Prescribing a New Kind of Rehab for Cancer Survivors
By LAURA LANDRO
Patients who undergo cardiac-bypass or joint-replacement surgery routinely are given specific guidance to the exercises and therapies they will need to return to their everyday activities and to prevent complications or relapse.
For cancer patients, the story is very different.
After undergoing often harsh and debilitating treatments, there is often little help for their return to normal life.
Now, an increasing number of hospitals are offering programs to provide cancer patients with comprehensive rehabilitation services, amid mounting evidence that these can help speed recovery, shorten hospital stays and improve quality of life.
Rehabilitation services are "an absolutely essential part of cancer care," says Dan McKellar, chairman of the Commission on Cancer. Last year the nonprofit standards-setting group, overseen by the American College of Surgeons, began requiring cancer programs to offer rehabilitation services to be eligible for accreditation. Major cancer centers are taking steps to better coordinate rehabilitation after treatment. And Medicare and most insurance companies are covering such services.
Doctors who specialize in rehabilitation medicine can evaluate patients for fatigue, pain, anemia and decreased endurance that result from chemotherapy, radiation and surgery. They can then prescribe physical and occupational therapy, as well as treatment for sleep problems, depression and cognitive impairment. Dietitians help with nutrition, as cancer can change the way the body uses food and patients often lose their appetite from treatment. Some institutions offer massage and yoga.
More than a third of the nation's 12.6 million cancer survivors had physical or mental health problems that put their overall health in jeopardy and had a negative impact on their quality of life, according to a recent study of federal health data funded by the National Cancer Institute. While patients may get emotional help from friends, family and support groups, physical problems may get scant attention once they are no longer in the care of oncologists and surgeons.
"When cancer patients are diagnosed, everyone sits down to look at the case, decide what to do and convey that plan to the patient, but the same sort of process doesn't happen for survivors of the treatment," says Kathryn Weaver, lead author of the study and an assistant professor at Wake Forest Baptist Medical Center in Winston-Salem, N.C. Patients, she adds, may feel their physical problems are "the new normal" and may not ask their doctors for help. And even though most hospitals have rehabilitation services, there may not be a formal program to identify cancer-patient needs or coordinate a care plan among different therapists.
One model being adopted by hospitals, including Johns Hopkins in Baltimore, M.D. and Bon Secours St. Francis Health System in Greenville, S.C., is called STAR, for Survivorship Training and Rehab. It uses specially trained teams of caregivers, coordinated by navigators such as nurses, to help patients with physical and emotional issues, as well as any other concerns that arise.
In 2011, Dan Yarborough, a 67-year-old attorney, had two stem cell transplants within months of each other and high-dose chemotherapy to treat multiple myeloma, a form of blood cancer, at Bon Secours. The treatments left him weak and fatigued, with pain and numbness in his feet that threw off his balance and left him unable to walk steadily and unable to stop himself from falling if he tripped. Golf and travel, favorite pastimes, were out of the question, and he was worried about being able to argue his cases standing in court.
While hospitalized for his second transplant, a nurse navigator from the hospital's STAR program set him up with regular physical therapy appointments and nutrition counseling. Staffers helped him establish goals such as improving his ability to get in and out of his SUV, and worked with his doctors to change medications that were linked to his foot problems.
The program was "incredibly valuable," Mr. Yarborough says, giving him back the stamina to return to work. He is following up with a recommended exercise program at a medical fitness facility owned by the hospital where his exercise plan is overseen by a STAR-certified physiologist for a $30-per-month fee.
The Bon Secours STAR team also deals with specific issues such as helping head and neck cancer patients restore normal functions of swallowing, speech and movement after treatment. "In a lot of hospitals you will see these patients fall through the cracks after surgery, so their cancer is gone but they can't turn their neck to drive a car," says Lori McKitrick, a speech therapist who oversees the program. "We are doing a great job saving people's lives but we have to help them live their lives too."
Julie Silver, an assistant professor at Harvard Medical School and expert in rehabilitation medicine, developed STAR after her own treatment for breast cancer, which she says left her too sick to care for her family or return to work. Her oncologist suggested she rest and try to heal on her own, but "it left me thinking there has to be a better way," Dr. Silver says. "Every cancer survivor should have the opportunity to heal as well as possible and function at optimal level whether their cancer is cured, in remission or they live with cancer as a chronic disease," Dr. Silver says.
She started a company, Oncology Rehab Partners, which helps health systems and hospitals create their own STAR programs for many types of cancer. STAR certification is used by insurance companies in reimbursement decisions. The program costs a typical hospital about $25,000 to launch with an annual fee of $10,000 for continuing education and recertification, Dr. Silver says.
Michelle Houle, 45, has been participating in the STAR program at Bon Secours since she was diagnosed with breast cancer in 2010. After chemotherapy, a bilateral mastectomy and radiation, Ms. Houle, on long-term disability from her job as a food company shelf manager, says she felt "about 90 years old." Nurse navigators at the hospital set her up with a specialist to help prevent lymphedema, a painful swelling of the lymph nodes and a common side effect of breast surgery, and she began a physical therapy regimen.
Ms. Houle suffered a recurrence in 2011 and is now on another chemotherapy regimen, but keeps up her exercises at the hospital's medical fitness facility. She is slowly returning to activities like gardening and housework. The rehabilitation program provides "a base to keep you going," she says, "and there is always someone to talk to if I'm feeling side effects."
Signature Healthcare in Brockton, Mass, which includes Brockton Hospital and 150 employed doctors, treats local cancer patients and those who have had treatment at major centers in Boston, then return home for follow-up with difficult physical aftereffects. Last week, it launched its own STAR program after 23 staffers went through six months of training and received STAR certification. "These needs have been unmet for such a long period of time, and they are very excited to be able to offer this enhanced level of service" says Linda McAlear, the program's coordinator.
A version of this article appeared January 29, 2013, on page D1 in the U.S. edition of The Wall Street Journal, with the headline: Prescribing a New Kind of Rehab for Cancer Survivors.
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