975
Cancer Rehabilitation in the New Millennium
Cancer Rehabilitation into the Future
Lynn H. Gerber, M.D.
Rehabilitation Medicine Department, National In-
stitutes of Health, Bethesda, Maryland.
This article was developed from a presentation at
the conference “Cancer Rehabilitation in the New
Millennium: Opportunities and Challenges,” New
York, New York, June 4 –5, 1999.
Address for reprints: Lynn H. Gerber, M.D., Reha-
bilitation Medicine Department, National Institutes
of Health, Building 10, Room 6S235, 9000 Rock-
ville Pike, Bethesda, MD 20892.
*This article is a U.S. Government work and, as
such, is in the public domain in the United States
of America.
Received February 10, 2001; accepted March 1,
2001.
© 2001 American Cancer Society
Supplement to Cancer
The 5-year survival for many cancer sites exceeds 50%, suggesting that these patients
are living longer and may be considered to have a chronic illness. The incidence of
cancer increases from 500 in 100,000 to 2000 – 4000 in 100,000 as women or men age
from 50 to 80 years. Our population is aging and the prevalence of cancer is increasing.
Treatments for cancer are quite complex, and they are often delivered to elders who
have a variety of medical problems and are receiving additional medications that
may complicate overall patient management. Hence, these patients may have
extremely complex functional problems. Cancer patients need comprehensive care
designed to relieve symptoms of pain, fatigue, and weakness. They need education
to help support their ability to reach functional independence and maintain
quality of life. Rehabilitation professionals are essential for the comprehensive care
of cancer patients throughout the phases of their disease: treatment planning,
treatment, remission, recurrence, and end of life. The needs of this population can
better be served if several processes are put into effect. Rehabilitation professionals
must be trained to manage problems associated with cancer and its treatments.
Research about what are effective and efficient rehabilitation treatments must be
done to determine how best to treat cancer patients throughout the various phases
of their illness. Physicians and patients must be alerted to the importance of
rehabilitation interventions to the overall function of these patients. Cancer 2001;
92:975–9. © 2001 American Cancer Society.
KEYWORDS: cancer, rehabilitation, function, disability.
T oday we are treating patients with cancer diagnoses who are living
longer. They are a greater management challenge but also have
higher expectations for participation in a full and active life. Hence,
the model for meeting the comprehensive needs of patients with
cancer diagnoses and their families should change from one of an
acute, soon-to-be-fatal condition to that of a chronic illness. This
approach highlights the fact that there are multiple stages that impact
an individual’s life throughout the course of the illness and its treat-
ments. Problems during the initial phase of diagnosis and definitive
treatment planning are different from those that may arise from other
phases, such as during the recurrence or end-of-life phases (Table 1).
Cancer patients have significant need for good disease management
by cancer specialists whose treatments target control of organ-spe-
cific disease, and they require input from rehabilitation specialists
whose interventions address functional needs that arise from the
impact of the disease or its treatments.
Cancer is a common diagnosis and often a chronic and complex
disease process. This suggests that health care professionals with
varied backgrounds are needed for comprehensive care. Data sup-
porting this view come from the Surveillance, Epidemiology, and End
Results (SEER) program,1 which tracks changes in disease prevalence
and distribution by age, gender, race, and regional demographics. The
976 CANCER Supplement August 15, 2001 / Volume 92 / Number 4

TABLE 1
Rehabilitation-Related Issues for Cancer Patients

Phase of cancer Patient needs Symptoms Impact of symptoms on function

I. Pretreatment and evaluation Information about treatment options and impact of illness Pain Daily routines
Anxiety Sleep/Fatigue
Depression
II. Treatment Information Pain Daily Routines
Support Anxiety Sleep/Stamina
Rehabilitation interventions Loss of mobility Self-care
Help with daily routines Wound/Skin care Comesis
Vocational, home, etc. Speech/Swallowing Communication
III. Posttreatment Support Pain/Weakness Sleep/Fatigue
Rehabilitation intervention Anxiety/Depression ADL
Loss of mobility Vocational/Avocational
Edema Cosmesis
Fatigue/Stamina
IV. Recurrence Education Pain/Weakness Sleep/Fatigue
Support Anxiety/Depression Disability
Rehabilitation intervention Fatigue/Stamina Disruption of routines
Edema Cosmesis
Bony instability Vocational/Avocational
Anorexia
V. End of life Education Pain Dependence
Support Fatigue Immobility
Palliative rehabilitation Anorexia

ADL: activities of daily living.

statement that cancer is a chronic illness is supported
by the survival rate data. The 5-year survival rate for all
patients with cancer at 23 selected sites has increased
from 49.3% to 53.9% over the interval 1974 –1990. Pa-
tients with some primary tumor types (e.g., pancreatic
cancer) have had little change in survival rates, but
others (e.g., those with colon, rectum, and prostate
cancer) have had substantial increases in survival. The
tumor types that are most prevalent in the United
States include prostate, lung/ bronchus, colon/rec-
tum, bladder, lymphoma, and oral cavity for men and
breast, colon/rectum, lung/bronchus, uterus, and
ovary for women. More than 50% of those with these
types of tumors (except for lung and ovary) will survive
longer than 5 years. They will most likely benefit from
rehabilitation interventions.
Cancer is a commonly seen group of diseases with
an incidence rate that climbs as our population ages.
The incidence rate per 100,000 population is 500 for
males age 50 years and 4000 for males age 80 years; it
is 500 for females age 50 years and 2000 for females
age 80 years.1 The American Cancer Society predicted
that there would be 1.2 million new cancer diagnoses
in 1999 and that 8 million persons would require can-
cer-related care in the same year.
Cancer management is quite complex. Notably,
cancer is prevalent in the elderly, who as a group have
more comorbidities and often have risks for higher
disability. Oncologic treatment (surgical, radiothera-
peutic, chemotherapeutic, biologic, and their combi-
nations) have been successful in prolonging life but
frequently produce toxicities that result in functional
loss. Symptoms resulting from these treatments often
require medications that also produce side effects,
such as weakness, fatigue, and somnolence. The im-
pact of these problems often necessitates treatments
aimed at functional restoration rather than primary
disease management. Referrals to rehabilitation pro-
fessionals usually target specific impairments at the
anatomic level (such as loss of range of motion, dys-
phagia, or lymphedema) or problems of mobility.
Rarely do cancer specialists give rehabilitative care to
help prevent impairments such as the effects of radi-
ation on the range of motion of the head and neck, or
help with problem solving of existing impairments.
For example, rehabilitation specialists may contribute
strategies to manage the impact of fatigue on daily
living or work needs within the context of the life stage
and the individual needs of the patient and family.
Examples of what rehabilitation professionals can of-
fer are presented in Table 2.
Lehmann et al.2 identified the needs of a cancer
population and concluded that 438 of 805 patients
surveyed had impairments and/or functional limita-
tions. These included psychologic distress, general
weakness, dependence in activities of daily living
 Cancer Rehabilitation into the Future/Gerber 977

TABLE 2
Possible Contributions of the Rehabilitation Specialist during Five Phases of Disease

Phases of disease Issues for rehabilitation professionals to address

I. From diagnosis to treatment planning 1. What to expect regarding the impact of cancer treatment on function
2. Understanding function and how to preserve it
3. Comprehensive rehabilitation pretreatment (e.g., ROM, ADL, strength)
II. Treatment 1. Evaluating the effects of treatments on function (surgery, chemotherapy, radiation, biologic agents)
2. Preserving and restoring function through exercise, edema management, and increased activity
3. Controlling pain using heat, cold, and TENS
III. Posttreatment 1. Developing and supporting a program to help restore daily routines and promote a healthy life-style
2. Educating the patient about what to self-monitor (strength, ROM, edema, pain, etc.)
3. Supervising a maintenance program of exercise, edema management, and mobility
IV. Recurrence 1. Educating the patient about the impact of recurrence and its effect on function
2. Educating the patient about what to monitor in the context of the new clinical status
3. Supervising the patient in an appropriate program to restore function or prevent its decline
4. Assisting the patient in maintaining activity and quality of life
V. End of life 1. Educating patient/family regarding mobility training, good body mechanics, and assistive devices
2. Pain management (nonpharmacologic treatment) and symptom control
3. Maintaining independence and quality of life

ROM: range of movement; ADL: activities of daily living; TENS: transcutaneous electrical nerve stimulation.

(ADL), pain, difficulties with balance in ambulation, does during the day. Physical performance and lean
housing, neurologic deficits, family support, and mass are among the most important clinical factors in
work-related problems and finances (in decreasing predicting the survival time of cancer patients. Those
order of frequency). Many of these are remediable who have anorexia, significant weight loss, and dys-
with physical therapeutic and rehabilitative interven- pnea are at highest risk for morbidity and mortality.11
tions, and yet they were not being addressed. Whelan Using measures that are more focused on cardiovas-
et al.3 summarized the symptoms of cancer patients as cular and musculoskeletal models will advance our
identified by the patients themselves. These included understanding of functional limitations and adapta-
fatigue, worry and anxiety, sleep disruption, and pain. tions in this population. These will help determine
The patients indicated that they needed more educa- whether our interventions are effective in ameliorating
tion about their disease, better social support, and functional limitations and subsequently improving
help with ADL. The subtext is that patients fear dis- survival. We do know, for example, that patients re-
ability and dependence, and the implication is that ceiving bone marrow transplantation who have severe
they are not receiving treatment for these symptoms fatigue and decreased physical performance often re-
and concerns. The needs that this population have, as quire an extended period for recovery of physical
identified by both the medical community and pa- function. This can be ameliorated through an aerobic
tients, present a challenge to the health care commu- exercise program.12 Hence, measures of aerobic fit-
nity. Because many of these concerns and needs are ness and daily routines would be useful in establishing
amenable to physical medicine and rehabilitative patients’ needs as well as their response to rehabilita-
therapeutics, it is our responsibility to educate our tive interventions.
colleagues about what we can offer to this patient The most frequently identified concerns of pa-
group to improve their functional independence and tients with cancer diagnoses pertain to their level of
quality of life.4 It is up to the rehabilitation profession- dependence. Most fear disability, but symptoms such
als to demonstrate the efficacy of their interventions. as pain, anxiety, and fatigue are also common. Sub-
What successes and improvements have we stantial progress has been made in pain management,
made? What remains to be done? How do we proceed? and rehabilitation specialists have contributed to this
We have improved our abilities to assess and mea- improvement, especially in the application of non-
sure changes in patients with cancer diagnoses during pharmacologic treatment. There is value in learning
the past decade. Much of this has resulted from de- more about the mechanisms of action and the best
veloping and improving the methodology in our mea- therapeutic prescriptions of modalities of heat, cold,
sures of quality of life.5–10 We have need for improving and electrical stimulation. The efficacy and mecha-
our measures of physical performance in this popula- nisms of action of relaxation training and guided im-
tion and learning about what each patient actually agery in pain reduction would also be useful to study.
978 CANCER Supplement August 15, 2001 / Volume 92 / Number 4
The three most prevalent primary tumors (breast,
prostate, and lung/bronchus) metastasize to bone,
threatening mobility and the safety of the skeletal
system during daily routines. Concomitantly, breast
and prostate cancer are associated with relatively long
life expectancy, even after bony metastatic disease is
diagnosed. It is critical that patients be referred for
proper rehabilitation for their safety as well as to assist
them in maximizing their potential for independent
function. Equally important is to evaluate critically
what is known about what to do and when to do it to
improve function, and help assure these patients’
safety. More data are needed to better understand
risks for fracture and the capability of metastatic bone
to withstand various loads in performing antigravity
activity.
Perhaps one of the most important areas for re-
search in cancer rehabilitation is the systematic study
of the causes and treatments of cancer-related fatigue,
and in particular the role of muscle wasting as it
relates to this. Cancer fatigue is seen frequently and is
experienced as a significant problem, for which there
are many possible explanations. Fatigue may result
from disturbances of mood, sleep, or cardiopulmo-
nary conditioning, or from muscle weakness, pain,
wasting, or chronic inflammation.13 The causes are
protean and include local and distant effects of tumor,
treatment toxicities and comorbidities, and their treat-
ments. It has been demonstrated that physical func-
tion seems to influence social function and is highly
related to emotional function.14 Therefore, one impor-
tant goal of treatment is to improve physical perfor-
mance. Rehabilitation specialists are well suited to
assess fatigue, identify those organ systems contribut-
ing to it, and select interventions that might help
ameliorate the symptoms. Exercise is one of the major
modalities that we offer; its benefits include improve-
ment in mood, sleep pattern, fitness, lipid profile,
strength, and functional activity, as well as pain reduc-
tion. Intervention trials designed to maintain or re-
store physical function, aerobic capacity,15 and hema-
tologic indices have been effective.16 We should also
assess the best ways in which to do this, and deter-
mine how these methods work.
It is important to measure the impact of treat-
ments such as aerobic conditioning, strengthening,
increasing flexibility, and mechanical efficiency on
immune status and cytokine regulation17 in the cancer
population. For example, exercise may down-regulate
interleukin-1 or other myotoxic cytokines. Increase in
muscle mass may improve tolerance to chemotherapy
and stimulate growth factors that stimulate myofibril
size or mitochondrial efficiency, resulting in improved
physical performance. The associations between
physical performance and longevity have not been
explained satisfactorily. In fact, a major question for
rehabilitation specialists is whether any of our inter-
ventions or educational strategies can protect muscle
and bone from local and distant effects of tumor or
their treatment.
Proper care for cancer patients now and in the
future will continue to require a shift in our thinking
about what a cancer diagnosis implies. In many pa-
tients, cancer is a chronic illness, requiring a variety of
interventions provided by a multitude of specialists,
including rehabilitation professionals. This care
should be seen as needed throughout the phases of
illness and stages of an individual’s life. The popula-
tion we will need to serve is growing and aging, pre-
senting us with significant and complex care issues
and requiring significant resources. We must educate
our professional community to understand the role
that rehabilitation should play in planning treatment
for the cancer patient. At the same time, we must
objectively demonstrate the efficacy of rehabilitative
interventions. Future research will help improve qual-
ity of care and possibly identify newer strategies for
the treatment of serious problems associated with
such sequelae as bony metastatic disease, muscle
wasting, and cancer fatigue. The mechanism of action
of exercise interventions on immune regulation and
control of inflammation is another exciting area for
investigation.
Good care must also incorporate the unique
needs and wishes of patients as perceived by them
within the context of their own environment. This
presents a substantial challenge to a traditional health
care delivery system.
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