Decrease Burden of Cancer to Individuals & Society

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Work 46 (2013) 455–472 DOI 10.3233/WOR-131755 IOS Press

Cancer rehabilitation may improve function in survivors and decrease the economic burden of cancer to individuals and society Julie K. Silvera,∗ , Jennifer Baimaa, Robin Newmanb , Mary Lou Galantinoc and Lillie D. Shockneyd,e a

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA c School of Health Sciences, The Richard Stockton College of New Jersey, Galloway, NJ, USA d Departments of Surgery, Oncology and Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA e Johns Hopkins University School of Nursing, Baltimore, MD, USA b

Received 8 October 2012 Accepted 8 September 2013

Abstract.

BACKGROUND: Cancer and its treatment may cause physical impairments and psychological distress in survivors. Rehabilitation is a critical component of quality cancer care, returning survivors to their highest functional potential.

OBJECTIVE: This overview focuses on the benefits of multidisciplinary cancer rehabilitation – including improving physical function, reducing psychological distress, promoting return to work and, therefore, decreasing the economic burden of cancer and its treatment on individuals and society in general.

METHODS: Relevant literature was identified through a search of the PubMed database and reviewed for its relevance to cancer rehabilitation and the topic of this article. Search terms included, but were not limited to, cancer rehabilitation, cancer prehabilitation, disability, return to work, employment, and unemployment.

RESULTS: Cancer survivors are less likely to be employed and take more sick leave than workers without a history of cancer. Pain, musculoskeletal issues, deconditioning, fatigue, balance, psychosocial issues, and lymphedema are most amenable to rehabilitation.

CONCLUSION: Overall health and the need for work accommodations must be addressed in order to improve return to work and subsequent productivity in cancer survivors. Survivors are usually best served by a multidisciplinary care team comprising members who can address the myriad impairments affecting survivor function.

Keywords: Return to work, disability, survivorship, cancer-related impairments, prehabilitation

1. Introduction

∗ Corresponding author: Julie K. Silver, Harvard Medical School, Department of Physical Medicine and Rehabilitation, Countway Library, 2nd Floor, 10 Shattuck Street, Boston, MA 02115, USA. Email: julie_silver@hms.harvard.edu.

One does not have to look very far to see the positive impact that rehabilitation has on improving outcomes in persons with serious injuries and illnesses. The direct outcomes that are most obvious when an individual’s performance is measured (e.g., improved physical function) may translate into significant indirect out-

c 2013 – IOS Press and the authors. All rights reserved 1051-9815/13/$27.50

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comes that benefit society as well. This overview focuses on the benefits of multidisciplinary cancer rehabilitation – including improving physical function, reducing psychological distress, promoting return to work and, therefore, decreasing the economic burden of cancer and its treatment on individuals and society in general.

To better understand the impact that cancer rehabilitation might have on an individual and society, it is helpful to look back at the evolution of cardiac rehabilitation and its early focus on employment issues. During the early first half of the 20th century, when someone had a heart attack, the medical approach was very cautionary in response and bed rest was a primary intervention. For example in 1929, an article in the journal Medicine offered this advice about how to help patients who had recently suffered a heart attack: The nurse should be carefully instructed to do everything in her power to aid the patient in any physical activity so that all possible movements such as feeding himself or lifting himself in bed are spared. . . Finally, the patient should be urged to spend at least six weeks, and preferably eight weeks or more, absolutely in bed [1].

Since heart disease was fairly common, it is not surprising that by the late 1930s many people were out of work due to this condition. The New York State Employment Service began to explore why so many people were unemployed, and a resulting survey revealed that 80% of people on disability were cardiac patients unable to return to work [2]. This led to the establishment of cardiac “work evaluation units” in teaching hospitals, rehabilitation centers, and community hospitals. The experts who ran these units, typically cardiologists who directed a team of caregivers, evaluated the patients, physically and psychologically, for work. Their goals were to: 1) provide clinical services utilizing a team approach; 2) provide a place to educate physicians in training; and, 3) promote cardiac research.

Initially, the evaluation and treatment recommendations did not include formal exercise because physical activity was still considered harmful to cardiac patients. Pioneering research beginning in the 1950s began to better define the role of physical activity after a heart attack, and by the 1960s it was known that early mobilization of heart patients under a clinically implemented and supervised protocol was optimal. This led to the development of cardiac rehabilitation as a model of care that was able to increase functional ability, decrease mortality and was safe and cost-effective [3].

There is no doubt that cancer, like heart disease, places an enormous economic burden on society. In a

recent article, Mariotto et al. [4] determined that the healthcare costs related to cancer (based on approximately 13.8 million cancer survivors in the United States) was estimated to be $124.57 billion. Furthermore, based on current growing incidence of cancer and survival rates, there would be an estimated 18.1 million survivors by 2020 – generating an annual cost of $157.77 billion that year. This economic burden is not unique to the United States, of course [5,6].

In a study published in the American Journal of Managed Care, researchers focused on the personal financial burden of cancer in the working-age population [7]. This study found that the mean out-of-pocket medical expenditure for patients diagnosed with cancer was $1170 greater than for those without a cancer diagnosis. This study also found that individuals undergoing cancer treatment were less likely to be employed full time. Among the participants who were undergoing active cancer treatment, on average, 22.3 more workdays were missed annually than for those without cancer.

2. Understanding employment issues in cancer survivors A meta-analysis published in the Journal of the American Medical Association by de Boer et al. [8] noted that although nearly half of adult cancer survivors are younger than 65 years of age, the association between cancer survivorship and employment status is unknown. In an attempt to better quantify this relationship, de Boer and colleagues performed a systematic review of studies published between 1966 and June 2008 in which employment was an outcome.

Twenty-six articles describing thirty-six studies from twenty-one different countries were included. In summary, they found that unemployment rates were higher in patients with breast, gastrointestinal, and female reproductive organ cancers (compared with controls), although unemployment rates were not higher in patients with prostate, testicular, or cancers of the blood.

Overall, these researchers found that cancer survivors were more likely to be unemployed than healthy controls (33.8% versus 15.2%; pooled relative risk [RR] 1.37; 95% confidence interval [CI] 1.21–1.55). Their blunt conclusion was, “Cancer survivorship is associated with unemployment” [8].

It is now well known that cancer therapies, often administered either sequentially or in combination with other drugs or treatments, cause many cancer survivors

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to function at a lower level during and after acute treatment than they did prior to diagnosis. The majority of survivors will experience impairments either from the disease itself or treatment toxicity – too often leading to a decrease in their quality of life (QOL) [9]. Moreover, in a recent systematic review of 64 studies, Mehnert found that, overall, only 63.5% of participants managed to return to work (range 24–94%) [10]. The mean duration of absence from work was calculated to be 151 days. Cancer survivors were found to be at significantly increased risk for unemployment, early retirement, and were less likely to be reemployed. Between 26 and 53% of survivors lost their job or quit working over the 72-month period following diagnosis. An even higher proportion of patients experienced at least temporary occupational changes that included changes in work schedules or hours, wages, or a decline in work ability compared to people who had not been diagnosed with cancer.

Research continues to demonstrate that cancer survivors struggle with employment issues after diagnosis. For example, a 2013 German study by Noeres et al. [11] found that one year after primary surgery, survivors with breast cancer were nearly three times as likely to have left their jobs compared to the reference group. Another 2013 study from a group of Swedish investigators provided some insight into the relationship between breast cancer, arm symptoms and absence from work; finding that breast and arm symptoms (which are often amenable to rehabilitation interventions) were strongly associated with being on sick leave [12].

Lillehorn et al. [13] explored the meaning of work in women (n = 56) with breast cancer and found that their average length of sick leave was 410 days (range 0–942 days). Women treated with chemotherapy had on average more than twice the amount of sick leave as those who did not. Importantly, not returning to work motivation emerged in the following four categories 1) I’m still too fragile to return to work, 2) My workplace is a discouraging place, 3) I took an opportunity to pause, and 4) I’ve lost the taste for work while, in contrast, returning to work motivation emerged in the following two categories 1) Work generates and structures my everyday life, and 2) I miss my workplace.

Although more research is required on the subject of cancer and employment, the current studies provide a glimpse at the scope of the problem as well as some solutions. For example, in a recent systematic review that included twenty-eight cohort studies, van Muijen and colleagues [14] found that there were a limited num-

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ber of prognostic factors that could be associated with return to work and employment in cancer survivors.

Heavy work, chemotherapy, old age, low educational level and low income were negatively associated with return to work while less invasive surgery was positively associated with employment, and interestingly, breast cancer survivors had the greatest chance of return to work. Amir and Brocky [6] found that there are four groups of factors associated with return to work: 1) impact of the cancer site; 2) impact of treatment; 3) occupational status; and, 4) the roles of others. Similarly, in a review of the literature, Steiner et al. [15] found that factors influencing returning to work included cancer site, clinical prognosis, treatment modalities, socioeconomic status, and attributes of the job itself.

With respect to the “attributes of the job itself” factor, it is important to consider both the physical and cognitive factors that affect work performance. For example, in an interesting survey study by Schmalenberger et al. [16], the experience of female musicians diagnosed with breast cancer was evaluated. Commonly reported symptoms included fatigue (70%), problems with cognition (53%), limitations in upper body movement (51%), and pain (45%). Many of the participants also reported that their symptoms were present long-term (more than one year after treatment ended) and affected their ability to function as musicians.

Cancer-related symptoms and associated impairments may continue to interfere with work performance for ten years or more after the initial diagnosis, possibly presenting as a termination of employment or an increase in the amount of sick leave taken. Cancer survivors take more sick leave than controls in the first year after diagnosis for obvious reasons. Unfortunately, this higher rate of leave may not diminish after the patient has been adequately treated. A Norwegian study on sick leave patterns found that patients with rectal, lymphogenic, breast, or “other” (not reported) types of cancer had higher rates of sick leave than agematched controls five years after diagnosis [17]. An American study found that long-term cancer survivors had a lower functional status even eleven years after cancer diagnosis [18]. Although the number of sick leave days was not assessed in this study, the investigators pointed out that since many cancer survivors are retired at the time of diagnosis, sick leave may not appropriately capture lost productivity or decline in functional status.

Another factor that may not have been captured in this study is health insurance status. This is particu-

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larly important in the United States and other countries that rely on third party payor reimbursement. Cancer survivors who carry the health insurance on their job are more likely to keep working than those who have insurance on their spouse’s plan, thus bringing gender disparities into return to work assessment – many more men than women are the primary carrier of health insurance for their family. This observation reinforces the scope of myriad factors, outside of cancer diagnosis and prior functional status, that are involved in return to work and work productivity outcomes in cancer survivors.

In a review of forty-five studies, Feuerstein et al. [19] found that the modifiable categories that have been studied in cancer survivors included: 1) health and well-being; 2) symptoms; 3) function; 4) work demands; 5) work environment; and 6) policy, procedures and economic factors. Needs to be addressed in order to improve return to work and subsequent productivity in cancer survivors include not only the health of the cancer survivor, but also the options for work accommodations as well. As the 5-year survival rate in the United States approaches 70% [20], it may seem obvious that helping cancer survivors to function optimally at work, regardless of their current disease and treatment status, is of benefit to them and to society.

3. Categorizing cancer-related impairments and work-related disability in cancer survivors To better understand how to help cancer survivors in the workplace, it is helpful to consider how the terms impairment and disability are defined and relate to each other. The term handicap is also important, though probably used less frequently in rehabilitation medicine than in the past.

The World Health Organization (WHO) has previously defined the terms disability, impairment, and handicap [21]. According to the WHO, an impairment is any loss or abnormality of psychological, physiological, or anatomical structure or function. Impairments are problems that one encounters on physical, cognitive or psychological examination. Impairments in cancer survivors who have undergone chemotherapy might include alopecia or neuropathy. Cancer and its treatments may produce a wide range of impairments from the very obvious amputation of a limb, to subtle problems with balance that are difficult to detect without specialized testing.

Disability has been defined as an impairment that results in and includes any restriction in or lack of abil-

ity to perform an activity in the manner or within the range considered normal for a person. In rehabilitation medicine, there is a strong emphasis on quantifying function because lack of function affects how people perceive their quality of life. For example, in a breast cancer survivor who is post mastectomy, shoulder pain (symptom) that results in loss of range of motion of the shoulder (impairment) may not be much of a problem in a retired woman who does not tend to lift her arm overhead very often. However, in a woman who works as a dance instructor who must lift her arms over her head, this same symptom and impairment can cause significant disability and inability to function.

According to the WHO, a handicap is a disadvantage resulting from an impairment or a disability that limits or prevents the fulfillment of a role that is normal for that individual, such as participation in usual work activities. According to this definition, if the dance instructor had lost her job because of her disability, she would have been classified as having a handicap.

Historically, overall function has been viewed in terms of interrelated areas of physical performance, such as muscular strength, range of motion, and cardiopulmonary endurance [22]. A more contemporary appreciation of function encompasses not only the individual’s physical condition but also aspects of their psychoemotional state as well as their social and environmental situation. The WHO’s International Classification of Functioning, Disability and Health (ICF) describes a framework that takes this multidimensional or biopsychosocial approach to describing function [23].

Within the ICF framework, function is defined as the interaction between an individual (personal perspective), their health condition (biological perspective), and the social and personal context in which they live (societal perspective) [23,24]. It is the complex interaction between these variables that determines functional health and disability [25].

Within the ICF model, the terms used to define the domains of human function are body structure and function, activities, and participation. Functioning, then, is an umbrella term that encompasses all three of the domains. Health conditions, the environment, and personal factors can interact within the domains (or can interact within functioning, causing disordered functioning) and influence whether or not individuals are diagnosed with disabilities. The ICF framework is being used increasingly as both a clinical and research model [26]. Uniform use of these terms in studies that assess functional status and employment will allow for improved comparison of research findings.

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Table 1 Example of cancer-related impairment(s) and associated work-related disability Examples of cancer-related impairment(s)* System: Neurologic system (peripheral) Etiology: Often due to cancer treatments (e.g., chemotherapy-induced peripheral neuropathy, radiation-induced plexopathy, etc.)

Affecting: Upper extremity Causing: Various impairments that may include weakness/paralysis, sensory loss, decreased fine and/or gross motor function and so on.

Work-related disability Difficulty or inability to: – Perform ADLs such as dressing and grooming in preparation for work – Get to work, including using a key, operating a motor vehicle, using magnetized identification card to enter a building, setting an alarm using a key pad, etc.

– Perform fine motor tasks including writing, using a telephone, typing on a computer or other keypad, operating machinery or other technical skills – Lift, carry or hold arms in various positions due to weakness – Dress including donning pants or socks or shoes – Drive a car or other vehicle – Walk for prolonged periods (e.g., going from parking lot or from public transportation drop-off to worksite) – Maintain balance (resulting in falls and injuries, especially during inclement weather) – Stand, squat, or other required lower extremity positions

∗ There are hundreds of possible impairments that may result from cancer and/or cancer treatment and affect one or more organ systems in the body. Therefore, this example is designed to demonstrate the relationship between impairments and work-related disability as it relates to only one organ system, the peripheral nervous system.

Table 1 provides an example of cancer-related impairments and how they might translate into work- related disability. By understanding decrements in health in the context of their effect on participation in employment, we will be able to more readily address the gaps in survivorship care and workplace accommodation.

4. Cancer rehabilitation as an intervention to improve both impairments and disability Identifying impairments as early as possible after diagnosis and throughout the cancer care continuum is a critical first step in reducing the incidence and severity of future disability [27]. Prehabilitation offers a unique opportunity to perform post diagnosis but pretreatment baselines and interventions [28]. The definition of prehabilitation is “. . . a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments” [27]. Rehabilitation typically follows initiation of treatment with assessments and interventions occurring as needed during or following cancer treatments; sometimes even years after treatment. During this period, rehabilitation clinicians are taught to “focus on function” or lack thereof – which often translates into disability. WHO defines rehabilitation as “processes intended to enable people

with disabilities to reach and maintain optimal physical, sensory, intellectual, psychological and/or social function” [29]. These definitions of prehabilitation and rehabilitation can certainly encompass maintaining or regaining function in the workplace.

Common impairments seen in cancer survivors include musculoskeletal dysfunction and limited range of motion. Pain is common in both cancer sufferers and survivors and must be adequately addressed in order to allow for concentration and mobility at work or home. A common example of a musculoskeletal issue is internal derangement of the shoulder joint in a breast cancer patient that responds to physical therapy for strengthening of the scapular stabilizer muscles.

Decreased cervical range of motion in a head and neck cancer survivor, which may affect driving and getting to and from work, is another example of a musculoskeletal issue that can affect employment. Many factors may actually contribute to self-limitations in driving – from driving less to not driving at all – during and following treatment for head and neck cancers. A small study of self-reported driving behaviors in a convenience sample of head and neck cancer patients found that the following factors were most closely related to self-restricted driving [30]: 1) driving under challenging conditions (such as driving in traffic); 2) perceived impaired cognitive function; 3) cancer-related distress; and 4) limited neck mobility. Because a patient’s perception of potential problems can have significant impact on his/her behaviors, regardless of actual deficits, both actual and perceived barriers to driving need to be addressed. Additionally, a small pilot study has shown

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that self-restricted driving can cause an increase in anxiety and depressive symptoms [31]. Several other factors have been identified as risk factors for lower quality of life following treatment for head and neck cancer. The strongest predictors in a study of selected patients following surgery included: a lower body mass index, depression, younger age, and gastrostomy [32].

Of note, in this study, patients were excluded if their attending physician felt that they had extensive emotional distress or poor physical condition. Additional factors that may be associated with lower quality of life are a history of radiation therapy and higher education. These findings can be used to help healthcare providers more readily identify patients most at risk for decreased quality of life following treatment of head and neck cancers.

It is important to note that a decrease in physical function has significant psychological sequelae (and vice versa). Better understanding of the critical relationship between physical function and distress in cancer survivors is emerging as an important issue. Banks et al. [33] conducted a study of approximately 90,000 Australian men and women aged 45 years and older using a Medicare database in order to determine whether the observed levels of psychological distress in cancer survivors related to the diagnosis, treatment or disability. The authors of this review concluded, “The risk of psychological distress in individuals with cancer relates much more strongly to their level of disability than it does to the cancer diagnosis itself” [33], thus highlighting how strongly physical functioning is linked to emotional functioning.

Pain, musculoskeletal issues, deconditioning, fatigue, balance, psychosocial issues, and lymphedema are the cancer-related symptoms most amenable to rehabilitation in cancer survivors [34]. Deconditioning, fatigue, balance impairment, and psychosocial problems often improve with appropriate exercise interventions. Treatment of pain as well as strengthening and flexibility exercises can cause a significant improvement in the work productivity of affected patients. The treatment of lymphedema initially involves local compression, manual drainage, skin care, and a therapeutic exercise program. Treatment of disorders amenable to medical care will likely result in improved functional status, improve return to work options, and diminish sick leave. In fact, in a Cochrane Database Systems Review, de Boer et al. [35] noted that cancer survivors are 1.4 times more likely to be unemployed than healthy people. In this review, the authors also noted that, while there is a lack of high quality studies doc-

umenting the efficacy of physical, psychological, and vocational interventions in cancer survivors, there is moderate quality evidence to suggest that employed patients with cancer benefit from multidisciplinary interventions compared to usual care.

5. Building the multidisciplinary rehabilitation team Historically, cardiac rehabilitation involved a multidisciplinary team effort, and cancer rehabilitation programs have generally taken this same approach. The first cancer rehabilitation programs began to emerge in the 1970s when research started to demonstrate the efficacy of interventions [36,37]. Since then there have been many studies demonstrating the efficacy of multidisciplinary cancer rehabilitation care. In fact, according to a recent review of the cancer rehabilitation literature, with 1,743 publications retrieved from 1967–2008, scientific production in the field of cancer rehabilitation alone has grown 11.6 times while the whole field of disease rehabilitation has grown only 7.8 times [38].

Today, there is a growing trend towards developing survivorship as a distinct part of cancer care that includes evidence-based cancer rehabilitation interventions [27]. Similar to other models of care, such as those for stroke, spinal cord injury or orthopedic rehabilitation, cancer survivors are ideally treated by a multidisciplinary healthcare team. The team should interface appropriately with key individuals at the workplace to help facilitate support and transitions for survivors. Cancer rehabilitation teams should ideally include (but not be limited to) physiatrists, oncology and/or rehabilitation nurses, mental health professionals and physical, occupational, and speech therapists.

Vocational counselors are also important members of the team, especially when used to encourage optimal employment and workplace function.

In the systematic review published by the Cochrane Database cited earlier, de Boer et al. extended their conclusions to include “cancer is a significant cause of absence from work, unemployment and early retirement” [35]. There is moderate evidence to support the use of multidisciplinary intervention that includes physical, psychological, and vocational components to increase return-to-work rates [35]. Beneficial interventions may include physical, occupational or psychosocial therapy interventions that address an individual’s limitations (i.e., joint range of motion, pain, gait,

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and strength) or specific diagnoses (i.e., chemotherapyinduced peripheral neuropathy, radiation-induced fibrosis syndrome, lymphedema, postmastectomy pain syndrome, depression, or anxiety). Furthermore, vocational rehabilitation interventions including specific vocational training and assistance with job placement have been associated with increased odds for employment [39]. There is, however, a need for additional health professional training and patient education in multidisciplinary oncology rehabilitation as well as additional research focused on prospective surveillance of all cancer types in order to determine the relationship between successful rehabilitation and sustainable return-to-work rates for cancer survivors.

In an effort to increase interest in health professional training in oncology rehabilitation, following is a discussion of the roles that some of the members of the rehabilitation team may play in multidisciplinary treatment of survivors, especially as they relate to occupational issues. It is important to note that there can be a great deal of crossover in provider roles depending upon the disciplines involved. Moreover, these roles may vary based on where the clinicians practice (geography), the specific practice within an institution (organizational structure) and individual skill set and preferences. The descriptions that follow are not meant to be restrictive but rather, generally describe the roles that the various clinicians who may participate in a multidisciplinary cancer rehabilitation team might play. Regardless of the discipline, team members should have a sophisticated understanding of work issues related to cancer survivors and need to focus not only on the survivor’s actual job, but also on other issues that may affect readiness or performance such as: 1. Is the survivor sleeping well at night and rested in the morning?

2. Does the individual have any problems getting ready for work in the morning, including problems eating, dressing, grooming, etc.?

3. Are there any barriers getting to and from work?

5.1. The role of the physiatrist A physiatrist is a physician who specializes in physical medicine and rehabilitation (PM&R) and the goal of physiatric intervention is to return patients to their prior functional status. Even with excellent rehabilitation interventions it is not always possible to return cancer survivors to their prior functional status. However, through rehabilitation measures, cancer survivors who were very sedentary prior to diagnosis may actu-

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ally be able to achieve a higher functional status after cancer treatment than they had before diagnosis.

The physiatrist may either be involved from the initial cancer diagnosis and throughout the course of treatment or may not become involved until the patient has completed all treatment. Regardless, physiatrists “focus on function” and therefore the role of the physiatrist is to screen for, assess, diagnose, treat, and follow the recovery of physical impairments; all promoting the improvement in functional status of the survivor (Table 2). This involves taking an appropriate medical history as well as completing a thorough physical examination of the musculoskeletal and neurologic systems; assessing such measures as strength, sensation, and range of motion. Pain complaints and bone health must be addressed in all cancer survivors. The physiatrist may be helpful in assessing and then treating cancer-related fatigue or cognitive impairment.

Screening for comorbid musculoskeletal conditions and cancer recurrence might necessitate orders for diagnostic testing. The physiatrist can then initiate many types of treatment including prescription of medications, performance of injections, and referral for physical, occupational, and/or speech therapy consultations.

If the patient is not expected to regain the functional status necessary to perform his/her current or prior job, the physiatrist may also order a vocational rehabilitation consultation. If the patient is struggling with emotional adjustment to diagnosis, treatment and/or new impairments, the physiatrist can initiate a mental health consultation. The physiatrist should then work to link recommendations from the collaborating therapists in order to achieve the best possible outcome. Ideally, the physiatrist should outline the goals for cancer rehabilitation and coordinate the multidisciplinary team effort.

5.2. The role of the oncology nurse navigator The oncology nurse navigator has an important role in assessing the barriers that could impact a patient’s ability to receive the cancer treatment they need as well as continue or return to work during and after treatment. Patient-centered care necessitates having an understanding of the individual and his or her values. Asking questions about work will help the oncology nurse navigator better understand the importance of employment to the individual. The oncology nurse navigator is often the first person to ask questions about a survivor’s job and daily responsibilities.

Work issues should be addressed at the initial evaluation – not simply listed as barriers to treatment but,

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J.K. Silver et al. / Cancer rehabilitation may improve function in survivors and decrease the economic burden Table 2 Essential physiatry assessments and interventions

Obtain medical and functional history Perform physical examination of the musculokeletal and neurologic system and document physical impairments Address bone health as well as musculoskeletal, neurologic and pain issues Assess fatigue and investigate whether other symptoms are interfering with sleep, including pain, anxiety, hot flashes, sleep apnea, etc.

Order and evaluate appropriate imaging studies or other tests Prescribe medical treatment, including prescription medications Perform appropriate injections or other procedures to treat pain and dysfunction Refer for appropriate speech, occupational, and physical therapy consultations Prescribe prosthetic and orthotic devices and assistive equipment Assess distress and refer for appropriate mental health consultations Initiate appropriate vocational rehabilitation consultations Interface with workplace officials, as appropriate Identify barriers to work and implement strategies to overcome them Assist with paperwork and documentation of disability or work limitations Recommend an appropriate return-to-work plan Monitor for setbacks and adjust rehabilitation strategies as needed Table 3 Essential oncology nurse navigator assessments and interventions Provide gross assessment of physical functioning and current work status Ensure that disability paperwork is completed by the appropriate provider, if needed Inquire about any assistance the patient may need with the human resources/workplace interface Refer patient to appropriate healthcare professionals, including cancer rehabilitation specialists, mental health professionals, or vocational counselors Work with the patient to ensure he/she has the appropriate support in the workplace Revisit workplace issues during subsequent visits as the patient’s situation may change over time

instead, actively incorporated into the newly diagnosed cancer patient’s needs assessment (Table 3). Because employment provides people with a regular paycheck to meet their bills, and is also often the source of their health insurance benefits, it is not surprising that many newly diagnosed cancer survivors almost immediately begin to worry about how their cancer diagnosis and treatment will impact their ability to work.

While some people may want to take time off from work to undergo treatment, others might resist. Many cancer patients are, in fact, able to continue to work during most of their treatment, enabling them to keep at least some of their usual routine, income and benefits. Notably, the type of cancer the patient has and the anticipated treatment that the patient may receive can give the nurse navigator a framework for determining what may be needed in the form of time away from work (e.g., flex-time might be an option) as well as what other resources might be able to offset financial loss due to missed days from work. It is also important to recognize that some patients may consider work issues when they choose the type of treatment they are willing to undergo. For example, if patients believe that they are not able to be absent from work (i.e., they may fear being fired or demoted or worry about paying their bills), then they may elect to opt out of certain more extensive treatments that the medical team may recom-

mend. In this type of situation, employment issues may actually become a significant barrier to patients receiving optimal treatment for their cancer.

Beyond obvious economic issues, there may be other reasons why a survivor would want to continue working, including emotional support from colleagues or distraction from distress. However, the type of work involved can impact the ability of the patient to work during treatment. For example, a patient who works with young children may not be able to work while receiving chemotherapy due to the risk of infection. A patient who has a physically demanding job, such as a construction or assembly line worker, may not be able to meet productivity requirements during treatment.

Individuals with jobs that are cognitively demanding, such as physicians or air traffic controllers, may not be able to concentrate well enough to perform their job safely.

The oncology nurse navigator is often uniquely positioned to explore a host of employment-related issues that may impact cancer treatment. Following is a list of questions that is designed to help a nurse navigator better understand how employment may directly or indirectly affect a patient receiving and/or adhering to their prescribed treatment and, as such, should be included in the needs assessment:

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1. Does the patient work outside of the home or at home for a business (including self-employment)?

2. Is the patient’s health insurance provided by their place of work? Does it include a prescription drug card?

3. What type of work does the patient do? Is it fulltime or part-time and how long has the patient been employed with the company?

4. Can the patient describe a typical day at work?

5. How far away from the patient’s home is the place of work? How far away is the place of business from the cancer center where treatment will be administered?

6. Does the patient enjoy the type of work he/she does?

7. Does the patient have a good working relationship with his/her supervisor?

8. Is the supervisor aware that the patient is ill or has been diagnosed with cancer?

9. Are there any concerns regarding the need to periodically be off work during specific segments of the prescribed treatment?

10. Does the patient have adequate sick days accumulated?

11. Is the patient dependent on a “full paycheck” to meet his/her monthly bills?

12. Is the patient aware of resources that can provide more information about cancer and employmentrelated issues (e.g., Cancer and Careers [40] or the Patient Advocate Foundation [41])?

The answers to these questions then set the stage for determining what additional resources and/or education may be needed to support the patient during treatment. Of particular note, the financial resources needed to offset the expense of the prescription drugs associated with a patient’s treatment can be considerable and would need to be evaluated as those expenses would not have been factored into the patient’s monthly bills prior to the cancer diagnosis. If the individual will be receiving radiation daily for several weeks, it may be simpler to arrange treatment at a facility close to work so that treatment can be given prior to the patient’s work shift or at the end of the work day.

A discussion regarding whether the employee wants his employer to know about his cancer diagnosis also needs review. Though many cancer survivors will want their employer and/or immediate supervisor to know about a major illness, there are others who prefer to keep their diagnosis and treatment plan confidential.

The oncology nurse navigator should try to help the

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newly diagnosed patient determine just how much information he/she wants to reveal to employers, supervisors and coworkers. It is important to explain to the newly diagnosed patient that while more information can always be shared later, it is impossible to “take back” any information once it is shared.

The importance of this discussion applies to patients with metastatic disease as well. For patients whose metastatic disease is stable or controlled through continuous treatment, there may not be any reason to share information with an employer. However, if the disease is not controlled, and the patient’s short-term prognosis is poor, the individual may want to let his or her employer make plans in the event that he/she is no longer able to work.

5.3. The role of the physical therapist A significant proportion of cancer survivors experience deficits in function and restriction in participation in life roles that can remain many years after diagnosis [8,42–44]. Following oncology treatment, patients are often not ready to fully return to their prior level of function and may benefit from physical therapy that addresses tangible issues such as acute and chronic pain, fatigue, gait deviations, and deconditioning [34] as well as complex issues such as emotional dysfunction (e.g., depression or anxiety), recovery of overall function, resumption of activities of daily living and community activities, and return to work [8, 25] (Table 4). For many of these cancer survivors, returning to work is actually a therapeutic event and an achievement in their therapy and recovery status [8].

The physical therapist may play a recurring role along the continuum of survivorship, providing episodes of care during pre/postoperative, chemotherapy, radiation therapy and post treatment periods. Returnto-work status is addressed through determination of work demands and functional assessment of the cancer survivor [45]. Physical therapists, similar to others on the rehabilitation team, provide interventions that support meaningful participation in work-related activities and a holistic approach that integrates survivor functional potential with environmental conditions and the various restrictions that must be applied in order to foster optimal return to work.

Physical therapy addresses limitations in strength, endurance, range of motion, balance, swelling, gait, posture, sensation, pain, and vocational requirements by using treatment techniques that “promote the ability to move, reduce pain, restore function, and prevent dis-

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J.K. Silver et al. / Cancer rehabilitation may improve function in survivors and decrease the economic burden Table 4 Essential physical therapy assessments and interventions

Evaluate ability to perform mobility and activities of daily living (ADLs) such as transfers, bathing, and dressing Evaluate instrumental activities of daily living (IADLs) such as household chores, shopping, going to the bank, getting gas, and including the ability to independently ambulate to/from household demands (self-care) and work Use functional assessment and quality of life scales to assess survivors and determine goals of treatment Evaluate underlying pain from surgery, adjuvant chemotherapy and/or radiation and any subsequent limitation in range of motion, flexibility, balance and/or ability to perform in all activities of daily living Evaluate the need for workplace demands, including ergonomic set-up for optimal work station, the impact of cancer-related fatigue on workload, energy expenditure and the ability to foster a graded exercise program Evaluate the impact of cognitive dysfunction and recommend compensatory strategies and/or environmental modifications to improve ADLs/IADLs and work performance Foster functional-based programs Establish a home-based exercise program to increase strength and endurance, including evidence-based complementary therapies where appropriate (e.g., yoga and tai chi) Evaluate upper and lower extremity functions for proper body mechanics, including lifting, carrying, and transferring as well as functional capacity testing where appropriate Evaluate lymphedema in affected body part(s), treat through complete decongestive therapy program and prevent further exacerbation or risk at work Evaluate impact of spirituality on trajectory of survivorship Address self-perception and body image concerns Determine specific needs for improving psychosocial function (self-image, self-esteem and self-efficacy to perform essential work functions) and provide appropriate referrals (e.g., pastoral counseling)

ability” [46]. For example, when pain is present, physical therapists can measure the impact of that pain on function [45] and provide treatment through increasing range of motion, pain management techniques, and mind-body therapies. If lymph nodes were removed or affected during cancer surgery and/or treatment, patients have an inherent risk of lymphedema. Decongestive lymphatic therapy, which is a complex form of physical therapy that includes the redirection of lymph flow through intact cutaneous lymph nodes, the use of compressive wrappings, and comprehensive skin care [47], may help to decrease limb volume [47,48].

It is even possible that patients may experience physical deficits related to cancer treatments many years later [25] and as such these survivors may benefit from physical therapy and other rehabilitation services many years after their original diagnosis [42].

Physical therapists also work with individuals to develop general fitness/wellness programs that support healthier and more active lifestyles during the survivorship period and may help prevent loss of mobility [46] as well as secondary and long-term side effects of treatment. In fact, evidence suggests a relationship between exercise and primary cancer prevention [49]. Furthermore, exercise has demonstrated benefit when used as an intervention for treating cancer-related fatigue, with decreases in fatigue levels of 40 to 50% [49]. Following improvement in strength and function through an exercise program, the physical therapist can develop a realistic training program geared to the specific demands of work. A work hardening/conditioning program is a work-related intensive, goal-oriented treat-

ment program specifically designed to restore an individual’s systemic, neuromusculoskeletal, and cardiopulmonary functions [46]. The goal of the program is to “restore the injured employee’s physical capacity and function for return to work” [46]. While the term “work hardening” is currently used predominantly in worker’s compensation cases that involve an injury sustained at the work place, this concept of trying to simulate work performance – job specific tasks – and improve physical stamina as well as psychological readiness, may help prepare cancer survivors to return to work.

Following is a list of questions that is designed to help a physical therapist better plan for achieving optimal function at work. Further, appreciating the patient’s goals and vision for their daily activities, including work, will create a context for appropriate rehabilitation strategies that integrate work-related issues throughout the survivorship period with the overall goal being realization of a better quality of life.

1. What is the patient’s body image, perception of capabilities in activities of daily living/instrumental activities of daily living (ADLs/IADLs), and potential for return to work?

2. How are ADLs/IADLs currently being managed and are they impacting work? If so, is there assistance at home and/or work to help the survivor feel confident in these tasks?

3. Does pain, cancer-related fatigue or lymphedema interfere with movement and function?

J.K. Silver et al. / Cancer rehabilitation may improve function in survivors and decrease the economic burden

4. Does fear of recurrence prevent movement or foster lack of motivation in ADLs/IADLs or return to work?

5. What environmental barriers exist that prevent function and successful completion of tasks?

6. Are there cognitive concerns impeding the patient’s full return to work? What are the demands of the job?

7. What are the patient/employers work-related needs?

8. What specific modifications/accommodations are necessary to ensure mutual goals?

9. What self-care elements are necessary for improving confidence and self-efficacy in ADLs/ IADLs and on-the-job performance?

10. What support systems are in place for successful outcome?

The patient’s responses to these questions will provide the underpinning for determination of appropriate physical therapy assessment and intervention.

5.4. The role of the occupational therapist According to the American Occupational Therapy Association, “occupational therapists and occupational therapy assistants help people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations)” [50]. The occupational therapist plays an important role in addressing a cancer survivor’s activities of daily living, instrumental activities of daily living, work, leisure and social participation throughout the continuum of survivorship. Occupational therapists support meaningful participation in valued work activities through a patient-centered approach that carefully considers each cancer survivors abilities, environmental supports and barriers, and occupational demands.

Work contributes to valued roles and routines. However, side effects or late effects of cancer treatment such as physical, emotional or cognitive changes can impact an individual’s ability to work [50]. These changes can disrupt activities of daily living such as performance of a morning routine in preparation for work, instrumental activities of daily living such as community mobility, or social participation including outings or gatherings with colleagues. According to the American Occupational Therapy Practice Framework: Domain and Process, job performance includes “work skills and patterns; time management; relationship with coworkers, managers, and customers; creation, production, and distribution of products and

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services; initiation, sustainment, and completion of work; and compliance with work norms and procedures” [51]. Occupational therapy practitioners analyze these many factors that contribute to job performance and their unique relationship to the client using holistic, client-centered models for assessment and intervention [52–54].

A recent study of newly diagnosed patients with thoracic cancer found that of the 540 people screened, 273 (51%) reported levels of distress that warranted a full occupational therapy evaluation [55]. Of those who underwent evaluation, 266 (95%) reported a total of 681 problems (median of 4 per patient). The problems reported were mostly within the domain of self-care (553 or 78%), specifically in the categories of transfers, functional mobility and bathing/showering.

The occupational therapists developed a total of 646 goals (median of 2 per patient) resulting in 652 interventions that included provision of specialized equipment (79%), advice (32%), and referral to another professional or agency (23%). Patients reported that most goals were achieved (98%).

Occupational therapy practitioners working in oncology address the side effects of cancer and its treatment through intervention aimed at restoring function, including development of home exercise programs that improve strength and mobility; modification of activities such that individuals learn ways to conserve energy during important everyday activities; or modification of environments such as the workplace, home, or community [51] (Table 5). Depending on the stage and prognosis of the cancer, occupational therapy intervention methods can remediate, compensate, or adapt a client’s abilities in order to assist him/her in achieving a maximum level work performance. Occupational therapists may also be experts in cognitive rehabilitation, depending on their training. For example, side effects of cancer treatments such as neuropathy, fatigue, weakness or cognitive dysfunction may alter the cancer survivor’s ability to drive. However, driving is an activity that is often necessary for work. Cancer survivors may benefit from driver rehabilitation, a specialized area of occupational therapy, to further evaluate and address one’s ability to safely operate a vehicle with or without adaptive equipment.

Following is a list of questions that is designed to help an occupational therapist better understand how employment issues may directly or indirectly affect a patient receiving and/or adhering to their prescribed treatment and, as such, should be included in the needs assessment:

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J.K. Silver et al. / Cancer rehabilitation may improve function in survivors and decrease the economic burden Table 5 Essential occupational therapy assessments and interventions

Evaluate ability to perform self-care in preparation for work such as dressing and grooming and establish a morning routine with a focus on energy conservation and work simplification Evaluate ability to perform instrumental activities of daily living such as ability to drive and provide training in community mobility including adaptive equipment or public transportation as needed Evaluate the need for workplace modifications that address cognitive, physical, or emotional changes and implement necessary modifications to maximize work performance Evaluate the impact of cognitive dysfunction such as attention, memory or multi-tasking on essential job functions and recommend compensatory techniques or environmental modifications to improve work performance Evaluate the impact of fatigue on essential job functions and implement energy conservation strategies to maximize work performance Evaluate upper extremity functions such as lifting, carrying, typing or writing and customize a home exercise program and modifications to improve work performance Evaluate lymphedema in affected body part(s) and provide intervention(s) aimed at reduction of edema, including ways to minimize risk of exacerbating the condition at work Evaluate psychosocial function including self-image and self-esteem and implement strategies to enhance self-efficacy to perform essential work functions

1. Is the patient having difficulty performing selfcare or home management activities that interfere with work?

2. What is the patient’s psychosocial, emotional and spiritual connection to their work and the value of work in their daily life?

3. What are the patient’s roles, routines and habits related to work, self-care and instrumental activities of daily living?

4. Is the patient having difficulty with community mobility (e.g., getting to and from work or while at work)?

5. What are the patient’s work-related needs?

6. What job functions are difficult for the cancer survivor to perform?

7. Would work-related modifications enhance or support the cancer survivor’s ability to perform essential job functions?

8. What environmental support(s) or barrier(s) is the cancer survivor experiencing related to work?

9. What are the patient’s goals and priority areas for intervention related to work?

The patient’s responses to these questions can lay the foundation for occupational therapy assessment and intervention.

5.5. The role of the speech language pathologist A speech language pathologist evaluates and treats disorders that involve communication or swallowing (Table 6). Although swallowing and speech problems may affect any cancer survivor, they are most prevalent in survivors of head and neck cancer. Adjuvant chemotherapy can worsen dysphagia and swallowing impairments are usually more common than speech

impairments after radiation therapy [56]. However, one study estimates that about half of oral and oropharyngeal cancer patients experience difficulty with speech every day [57]. These impairments result in significant health care cost burden, both in terms of actual treatment cost as well as lost productivity of the patient after treatment [58]. While these functions may improve in survivors of head and neck cancer with tissue healing and decreasing edema, a speech-language pathologist can perform a vital role in the patient’s return to speaking and eating in public, a necessity associated with nearly all occupations.

The speech-language pathologist can demonstrate exercises designed to mobilize the many muscles of the mouth, jaw, and neck. Pretreatment exercises (prehabilitation interventions) result in a measurable improvement in posttreatment swallowing function [59– 61]. Therapists can help the patient find ways to improve their speech or ways to communicate if they are unable to speak well. They can provide education on the muscles of speaking and chewing and the expected course and likelihood of return to function.

They should address common issues after treatment of head and neck cancer, such as trismus (inability to fully open the mouth) and xerostomia (dry mouth.) The speech-language pathologist should also work closely with the occupational therapist and dietician in order to coordinate eating strategies and ensure that the patient is getting adequate hydration and nutrition. Of note, patients treated in a multidisciplinary fashion are more likely to comply with the treatment recommendations of the speech-language pathologist [62].

In addition, although many people may not know that speech language pathologists can be very helpful to patients with mild cognitive impairment (“chemo brain”) or other cognitive dysfunction, according to

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Table 6 Essential speech-language pathology assessments and interventions Assess vocal skills and offer strategies for impairments Assess swallowing safety and efficiency Recommend appropriate consultations with dietician and coordinate care Evaluate for and offer symptomatic treatment of xerostomia Evaluate for trismus and offer strategies for associated functional limitations Perform a physical examination that includes documenting abnormalities in jaw excursion and cervical range of motion Perform and/or interpret swallowing study Devise a plan of exercises to improve speech or other impairments Suggest diet and swallowing strategies to avoid aspiration of food Devise a plan of exercises to improve swallowing function Consider essential job functions and recommend appropriate strategies and/or adaptive equipment Strategize with patient about what and how to eat at work, especially if the individual is malnourished, has difficulty chewing or swallowing, or needs extra time to eat Facilitate interface with the workplace to promote function, safety and comfort if the patient has specific limitations Table 7 Essential mental health assessments and interventions Assess for distress, recommend appropriate interventions, follow up and adjust recommendations as necessary Assess for and treat mental and/or behavioral health issues, including anxiety and depression Evaluate sleep and recommend sleep hygiene and other strategies to improve adequate rest Recommend and instruct patients on appropriate cognitive behavioral therapies or strategies Assess readiness for return to work or other psychological workplace issues Determine barriers to normal function at work and recommend strategies to overcome them, if possible Assess other factors that may influence work, including health insurance benefits, financial pressure, etc.

Interface appropriately with workplace to facilitate occupational function

the American Speech-Language-Hearing Association, their scope of practice specifically includes cognitive interventions that focus on memory, concentration, sequencing, executive function and so on [63].

5.6. The role of the mental health professional Mental health professionals come from various clinical backgrounds such as mental health counselor, oncology social worker, psychologist, neuropsychologist, or psychiatrist. In fact, consultation with more than one of these professionals may be helpful during the course of cancer care. A mental health counselor may fulfill the role of someone that patients can talk to about their feelings and should be able to help the patient strategize about work barriers and how to overcome them.

Many counselors can also help patients with cognitive behavioral strategies designed to decrease stress or anxiety and address concerns about physical intimacy or other sexual issues.

Mental health professionals can assess and treat common psychosocial disorders (Table 7) including anxiety and depression. They can offer strategies for recognizing and dealing with posttraumatic stress disorder (PTSD) that can appear not only after a trauma, but also after surviving cancer. They can follow survivors with known mental health disorders that predate their diagnosis with the intent to enhance compliance

and the success of treatment. They may recommend strategies that help someone adjust to new impairments and disability. Fear of recurrence, risk of second cancers, fertility, and worry over delayed effects of treatment are common concerns of survivors [64] that may also necessitate mental health intervention. Oncology social workers have many roles and, according to the Association of Oncology Social Work, the scope of practice includes, but is not limited to, services to survivors, families and caregivers that foster coping and adaptions to cancer and its effects to maintain or improve quality of life; assist in navigating survivors through the healthcare system to achieve quality care; and mobilize new or existing family, system and community resources to provide social and emotional support to survivors [65]. Psychologists and psychiatrists tend to focus on the diagnosis and treatment of mental health conditions such as depression. Both may perform psychotherapy and utilize cognitive behavioral and other therapies. Psychiatrists may also prescribe medications. Neuropsychologists can perform testing to assess cognitive changes that may have occurred after treatments such as radiation and chemotherapy.

The presence of depression and anxiety in cancer survivors varies greatly by the type of cancer as well as the age and gender of the patient [66]. Prevalence rates have been estimated as high as fifty percent in cancer patients when subclinical levels are included.

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J.K. Silver et al. / Cancer rehabilitation may improve function in survivors and decrease the economic burden Table 8 Essential vocational counselor assessments and interventions

Assess prior job experience and current work status Diagnose and treat impairments as they relate to work function Evaluate workplace barriers and identify strategies to overcome them Interface with workplace to assist return to optimal occupational function, if appropriate Evaluate need for vocational or on-the-job training or further college or university training Assess current job skills and determine if current employment status can be improved Help to find appropriate work opportunities Recommend reader or interpreter services or adaptive equipment for those with communication impairments Consider basic literacy training Direct patient to on-the-job support Link with appropriate rehabilitation technology to improve job performance Follow up appropriate with patient to maximize occupational success

Regardless, treating these symptoms not only improves quality of life, it likely enhances productivity at work as well. A review of ten studies found that, among the available types of psychiatric and psychological interventions for depression, cognitive behavioral therapy and pharmacologic intervention were more effective than problem-solving therapy [67]. All interventions were more effective than control conditions, thus demonstrating the need for adequate mental health access for cancer survivors. Furthermore, the authors point out that depression overall leads to delayed return to work.

5.7. The role of the vocational counselor A vocational counselor is trained in assessing job skills and retaining or finding new employment opportunities for their clients (Table 8). They can recommend appropriate rehabilitation technology to assist with job performance, teach or assist with communication skills (e.g., sign language for patients who can no longer hear due to their cancer or sequelae of cancer treatment), and provide encouragement regarding available jobs. Since cancer survivors are typically a small percentage of their clients and different types of cancer may yield very different impairments, vocational counselors should take their cues from the cancer survivor as to the pace of return to work.

Many cancer survivors remain employed in their precancer job or occupation and many of these may never even take time off from work. However, some cancer survivors may either need assistance with workplace modifications so that they can perform their current job, or alternately they may need help finding a new job. In the United States, a vocational counselor may initiate referral to the Office of Vocational Rehabilitation that, in each state, can help with funding of job placement, training, and workplace modification. A study of state vocational rehabilitation services demon-

strated that only 0.4% of the population receiving services were cancer survivors [68]. However, the same study revealed that 51.6% of the unemployed cancer survivors achieved successful employment after utilizing these services. Factors that were associated with greater likelihood of being unemployed were gender (men), lower educational levels, and provision of cash or medical benefits. Although it is disheartening to observe that those patients receiving financial benefits were less likely to return to work, this could actually reflect the severity of their illness rather than a financial disincentive to return to work. As more cancer patients participate in vocational rehabilitation, we will hopefully learn more about ways to encourage gainful employment and educate patients about the transition period offered in many states, during which survivors can attempt return to work while retaining some of their benefits.

Following job placement, support from a vocational counselor can make the difference in job retention.

A study of young cancer survivors demonstrated that those who received job placement assistance were twice as likely to be employed. Those who received onthe-job support were four times more likely to be employed [68]. Clearly, vocational rehabilitation provides documented benefits in cancer survivors.

6. Case study highlighting a multidisciplinary rehabilitation team approach to return to work The following is a fictional case designed to highlight how a best practices multidisciplinary team approach might facilitate optimal physical, psychosocial, functional and work outcomes: “Mary� is a 57-year-old woman who was diagnosed with stage II right sided breast cancer and opted to undergo a mastectomy with reconstruc-

J.K. Silver et al. / Cancer rehabilitation may improve function in survivors and decrease the economic burden

tion followed by chemotherapy and radiation therapy. Mary’s past medical history is relatively unremarkable with the exception of some anxiety that has been treated by her primary care physician with anxiolytic medications on an as needed basis. Prior to her diagnosis, Mary was working full time as a sales representative for a manufacturing company.

Her job involves significant travel by both car and plane; during which she must pull, lift and carry her demonstration products that weigh up to 20 pounds as well as her suitcases that can weigh up to 30 pounds combined. She is a single mother with two children – a daughter in high school and a son in college. Mary has a boyfriend who is emotionally but not financially supportive.

As part of her initial evaluation with the surgical oncologist, Mary met with the breast nurse navigator. The nurse navigator screened Mary for distress as well as physical impairments and identified increased anxiety as well as preexisting arm, shoulder and neck pain bilaterally, but worse on her dominant right side. Recognizing that some of Mary’s anxiety was related to her being a single mother and the sole provider for her children, the nurse navigator referred her to a vocational counselor. The nurse navigator also referred Mary to an oncology social worker for her anxiety, and a physiatrist for her upper quadrant pain issues.

A vocational counselor was able to advise Mary on how to negotiate a temporary medical leave followed by a stepwise return to work schedule with her employer. The social worker used cognitive behavioral strategies to help Mary decrease her stress and anxiety and, later in Mary’s course of treatment, provided counseling about intimacy and sexuality issues that arose. The physiatrist diagnosed rotator cuff impingement and cervical myofascial pain syndrome bilaterally. Because the right side was more affected and was also the side on which Mary was scheduled for surgery and other cancer treatments, the physiatrist recommended more aggressive intervention immediately on the right side and conservative treatment on the left side. The physiatrist performed a subacromial injection and trigger point injections in the paracervical region preoperatively. He also referred Mary to physical therapy to address musculoskeletal diagnoses and occupational therapy to help with adaptive strategies and equipment for work that would allow Mary to decrease the stress on her upper body during and after cancer treatment.

During a follow-up visit after chemotherapy treatment, Mary complained of “chemo brain” and an in-

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ability to comfortably deliver even her standard sales pitch when practicing for her return to work. The physiatrist, recognizing the symptoms of mild cognitive impairment, referred Mary to a speech-language pathologist. The speech-language pathologist, who was skilled in cognitive rehabilitation, was able to help Mary with her memory, attention, focus, organization, and oral presentation skills.

With the support of this multidisciplinary team, Mary successfully completed her cancer treatments, and her preexisting musculoskeletal impairments improved. She was out of work for a total of two months, worked part time for three months (using adaptive strategies and equipment prescribed by the occupational therapist) and was able to return to work full time after five months. Mary’s anxiety was well managed by a combination of the anxiolytics prescribed by her primary care physician and cognitive and behavioral strategies recommended by the oncology social worker and speech-language pathologist. This supportive team approach facilitated a manageable treatment, recovery and return to work schedule that prevented a significant loss in income for this single mother.

7. Conclusion Rehabilitation is a critical component of quality cancer care. From diagnosis onward, rehabilitation of cancer survivors may positively impact their ability to work which can, in turn, significantly ease the economic burden of cancer on the individual, their family and society in general. While increasing the potential for employment in cancer survivors has many benefits, there is an urgent need for research focused on how rehabilitation can improve employment outcomes.

For example, the prospective surveillance model has been studied in breast cancer survivors [69]; however, it is not currently known if screening newly diagnosed breast cancer survivors that results in the identification and treatment of post diagnosis but pretreatment shoulder and arm impairments (e.g., rotator cuff impingement) would contribute to improved work outcomes.

Although there is evidence to suggest that breast and arm symptoms are associated with sick leave [12], and it makes sense that identifying and treating impairments early would result in better work outcomes, this relationship has yet to be confirmed. Another area lacking in comprehensive research into the relationship between impairments and employment is in the head and neck cancer survivor population. These patients, in par-

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ticular, have many challenges in returning to work and further study is needed in order to determine which rehabilitation interventions will best help them overcome return-to-work barriers. Clearly, further study of the difference between types of cancer and successful return to work will help healthcare professionals better anticipate impairments and necessary services. In addition, early dual screening for physical and psychological impairments, from diagnosis onward, will be necessary in order to offer appropriate and timely treatment interventions that facilitate improved outcomes.

Despite the fact that more research is needed, cancer rehabilitation can and will help ease the path survivors take back to successful and sustained employment.

Acknowledgements The authors acknowledge and thank Julie A. Poorman, PhD, for her assistance with manuscript preparation.

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