Cancer Prehabilitation

15-48 Cancer Prehabilitation

Nancy Benson: Back in 2003, Dr. Julie Silver was like many women — a wife and working mom with three small children. Then one more thing was put on her plate — a breast cancer diagnosis. It was caught early, but her treatment progressed as it does for many cancer survivors.

Julie Silver: So I actually felt really good in the beginning and really terrible at the end. My oncologist told me, “Go home and try to heal and when you’re ready try to go back to work if you can.” And I was never offered any type of help like rehabilitation to heal.

Benson: Silver is Associate Professor of Physical Medicine and Rehabilitation at the Harvard Medical School. And as far as she’s concerned, treating someone without considering a rehab program seems like incomplete care. Doctors prescribe rehabilitation routinely for many other conditions. So why not cancer?

Silver: We certainly do for people who have strokes. We certainly do for people who are in car accidents or have orthopedic surgery, such as total hip replacements or knee replacements. And we even offer rehabilitation for people with sports injuries. So the idea of not offering rehabilitation or offering very little doesn’t make a lot of sense.

Benson: Ever since her own illness, Silver has been pushing for doctors to include rehab for cancer patients, and created the STAR program for certification of oncology rehab. She says doing cancer rehabilitation right involves treatment tailored to the patient. And it’s much more than a lifestyle adjustment.

Silver: So for example, if we say exercise is good for cancer survivors, that’s a lifestyle intervention and that’s very important, but that is different than saying therapeutic exercise that is prescribed by a physical therapist will help this woman who just had a mastectomy lift her arm overhead so that she can now use her arm better and have less pain. So that’s very different. When we talk about rehabilitation that includes exercise, but includes a lot of other things that are designed to treat impairment that can include medication, injections, physical therapy, occupational therapy, speech therapy for swallowing and speech disorders, cognitive rehabilitation to help with memory, concentration, attention, focus,s and things like that — when we talk about that what we’re really talking about is treating specific impairment that are caused by the cancer or the cancer treatment.

Benson: Without rehab, cancer therapy can cause pain, fatigue, sleep problems, sexual dysfunction, anxiety and depression. And those symptoms can last a lifetime. In fact, Silver says physical disability is the number one reason for distress among cancer survivors. But she says if we know those difficulties are possible as a result of treatment, it gives rehab specialists a chance to prevent them. She advocates beginning rehabilitation immediately after diagnosis, before cancer treatment even starts. Silver calls it “prehabilitation.”

Silver: Prehabilitation is on the rehabilitation care continuum at the very beginning when someone is newly diagnosed with cancer and is about ready to begin treatments. So in prehab there’s actually this window of time between diagnosis and the start of cancer treatments when we potentially can offer specific assessments and interventions that can help people to improve their physical and psychological health outcomes. An example of prehab would be in men newly diagnosed with prostate cancer. We know that very specific pelvic floor exercises can help improve urinary continence after surgery, so since we have this research that shows that these very specific exercises can help post operatively, if they are done pre-operatively, then it makes a lot of sense to do that as a prehab intervention.

Benson: Silver says prehabilitation has been used with heart patients, orthopedic patients, and in geriatrics for more than 50 years. It’s based on anticipation of a coming stressor.

Silver: I really think of prehab as offering someone an umbrella before they go into the storm. You’re not going to protect them from the storm completely, but what you’re trying to do is figure out what will really help as they go into the storm to get them through it better.

Benson: Silver’s review article on cancer prehabilitation in the American Journal of Physical Medicine and Rehabilitation finds that prehab improves cancer patients’ health and stamina, helps prevent complications, and can even open the door to treatment options that otherwise wouldn’t be available. That’s why she says prehab screening should occur immediately upon a cancer diagnosis.

Silver: Let’s say that we have a newly diagnosed women with breast cancer and she is going to have a mastectomy and she can’t reach her arm up over her head right now. She’s going to end up at some point later after the surgery with radiation therapy and we know that the surgery may further limit her arm range of motion. So after the surgery she’ll have even less range of motion than she had pre-operatively and pre-operatively she had a problem. And then by the time she gets to having the radiation therapy they can’t even get her arm positioned well enough to deliver that cancer treatment. So that’s a big problem. If this was identified early, she probably could have had minimal interventions — physical therapy or occupational therapy — before she had surgery to get her arm moving well, and then a follow through with her cancer treatments and been much better off.

Benson: However, that doesn’t mean patients should delay cancer treatment to get prehabilitation.

Silver: There does need to be a balance between delaying treatment and offering prehab interventions. In general, delays are not ideal, so what I recommend is that people talk to their oncologists, but that they really don’t want their treatment delayed. What you’re trying to do is use that window of time between diagnosis and the start of treatment. This usually exists because people are waiting to get on a surgical schedule, or they might be getting second or third opinions, or they may be waiting for other tests and they’re sitting at home thinking, Is there anything I can do right now to help myself? So the idea of prehab is to use that period of time when other things might be happening to get yourself ready for upcoming treatment.

Benson: Silver says it takes surprisingly little time to do that.

Silver: You might need a week or two weeks or three weeks. Maybe you have more time depending on what’s happening with your surgery or your chemotherapy schedule or your second or third opinions, but often you really don’t need that much time to see some effect. Prehab doesn’t have to be completely isolated from the rest of treatment; it’s just the beginning of the rehabilitation continuum.

Benson: Silver says many hospitals offer some form of cancer prehabilitation more informally, and it’s often covered by insurance. But she says much more research is needed to guide the most productive approach, because the need will only increase. You can find out more about cancer prehabilitation online at oncology-rehab-partners-dot-com, then click on “survivors.” our production director is Sean Waldron. I’m Nancy Benson.