Making Cancer Rehabilitation Services Work for Cancer Patients: Recommendations for Research and Practice to Improve Employment Outcomes

The influence of telehealth-based cancer rehabilitation interventions on disability: a systematic review

PURPOSE

To characterize delivery features and explore effectiveness of telehealth-based cancer rehabilitation interventions that address disability in adult cancer survivors.

METHODS

A systematic review of electronic databases (CINAHL Plus, Cochrane Library: Database of Systematic Reviews, Embase, National Health Service's Health Technology Assessment, PubMed, Scopus, Web of Science) was conducted in December 2019 and updated in April 2021.

RESULTS

Searches identified 3,499 unique studies. Sixty-eight studies met inclusion criteria. There were 81 unique interventions across included studies. Interventions were primarily delivered post-treatment and lasted an average of 16.5 weeks (SD = 13.1). They were most frequently delivered using telephone calls (59%), administered delivered by nursing professionals (35%), and delivered in a one-on-one format (88%). Risk of bias of included studies was primarily moderate to high. Included studies captured 55 measures of disability. Only 54% of reported outcomes had data that allowed calculation of effect sizes ranging -3.58 to 15.66.

CONCLUSIONS

The analyses suggest small effects of telehealth-based cancer interventions on disability, though the heterogeneity seen in the measurement of disability makes it hard to draw firm conclusions. Further research using more diverse samples, common measures of disability, and pragmatic study designs is needed to advance telehealth in cancer rehabilitation.

IMPLICATIONS FOR CANCER SURVIVORS

Telehealth-based cancer rehabilitation interventions have the potential to increase access to care designed to reduce disability across the cancer care continuum.

Milestones and turning points in the experience of physical activity throughout cancer care: a qualitative study to inform physical activity promotion

PURPOSE

Physical activity (PA) is an important supportive care strategy to manage cancer and treatment-related side effects, yet PA participation is low among people diagnosed with cancer. This study examined patients', health professionals', and managers' perspectives on PA throughout cancer care to glean implications for PA promotion.

METHODS

Random selection and purposeful sampling methods allowed for the recruitment of 21 patients (76.2% women) and 20 health professionals and managers (80% women) who participated in individual semi-structured interviews. Interview questions explored facilitators and barriers to PA participation and promotion across the cancer care continuum. Interviews were audio-recorded and transcribed. Then, qualitative thematic analysis was performed.

RESULTS

The analysis produced five main themes describing milestones in PA participation throughout cancer care: (1) Getting Started, (2) Discovering PA Resources, (3) Taking Action, (4) Striving for Change, and (5) Returning to a "New Normal." The sub-themes underscored turning points, i.e., tasks and challenges to PA participation that had to be overcome at each milestone. Achieving milestones and successfully navigating turning points were dependent on clinical, social, and community factors.

CONCLUSION

Cancer patients appear to progress through a series of milestones in adopting and maintaining PA throughout cancer care. Intervention strategies aimed at promoting PA could test whether support in navigating turning points could lead to greater PA participation. These findings require replication and extension, specifically among patients who are men, younger adults, and culturally diverse.

Looking back: a review of policy implications for exercise oncology

The evidence to support the benefits of exercise for people living with and beyond cancer is robust. Still, exercise oncology interventions in the United States are only eligible for coverage by third-party payers within the restrictions of cancer rehabilitation settings. Without expanded coverage, access will remain highly inequitable, tending toward the most well-resourced. This article describes the pathway to third-party coverage for 3 programs that address a chronic disease and utilize exercise professionals: the Diabetes Prevention Program, Supervised Exercise Training for Peripheral Artery Disease, and Cancer Rehabilitation. Lessons learned will be applied toward expanding third-party coverage for exercise oncology programming.

Implementing and sustaining a breast cancer prospective surveillance rehabilitation program: an institutional perspective

BACKGROUND

The prospective surveillance model (PSM) is an evidence-based rehabilitation care delivery model that facilitates functional screening and intervention for individuals undergoing cancer treatment. While PSM is empirically validated and feasible in practice, implementation into cancer care delivery has languished. The purpose of this manuscript is to characterize the barriers and facilitators to implementing PSM in a breast cancer center and to share policy and process outcomes that have sustained the model in practice.

METHODS

The PSM implementation was undertaken as a quality improvement initiative of our cancer center. We retrospectively assessed barriers to implementation and define those according to the Consolidated Framework for Implementation Research (CFIR). Implementation strategies are defined based on the Expert Recommendations for Implementation Change (ERIC) taxonomy. Breast center policy changes and stakeholder-reported process improvement outcomes at the clinic and system level are described.

RESULTS

PSM implementation facilitation was driven primarily by adapting the model to align with the cancer center workflow, engaging interdisciplinary stakeholders as program champions, enhancing knowledge and awareness among cancer care providers, and changing infrastructure to support the model. System and clinic-level policy and process changes included the development of clinical pathways, EHR order sets and automated referrals, new staffing models, and adapted clinical workflows.

CONCLUSION

Our report provides insight on implementing the PSM at a single institution in a cancer care delivery setting. Successful implementation strategies addressed individual, clinic, and system-level barriers and facilitated process and policy changes that have enabled PSM sustainment. Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity.

IMPLICATIONS FOR CANCER SURVIVORS

Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity.

Predictors of cancer rehabilitation medicine referral and utilization based on the Moving Through Cancer physical activity screening assessment

PURPOSE

Cancer survivors experience high rates of physical inactivity that often go unaddressed. The My Wellness Check program (MWC) is an EHR-integrated screening and referral system that includes surveillance of physical activity and triage to cancer rehabilitation medicine services. This study examined assessment of physical activity and subsequent referrals to cancer rehabilitation medicine.

METHODS

A secondary analysis was performed for survivors who completed the MWC between April 2021 and January 2022. Univariable and multivariable logistic regression modeled determinants of qualification for a physical activity referral and provider completion of referral to cancer rehabilitation medicine. Referral was based on responses to the Moving Through Cancer questionnaire. Adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI) were calculated.

RESULTS

There were 1,174 survivors who completed the assessment, of which 46% (n = 540) reported physical inactivity. After controlling for group differences, individuals with moderate-severe physical dysfunction (aOR: 1.750; 95% CI: 1.137, 2.693) had higher odds, and self-reporting Hispanic or Latino ethnicity (aOR: 0.720; CI: 0.556, 0.932) had lower odds of physical inactivity. Only 31% (n = 168) received a completed physician referral to cancer rehabilitation medicine following identification of physical inactivity. No patient-level factors were associated with receiving a physician referral. Following referral, 8% (n = 13) utilized cancer rehabilitation medicine services.

CONCLUSIONS

Patient-level and clinical factors may predict qualification for physical activity referrals; however, they don't appear to predict referral completion to cancer rehabilitation medicine. Future research should focus on potential provider- and organization-level factors that interact and influence access to cancer rehabilitation medicine services.

Advancing Pediatric Oncology Rehabilitation: Survey Findings of Health Professionals' Perceptions of Barriers to Care and a Framework for Action

PURPOSE

To explore pediatric oncology referral practices, gather healthcare providers' perspectives of barriers to access and provision of rehabilitation service across Canada, and inform a framework for action to optimize rehabilitation care and inform future research.

METHODS

A cross-sectional survey was conducted with Canadian healthcare professionals (HCPs) working in pediatric oncology.

RESULTS

A total of 54 responses were received, and 34 corresponded to HCPs who refer children with cancer to rehabilitation services. Results suggest that approximately 25% of children are referred to rehabilitation services, primarily when the child presents with, or is at risk of, significant functional disability due to surgery. A primary barrier to service provision identified across HCPs included a lack of funding and resources. Medical professionals further identified a lack of specialized pediatric oncology rehabilitation services, whereas rehabilitation professionals identified the lack of pediatric oncology specific space and equipment. Identified themes from open-ended survey questions include the need for (1) dedicated funding and resources, (2) improved access, and (3) the need for specialized pediatric oncology rehabilitation services.

CONCLUSION

Several barriers exist in the Canadian healthcare context that impact the delivery of rehabilitation services for children with cancer. We propose a framework for action to advance clinical care and guide future research.

Cancer-Related Care Costs and Employment Disruption: Recommendations to Reduce Patient Economic Burden as Part of Cancer Care Delivery

Cancer survivors are frequently unprepared to manage the out-of-pocket (OOP) costs associated with undergoing cancer treatment and the potential for employment disruption. This commentary outlines a set of research recommendations stemming from the National Cancer Institute's Future of Health Economics Research Conference to better understand and reduce patient economic burden as part of cancer care delivery. Currently, there are a lack of detailed metrics and measures of survivors' OOP costs and employment disruption, and data on these costs are rarely available at the point of care to guide patient-centered treatment and survivorship care planning. Future research should improve the collection of data about survivors' OOP costs for medical care, other cancer-related expenses, and experiences of employment disruption. Methods such as microcosting and the prospective collection of patient-reported outcomes in cancer care are needed to understand the true sum of cancer-related costs taken on by survivors and caregivers. Better metrics and measures of survivors' costs must be coupled with interventions to incorporate that information into cancer care delivery and inform meaningful communication about OOP costs and employment disruption that is tailored to different clinical situations. Informing survivors about the anticipated costs of their cancer care supports informed decision making and proactive planning to mitigate financial hardship. Additionally, system-level infrastructure should be developed and tested to facilitate screening to identify survivors at risk for financial hardship, improve communication about OOP costs and employment disruption between survivors and their health-care providers, and support the delivery of appropriate financial navigation services.

A Scoping Review of Food Insecurity and Related Factors among Cancer Survivors

Despite growing awareness of the financial burden that a cancer diagnosis places on a household, there is limited understanding of the risk for food insecurity among this population. The current study reviewed literature focusing on the relationship between food insecurity, cancer, and related factors among cancer survivors and their caregivers. In total, 49 articles (across 45 studies) were reviewed and spanned topic areas: patient navigation/social worker role, caregiver role, psychosocial impacts, and food insecurity/financial toxicity. Patient navigation yielded positive impacts including perceptions of better quality of care and improved health related quality of life. Caregivers served multiple roles: managing medications, emotional support, and medical advocacy. Subsequently, caregivers experience financial burden with loss of employment and work productivity. Negative psychosocial impacts experienced by cancer survivors included: cognitive impairment, financial constraints, and lack of coping skills. Financial strain experienced by cancer survivors was reported to influence ratings of physical/mental health and symptom burden. These results highlight that fields of food insecurity, obesity, and cancer control have typically grappled with these issues in isolation and have not robustly studied these factors in conjunction. There is an urgent need for well-designed studies with appropriate methods to establish key determinants of food insecurity among cancer survivors with multidisciplinary collaborators.

Work- and school-related distress among patients with cancer: Single-site retrospective chart review

OBJECTIVES

To (1) describe the prevalence of work- or school-related distress among patients with cancer and (2) compare overall distress among those impacted at work or school to overall distress among those not impacted at work or school.

DESIGN

Retrospective chart review.

PARTICIPANTS

All patients visiting the study site March 2016-December 2020 who completed the NCCN Distress Thermometer and Problem List.

METHODS

Descriptive statistics examined work- or school-related distress across patient characteristics and compared mean Distress Thermometer scores between patients with and without work- or school-related distress.

FINDINGS

Among 1,760 unique patients, 7.5% reported work- or school-related distress at one or more visits. Rates were highest among patients seen for neurological (14.1%), skin (10.6%), and gastrointestinal (9.2%) cancers. Those reporting work- or school-related distress had higher overall distress scores (mean = 4.76; SD = 2.52) than others (mean = 3.37; SD = 2.92) (g=-0.482; t=-5.327, p < 0.001).

CONCLUSIONS

Although the prevalence of work- or school-related distress was low in this sample, the magnitude of this distress emphasizes the importance of having effective resources available for patients with cancer who experience work- or school-related problems.

IMPLICATIONS

More research is needed to understand how well distress screening processes identify and support patients with work- or school-related problems.

Co-design of a return-to-work intervention after breast cancer treatments: feasibility study protocol (Preprint)

Background

The mortality rate from breast cancer has been declining for many years, and the population size of working-age survivors is steadily increasing. However, the recurrent side effects of cancer and its treatment can result in multiple disabilities and disruptions to day-to-day life, including work disruptions. Despite the existing knowledge of best practices regarding return to work (RTW) for breast cancer survivors, only a few interdisciplinary interventions have been developed to address the individualized needs and multiple challenges of breast cancer survivors, health care professionals, and employer and insurer representatives. Thus, it seems appropriate to develop RTW interventions collaboratively by using a co-design approach with these specific stakeholders.

Objective

This paper presents a protocol for developing and testing an innovative, interdisciplinary pilot intervention based on a co-design approach to better support RTW and job retention after breast cancer treatment.

Methods

First, a participatory research approach will be used to develop the intervention in a co-design workshop with 12 to 20 participants, including people affected by cancer, employer and insurer representatives, and health care professionals. Next, a pilot intervention will be tested in a primary care setting with 6 to 8 women affected by breast cancer. The acceptability and feasibility of the pilot intervention will be pretested through semistructured interviews with participants, health care professionals, and involved patient partners. The transcribed data will undergo an iterative content analysis.

Results

The first phase of the project—the co-design workshop—was completed in June 2021. The pilot test of the intervention will begin in spring 2022. The results from the test will be available in late 2022.

Conclusions

The project will offer novel data regarding the use of the co-design approach for the development of innovative, co-designed interventions. In addition, it will be possible to document the acceptability and feasibility of the pilot intervention with a primary care team. Depending on the results obtained, the intervention could be implemented on a larger scale.

International Registered Report Identifier (IRRID)

DERR1-10.2196/37009

Stakeholder-Identified Interventions to Address Cancer Survivors' Psychosocial Needs after Completing Treatment

The interventions used in cancer-survivorship care do not always address outcomes important to survivors. This study sought to understand stakeholders’ views on the key concerns of cancer survivors after treatment and the interventions needed to meet survivors’ and families’ psychosocial needs after completing cancer treatment. We conducted a descriptive qualitative study using semi-structured interviews with stakeholders (survivors, family/friend caregivers, oncology providers, primary care providers, and cancer system decision-/policy-makers) from across Canada. For the data analysis, we used techniques commonly employed in descriptive qualitative research, such as coding, grouping, detailing, and comparing the data. There were 44 study participants: 11 survivors, seven family/friend caregivers, 18 health care providers, and eight decision-/policy-makers. Stakeholder-relevant interventions to address survivors’ psychosocial needs were categorized into five groups, as follows: information provision, peer support, navigation, knowledge translation interventions, and caregiver-specific supports. These findings, particularly interventions that deliver timely and relevant information about the post-treatment period and knowledge translation interventions that strive to integrate effective tools and programs into survivorship care, have implications for future research and practice.

Factors of decisive importance for being in work or not during two years after breast cancer surgery: content analysis of 462 women's open answers

Background

Paid work is one of the most important aspects in life among working-aged women diagnosed with breast cancer. Despite several attempts, no previous study provides a comprehensive overview from the women’s perspective about factors of importance for being able to work or not. Therefore, the aim of this study was to gain knowledge about factors that women themselves state are of decisive importance for being able to work or not during the first two years after breast cancer surgery.

Methods

Data was collected in a two-year follow-up questionnaire within the frame of a prospective cohort study of working-aged women who had undergone breast cancer surgery. 749 were included in the questionnaire study and of the 616 (82%) responding women, 462 (75%) wrote statements on an open-ended question about factors of decisive importance for being able to work or not work during the past two years. The statements were analyzed with content analysis.

Results

Five categories of factors of importance for being able to  work or not were identified, each covering several sub-categories: Health and wellbeing, Contacts and encounters, Flexibility and adjustment possibilities, Socioeconomic consequences from working/not working, and Own motivation and characteristics. A wide variety of factors were mentioned by the women and the findings give a multifaceted picture of many single but interrelated factors of decisive importance for being able to work/not work. The importance of flexibility in the return-to-work process was stressed, as well as the importance of supportive encounters from, e.g., colleagues, managers, as well as relatives.

Conclusions

The results give a comprehensive overview over a variety of different types of factors for being able to return to/remain in work or to not work after breast cancer surgery, adding new knowledge about e.g. the importance of colleagues, and the women’s own preferences or characteristics. These are factors that different stakeholders, both from healthcare but also from the work place and the insurance office, need to be aware of and collaborate around to support women with breast cancer during the period of treatment, rehabilitation and return to work.

Distinct employment interference profiles in patients with breast cancer prior to and for 12 months following surgery

PURPOSE

To identify subgroups of female breast cancer patients with distinct self-reported employment interference (EI) profiles and determine which demographic, clinical, and symptom characteristics, and quality of life outcomes were associated with subgroup membership.

METHODS

Women with breast cancer (n = 385) were assessed for changes in EI over ten times, from prior to, through 12 months after breast cancer surgery. Latent profile analysis (LPA) was used to identify subgroups of patients with distinct EI profiles.

RESULTS

Three distinct EI profiles (i.e., None - 26.2% (n = 101), Low - 42.6% (n = 164), High - 31.2% (n = 120)) were identified. Compared to the None and Low groups, patients in the High group were more likely to be younger. Higher proportions in the High group were non-White, pre-menopausal prior to surgery, had more advanced stage disease, had received an axillary lymph node dissection, had received neoadjuvant chemotherapy, had received adjuvant chemotherapy, and had a re-excision or mastectomy on the affected breast within 6 months after surgery. In addition, these patients had lower quality of life scores. Compared to the None group, the High group had higher levels of trait and state anxiety, depressive symptoms, fatigue and sleep disturbance and lower levels of cognitive function.

CONCLUSIONS

This study provides new knowledge regarding EI profiles among women in the year following breast cancer surgery. The non-modifiable risk factors (e.g., younger age, being non-White, having more advanced stage disease) can inform current screening procedures. The potentially modifiable risk factors can be used to develop interventions to improve employment outcomes of breast cancer patients.

Late effects of cancer (treatment) and work ability: guidance by managers and professionals

BACKGROUND

The prevalence of the group of workers that had a cancer diagnosis in the past is growing. These workers may still be confronted with late effects of cancer (treatment) possibly affecting their work ability. As little is known about the guidance of this group, the aim of this study was to explore the experiences and ideas of managers and professionals about the guidance of these workers in the case of late effects of cancer (treatment). Given the positive associations with work ability of the job resources autonomy, social support by colleagues and an open organisational culture found in several quantitative studies, these job resources were also discussed. Further ideas about the influences of other factors and points of attention in the guidance of this group of workers were explored.

METHODS

Semi-structured interviews were conducted with managers (n = 11) and professionals (n = 47). Data-collection was from November 2019 to June 2020. The data were coded and analysed using directed content analyses.

RESULTS

The late effects of cancer or cancer treatment discussed were physical problems, fatigue, cognitive problems, anxiety for cancer recurrence, and a different view of life. The self-employed have less options for guidance but may struggle with late effects affecting work ability in the same way as the salaried. Late effects may affect work ability and various approaches have been described. Autonomy, social support of colleagues and an open organisational culture were regarded as beneficial. It was indicated that interventions need to be tailor-made and created in dialogue with the worker.

CONCLUSIONS

Especially with respect to cognitive problems and fatigue, guidance sometimes turned out to be complicated. In general, the importance of psychological safety to be open about late effects that affect work ability was emphasized. Moreover, it is important to take the perspective of the worker as the starting point and explore the possibilities together with the worker. Autonomy is an important factor in general, and a factor that must always be monitored when adjustments in work are considered. There is a lot of experience, but there are still gaps in knowledge and opportunities for more knowledge sharing.

Functional, work-related rehabilitative programming for cancer survivors experiencing cancer-related fatigue

Introduction

Cancer-related fatigue negatively impacts 50–90% of cancer survivors. In North America, approximately 50% of return-to-work interventions initially fail for survivors, with cancer-related fatigue often cited as a barrier to workability. Occupational therapy-driven cancer-related fatigue work-related programming for survivors is sparse, despite many published reviews calling for interdisciplinary interventions; to address work-related performance, specific functional interventions are likely to be needed. Further exploration and a broader understanding of survivors’ cancer-related fatigue management, participation in rehabilitative programmes, and plans for return to work are necessary to target survivor needs better.

Method

Drawing on social theory, this exploratory descriptive study utilised content and thematic analysis of interviews from 12 survivors to explore and describe the perspectives of survivors experiencing cancer-related fatigue yet desiring to work.

Results

Content analysis reflected distinct differences in fatigue-related terminology. Thematic analysis identified three themes specific to cancer-related fatigue and workability: valuing physical wellness, perceived cognitive impacts of cancer-related fatigue on function and workability, and the lack of transition from physical exercise to functional work-related activities.

Conclusion

Survivors identified gaps in care related to managing cognitive symptoms and the need for functional, work-related interventions to manage cancer-related fatigue. With their expertise in function, occupational therapists are well positioned to facilitate work-specific interventions, within cancer-specific exercise programming.

A multidisciplinary working model for promoting return to work of cancer survivors

BACKGROUND

Despite wide recognition of the necessity of an integrative maintenance and return to work (RTW) program for cancer survivors, no such program has been described in the literature.

AIMS

To examine a working model of an integrative multidisciplinary health care approach for promoting RTW, using the Delphi method.

METHODS

A working model for promoting cancer survivors' RTW by oncology health professionals was subjected to two rounds of evaluation by an expert panel in accordance with the Delphi research method. Twenty-six international experts in oncology (social workers, nurses, psychologists, physicians, and cancer patients) participated in the first round and 16 participated in the second round.

RESULTS

The mean score of the working model's applicability was 6.07 (SD = 1.07, range = 1-7). The model outlines in detail an integrative approach for promotion of RTW according to two axes: the oncology health professionals' role and the timeline axis featuring four stages of oncology treatment and follow-up.

CONCLUSIONS

Our proposed model addresses the need for an integrated program that may increase the rate of RTW and improve the quality of life of cancer survivors. The model should be subjected to further evaluation, especially its adaptability to different health systems in different countries.

Factors associated with humanistic burden and indirect cost among patients with cancer in Japan

AIMS

Patients with cancer experienced reduced health-related quality-of-life (HRQoL), increased work productivity and activity impairment (WPAI), and indirect costs. With the current emphasis on economic evaluation of health technology in Japan, it is important to understand how indirect costs correlate with HRQoL and patient characteristics. It is also crucial to assess the patient characteristics associated with the HRQoL, WPAI, and indirect costs among patients with any types of cancer.

MATERIALS AND METHODS

This cross-sectional study used data from the 2017 Japan National Health and Wellness Survey (NHWS). Respondents self-reported their HRQoL and WPAI by answering validated SF-12v2 and WPAI questionnaires, respectively. Indirect costs were derived using the human capital method. Correlation between HRQoL components and indirect costs were assessed using Spearman's rank-order correlation. Correlation between patient characteristics and HRQoL, WPAI, and indirect costs were analyzed using generalized linear models.

RESULTS

A total of 1,540 patients with any types of cancer, 254 with breast cancer, and 144 with colorectal cancer were included in the analyses. There was significant negative correlation between the indirect costs and HRQoL components among patients with any types of cancer. Patients with lower comorbid burden, higher household income, employed, married, or living with partner, never smokers, and exercised tended to have higher HRQoL. Being never smokers, having lower comorbid burden, normal weight, and exercised were associated with lower WPAI measures. Additionally, patients who were older, not married, not obese, and not smoking tended to incur lower indirect costs.

CONCLUSIONS

The negative correlation between HRQoL and indirect costs among patients with cancer emphasized the needs to improve health outcomes and reduce indirect costs of patients. The factors associated with cancer burden identified in this study provide insights to allow targeted intervention to improve HRQoL and lessen the WPAI and indirect cost among cancer patients in Japan.

Can Multidisciplinary Inpatient and Outpatient Rehabilitation Provide Sufficient Prevention of Disability in Patients with a Brain Tumor?-A Case-Series Report of Two Programs and A Prospective, Observational Clinical Trial

Brain tumor (BT) patients have a high incidence of disability due to the effects of the tumor itself or oncological treatment. Despite the incidence of neurological and functional deficits caused by BT, rehabilitation of those patients is not as properly established as in patients with other neurological conditions. The aim of the research was to evaluate the effectiveness of a multidisciplinary rehabilitation, carried out as an out- or in-patient program, as prevention of disability in BT patients. This was developed as a case-series report of two programs and a prospective, observational clinical study in BT patients who were allocated to inpatient (n = 28) or outpatient (n = 26) rehabilitation programs. The patients were assessed using the Barthel Index, Berg Balance Scale, Functional Independence Measure (FIM), Functional Assessment of Cancer Therapy-Brain and Cognitive Function, and Addenbrooke's Cognitive Examination III (ACE III) upon admission and after 12 weeks of rehabilitation. Analysis of the results showed that patients in both programs significantly improved their physical functioning scores in daily activities (p < 0.0001). We also observed significant reductions in most post-intervention cognitive complaints (p < 0.05), except for the FIM social functioning and ACE III language functioning in the outpatient group (p > 0.05) in contrast to inpatients (p < 0.001). This is evidence that early multidisciplinary rehabilitation is an effective therapeutic strategy to reduce BT symptoms and disability in this group of patients.

Factors associated with sleep quality during chemotherapy: An integrative review

Aim

To identify the most important factors associated with sleep pattern changes in patients with cancer during chemotherapy treatment.

Design

An integrative review of the literature was performed between December 2017-August 2018.

Methods

Two independent reviewers searching the National Library of Medicine (PubMed/MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Latin American and Caribbean Literature in Health Sciences (LILACS), Scopus and Scielo. The process followed the recommendations of the PRISMA tool. A total of 16 articles were selected for the final study sample, including 11 cohort studies and 5 cross-sectional studies.

Results

The predisposing factors for the most prevalent sleep disturbances were precipitants related to the disease and the treatment, such as fatigue, pain, depression, anxiety and distress. Predisposing factors related to lifestyle and demographic characteristics have a significant correlation with sleep disturbances.

Employment Outcomes Among Cancer Survivors in the United States: Implications for Cancer Care Delivery

The national prevalence of employment changes after a cancer diagnosis has not been fully documented. Cancer survivors who worked for pay at or since diagnosis (n = 1490) were identified from the 2011, 2016, and 2017 Medical Expenditure Panel Survey and Experiences with Cancer supplement. Analyses characterized employment changes due to cancer and identified correlates of those employment changes. Employment changes were made by 41.3% (95% confidence interval [CI] = 38.0% to 44.6%) of cancer survivors, representing more than 3.5 million adults in the United States. Of these, 75.4% (95% CI = 71.3% to 79.2%) took extended paid time off and 46.1% (95% CI = 41.6% to 50.7%) made other changes, including switching to part-time or to a less demanding job. Cancer survivors who were younger, female, non-White, or multiple races and ethnicities, and younger than age 20 years since last cancer treatment were more likely to make employment changes. Findings highlight the need for patient-provider communication about the effects of cancer and its treatment on employment.

Recommendations for Research and Practice to Improve Work Outcomes Among Cancer Survivors

Major knowledge gaps limit the development and implementation of interventions to improve employment outcomes among people with cancer. To identify research priorities to improve employment outcomes after cancer, the National Cancer Institute sponsored the meeting "Evidence-Based Approaches for Optimizing Employment Outcomes among Cancer Survivors." This article describes research recommendations stemming from the meeting. At the patient level, longitudinal studies are needed to better understand how patient sociodemographic and clinical characteristics and their experiences at work shape employment outcomes. Interventions that mitigate the impact of cancer and its treatment on employment are critical. At the provider-level, future research is needed to characterize the extent to which physicians and other healthcare providers talk to their patients about employment concerns and how that information is used to inform care. Additionally, there is a need to test models of care delivery that support routine screening of employment concerns, the capture of employment outcomes in electronic health records, and the effective use of this information to improve care. At the employer level, evidence-based training programs are needed to prepare supervisors, managers, human resources staff, and occupational health professionals to address health issues in the workplace; and future interventions are needed to improve patient -employer communication and facilitate workplace accommodations. Importantly, research is needed that reflects the perspectives and priorities of patients and their families, providers and healthcare systems, and employers. Transdisciplinary partnerships and stakeholder engagement are essential to ensure that employment-focused interventions and policies are developed, implemented, and sustained in real-world healthcare delivery and workplace settings.

Impact of physical and psychosocial dysfunction on return to work in survivors of oral cavity cancer

OBJECTIVE

To compare the levels of social support, physical function, and social-emotional function between oral cavity cancer survivors who did or did not resume work 6 months or longer after treatment completion.

METHODS

This cross-sectional study examined survivors of oral cavity cancer who were treated at the outpatient radiation department of a medical center in Northern Taiwan. Questionnaires were used to collect data regarding perceived social support, physical function, social-emotional function, and return to work status after treatment. Logistic regression was conducted to determine factors related to returning to work.

RESULTS

We examined 174 survivors of oral cavity cancer, 55.2% of whom returned to work after treatment. Relative to survivors who returned to work, those who did not return to work reported needing greater tangible social support, having fewer positive social interactions, having poorer physical function, and having poorer social-emotional function. Multivariable analysis indicated that younger age (OR = 0.864, P < .05), higher family income (OR = 10.835, P < .05), sufficient tangible social support (OR = 0.943, P < .05), positive social interaction (OR = 1.025, P < .05), and better physical function (OR = 1.062, P < .05) were significantly associated with the return to work.

CONCLUSIONS

Survivors of oral cavity cancer who did not return to work had worse physical and social-emotional function and required more tangible social support and positive social interactions. Providing occupational rehabilitation and counseling for oral cavity cancer survivors may help them return to work.

Best-Evidence Rehabilitation for Chronic Pain Part 2: Pain during and after Cancer Treatment

Pain during, and especially after, cancer remains underestimated and undertreated. Moreover, both patients and health care providers are not aware of potential benefits of rehabilitation strategies for the management of pain during and following cancer treatment. In this paper, we firstly provided a state-of-the-art overview of the best evidence rehabilitation modalities for patients having (persistent) pain during and following cancer treatment, including educational interventions, specific exercise therapies, manual therapies, general exercise therapies and mind-body exercise therapies. Secondly, the findings were summarized from a clinical perspective and discussed from a scientific perspective. In conclusion, best evidence suggests that general exercise therapy has small pain-relieving effects. Supporting evidence for mind-body exercise therapy is available only in breast cancer patients. At this moment, there is a lack of high-quality evidence to support the use of specific exercises and manual therapy at the affected region for pain relief during and after cancer treatment. No clinically relevant results were found in favor of educational interventions restricted to a biomedical approach of pain. To increase available evidence these rehabilitation modalities should be applied according to, and within, a multidisciplinary biopsychosocial pain management approach. Larger, well-designed clinical trials tailored to the origin of pain and with proper evaluation of pain-related functioning and the patient’s pain experience are needed.

Catalyzing Research to Optimize Cancer Survivors' Participation in Work and Life Roles

Participation refers to a state of health in which a person is able to fully engage in roles and life situations. Adults living with and beyond cancer often report persistent participation restrictions that affect their productivity and quality of life. The American Occupational Therapy Foundation convened a group of scientists from seven different disciplines in a Planning Grant Collective (PGC) to stimulate research to identify scalable ways to preserve and optimize participation among cancer survivors. Participants identified challenges, prioritized solutions, and generated novel research questions that move beyond symptom and impairment mitigation as outcomes to identify interventions that improve participation in roles and life situations. This article summarizes the PGC discussion and recommendations regarding three challenges: (a) the dynamic and multi-faceted nature of participation, (b) a need to integrate the concept of participation within the culture of oncology, and (c) identification of priority areas in which new lines of research regarding participation would be most impactful.

Improving body function and minimizing activity limitations in pediatric leukemia survivors: The lasting impact of the Stoplight Program

BACKGROUND

After acute lymphoblastic leukemia (ALL) treatment, children can have persistent muscle weakness, range of motion limitations, and decreased function after treatment. The Stoplight Program (SLP), a proactive physical therapy intervention, was administered as the standard of care during ALL treatment to prevent and minimize these impairments. The purpose of this follow-up study was to measure body function and activity limitations in ALL survivors who completed the SLP and compare them to a pre-SLP control group, thus evaluating the longer term impact of the SLP.

PROCEDURE

Two cohorts of survivors of pediatric ALL ages 5 to 18 years were assessed 18 to 24 months after completing ALL treatment. Measurements included both the body coordination subtest and the strength and agility subtest of the Bruininks-Oseretsky Test of Motor Proficiency, active dorsiflexion range of motion (ADROM), and physical activity by self-report.

RESULTS

The control group and SLP group did not differ in size (n = 15), mean age (9 years), or time off ALL treatment (20 months). The SLP group had better scale scores for bilateral coordination (P = 0.05), running speed/agility (P < 0.01), and strength (P = 0.01). The number of survivors with 5 degrees or greater of ADROM (right) was significantly greater in the SLP group. ADROM had a positive correlation with strength/agility standard score in the combined survivor group.

CONCLUSION

The SLP is a proactive physical therapy intervention that continues to positively impact children after treatment. Referral to physical therapy should be the standard to optimize long-term function.

Implementing personalized pathways for cancer follow-up care in the United States: Proceedings from an American Cancer Society-American Society of Clinical Oncology summit

A new approach to cancer follow-up care is necessary to meet the needs of cancer survivors while dealing with increasing volume and provider shortages, knowledge gaps, and costs to both health care systems and patients. An approach that triages patients to personalized follow-up care pathways, depending on the type(s) and level(s) of resources needed for patients' long-term care, is in use in the United Kingdom and other countries and has been shown to meet patients' needs, more efficiently use the health care system, and reduce costs. Recognizing that testing and implementing a similar personalized approach to cancer follow-up care in the United States will require a multipronged strategy, the American Cancer Society and the American Society of Clinical Oncology convened a summit in January 2018 to identify the needed steps to move this work from concept to implementation. The summit identified 4 key strategies going forward: 1) developing a candidate model (or models) of care delivery; 2) building the case for implementation by conducting studies modeling the effects of personalized pathways of follow-up care on patient outcomes, workforce and health care resources, and utilization and costs; 3) creating consensus-based guidelines to guide the delivery of personalized care pathways; and 4) identifying and filling research gaps to develop and implement needed care changes. While these national strategies are pursued, oncology and primary care providers can lay the groundwork for implementation by assessing their patients' risk of recurrence and the chronic and late effects of cancer as well as other health care needs and resources available for care and by considering triaging patients accordingly, referring patients to appropriate specialized survivorship clinics as these are developed, helping to support patients who are capable of self-managing their health, setting expectations with patients from diagnosis onward for the need for follow-up in primary care and/or a survivorship clinic, and improving coordination of care between oncology and primary care.

Follow the trail: Using insights from the growth of palliative care to propose a roadmap for cancer rehabilitation

Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.

Equitably improving outcomes for cancer survivors and supporting caregivers: A blueprint for care delivery, research, education, and policy

Cancer care delivery is being shaped by growing numbers of cancer survivors coupled with provider shortages, rising costs of primary treatment and follow-up care, significant survivorship health disparities, increased reliance on informal caregivers, and the transition to value-based care. These factors create a compelling need to provide coordinated, comprehensive, personalized care for cancer survivors in ways that meet survivors' and caregivers' unique needs while minimizing the impact of provider shortages and controlling costs for health care systems, survivors, and families. The authors reviewed research identifying and addressing the needs of cancer survivors and caregivers and used this synthesis to create a set of critical priorities for care delivery, research, education, and policy to equitably improve survivor outcomes and support caregivers. Efforts are needed in 3 priority areas: 1) implementing routine assessment of survivors' needs and functioning and caregivers' needs; 2) facilitating personalized, tailored, information and referrals from diagnosis onward for both survivors and caregivers, shifting services from point of care to point of need wherever possible; and 3) disseminating and supporting the implementation of new care methods and interventions.

Patient and provider communication about employment following a cancer diagnosis

PURPOSE

Cancer treatment can precipitate functional limitations that restrict survivors' ability to work. Yet, it is unclear whether healthcare providers discuss the potential for employment limitations with their patients. We assessed the frequency of patient-provider communication about employment, from the perspectives of survivors, and examined whether receiving a treatment summary was associated with employment communication.

METHODS

Cancer survivors who were working at diagnosis were identified from the Health Information National Trends Survey-4, conducted in 2014 (n = 290). Separate multivariable regression analyses examined the associations between survivor characteristics and employment communication and receipt of a treatment summary and employment communication.

RESULTS

Among cancer survivors who were working at diagnosis, 62.69% (95% CI 54.42-70.95) reported discussing employment with any healthcare provider at any time since diagnosis. Younger cancer survivors and those more recently treated were more likely to ever have employment discussions. Survivors who received a treatment summary were also more likely to ever discuss employment with any healthcare provider than survivors who did not receive a treatment summary (OR = 3.47, 95% CI 1.02-11.84).

CONCLUSIONS

Approximately two thirds of cancer survivors who were working at diagnosis ever discussed employment with a healthcare provider. Thus, for a sizable portion of cancer survivors, the potential impact of cancer on employment is never discussed with any healthcare provider.

IMPLICATIONS FOR CANCER SURVIVORS

Efforts are needed to proactively screen patients for cancer-related work limitations, empower patients to discuss employment concerns with their healthcare providers, and develop interventions that support survivors' goals for working throughout treatment and recovery.

A Bibliometric Analysis of the Landscape of Cancer Rehabilitation Research (1992-2016)

Cancer rehabilitation research has accelerated as great attention has focused on improving survivorship care. Recent expert consensus has attempted to prioritize research needs and suggests greater focus on studying physical functioning of survivors. However, no analysis of the publication landscape has substantiated these proposed needs. This manuscript provides an analysis of PubMed indexed articles related to cancer rehabilitation published between 1992 and 2017. A total of 22 171 publications were analyzed using machine learning and text analysis to assess publication metrics, topic areas of emphasis, and their interrelationships through topic similarity networks. Publications have increased at a rate of 136 articles per year. Approximately 10% of publications were funded by the National Institutes of Health institutes and centers, with the National Cancer Institute being the most prominent funder. The greatest volume and rate of publication increase were in the topics of Cognitive and Behavioral Therapies and Psychological Interventions, followed by Depression and Exercise Therapy. Four research topic similarity networks were identified and provide insight on areas of robust publication and notable deficits. Findings suggest that publication emphasis has strongly supported cognitive, behavioral, and psychological therapies; however, studies of functional morbidity and physical rehabilitation research are lacking. Three areas of publication deficits are noted: research on populations outside of breast, prostate, and lung cancers; methods for integrating physical rehabilitation services with cancer care, specifically regarding functional screening and assessment; and physical rehabilitation interventions. These deficits align with the needs identified by expert consensus and support the supposition that future research should emphasize a focus on physical rehabilitation.

Impact of sociodemographic characteristics on underemployment in a longitudinal, nationally representative study of cancer survivors: Evidence for the importance of gender and marital status

BACKGROUND

We examined the longitudinal association between sociodemographic factors and an expanded definition of underemployment among those with and without cancer history in the United States.

METHODS

Medical Expenditure Panel Survey data (2007-2013) were used in multivariable regression analyses to compare employment status between baseline and two-year follow-up among adults aged 25-62 years at baseline (n = 1,614 with and n = 39,324 without cancer). Underemployment was defined as becoming/staying unemployed, changing from full to part-time, or reducing part-time work significantly. Interaction effects between cancer history/time since diagnosis and predictors known to be associated with employment patterns, including age, gender/marital status, education, and health insurance status at baseline were modeled.

RESULTS

Approximately 25% of cancer survivors and 21% of individuals without cancer reported underemployment at follow-up (p = 0.002). Multivariable analyses indicated that those with a cancer history report underemployment more frequently (24.7%) than those without cancer (21.4%, p = 0.002) with underemployment rates increasing with time since cancer diagnosis. A significant interaction between gender/marital status and cancer history and underemployment was found (p = 0.0004). There were no other significant interactions. Married female survivors diagnosed >10 years ago reported underemployment most commonly (38.7%), and married men without cancer reported underemployment most infrequently (14.0%). A wider absolute difference in underemployment reports for married versus unmarried women as compared to married versus unmarried men was evident, with the widest difference apparent for unmarried versus married women diagnosed >10 years ago (18.1% vs. 38.7%).

CONCLUSION

Cancer survivors are more likely to experience underemployment than those without cancer. Longer time since cancer diagnosis and gender/marital status are critical factors in predicting those at greatest risk of underemployment. The impact of cancer on work should be systematically studied across sociodemographic groups and recognized as a component of comprehensive survivorship care.