Understanding and addressing the rehabilitation needs of patients with cancer

Feb. 04, 2022

According to Andrea L. Cheville, M.D., a physiatrist specializing in cancer rehabilitation at Mayo Clinic in Rochester, Minnesota, the goal of cancer rehabilitation is to optimize function and quality of life among patients with all forms of cancer by addressing their symptoms and impairments. "As rehabilitation specialists, we seek to help these patients continue living the fullest, most rewarding and productive lives possible within the constraints imposed by their disease and its treatment."

Common side effects of cancer treatments and their implications for physiatrists

According to Dr. Cheville, many of the acute effects of chemotherapy and other cancer treatments are relevant to the practice of physiatry. "Common side effects, such as drops in blood counts, and injuries to the kidneys, lungs and nerves highlight the tough realities of many currently available cancer treatments. Almost everything we do to eliminate cancer may adversely affect normal tissues and physiological systems."

The list of possible side effects includes focal mononeuropathy or chemotherapy-induced peripheral neuropathy, both of which, Dr. Cheville emphasizes, can cause patients to lose dexterity and balance and make them vulnerable to falls. Some cancer chemotherapy agents, especially taxanes, platins and other neurotoxic agents, may cause joint pain. Serial assessments of patients over the course of their cancer treatment have revealed that a spectrum of cognitive deficits also may occur, including a loss of executive cognitive functioning.

"For some of our patients who are in fairly demanding jobs, the onset of cognitive deficits can be the difference between employability and being out of work," says Dr. Cheville.

Interventions that remove primary tumors or affect the tissues surrounding a cancer can destabilize musculoskeletal structures. "Surgical removal of bones and muscle frequently affects peripheral nerves, and excision of lymphatics can lead to lymphedema," explains Dr. Cheville. "Radiation as well as surgery can cause loss of tissue suppleness and produce joint contractures, which may be significantly associated impairments and disability."

These side effects, symptoms and functional limitations, notes Dr. Cheville, demonstrate the importance of recognizing that patients with cancer may derive benefit from conventional rehabilitation treatments. "Nothing specific to having cancer prevents a patient from responding extremely well to physical and occupational therapy, injections, or other rehabilitation approaches. But finding an efficient way to identify who needs these services and how to deliver them remains challenging."

To address these challenges, Dr. Cheville and a team of Mayo Clinic colleagues are conducting a pragmatic clinical trial examining a novel, digitally enabled approach to identify, assess and alert patients with cancer who have the potential to benefit from rehabilitation services. The trial intervention explores how best to deliver needs-matched rehabilitation care in a timely and stepped fashion such that patients with complex needs may gain rapid access to an experienced clinician, while those with straightforward needs may first be offered self-management tools. Reports support the hypothesis that many patients' functional deficits may be addressed through self-management.

The Enhanced, Electronic Health Record (EHR)-Facilitated Cancer Symptom Control (E2C2) Pragmatic Clinical Trial is a cluster randomized pragmatic trial with a stepped wedge design. The trial involves two steps:

  • Systematically collecting and assessing patient-reported outcome measure (PROM) data for a number of domains, including sleep disturbance, pain, anxiety, depression, fatigue and functional decline among patients being treated for solid and liquid cancers
  • Connecting these patients with appropriate rehabilitation services

This multisite study involves 15 randomized clusters of patients receiving treatment from medical oncology teams at Mayo Clinic in Rochester, Minnesota (11 clusters), and at Mayo Clinic Health Systems campuses in Wisconsin and Minnesota (four clusters).

"Our goal with E2C2 is to test whether a symptom- and impairment-focused intervention will significantly reduce symptom and physical dysfunction scores, reduce unplanned hospitalizations and emergency department visits, improve adherence to cancer therapies, and improve self-reported quality of life," explains Dr. Cheville.

The population-based E2C2 trial includes all patients receiving care at Mayo Clinic and Mayo Clinic Health System medical oncology practices in the Midwest. Patients complete a PROM symptom screen at least monthly that includes six 11-point numerical rating scales. These data are shared with patients' care teams and used to drive EHR clinical decision support such that patients with PROM scores indicating moderate or severe symptoms receive a clinically appropriate response:

  • Patients with moderate symptoms (4 to 6 out of 10) receive automated delivery of self-management education, direction to a web-based resource hub and encouragement to seek social support on the Mayo Clinic Connect platform.
  • Patients with severe symptoms (seven or more out of 10) are offered the option to receive outreach from a nurse, physical therapist or social worker symptom care manager to develop personalized symptom or function management plans.

In both the trial's control and active intervention states, patients' oncology care teams are provided with patient PROM symptom scores via a range of EHR interfaces. PROM score presentation between the control and intervention states differs solely in the appearance of a "soft stop" alert when patients receiving intervention report severe symptoms.

"The goal is to assist care teams in providing patients with needs-matched symptom and impairment management strategies designed to improve quality of life, symptoms, function and adherence to cancer treatment, while reducing unplanned use of health care resources," explains Dr. Cheville.

According to Dr. Cheville, the E2C2 trial is built on the understanding that collaborative care approaches like those being used in the trial have considerable potential to improve the management of symptoms in patients with cancer and the potential to reduce health care disparities among vulnerable patient subgroups.

"The E2C2 intervention uses critical insights from the current evidence base to overcome barriers that have limited previous attempts at the development of scalable, pragmatic approaches to symptom management," explains Dr. Cheville.

To date, over 40,000 patients have participated in the pragmatic E2C2 trial. Data collection will continue through the end of June 2023.

For more information

Clinical Trials: Enhanced, EHR-Facilitated Cancer Symptom Control (E2C2) Pragmatic Clinical Trial. Mayo Clinic.

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