Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 47, Num. 1, 2001, pp. 55-59

Journal of Postgraduate Medicine, Vol. 47, Issue 1, 2001 pp. 55-59

Rehabilitation of Cancer Patients

Pandey M, Thomas BC

Department of Surgical Oncology, Regional Cancer Centre, Trivandrum, India.

Abstract

With the developments in cancer treatment, more and more patients are surviving their disease. However, very little emphasis is being placed to rehabilitate these cancer survivors. Ignorance, social structure, stigma attached in seeking psychological help, and poor communication skills of oncology staff all contribute to poor rehabilitative efforts. The priority of governmental agencies and health efforts to fight rampant communicable diseases, malnutrition, maternal health, and the frequent natural calamities, puts rehabilitation movements in the back seat. Treatment and prevention of disability and its rehabilitation requires comprehensive and multidisciplinary approach. There is an urgent need to promote physical and psychological rehabilitation.

To feel like a useful human being without any stigma attached, without any undue fears and pressure but with a sense of being needed and wanted, is what life is all about. Rehabilitative efforts among cancer patients should be directed towards this goal. The professional as well as the layman needs to be optimistic, without feeling reservation and contagiously exude it. Yet, despite better treatment methods, and higher survival rates today, the medical community has not been able to sufficiently change their attitudes toward cancer rehabilitation. (1) Disability is a significant problem for patients undergoing cancer treatments. This is often a result of local and distant effects of tumour as well as the treatment sequelae. Treatment and prevention of disability requires comprehensive and multidisciplinary approaches. These approaches are frequently long term, spanning several life stages. However, little is known about the rehabilitation outcomes over a longer period of time, (2) though current evidence strongly support the provision of a well organised, coordinated, multidisciplinary rehabilitation services based on a problem oriented approach. (3)

Rehabilitation specialists most frequently involved in treatment of cancer includes physiatrists, occupational, physical, and recreation therapists, speech-language pathologists, audiologists, and vocational counsellors. Other healthcare professionals join the team as and when needed for the management of particular problems, these include orthotists and prosthetists, psychologists, and dieticians. (3) The cancer rehabilitation team needs to be committed to help the patient achieve his or her functional goals through all phases of the disease and its treatment. Rehabilitation is a dynamic process that should begin soon after the diagnosis and continues for the duration of the illness and its treatment. (4)

Rehabilitation has recently seen many practical innovations and new evidence for specific interventions, but the major advances in rehabilitation are conceptual rather than being practical. Firstly, the approach to patients has shifted from a predominantly medical to one where psychological and socio-cultural aspects find an equally important place. Secondly, the need for organised specialist rehabilitation services like that for neurological disabilities is being recognised. (5) Gerber et al., (4) have identified the following areas that require attention in the process of physical rehabilitation:

• Immobility and its impact like generalized deconditioning, skin care and contractures.
• Upper extremity orthotic management.
• Metabolic problems.
• Myopathy as a result of direct tumour invasion of muscle and other soft tissues, paraneoplastic syndromes, carcinomatous myopathy, steroid myopathy, or carcinomatous neuromyopathy.
• Bone replacement by tumour along with prevention and management of pathologic fractures, spinal cord injury syndromes.
• Neuropathies and plexopathies.
• Lymphoedema and deep venous thrombosis.
• Bowel and bladder disorders.
• Other areas requiring rehabilitative efforts are:
• Independence.
• Body image.
• Speech.
• Confidence.
• Sexuality.
• Dignity.
• Family.
• Use of prostheses.
• Physical appearance.
• Finances, etc.

Physical rehabilitation of the cancer patient has its own ingrained problems - especially if the programme is to be initiated in a developing country. ‘Technology transfer’ is merely not enough, as only a limited few will have the means to afford it. State of the art physical restoration services like an artificial larynx, peast prostheses, and colostomy bags, are available in India, however, they are priced high and only a few can afford them. The technical expertise too is limited to a few select cities. Newer approaches to the concept of rehabilitation in the Indian setting needs be defined and these should take into account the financial aspects as well as easy availability.

The utilisation of a psycho-social rehabilitative facility however, is more involving. Ignorance of the availability or the impact of a psycho-social intervention, (6,7) as well as the stigma attached in seeking help from a psychotherapist, impinges on rehabilitative efforts in a developing country. Developing countries have poor infrastructure and lack proper treatment facilities at most centres. This leads to poor survival rates, and hence, more emphasis is placed on attaining quantity of life rather than quality. (8)

Factors that influence the patient’s need for a psycho-social rehabilitation programme and have been described in detail in literature. These are social support, (9) availability of information, (10) and communication amongst a multi-disciplinary staff, thereby facilitating a better rehabilitative process. (11) The type of cancer is a decisive factor in determining the degree of difficulty faced by the patient and its impact of rehabilitation,1 e.g. speech, presentability, nutrition, etc., in head and neck cancers; (12-21) social, and sexual issues faced by patients with cancer of the peast; (22-29) and cervix, prostate, and genital area. (30-38)

Razavi in a number of his studies (39-41) has emphasized the need for a comprehensive psycho-social support of cancer patients and their families taking into account the prevalence of psychosocial problems and psychiatric disturbances observed amongst them. He further stated that psychosocial interventions designed for this need should be divided into five categories namely prevention, early detection, restoration, support, and palliation. The fourth stage should involve supportive rehabilitation to lessen disabilities related to chronic diseases characterized by numerous cancer illness or its treatment, i.e. remission, progression, and active treatment. Other studies where the patients were interviewed or assessed for their specific needs concerning post-cancer treatment showed that a significant number desired professional help. (42,43) The desire for professional help concentrated significantly on role performance, cognition, control, family relations, and psychologic and somatic aspects. Focus group discussions and interviews revealed that patients preferred a rehabilitation programme with focus on reducing fatigue, reinforcing loadability, coping with social aspects, dietary aspects and finding new life targets.

The results of rehabilitation have been noted by various authors. Seifert et al., in their study stated that rehabilitation in a sports group improves the individuals’ subjective quality of life. (44) Similarly, patients in the study by Berglund et al., improved with respect to physical strength and increased their physical training and social activities more than the patients who did not participate in the rehabilitation programme. (45) Other advantages of having a rehabilitation programme associated with cancer care are improved personal confidence, (46) especially in the patients with head and neck cancers undergoing surgical treatment facilitating better adherence to or acceptance of prescribed procedures. (47)

Various types of rehabilitation methods like teleconferencing, (48) use of sport therapy, (49) use of family-oriented-rehabilitation programs especially in the paediatric cancers, (50) exercise rehabilitative training, (51) and most importantly involvement of cancer survivors in the rehabilitation programme and improvements in communication skills between the practitioner and the patients (52) have been described earlier.

A meta-analysis of data from trials of rehabilitation in stroke units has shown that rehabilitation services in such units are effective at reducing both mortality and morbidity possibly without extra resources. (53) Furthermore, these benefits can be achieved in routine practice, (54) and lasts for many years. (55) The meta-analysis was specially important as it helped to characterise the probable important ingredients of rehabilitation: i.e. coordination, expertise, and education.

Evidence in support of specialised coordinated rehabilitation services is less strong in other fields, but trials have shown benefits for patients with multiple sclerosis, (56,57) mild or moderate head injury, (58) and back pain. (59) Consequently the presumption should be that most patients with disability will benefit from being seen by a specialist, and coordinated rehabilitation service. It is no longer tenable to depict rehabilitation as an expensive placebo service.

The evidence for each part of the process of rehabilitation is much more difficult to identify and evaluate. The evidence in favour of assessment and goal planning has been reviewed recently. (60,61) Even though it is not subjected to meta analysis, and is difficult to systematically review it, there is reasonable support for these aspects of the process.

Rehabilitation in India had been amongst the least priority areas. However, efforts by the likes of the Indian Cancer Society have been able to provide specific and comprehensive rehabilitation services to many cancer patients and their families every year. (62) Several studies from India have highlighted the need and prospect of rehabilitative procedures, (8,63-68) use of a prosthesis, (69,70) screening procedure, (71) bioengineering future, (72) and phenotypic classification for visual acuity. (73)

The health priority of the country focuses on communicable diseases, (malaria, kala azar, filariasis, dengue, tuberculosis, leprosy, etc.) malnutrition in children, women’s health, etc. National Cancer Control Programme during the 7th and 8th five-year plans had focus on tobacco-related cancers providing facilities for treatment and early detection of cancer. The priority is on improving patients’ quantity of life, and quality of life (QOL) - let alone rehabilitation - if often ignored. (74) The limited allocation of funds to the health sector is also used for relief at the time of natural calamities. Specialised cancer treatment facilities are few and are located in major cities and metros. Taking all these factors into account, India has a long way to go before cancer treatment and rehabilitation can be provided to its population. A feasible solution would be for the psycho-social and community oriented services to be taken up by the non government voluntary organisations and those could be provided in association with existing treatment centres. These efforts may pidge the gap between cancer survival and their rehabilitation thereby lessening their sufferings and hastening the road to recovery.

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