A new push for cancer "rehab" is helping patients avoid
long-term physical disability and complications after treatment ends. WSJ's
Laura Landro and Julie Silver, Harvard Medical School assistant professor,
discuss on Lunch Break. Photo: Getty Images.
Patients who undergo cardiac-bypass or joint-replacement surgery routinely
are given specific guidance to the exercises and therapies they will need to
return to their everyday activities and to prevent complications or relapse.
For cancer patients, the story is very different.
After undergoing often harsh and debilitating treatments, there is often
little help for their return to normal life.
Now, an increasing number of hospitals are offering programs to provide
cancer patients with comprehensive rehabilitation services, amid mounting
evidence that these can help speed recovery, shorten hospital stays and improve
quality of life.
Rehabilitation services are "an absolutely essential part of cancer care,"
says Dan McKellar, chairman of the Commission on Cancer. Last year the nonprofit
standards-setting group, overseen by the American College of Surgeons, began
requiring cancer programs to offer rehabilitation services to be eligible for
accreditation. Major cancer centers are taking steps to better coordinate
rehabilitation after treatment. And Medicare and most insurance companies are
covering such services.
Doctors who specialize in rehabilitation medicine can evaluate patients for
fatigue, pain, anemia and decreased endurance that result from chemotherapy,
radiation and surgery. They can then prescribe physical and occupational
therapy, as well as treatment for sleep problems, depression and cognitive
impairment. Dietitians help with nutrition, as cancer can change the way the
body uses food and patients often lose their appetite from treatment. Some
institutions offer massage and yoga.
More than a third of the nation's 12.6 million cancer survivors had physical
or mental health problems that put their overall health in jeopardy and had a
negative impact on their quality of life, according to a recent study of federal
health data funded by the National Cancer Institute. While patients may get
emotional help from friends, family and support groups, physical problems may
get scant attention once they are no longer in the care of oncologists and
surgeons.
"When cancer patients are diagnosed, everyone sits down to look at the case,
decide what to do and convey that plan to the patient, but the same sort of
process doesn't happen for survivors of the treatment," says Kathryn Weaver,
lead author of the study and an assistant professor at Wake Forest Baptist
Medical Center in Winston-Salem, N.C. Patients, she adds, may feel their
physical problems are "the new normal" and may not ask their doctors for help.
And even though most hospitals have rehabilitation services, there may not be a
formal program to identify cancer-patient needs or coordinate a care plan among
different therapists.
One model being adopted by hospitals, including Johns Hopkins in Baltimore,
M.D. and Bon Secours St. Francis Health System in Greenville, S.C., is called
STAR, for Survivorship Training and Rehab. It uses specially trained teams of
caregivers, coordinated by navigators such as nurses, to help patients with
physical and emotional issues, as well as any other concerns that arise.
In 2011, Dan Yarborough, a 67-year-old attorney, had two stem cell
transplants within months of each other and high-dose chemotherapy to treat
multiple myeloma, a form of blood cancer, at Bon Secours. The treatments left
him weak and fatigued, with pain and numbness in his feet that threw off his
balance and left him unable to walk steadily and unable to stop himself from
falling if he tripped. Golf and travel, favorite pastimes, were out of the
question, and he was worried about being able to argue his cases standing in
court.
While hospitalized for his second transplant, a nurse navigator from the
hospital's STAR program set him up with regular physical therapy appointments
and nutrition counseling. Staffers helped him establish goals such as improving
his ability to get in and out of his SUV, and worked with his doctors to change
medications that were linked to his foot problems.
The program was "incredibly valuable," Mr. Yarborough says, giving him back
the stamina to return to work. He is following up with a recommended exercise
program at a medical fitness facility owned by the hospital where his exercise
plan is overseen by a STAR-certified physiologist for a $30-per-month fee.
The Bon Secours STAR team also deals with specific issues such as helping
head and neck cancer patients restore normal functions of swallowing, speech and
movement after treatment. "In a lot of hospitals you will see these patients
fall through the cracks after surgery, so their cancer is gone but they can't
turn their neck to drive a car," says Lori McKitrick, a speech therapist who
oversees the program. "We are doing a great job saving people's lives but we
have to help them live their lives too."
Julie Silver, an assistant professor at Harvard Medical School and expert in
rehabilitation medicine, developed STAR after her own treatment for breast
cancer, which she says left her too sick to care for her family or return to
work. Her oncologist suggested she rest and try to heal on her own, but "it left
me thinking there has to be a better way," Dr. Silver says. "Every cancer
survivor should have the opportunity to heal as well as possible and function at
optimal level whether their cancer is cured, in remission or they live with
cancer as a chronic disease," Dr. Silver says.
She started a company, Oncology Rehab Partners, which helps health systems
and hospitals create their own STAR programs for many types of cancer. STAR
certification is used by insurance companies in reimbursement decisions. The
program costs a typical hospital about $25,000 to launch with an annual fee of
$10,000 for continuing education and recertification, Dr. Silver says.
Michelle Houle, 45, has been participating in the STAR program at Bon Secours
since she was diagnosed with breast cancer in 2010. After chemotherapy, a
bilateral mastectomy and radiation, Ms. Houle, on long-term disability from her
job as a food company shelf manager, says she felt "about 90 years old." Nurse
navigators at the hospital set her up with a specialist to help prevent
lymphedema, a painful swelling of the lymph nodes and a common side effect of
breast surgery, and she began a physical therapy regimen.
Ms. Houle suffered a recurrence in 2011 and is now on another chemotherapy
regimen, but keeps up her exercises at the hospital's medical fitness facility.
She is slowly returning to activities like gardening and housework. The
rehabilitation program provides "a base to keep you going," she says, "and there
is always someone to talk to if I'm feeling side effects."
Signature Healthcare in Brockton, Mass, which includes Brockton Hospital and
150 employed doctors, treats local cancer patients and those who have had
treatment at major centers in Boston, then return home for follow-up with
difficult physical aftereffects. Last week, it launched its own STAR program
after 23 staffers went through six months of training and received STAR
certification. "These needs have been unmet for such a long period of time, and
they are very excited to be able to offer this enhanced level of service" says
Linda McAlear, the program's coordinator.
