a comprehensive cancer care team is neither high tech nor expensive, but resources and investments in staff results in improvements in patient experience and satisfaction — key elements of patient-centered care," Dr. Chasen explained.

Finally, people need to understand that palliative care is not only terminal care. A paradigm shift is needed "to enlighten physicians, healthcare workers, patients, and families alike that there is much that can be done when active chemotherapy or radiation is not a treatment option," he noted.

Dr. Chasen and colleagues have disclosed no relevant financial relationships.

CMAJ. Published online July 21, 2014. Abstract

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