In August 2016, the Healthcare Delivery Research Program of the Division of Cancer Control and Population Sciences at the National Cancer Institute convened a group of experts in a variety of fields to identify a research agenda for optimizing employment outcomes among cancer survivors. A core question asked of the attendees during the 2-day roundtable meeting was: What types of interventions are needed to prevent and/or mitigate work limitations among cancer patients and survivors?
The rehabilitation perspective is important to consider in discussions regarding employment outcomes following a cancer diagnosis, and several experts in physical medicine and rehabilitation were invited to participate in this important meeting. Some of what was shared with the group is that cancer and its treatment have the potential to cause serious impairment to various systems in the body.1 Moreover, it is not uncommon for patients to develop multiple physical, psychological, or cognitive impairments at the same time. Frequently, before cancer treatment even begins, patients may be dealing with some type of physical or psychological issue that may be compounded by their treatment as well as the creation of new problems during and after treatment. These impairments, even subtle ones, may lead to lost time from work or the inability to return to gainful employment at all.
Prehabilitation and rehabilitation approaches may reduce the incidence and severity of impairments and subsequent employment-related disability in cancer survivors.— Julie Silver, MD
It is impossible to tackle work limitations caused by cancer and its treatment without rehabilitation. A report by Silver et al2 defined cancer rehabilitation as “medical care that should be integrated throughout the oncology care continuum and delivered by trained rehabilitation professionals who have it within their scope of practice to diagnose and treat patients’ physical, psychological, and cognitive impairments in an effort to maintain or restore function, reduce symptom burden, maximize independence, and improve quality of life in this medically complex population.”
Ongoing Physical and Cognitive Dysfunction
To illustrate some of the many complicated relationships that a cancer diagnosis may have on survivors, it’s helpful to consider the female breast cancer population. Although breast cancer survivors in the United States tend to have a high return to work rate (93% according to one review3), it doesn’t mean these survivors are not coping with ongoing issues. Persistent arm and shoulder impairments are well documented in this population, and one review reported that the main risk factors for pain were radiation treatments and hormonal therapy.4 For example, aromatase inhibitors may cause arthralgias and tendinopathies of the hand and wrist, such as trigger finger—a condition in which a finger gets stuck in a flexed position—affecting upper body morbidity.5
It is estimated that between 10% and 64% of women report upper body symptoms from 6 months to 3 years following cancer treatment, with an incidence of lymphedema around 20%.6 Collectively, the symptoms causing upper body morbidity are associated with lost time from work.7 In addition, cluster symptoms, such as pain, insomnia, fatigue, and anxiety, may also negatively impact breast cancer survivors’ work attendance and/or performance.8
Cancer prehabilitation, a process on the continuum of care between a cancer diagnosis and treatment that establishes a patient’s baseline functional level with the goal of lessening the severity of treatment-related problems, and rehabilitation interventions may improve work-related outcomes.9,10 These interventions generally involve an interdisciplinary team of rehabilitation professionals, including physiatrists, as well as physical, occupational, and speech therapists; psychologists; rehabilitation nurses; orthotists; and others, to provide care.
Avoiding Potential Problems at Each Stage
Before treatment begins, physicians should address with patients not only the effect of therapies on the cancer, but the associated potential physical and cognitive impairments and subsequent disability that might result from the treatment as well. Discussions about cancer treatment should take into account employment factors and encourage an active shared decision-making approach between physician and patient. Plastic surgeons should ensure that conversations with patients about breast reconstruction are not overly focused on cosmesis and include a robust discussion of the potential physical impairments, function, and disability that may result from the surgery.
At diagnosis, patients should be screened for preexisting physical, psychological, and cognitive impairments. The prospective surveillance model is well documented in the breast cancer literature.11 Screening for upper body morbidity is essential, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure tool has been suggested in this population.12
Prior to Starting Treatment
Before treatment begins, there is often an opportunity to prevent or reduce the incidence of future impairments with targeted interventions. It’s important to note that prehabilitation therapy is not the same as general exercise routines. In fact, engaging in aerobic exercise likely will not impact upper body morbidity and disability in this patient population.
Prehabilitation approaches should target the specific impairments that breast cancer survivors encounter and seek to reduce them. Consultation by a physiatrist may be helpful in obtaining a comprehensive neuromusculoskeletal history and physical exam of the patient and looking for findings that may help to document current functional status as well as to anticipate future impairments and disability.
During and After Treatment
Patients who have been screened and identified as having physical and/or cognitive impairments should ideally be referred to a physiatrist, who is expert in managing pain and other symptoms, for further evaluation and the development of a rehabilitation treatment plan. Physiatrists routinely perform procedures that improve impairments and disability, such as muscular trigger point or botulinum toxin injections or corticosteroid injections in joints. These types of injections may be helpful in breast cancer survivors who have upper quadrant morbidity, including adhesive capsulitis, cervical radiculopathy, axillary web syndrome, radiation plexopathy, rotator cuff impingement, and myofascial pain.
For example, a woman who has rotator cuff impingement may benefit from a corticosteroid injection in the shoulder to reduce pain and associated inflammation, followed by physical therapy to improve range of motion and strength. This combination of treatment may cure the rotator cuff impingement. Once free of pain, the patient may sleep better and have less fatigue at work. Reduced fatigue and pain may result in less anxiety. Thus, the cluster of symptoms is effectively treated.
Of course, performing an injection in the shoulder should be weighed against the risk of lymphedema. Corticosteroid injections in the shoulder are not absolutely contraindicated in patients with breast cancer, but the physiatrist should carefully consider the benefits vs the risks of this therapy. Considerations should include whether the rotator cuff impingement occurred on the ipsilateral or contralateral side of the cancer and what oncology treatment the patient has had to date.
The physiatrist should also consider the physical examination and associated diagnostic findings, such as is there evidence of significant loss of range of motion and is the diagnosis of adhesive capsulitis present?
If the patient is disabled and cannot work, and it is documented that she is having difficulty performing basic activities of daily life, such as pulling a shirt over her head or blow-drying her hair, and/or performing instrumental activities of daily living, such as reaching for items on the top shelves in her kitchen, more aggressive treatment may be warranted.
Sean Smith, MD
Reducing Treatment-Related Disability
Prehabilitation and rehabilitation approaches may reduce the incidence and severity of impairments and subsequent employment-related disability in cancer survivors.11,12 Based on the current evidence, screening patients with breast cancer—as well as other cancer patients—and referring those with physical or cognitive impairments for rehabilitation intervention should be the standard of care. Prehabilitation literature in this patient population is sparse and provides an opportunity for more robust research. Employment status should be considered and tracked for every patient, and shared decision-making should include discussions on impairments, disability, and work function. ■
Disclosure: Dr. Silver reported no potential conflicts of interest.
Dr. Silver is Associate Professor and Associate Chair for Strategic Initiatives in the Department of Physical Medicine and Rehabilitation at Harvard Medical School. She also is a staff physiatrist at Spaulding Rehabilitation Network in Boston, Massachusetts.
1. Silver JK, Baima J, Mayer RS: Impairment-driven cancer rehabilitation: An essential component of quality care and survivorship. CA Cancer J Clin 63:295-317, 2013.
2. Silver JK, Raj VS, Fu JB, et al: Cancer rehabilitation and palliative care: Critical components in the delivery of high-quality oncology services. Support Care Cancer 23:3633-3643, 2015.
3. Islam T, Dahlui M, Majid HA, et al: Factors associated with return to work of breast cancer survivors: A systematic review. BMC Public Health 14(suppl 3):S8, 2014.
4. Hidding JT, Beurskens CH, van der Wees PJ, et al: Treatment related impairments in arm and shoulder patients with breast cancer: A systematic review. PLoS One 9:e96748, 2014.
5. Kirchgesner T, Larbi A, Omoumi P, et al: Drug-induced tendinopathy: From physiology to clinical applications. Joint Bone Spine 81:485-492, 2014.
6. Hayes SC, Johansson K, Stout NL, et al: Upper-body morbidity after breast cancer: Incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care. Cancer 118(8 suppl):2237-2249, 2012.
7. Wennman-Larsen A, Alexanderson K, Olsson M, et al: Sickness absence in relation to breast and arm symptoms shortly after breast cancer surgery. Breast 22:767-772, 2013.
8. Silver JK: Cancer rehabilitation and prehabilitation may reduce disability and early retirement. Cancer 120:2072-2076, 2014.
9. Silver JK, Baima J: Cancer prehabilitation: An opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil 92:715-727, 2013.
10. Silver JK, Baima J, Newman R, et al: Cancer rehabilitation may improve function in survivors and decrease the economic burden of cancer to individuals and society. Work 46:455-472, 2013.
11. Stout NL, Binkley JM, Schmitz KH, et al: A prospective surveillance model for rehabilitation for women with breast cancer. Cancer 118(8 suppl):2191-2200, 2012.
12. Harrington S, Michener LA, Kendig T, et al: Patient-reported upper extremity outcome measures used in breast cancer survivors: A systematic review. Arch Phys Med Rehabil 95:153-162, 2014.