What is Cancer Rehabilitation?
Being a cancer rehabilitation physiatrist is an incredibly rewarding experience. We help cancer survivors and their families deal with the physical, cognitive, emotional and social complications of cancer diagnosis and treatment. By 2025 there are projected to be over 17 million cancer survivors in the United States, a population of all ages and abilities. Cancer can affect any organ system and find its way into any part of the human body; thus, a cancer rehabilitation physiatrist’s scope of practice may be as wide, or as narrow as the physician chooses. Because of variations in disease trajectory, due to the disease itself as well as potential long term and late effects, cancer rehabilitation can be very dynamic.
While cancer rehabilitation follows the same basic principles as general rehabilitation, there are a number of important distinctions. First, the communication between the physiatrist and the members of the oncology team must be extensive, especially for patients in active cancer treatment. Since there are often a number of disciplines involved in the care of one patient at the same time (medical oncology, radiation oncology, surgery, palliative care), a cancer rehabilitation physiatrist interfaces with an especially wide circle of providers in other specialties. Meaningful dialogue with the oncology team requires that the cancer rehabilitation physiatrist has a good understanding of cancer care, helping guide maximally safe, timely and efficient restorative therapy. Many oncologists may not be familiar with the advantages of engaging rehabilitation service early and are very protective of their patients. Often, providing good care means interfacing with oncology by providing data for the merits of our services, and accessibility around oncology appointments.
Second, cancer rehabilitation incorporates an especially wide medical knowledge spectrum. In addition to a solid PM&R base, clinical focus often includes management of impairments such as lymphedema or fatigue, consideration of precautionary strategies related to underlying oncology factors, understanding of common impairment constellations by tumor type, modification of treatment approach by phase of disease, and anticipating potential radiation and chemotherapy side effects.
Third, a more somber distinction between cancer rehabilitation and many other rehabilitation subspecialties is that the cancer rehabilitation physiatrist is probably more likely to experience the passing of their patients. While usually expected in such cases, death of a patient is still a tragic event. However, a cancer rehabilitation physiatrist can help preserve dignity at end of life by facilitating self-care and other interventions that allow patients and their families to face the end on their terms. The relationship between physiatrists and their patients, particularly with those who have more extensive rehabilitation needs, such as spinal cord injury patients, is often very close and the patients highly value this care.
What kinds of things do you see in cancer rehabilitation? (common diagnoses, procedures, role in cancer care, etc.)
Pain and fatigue are the two most common complaints of cancer survivors. Neuropathy is probably one of the most predominant side effects from chemotherapy and other cancer treatment regimens. Chemo-induced peripheral neuropathy will most commonly cause neuropathic pain that the limits functioning and potentially impacts further treatment. Musculoskeletal problems often stem from local treatment effects, both acutely and long-term. For example, ipsilateral shoulder pain is highly prevalent in women undergoing mastectomy and/or radiation for breast cancer treatment. Head and neck cancer survivors often present with a trio of trismus, cervical dystonia, and dysphagia. Patients undergoing treatment of pelvic malignancies (cervix, uterus, prostate) often require restorative care for incontinence, pelvic pain, and impaired sexual function. Systemic effects of hormonal deprivation in both men and women often manifest as widespread pain and can sound overwhelming to the physician: widespread tendinopathies, bursopathies, myalgias, fatigue and low energy. Cardiovascular disease is the most common cause of death among long-term cancer survivors, thus a physiatrist with a special interest in cardiopulmonary system can provide a great service to the oncologic population.
Almost anything that is used for functional restoration or pain control in general physiatry is employed in cancer rehabilitation. In addition to interdisciplinary rehabilitation therapies, procedures are often employed. These include peripheral and axial injections, chemodenervation, acupuncture, osteopathic manipulation, electrodiagnosis, functional electrical stimulation, biofeedback training, and orthotics and prosthetic interventions. As a general rule, a cancer rehabilitation physiatrist should have a low threshold to discuss the proposed treatment with the oncologist taking care of the patient, as there are several safety considerations that may not exist in general rehab. Some examples are increased risk for infection or bleeding, medication interaction, or participation in clinical trials of anti-cancer agents that may prohibit the use of steroids.
The role of rehabilitation in cancer care goes beyond symptom management. Restoring a patient’s ability to tolerate physical stress can mean the difference between receiving treatment to control their disease versus shifting care into a palliative mode. A cancer rehabilitation physiatrist’s assessment of a patient’s function can provide an invaluable input to the oncology team deciding on a treatment course. Often the most challenging and rewarding experience is seeing patients through the devastating effects of critical illnesses that can complicate systemic cancer therapy, such as neutropenic sepsis with multi-system organ failure. Finally, rehabilitation can help preserve dignity and independence by teaching patients and their caretakers how to safely accomplish the tasks of daily care, allowing them to finish their journey at home, rather than in a facility.
In what kind of setting is cancer rehabilitation practiced? (acute, inpatient, outpatient, SNF, consults, etc.)
Cancer rehabilitation is practiced anywhere there is a cancer survivor in need of functional restoration! Outpatient clinics, acute care consult service, acute and subacute inpatient rehabilitation centers, hospice units are all places where a cancer rehabilitation medicine physician can make a difference. There are many misconceptions about restorative care for oncology patients across the entire survivorship spectrum that a cancer rehabilitation physician can help dispel. For example, healthcare providers may believe that Stage IV cancer diagnosis means that a patient can not engage in resistance exercise. In such cases a cancer rehabilitation physician consultant can help educate allied health professionals and other physicians to reduce unnecessary immobilization and prevent deconditioning.
Why should I consider a career in cancer rehabilitation? (what advantage(s)/disadvantage(s) does it give me, career opportunities, etc.) Do I need a fellowship to have a career in cancer rehabilitation? What are some things I should focus on to make myself a competitive candidate for fellowship? Should I do an away rotation?
A fellowship in cancer rehabilitation, particularly one affiliated with an established comprehensive cancer center, provides the most intense and immersive exposure to the entire breadth of cancer rehabilitation. It provides the opportunity to learn in 12 months what may otherwise take years because of the patient volume. As in any specialized training, there are intricacies of cancer rehabilitation that cannot be learned from textbooks. Access to mentors that provide input in real time is invaluable as well. Hospital organizations are aware of the projected increase in the cancer survivor population, thus cancer rehabilitation is a fast-growing field and completion of a cancer rehabilitation fellowship provides a competitive edge when seeking employment.
First and most important, focus on excellence in all aspects of PM&R as you will use a wide range of clinical knowledge in your cancer rehabilitation practice. Second, start to familiarize yourself with the cancer rehabilitation literature, and even, if possible, incorporate cancer rehabilitation into some of the presentations you may do in the course of your residency, since teaching always deepens a person’s knowledge. Third, try get some cancer rehabilitation experience, such as via an elective in cancer rehabilitation, in order to increase your exposure so you can be sure about your decision, and to start to make some personal connections that will help you in your career path.
If you feel an away rotation is necessary to be sure of your decision and get experience, it may be helpful. However, your program may have restrictions, and it can end up being an observership. It may be helpful for networking for future career goals.
Why haven't I heard of cancer rehabilitation before now?
It is a smaller subspecialty amongst PM&R subspecialties. Additionally, it is often lumped in with general rehabilitation, neurorehabilitation (e.g. the brain tumors), or pain disorders.
How many fellowship programs/positions are there currently nationwide?
Visit the Fellowship Program Directory to view all cancer rehabilitation fellowships.
What is the best way to network with those involved in cancer rehabilitation?
Members interested in Cancer Rehabilitation can join the Cancer Rehabilitation Physician Consortium of the AAPM&R bimonthly meeting to discuss opportunities for individual participation in via the subgroups of education, strategic initiatives, and research. Communication is primarily by e-mail and phone conferences. We meet face-to-face at least once a year at AAPM&R’s Annual Assembly. Cancer rehabilitation medicine specialists are generally approachable and want to support other physicians with this interest. Establishing a great mentor is an effective first step in creating your network.
How can I get more involved/learn more about cancer rehabilitation?
You can read more about it. The PM&R Knowledge NOW® section of the AAPM&R website contains the diagnosis and treatment of commonly seen conditions in cancer rehabilitation, under the heading of “Medical Rehabilitation.” The AAPM&R Cancer Rehabilitation Medicine Member Community is a great way to connect with other physicians and discuss emerging opportunities. The AAPM&R Annual Assembly offers courses in cancer rehabilitation topics. Articles about cancer prehabilitation1 and rehabilitation2 provide useful overview.
1. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. 2013; 63(5): 295-317.
2. Silver JK, Raj VS, Fu JB, Wisotzky EM, Smith SR, Kirch RA. Cancer rehabilitation and palliative care: Critical components in the delivery of high-quality oncology services. Supportive Care in Cancer. 2015 Aug 28.