Rehabilitation of Individuals with Cancer

Published on 04/03/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1337 times

Rehabilitation of Individuals with Cancer

R. Samuel Mayer

Summary of Key Points

• As cancer treatment improves, more patients are living longer with functional limitations, and quality of life issues become as important as survival.

• Rehabilitation must be patient centered and goal oriented. It requires an interdisciplinary team and the active participation of the patient.

• Impairments, activity limitations, and participation restrictions from cancer dramatically impact quality of life but are amenable to rehabilitation efforts.

• The focus of rehabilitation varies with the phase of the disease process.

• Important impairments include pain, fatigue, cognitive dysfunction, mood disorders, paresis, feeding difficulties, bone and soft tissue involvement, and bladder, bowel, and sexual dysfunction.

• Activity limitations can be ameliorated with training in activities of daily living, exercise, and adaptive equipment.

• Participation in home, vocational, and recreational activities plays a critical role in quality of life. Economic burdens, environmental barriers, and transportation problems often need to be addressed.

Introduction

The National Cancer Institute Dictionary of Cancer Terms defines rehabilitation as “a process to restore mental and/or physical abilities lost to injury or disease, in order to function in a normal or near-normal way.”1 Rehabilitation is critical to improving quality of life (QOL) for cancer survivors and maintaining dignity for persons with terminal illness. Rehabilitation requires several components to be successful.

First, it must be patient centered—that is, individualized to the patient’s needs, desires, and situation. Health care providers must always remember that the patient is the captain of the rehabilitation team. Rehabilitation that fails to respect a patient’s wishes will fail altogether. Most problems in rehabilitation occur when there are differences between the team’s goals and those of the patient.

Second, rehabilitation must be goal oriented. Goals should be meaningful to the patient’s quality of life. They must be measurable and concrete so they are transparent to the patient and the caregivers. Goals also must be achievable. Health care providers must balance realism with hope in counseling patients about their goals.

Third, rehabilitation requires an interdisciplinary team approach. In traditional multidisciplinary medical teams, different health care professionals each individually set goals appropriate to their area of specialization. In interdisciplinary rehabilitation, the team members work toward common goals not only by fulfilling the responsibilities of their particular discipline but also by helping meet the patient’s goals as a group. Team members must demonstrate a high degree of communication skills, humility, and commitment.

Lastly, rehabilitation also requires the active participation of the patient. Rehabilitation is not something done to an individual; it must be done with the individual. Rehabilitation is not a passive process and requires individuals to take responsibility for self-management of their illness. Rehabilitation is largely an educational process for the patient and family members.

The World Health Organization has recently published an International Classification of Functioning, Disability and Health, which is meant to supplement the International Classification of Disease (ICD-10).2 It presents a series of definitions that are crucial to understanding the role of rehabilitation in improving quality of life. These definitions are listed in Box 55-1. In this chapter, we will focus on impairments, activity limitations, and participation restrictions in patients with cancer and discuss how rehabilitation can ameliorate these disabilities.

Box 55-1   World Health Organization International Classification of Functioning, Disability, and Health Definitions

Impairments are problems in body function or structure such as a significant deviation or loss of a body part or organ system.

Activity limitations are difficulties an individual may have in executing activities of daily life.

Participation restrictions are problems an individual may experience in involvement in life situations.

Epidemiology of Cancer Disability

The number of cancer survivors continues to grow because more people are living longer with cancer as a result of new advances in surgery, medical, and radiation oncology.3 The result is that increasing numbers of patients face more years with cancer-related disability. Cancer survivors who are older than 55 years have significantly more pain and deficits in self-care and mobility than do control subjects.4 Focus needs to be directed away from mere survival toward the preservation and improvement of QOL for these survivors. In Japan, for example, the number of breast cancer survivors with lymphedema and pain in the chest wall, axilla, and arm is expected to double by 2020.5

Which Patients Should be Referred for Cancer Rehabilitation and When?

Patients with cancer can benefit from rehabilitation at every phase of the disease (Table 55-1). Clinicians should ask the patient the simple question: “Has your ability to function changed?” Because cancer is a complex, chronic illness, management requires vigilance and a comprehensive and preventive approach to illness and disability. The major concerns of persons with cancer include their overall health, fitness, fatigue, emotional and social function, and pain, which may vary during different phases of the disease. For example, in the initial phase, anxiety and disruption of routines may present the greatest challenges. During the treatment phase, fatigue, nausea, and sleep disruption may be the most significant problems. If the patient is having difficulty with mobility, self-care, fatigue, or pain, referral to a cancer rehabilitation program may be appropriate. Guidelines for referral for breast cancer rehabilitation have been published.6

Table 55-1

Phases of Cancer Rehabilitation

Phase Patient Needs Symptoms Impact
1. Evaluation and treatment planning Education Pain, anxiety, insomnia Disruption of daily routines
2. Primary training Education, acute care support Pain, fatigue, ROM, ↓ambulation, ADL support Daily routines, stamina (psychological social function)
3. Posttreatment (recovery) Education, support, chronic care, healthy lifestyle Pain, anxiety, depression, mobility, edema, fatigue, neuropathy, insomnia Work, family, avocation, cosmesis
4. Recurrence Education, support Same as above; metastatic disease effects Daily routines, work/play
5. End of life Education, support Pain, asthenia, depression Dependence

image

ADL, Activities of daily living; ROM, range of motion.

Impairments

Even when cancer is localized to one organ system, it may cause the loss of bodily function across many organ systems. Delineating these impairments in individuals is the first step toward ameliorating them; this process lies at the core of cancer rehabilitation.

Pain

Virtually every patient with cancer experiences pain during the course of the illness, and the pain often can become debilitating.7 Pain severity correlates closely with function, as demonstrated in one study of 216 Chinese patients with cancer who had metastatic disease.8 In that study, patients with increasing severity of pain had poorer function, whereas patients with mild, well-controlled pain functioned similarly to persons without pain.

Fatigue

Cancer-related fatigue has been described as “overwhelming and sustained exhaustion and decreased capacity for physical and mental work…not relieved by rest.”9 In addition, fatigue has been shown to have a negative impact on one’s economic status, social, and emotional status.10 It has been demonstrated that improving the quality of sleep is helpful, but increasing the amount of “rest” is not effective in reducing the symptoms of cancer-related fatigue.11 Exercise has been shown to mitigate fatigue.12 A further discussion of fatigue is provided in Chapter 45.

Delirium and Cognitive Dysfunction

In studies of patients with advanced cancer, the incidence of delirium ranges from 20% to 86%.13 Delirium may be reversible in 50% of cases with proper identification and management.14 The etiology of delirium in persons with cancer is usually multifactorial. Accurate assessment is critical for effective treatment. Risk factors for the development of delirium in patients undergoing bone marrow transplant before transplantation included lower cognitive function, lower physical function, and higher blood urea nitrogen, alkaline phosphatase, and magnesium levels.15

Medications play a large role in the development of delirium. In a study of 216 hospitalized patients with cancer, use of corticosteroids, opioids, and benzodiazepines was most frequently associated with delirium.16 The clinician must also consider metabolic factors. Fever and sepsis often produce acute delirium, and dehydration and uremia frequently contribute to the condition. Hypoxia and hypoglycemia are additional factors that can be easily assessed.

Delirium may present as either a hypoactive or a hyperactive state. In hypoactive cases, dehydration is a frequent contributing factor. Medication adverse effects (especially opioids and corticosteroids) and liver failure are often implicated in hyperactive states.

Patients with cancer often report cognitive difficulties after chemotherapy and other treatment regimens. However, a new study indicates no significant differences in the long-term cognitive function of cancer survivors versus control subjects.17 Many of these reports of cognitive difficulty may relate to fatigue.

Mood Disorders

Receiving a cancer diagnosis is stressful and frightening for most persons. Initially, they may experience symptoms of shock, disbelief, denial, or despair as they struggle to accept and incorporate the reality of the diagnosis. Patients may also experience a variety of normal fears throughout their treatment course, including fears of disability, loss of societal roles, loss of control, loss of desirability, abandonment, and death. Overall, however, most patients cope successfully with cancer diagnosis and treatment and experience good long-term psychological adjustment. Many patients even describe positive changes in their lives related to their diagnosis, including positive changes in self-perception, interpersonal relationships, priorities, and goals.

Although most patients cope well, a significant number experience serious mood disorders. Estimates of the prevalence of depression among patients with cancer range from 15% to 25%.18 Anxiety is quite common and may be related to poorly controlled pain, abnormal metabolic states, or medication-related adverse effects. Patients may also experience posttraumatic stress disorder (PTSD) in response to cancer diagnosis and treatment. PTSD is an anxiety disorder that develops after an extremely stressful event, such as the development of a life-threatening illness. Within 5 years of diagnosis, between 10% and 15% of cancer survivors may meet the criteria for PTSD.19

Neurologic Impairments

A wide variety of impairments of nervous system function may result from cancer, either by direct effect at the primary or metastatic tumor site or secondarily as a consequence of surgical or radiation treatment. These impairments, regardless of the tumor’s location, extent, or type, may have an adverse impact on the individual’s physical, social, vocational, and emotional capabilities. Important differences exist between the management of patients with cancer of the central nervous system and that of patients with other types of acquired neurologic disability.

Hemiplegia

Brain tumors vary widely in aggressiveness and prognosis. The extent to which tumor type or location has an impact on rehabilitation outcomes is not clear. However, one study found a tendency for greater gains in patients with meningiomas and left hemispheric lesions. Patients receiving inpatient acute rehabilitation show similar gains regardless of whether they have a primary brain tumor or a brain tumor resulting from metastatic disease.20 Some studies have shown that patients with a brain tumor have shorter lengths of stay on acute rehabilitation units compared with patients who have other noncancerous brain disorders.21

Most patients with brain tumors have multiple impairments depending on tumor location and size and the volume of tissue excised at surgery. In a study of patients undergoing acute rehabilitation, the most common neurologic deficits included impaired cognition (80%), weakness (78%), and visual-perceptual dysfunction (53%).20 Rehabilitation efforts should focus on the patient’s neurologic and functional status, co-existing medical problems, and tolerance of physical activity. As for patients who have had a stroke or traumatic brain injury, goal setting should be appropriate to the individual’s physical, cognitive, and behavioral status and include early planning for postacute rehabilitation care.

Paraplegia and Tetraplegia

The incidence of cancer-related spinal cord injury (SCI) may exceed that from trauma and represents the most frequent type of nontraumatic SCI.21 Spinal cord metastases produce a clinical syndrome characterized initially by pain in 90% of cases, followed by weakness, sensory loss, and sphincter dysfunction. Weakness is present in 74% to 76% of patients, autonomic dysfunction is present in 52% to 57% of patients, and sensory loss is present in 51% to 53% of patients.22,23 Pain alone may persist for a month or more (average 6 weeks) before significant neurologic changes develop. Acute onset of back or neck pain in a patient with cancer should be considered to be spinal metastasis until proven otherwise.

Positive results have been demonstrated after rehabilitation for persons with disability from spinal cord tumors.22 Factors that have been identified as better prognostic indicators for survival after inpatient rehabilitation include lymphoma, myeloma, breast and kidney cancer, spinal cord injury as the presenting symptom, slow progression rate of neurologic symptoms, combined surgery and radiation treatments, partial bowel control, and partial independence with transfers on admission.

Comprehensive SCI care includes attention to ventilatory ability in patients with high spinal levels of injury, along with management of pain, autonomic dysreflexia, pulmonary and urinary tract infections, thromboembolic disease, bowel and bladder dysfunction, decubitus ulcers, limb contractures, and spasticity. Certain measures instituted immediately after the onset of spinal cord dysfunction remain standards of acute care in this patient population. Prophylaxis for lower extremity venous thromboses with low molecular weight heparin should be immediately initiated unless otherwise medically contraindicated. Other areas of management that should be instituted early for patients with loss of thoracic musculature include incentive spirometry and chest physiotherapy. Initiation of intermittent bladder catheterization every 4 to 6 hours when daily bladder volumes are less than 2L should be routine treatment, along with instituting a bowel program with daily or every other day suppository or digital stimulation. Other key measures in early spinal cord care include prevention of skin breakdown. Additionally, at least daily limb range of motion should be initiated immediately after the onset of the spinal cord injury.

Speech/Swallowing/Nutrition

Disorders of speech and swallowing may be the result of direct tumor invasion of the oral cavity, larynx, pharynx, esophagus, or adjacent structures or the result of surgical or radiation treatment, or they may be consequent to cancers of the nervous system that affect pharyngeal or laryngeal control. Head and neck cancers constitute about 3% to 5% of all malignancies. Preservation of swallowing, having a natural airway, and intact speech are critical components that affect QOL in patients with head and neck cancer. Among these patients, swallowing has been shown to have the largest impact on global QOL.24

As soon as feasible after surgery, oral-motor exercises should be initiated by speech/language pathologists with a focus on strength, range of motion, and sensory awareness of the involved structures. Common interventions include modifying food texture, such as thickening liquids or puréeing solid food, and/or altering head posture and swallowing behaviors. The latter may include techniques such as chin tuck to prevent laryngeal penetration, head rotation to reduce retention in the piriform sinus, enforced double or effortful swallows to reduce pharyngeal residue, or supraglottic swallowing to optimize vocal fold closure and airway clearance.

In most patients with head and neck cancer, impaired vocal communication occurs at some point during treatment. It is important to keep in mind that multiple conditions other than total laryngectomy can result in deficient phonation in patients with cancer. These conditions include copious secretions, localized edema, fibrosis and scarring, presence of a tracheostomy, glossectomy, loss of oral mobility from local tumor or trismus, and neurogenic pharyngeal or laryngeal paralysis. Patients who have had a total laryngectomy lack a source of voice production and need to replace laryngeal function with either an artificial larynx (electrolarynx), esophageal speech, or tracheoesophageal puncture voice restoration with a prosthetic surgical device.

Bone Tumors and Amputations

Soft tissue and bony sarcomas are managed with amputation or limb-sparing procedures. Limb salvage procedures are increasing in frequency and are associated with long-term survival, local recurrence rates, and QOL equivalent to those of patients with amputations. These procedures are largely made possible by improved surgical techniques that preserve unaffected tissue, advances in endoprosthetic design and durability, soft tissue reconstructive procedures, and radiation and chemotherapy effectiveness in controlling local and distal spread.

Rehabilitation after limb-sparing procedures depends on the extent of soft tissue and bony resection, and because of the nature of the tumor resection, skeletal reconstruction, and soft tissue and muscle transfers, rehabilitation may be more intensive than after amputation. Rehabilitation includes instruction regarding use of mobility aids and orthotics for joint stabilization and assistance with strengthening and endurance exercises, in collaboration with the treating surgeon. Although various strategies are used in the mobilization of patients after reconstruction of the lower extremity, these patients often require a period of strict bed rest (as long as 7 to 10 days) to allow wound healing, edema control, and maintain limb alignment, followed by several days of dangling the extremity for short intervals. If this regimen has been successfully achieved, physical therapy can begin with ambulation with an assistive device such as a crutch or walker.

Patients who undergo amputation as a result of a tumor differ from patients who undergo amputation for dysvascular and traumatic reasons in several important ways. In patients who have cancer, fatigue, anemia, nausea, and toxic effects of chemotherapy may diminish functional capacity. Wound healing may be delayed over irradiated areas, and skin may be less tolerant of prosthetic wear. Persons who undergo amputation as a result of cancer typically have shorter residual limbs to obtain tumor-free margins. It is more common in this population to have more proximal sites of amputation, such as forequarter or shoulder disarticulation in the upper limbs or hemipelvectomy in the lower limbs. Weight loss, muscle atrophy, and residual volume shifts, particularly during chemotherapy, may prolong the wait for a definitively fitted prosthesis. In these cases, the use of flexible, adjustable sockets to permit continued prosthetic wear and training has proven beneficial for patients with early postoperative fluctuations in stump size.

Otherwise, the rehabilitation of amputees with cancer is similar to that for other patients who have undergone amputation, including the use of a multidisciplinary team, preoperative education for the family and patient about what to expect at different stages of preprosthetic and prosthetic training, and early initiation of exercises to improve strength and stamina. Rehabilitation often commences in the operating room when it is recommended that an immediate postoperative rigid dressing be fitted to the residual limb. Early use of rigid stump dressings has been shown in some studies to reduce time to delivery of the first definitive prosthesis, control stump edema and pain, reduce phantom limb sensation, help shape the residual limb, and speed incision healing. Otherwise, stump shrinker socks or elastic wraps are used to control the shape of the residual limb. Preprosthetic training includes upper body strengthening and endurance exercises and should include unipedal walking with appropriate assistive devices until weight-bearing through the prosthetic leg is advised. The timing of fabrication of a permanent prosthesis will depend on the type and extent of the surgery and the status of other concurrent medical management, including chemotherapy.

Bone metastases are a frequent source of cancer-related physical impairment that requires the active involvement of the rehabilitation team. Challenges for the treating team arise when metastatic bone lesions produce severe pain that limits function or imposes risks of fracture during therapeutic exercise or mobility. The incidence of pathological fracture among all tumor types is about 8%, with breast carcinoma responsible for the majority of these fractures. Sixty percent of all long bone fractures involve the femur, with most of these fractures involving the proximal portion.25 If the patient is deemed at risk for a pathological fracture, he or she should not bear weight on the affected structure, pending orthopedic consultation.

Rehabilitation for this patient population focuses on removing weight from or immobilizing compromised bone through the provision of assistive devices and orthoses, strength and balance training, and modification of the patient’s environment. Whenever possible, bed rest should be avoided because it adds to general debility and further functional loss and increases the risks of hypercalcemia and thromboembolic disease. It is critical to first rule out the co-existence of upper extremity lytic lesions before prescribing assistive devices that require weight support through the arms. Bracing may reduce risk or symptoms of a pathological fracture involving the upper extremities and can facilitate use of the arms in functional activities. Persons with upper limb lesions should be taught to minimize torsion and weight loading and may benefit from an arm sling or humeral cuff support. In the spine, when more rigid bracing is not tolerated because of poor skin tolerance or discomfort, a thoracolumbar corset provides limited support and pain relief.

Patients with cancer who experience pathological fractures and associated functional deficits have been shown to make significant gains when admitted to an inpatient rehabilitation hospital unit.26

Soft Tissue Impairments Associated with Cancer Diagnoses

Cancer, its treatments, or both can cause significant soft tissue abnormalities. One of the most frequently observed abnormalities is lymphedema, that is, extremity swelling that results from disruption of the lymphatics after axillary or groin dissection. The use of manual lymph drainage and compression garments is effective in controlling edema. When applied early in the course of treatment, before the development of significant volume increase (e.g., >250 mL increase in the arm), lymphedema can be reversed.27 Traditionally, patients with lymphedema have been told not to lift weights. However, new data show that not only does weightlifting not worsen lymphedema, but it may be beneficial.28

Another frequently seen complication of cancer treatment is radiation fibrosis. This process is associated with vascular permeability, inflammation, and release of proinflammatory cytokines (e.g., interleukins and transforming growth factor–β) and continues well past cessation of the radiation therapy. The use of antifibrotic agents in the treatment of this problem has shown promise.29

Allogeneic bone marrow transplantation has prolonged life for many persons with hematologic malignancies. One of the complications of this procedure is rejection of the host by the transplanted, immunocompetent engrafted cells, called graft versus host disease. The immunologic reaction is often brisk, resulting in organ damage (fibrosis) to the lung, liver, and notably skin and soft tissue. In the chronic form of graft versus host disease, limb edema, peau d’orange, fasciitis, and enthesitis can occur, resulting in significant loss of joint motion. Subsequent muscle atrophy may occur as a result of disuse and associated loss of upper and lower extremity mobility.30

Sexual Function

Sexual function can be very important to patients with cancer, yet it is seldom discussed by the patient and physician. In persons with breast cancer, treatment often produces adverse effects of fatigue, nausea, and diminished vaginal lubrication, not to mention the significant body image changes that accompany mastectomy. A metaanalysis of 36 studies of sexuality in patients with testicular cancer showed that problems were largely related to ejaculatory dysfunction, but fortunately, rates of decreased sexual desire were low and may improve with time.31 Erectile dysfunction is a common adverse effect of prostatectomy and hormonal and radiation therapy in persons with prostate cancer. Colorectal cancer surgeries often lead to sexual dysfunction in men. Not surprisingly, gynecologic cancers often produce changes in vaginal sensation, structure, and lubrication. On a positive note, however, 63.5% of patients with cancer who received brief sexual counseling reported improvement.32

Activity Limitations

It is not surprising that many persons with cancer have significant limitations in their activities. These limitations include reduced mobility and limited ability to perform activities of daily living (ADLs). ADLs often result from neurologic or orthopedic impairments but may also be related to fatigue. Communication and socialization skills may be adversely affected by cognitive deficits, impairment of speech, or depression and anxiety.

Activities of Daily Living

Basic ADLs include feeding, dressing, hygiene, and toileting. These ADLs are virtually universal to human dignity across world cultures. Impairments of upper limb function play an obvious role in limiting performance of ADLs, but other impairments also can impede these functions. Cognition is critical to sequencing, awareness, and carryover in the performance of ADLs. Pain and fatigue can also limit the individual’s ability to complete these tasks. Lower limb impairments can limit standing and transferring, which makes dressing, hygiene, and toileting difficult.

When persons become disabled enough to require assistance with these skills, the burden generally falls on caregivers. In one study of 483 patients with cancer at varying stages of their disease course, 18.9% had unmet needs in their ADLs because of a lack of a suitable caregiver.33 In patients with advanced-stage cancer, the percentage of caregivers with a high level of psychological distress varies from 41% to 62%, directly depending on the functional status of the patient.34

Rehabilitation efforts, particularly with the involvement of occupational therapy, can significantly reduce this burden on caregivers and enhance the QOL for patients with cancer who have disabling impairments. Addressing functional loss from impairments of the upper limb, such as chemotherapy-related peripheral neuropathy of the hand or radiation-induced brachial plexopathy, can substantially improve performance of ADLs. Simple adaptive aides (Fig. 55-1) can help patients achieve everyday tasks. To improve feeding independence among patients with cancer who have upper limb neurologic dysfunction, Chinese researchers used positioning, feeding aid supports, and upper limb supports and significantly improved function during a 3-week treatment intervention.35 Home-based occupational therapy interventions produce a high level of patient and caregiver satisfaction, reducing the burden of care.

image
Figure 55-1 Adaptive aides. From top to bottom: leg lifter, dressing stick, reacher, long shoe horn, long-handled sponge.

Exercise for Patients with Cancer

Exercise is one of the most effective strategies for symptoms associated with cancer fatigue, sleep disruption, and abnormalities of mood, physical function, and QOL.36 Metaanalyses37 suggest that for adults with a variety of cancer diagnoses and who are receiving a variety of exercise interventions, exercise improves physical function, QOL, and cardiorespiratory fitness and decreases cancer-related fatigue.38,39 The great majority of these studies employ aerobic exercise, using ergometry and walking programs and, occasionally, aquatic therapies. Table 55-2 outlines contraindications for exercise.

Table 55-2

Contraindications to Exercise in Patients with Cancer

Organ System Parameter Recommended Restriction
Hematologic Platelets 20,000-50,000 No resistive exercise
Platelets <20,000 Limited ambulation, no showering or high fall risk activities
ANC <1000 Neutropenic precautions
Pulmonary FEV1 or FVC <50% predicted
Pulse oximetry <90%		 Limit aerobic exercise and consider oxygen supplementation
Cardiac HR >80% maximal (220 minus age) Limit aerobic exercise
LVEF <20% Limit aerobic exercise
Unstable arrhythmias Exercise only with cardiac monitoring
Skeletal >50% cortical involvement Non–weight-bearing
25%-50% cortical involvement Partial weight bearing
0-25% cortical involvement No high-impact activities or sports
Lymphedema Any grade No restriction for exercise or weightlifting
Gastrointestinal Uncontrolled emesis or diarrhea No strenuous activity

image

ANC, Absolute neutrophil count; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; HR, heart rate; LVEF, left ventricular ejection fraction.

Participation Restrictions

Family and Social Relationships

Cancer can often draw a family together; however, it just as often leads to significant distress for families. Support groups can be helpful, yet fewer than half of patients receive information about them, even in large tertiary oncology centers.40 In one study of 121 patients with cancer, caregiver QOL was significantly correlated to the social/family and functional dimensions of the patients’ QOL; physical and emotional dimensions did not correlate.41 Cancer also can place significant economic burdens on families. Indeed, cost considerations play a large role in patient decision making regarding cancer treatment, especially among the poor.

Vocational Rehabilitation

Work disability after a cancer diagnosis is a common occurrence. Short and Vargo42 conducted phone interviews of 1433 cancer survivors at 1 to 5 years after diagnosis. More than half had quit work during their first year after cancer diagnosis, but fortunately, three quarters of those subsequently returned to work. A projected 13% had indefinite work disability. Survivors of central nervous system, head and neck, and stage IV blood and lymph malignancies had the highest risk of quitting work.

Fortunately, U.S. laws in recent years have provided more protection to cancer survivors returning to work. These laws include the Americans with Disabilities Act, Family and Medical Leave Act, and the Health Information and Portability Act. Nevertheless, a number of barriers still stand in the way of gainful employment for cancer survivors with disability. These barriers include ignorance on the part of both employers and cancer survivors of their rights, discrimination, and limits on preexisting conditions in health insurance benefits.

Little is known about which medical impairments have the greatest impact on employability. Undoubtedly cognitive and communication deficits play a large role, as evidenced by the high work disability rates among survivors of central nervous system and head and neck malignancy.42 Fatigue and pain are also likely to limit work participation. Spelten and colleagues43 studied 235 cancer survivors in the Netherlands. Fatigue levels strongly predicted inability to return to work.

Transportation

Patients with cancer may be limited in their ability to drive, fly, or take public transportation. They may not have caregivers available to help transport them. Lack of transportation can become a major barrier to cancer treatment, which often involves frequent medical visits. Some patients forgo recommended treatments because of lack of adequate transportation. Thus it behooves physicians to explore with patients any limits to their ability to get transportation. Galski and colleagues46 showed that patients receiving chronic, stable, opioid analgesic therapy can drive safely. Patients with cerebral dysfunction as a result of a tumor, paraneoplastic effects, or treatment adverse effects should be evaluated for their ability to drive safely before they are allowed to return to the road. Well-defined off-road driver evaluation tools are available.

Related posts:

WHO Classification of Hematologic Malignancies Myeloproliferative Neoplasms Cancer of the Head and Neck Biostatistics and Bioinformatics in Clinical Trials Carcinoma of the Pancreas Cancer of the Lung: Non–Small Cell Lung Cancer and Small Cell Lung Cancer