Incorporating a physiatrist into a palliative care team adds further expertise to the management of patients with often-complex care needs.
—Sean Smith, MD
The role of a physical medicine and rehabilitation physician at cancer centers continues to grow, as survivors live longer and national cancer organizations advocate for more rehabilitation services throughout the continuum of survivorship care. Working with physiatrists at your institution can help improve access to necessary patient care services and maintain compliance with the 2012 accreditation standards for oncology practices issued by the American College of Surgeons’ Commission on Cancer (CoC), the most recent provisions of which took effect in January 2015. The CoC’s new Cancer Program Standards call for several additional patient-centered standards, including improved access to different services, proper symptom screening assessment, and the potential integration of multidisciplinary care into survivorship care plans.
This article launches the Physiatry in Oncology column, which will explore the benefits of physiatric services for individuals with a history of cancer. In this article, I provide actionable ways that physical medicine and rehabilitation practices can be integrated into cancer centers and comply with the CoC guidelines. Future columns will address specific cancer diagnoses and the physical and cognitive impairments that survivors may face as a result, with the goal of encouraging collaboration between members of interdisciplinary care teams to improve patient care.
Role of Rehabilitation in Cancer Care
Many organizations are recognizing the need for cancer rehabilitation and are integrating this service into their guidelines and recommendations. The CoC’s Cancer Program Standards mandate that all cancer centers have a policy or procedure in place to access rehabilitation services for accredited centers and that patients are appropriately screened and referred for ancillary and supportive care services.1
The American Cancer Society also explicitly recognizes and advocates for impairment-driven rehabilitation services and emphasizes the identification and treatment of specific impairments that decrease physical, cognitive, or psychosocial functioning.2 Physiatrists are trained in the treatment of disorders related to the nerves, muscles, bones, and brain and provide care that is distinct from what could be accomplished through routine exercise programs or referrals to a physical therapist, because the complexity and constellation of patients’ symptom burden often necessitate a more comprehensive approach to care.3
Other cancer survivorship organizations such as Livestrong also recognize the benefits that physical medicine and rehabilitation services provide, and the push to integrate these services into oncologic care is continuing to gain momentum. Working with a physical medicine and rehabilitation department or provider can help ensure a seamless transition for survivors into this now-mandatory component of care.
Physiatrists and Symptom Management
Cancer centers are required to provide palliative care services to their patients for both pain and nonpain symptom management. While it is not mandated that cancer centers have a dedicated clinic for these services, those centers that do should consider having a physiatrist as a member of their multidisciplinary care team.
Although a palliative care–trained oncologist has valuable skills in pain management and the diagnosis of disease progression or recurrence, a physiatrist has expertise in diagnosing and managing the musculoskeletal and neurologic deficits that a patient with cancer may face as a result of the disease and/or its treatment. Co-managing patient care with a physiatrist and/or triaging patients to a physiatrist can optimize their care.
At my institution, the University of Michigan Comprehensive Cancer Center, a physiatrist is present on one of the three weekly clinic days. Patients are referred to the clinic by an oncologist and, if appropriate, evaluated by a physiatrist either independent of or in conjunction with the medical oncology symptom management providers in the clinic. Examples of typical reasons for referrals to the physical medicine and rehabilitation clinic include the alleviation of back pain, peripheral joint pain and restriction, neuropathy, and generalized debility.
Rehabilitation Specialists on Hospital Committees
The CoC’s Cancer Program Standards mandate that an Integrated Network Cancer Program in hospitals—which is characterized by a unified cancer committee, standardized registry operations with a uniform data repository, and coordinated service locations and practitioners—have a rehabilitation representative on its cancer committee. The new standards also strongly recommend that comprehensive cancer centers have one on their cancer committee as well. (For additional information, visit www.facs.org/quality%20programs/cancer/accredited/incp.)
While the CoC’s standards do not specify that the rehabilitation representative must be a physiatrist, consideration should be given to inviting a physical medicine and rehabilitation physician onto the committee whenever possible. The physiatrist’s medical background and role in the rehabilitation setting as a team leader make him or her uniquely suited to managing the complex interdisciplinary nature of cancer rehabilitation.
Survivorship Care Plans
The CoC’s new guidelines also require that survivorship care plans be a mandatory component of oncology care and be provided to patients after completion of acute treatment for malignancy. In addition to summarizing oncologic treatment to date, these plans must provide patients with a follow-up plan to monitor recurrences and long-term or late treatment side effects, including problems with cognition, pain, muscle weakness, fatigue, anxiety, and depression, which may impact patients’ physical and mental function.
Survivorship care plans should also include either a follow-up appointment with a physical medicine and rehabilitation physician or information about how to get a referral to one if needed. Appropriate screening for symptoms and subsequent referral to a physiatrist if indicated, satisfy eligibility requirements for cancer center accreditation and, more importantly, reduces the risk that patients’ symptoms will go unaddressed.
Integrating Rehabilitation Into Palliative Care
The goal of inpatient cancer rehabilitation is to discharge a patient back home safely and efficiently and transition the patient to the outpatient setting for symptom management if necessary. Consulting with a physiatrist should be considered if a patient is not functionally able to return home—for example, if the patient is at risk for falls, has neurologic bowel or bladder deficits, or is simply unable to care for himself or herself.
Physiatrists can also provide survivors in the palliative care setting with recommendations for proper equipment for walking, such as wheelchairs, canes, or walkers; orthotics; home-based exercises to improve mood and physical function; and interventions for pain. Incorporating a physiatrist into a palliative care team adds further expertise to the management of patients with often-complex care needs. ■
Disclosure: Dr. Smith reported no potential conflicts of interest.
1. American College of Surgeons Commission on Cancer: Cancer Program Standards 2012: Ensuring Patient-Centered Care, V1.2.1. Chicago, American College of Surgeons, 2012.
2. American Cancer Society: Cancer Treatment and Survivorship Facts & Figures 2014-2015. Atlanta, American Cancer Society, 2014.
3. Silver JK, Baima J, Mayer S: Impairment-driven cancer rehabilitation: An essential component of quality care and survivorship. CA Cancer J Clin 63:295-317, 2013.
Physiatry in Oncology explores the benefits of cancer rehabilitation in oncology clinical practice to screen survivors for physical and cognitive impairments along the care continuum to minimize survivors’ disability and maximize their quality of life. The column is guest edited and occasionally written by Sean Smith, MD, Director of the Cancer Rehabilitation Program at the University of Michigan Department of Physical Medicine and Rehabilitation in Ann Arbor.