Introduction
As the number of oncology patients grows in the United States, rehabilitation professionals are asked to be involved in the care at various points before, during, and after treatment. Rehabilitation services can be delivered in numerous postacute care settings; however, as value becomes increasingly important, cost and outcome measures within the various settings will help determine where the care is delivered. Only 2.4% of all oncology patients utilize inpatient rehabilitation services. High-quality rehabilitation services have been shown to be a key component in the oncologic care spectrum, and some of these patients are best managed in inpatient rehabilitation facilities (IRFs).
Epidemiology
Cancer survival from breast and gynecologic malignancies is becoming more prevalent as early screening, better diagnostic techniques, and improved treatment regimens are utilized more frequently. Female breast cancer is the most commonly diagnosed malignancy in the United States accounting for an estimated 268,600 new cases in 2019, which comprises 15.2% of all new cancer diagnoses. Less commonly, uterine cancer accounts for 61,880 cases (3.5% of new cancer diagnoses), ovarian cancer with 22,530 cases (1.3%), and 13,170 people with (0.7%) new cervical cancer diagnoses in 2019. Vulvar cancer accounts for only 6070 (0.3%) of new cancer diagnoses over the same time span. Given focused screening leading to early identification followed by more comprehensive chemotherapy/hormonal therapeutic options, surgical techniques, and radiation protocols, 5-year survival for these malignancies ranges from 47.6% (ovarian) to 89.9% (breast).
Reason for Admission to Acute Inpatient Rehabilitation
To be considered for admission to an acute IRF, a patient must meet several criteria ( Table 23.1 ). The Centers for Medicare and Medicaid Services (CMS) also mandates that supporting documentation, including preadmission screens, postadmission physician evaluations, and individualized overall plans of care, be included for compliant IRF admission. The 60% rule requires that IRF admits no less than 60% of patients that can be identified as having 1 out of 13 specific conditions. Although cancer is not explicitly stated within the 60% rule, several cancer diagnoses may be consistent with the listed conditions, that is, metastatic brain tumor patients representing nontraumatic brain injuries or spinal cord lesions as nontraumatic spinal cord injuries ( Table 23.2 ). However, in skilled nursing facilities, CMS is initiating the Patient-Driven Payment Model starting on October 1, 2019, which will include cancer as a compliant diagnosis which, if successful, could provide a model for compliant IRF admission of oncology patients in the future.
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| Stroke | Spinal cord injury |
| Congenital deformity | Amputation |
| Major multiple trauma | Fracture of femur (hip) |
| Brain injury | Burns |
| With evidence that less intensive treatments were attempted and failed to improve the patient’s condition before admission to IRF | |
| Systemic vasculitides with joint inflammation leading to the functional impairments of ambulation and ADLs |
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Breast and gynecological cancer patients comprise between 3% and 5% of an inpatient rehabilitation population with admissions generally related to impairments due to the spread of the cancer beyond the primary site or sequelae of treatment. The most common sites of metastasis in patients with breast cancer are bone, lung, brain, and liver. Endometrial carcinoma typically demonstrates localized metastasis, but can also spread to the lungs. Less commonly endometrial cancer manifests in the bone, brain, liver, and adrenals. Patients with ovarian cancer often demonstrate localized spread within the peritoneum, retroperitoneum, and even distant sites of metastasis. Multidisciplinary teams within IRF, including physiatrists, advanced-care practitioners, physical and occupation therapists, speech language pathologists, rehabilitation nurses, social workers, clinical nutritionists, case management, pastoral care, and psychologists, are often well equipped to manage people with various disease-related conditions. The following sections will discuss inpatient rehabilitation management of these patients and impairments associated with the treatment.
Inpatient Rehabilitation Management
Localized Surgical Resection
The goal of surgical intervention for breast and gynecological cancers is to minimize risk of local recurrence while simultaneously minimizing patient morbidity. Surgical planning involves identifying and removing tissues that have visible tumor or are at risk for microscopic tumor infiltration, determining which tissues can be spared and which locally advanced tumors are amenable to resection. Wide local excision has long been the strategy, but tumor recurrence rates remain high with this technique. An analysis of cervical cancers after surgical resection has been recently used to help model tumor growth and to improve outcomes for patients undergoing wide local excisions. By achieving more complete resection of a tumor initially, patients have better response to adjuvant treatments.
Early in the 20th century, radical mastectomy was the surgical intervention of choice for patients with breast cancer; however, currently breast conservation techniques are utilized more frequently. Periareolar incisions and localized lumpectomies are used for tumors that are not as large and are less than 2 cm from the areola. For patients undergoing mastectomy, whether electively or out of medical necessity, the need for reconstruction is discussed in the preoperative and the surgical approached is tailored to the needs of the patient. Furthermore, sentinel lymph node dissection (SLND) has replaced axillary lymph node dissection (ALND) as the primary method of staging in part not only because of its diagnostic utility but also because of decreased risk of postmastectomy lymphedema.
Breast surgical complications, including wound infections, axillary seromas, axillary paresthesia, lymphedema, and brachial plexus injury, can be seen at higher rates in SLND plus ALND when compared to SLND alone. These surgical complications can oftentimes be managed in an IRF. Wound care nursing along with antibiotic therapy (if indicated) can enhance wound healing. The patients with brachial plexus injuries can have significant impairment of the affected limb. A comprehensive rehabilitation therapy program with physical and occupational therapy can help to restore function.
Patients in an IRF population can admit secondary to complications from a surgical procedure adding to the medical necessity required for inpatient rehabilitation admission. Enhanced recovery programs in acute care hospitals have been shown to decrease inpatient length of stay and minimize surgical complications, including hemorrhage, wound dehiscence, anastomotic leakage, abscess, or small bowel obstruction. These complications may lead to patient transfer to a postacute care setting sooner after surgical intervention to further facilitate recovery before returning home.
In patients with endometrial cancer, deoxyribonucleic acid damaging agents such as platinum-based chemotherapies have been used as an adjunctive treatment to surgical debulking. Ovarian cancer has a much higher mortality rate than most other gynecologic cancers due to its advanced stage (75% of cases) at the time of diagnosis. Localized spread occurs to the uterus and fallopian tubes, but there can also be contiguous spread to the colon, bladder, and peritoneum. First-line chemotherapy for metastatic ovarian cancer also involves utilization of platinum-based compounds and taxanes. Neoadjuvant chemotherapy reduces the rate of patients needing to undergo multiple bowel resections, which also minimizes the risk of surgical complications. To maximize disease-free survival in patients with advanced ovarian cancer, these patients often undergo modified pelvic exenteration with adjuvant chemotherapy (paclitaxel/carboplatin plus/minus bevacizumab) and as a result these patients sometimes have a new colostomy or an ileostomy. Wound care and ostomy nursing care within an IRF are often needed to help patients and families manage a new colostomy or an ileal conduit for locally invasive metastatic disease amenable to resection. Patients with ovarian cancer who are more frail tend to have more surgical complications, shorter disease-free survival and increased mortality than those who do not meet the frailty index independent of patient age. The inpatient rehabilitation team can often intervene during the pre- or postoperative period to minimize this risk.
Intracranial Metastatic Disease
A percentage of 25 to 30 of brain tumors admitted to IRFs are due to metastatic disease. These are diagnosed with computed tomography or magnetic resonance imaging when neurologic symptoms manifest. Breast cancer is one of the most common primary sites for metastatic spread to the brain. Seventy percent of these patients with metastatic breast cancer present with hormone receptor–positive disease with endocrine therapy as the first-line treatment. There is a higher incidence of cerebellar metastases in patients with breast carcinoma. The location of the lesion corresponds to the symptoms that manifest within the patient. Patients with cerebellar lesions may demonstrate ataxia that can increase risk for falls. Physical therapy interventions, including balance and postural training, gait training, and the use of orthotics, can minimize this risk. Nearly all patients with a metastatic intracranial lesion receive steroids during their disease. However, there is not a standardized method of dosing or weaning. The physician overseeing the care initiates a taper in effort to obtain the minimum effective dosage of the steroid. Glucocorticoid-induced myopathy (GIM) is a serious complication noted with long-term steroid use. Sixty percent of those with GIM have proximal muscle weakness that can negatively impact activities of daily living (ADLs). Maximizing functional independence with ADLs is often a goal for patients within an IRF. Considerations must also be made by the provider regarding the management of seizure prophylaxis and venous thromboembolism prophylaxis/treatment.
Surgical resection of brain tumors may also be considered for patients who have significant disease burden and to minimize symptoms. Several randomized trials have recommended the use of surgery for single brain metastatic disease to increase survival. Although targeted radiation therapy is favorable, in patients with metastatic disease may receive whole-brain radiation therapy (WBRT).
Ninety percent of patients receive WBRT complaining of cognitive impairment. Physiatrists may use neurocognitive stimulant medications to improve functional outcomes in patients with metastatic breast or gynecologic cancer. For example, memantine, in addition to hippocampal avoidance, has been shown to reduce neurocognitive side effects in patients receiving WBRT and targeted stereotactic radiation surgery. Methylphenidate and modafinil are also reasonable options, given their favorable side effect profiles.
Spinal Metastatic Disease
The spine is the most common site of bony metastatic disease, which is thought to be due, in part, to its high vascularity with antegrade arterial spread and retrograde spread via Batson’s plexus. The majority, 70%, of spinal metastases are found in the thoracic spine with 22% in the lumbosacral spine and 8% in the cervical spine. With most of these lesions in the thoracic and lumbar spine, the patients often manifest with paraplegia as opposed to tetraplegia. Metastatic disease to the spine accounts for up to 30% of patients at the time of initial diagnosis leading to epidural spinal cord compression. For these patients with spinal cord compression, initial management is with steroids followed by surgical resection, spine stabilization, and radiation therapy. Early on these patients may demonstrate a flaccid paralysis, but eventually upper motor neuron dysfunction predominates. This can manifest as hyperreflexia or hypertonicity (spasticity or dystonia). Treatment of spasticity and dystonia can include therapeutic intervention, exercises, bracing, oral antispasmodic medications, botulinum toxin injections, neurolytic agents (i.e., phenol), and/or intrathecal baclofen. The rehabilitation team must also manage and prevent other associated conditions such as neurogenic bowel/bladder, pressure ulcers, venous thromboembolism, restrictive lung disease, and pain. Patients undergoing spinal stabilization surgery have been shown to have improvements in ADLs, quality of life (QoL), and disease-related life expectancy with implementation of a multidisciplinary team approach.
Bony Metastatic Disease/Pathologic Fractures
The multidisciplinary rehabilitation team must also manage patients with bony metastatic disease outside of the spinal column. Lower extremity bony metastatic disease, excluding the spine, occurs more often than upper extremity metastatic disease (76% vs 24%, respectively). Within the appendicular skeleton the femur is the most common site of metastatic disease followed by the humerus and the tibia, respectively. Patients with bony metastatic disease, who are surgical candidates, often undergo tumor resection followed by intramedullary nailing in long bones or plate and screw fixation when appropriate. Radiation therapy can also be used as an adjunctive treatment or as primary palliative therapy. Survivability in these cases is related to premorbid performance status and site of primary cancer. Patients with metastatic bone disease can also present with hypercalcemia due to bone destruction of the associated malignancy. Healthy bone has endocrinologic-mediated osteoblast and osteocyte signaling, which ensures the integrity of the bony matrix. In patients with metastatic breast cancer the breast cancer cells secrete factors that enhance osteoclastic activity causing bone resorption. This, in turn, increases the release of signaling factors, that is, TGF-β, from the matrix, which enhances tumor invasion and growth. Further tumor invasion leads to more bone destruction, which can manifest as a fracture or pain and can also cause nerve compression. Bisphosphonates such as zoledronic acid and pamidronate have been used to prevent progression or delay skeletal complications in breast cancer patients. In patients that have hypercalcemia or osteolytic lesions, zoledronic acid has been proven to be superior to pamidronate.
When treating patients with bony metastatic disease, the rehabilitation team must consider sites of known metastasis and weight-bearing restrictions when developing the rehabilitation plan. General precautions for patients with bone metastases include limiting manual muscle testing and avoiding progressive resistance training in the affected limb. Therapists also encourage the use of assistive devices to offload the affected limb. For spinal metastases, patients should avoid excessive spinal flexion, extension, or rotation while monitoring for worsening pain. Mirels’ criteria can be used to predict the risk of pathologic fracture. The interdisciplinary team within an IRF implements a plan of care to maximize function while minimizing risk of adverse skeletal events.
Other Common Impairments
Chemotherapy-Induced Peripheral Neuropathy
As stated earlier, taxanes and platinum-based chemotherapies are used as first-line agents to treat many gynecologic cancers. Unfortunately, platinum-based compounds (70%–100%) and taxanes (11%–87%) have the highest rates inducing chemotherapy-induced peripheral neuropathy (CIPN). CIPN usually manifests as a small fiber, sensory neuropathy that can also be associated with motor or autonomic dysfunction. With electrodiagnostic testing a primarily axonal, sensorimotor polyneuropathy is seen. The development of the symptoms often occurs late in the chemotherapy course, which makes it difficult to determine if dose adjustments can mitigate risk; however, once symptoms begin, oncologists often adjust treatment. Patients usually complain of a stocking/glove distribution of the neuropathy, and patients can also complain of numbness, tingling, paresthesias, dysesthesias, or allodynia. A combination of anticonvulsant medications such as gabapentin, carbamazepine, oxcarbazepine, lamotrigine, and topiramate along with antidepressants such as amitriptyline, nortriptyline, venlafaxine, and duloxetine has been shown to be effective in treating neuropathic pain.
In addition to pain, balance deficits can be seen in patients with CIPN, which can increase his or her risk for falls. Fall risk has been noted to be two to three times more likely in patients with CIPN. Balance exercises have been shown to improve symptoms, including pain, and maximize function. When balance training is combined with endurance training, functional status improves while also improving the QoL. Breast cancer patients with CIPN of the hands noted significant difficulty in their ability to return to work up to 1 year after the completion of treatment, which also negatively impacts health-related QoL. A comprehensive rehabilitation program with physical and occupational therapy to address these issues is important in both inpatient and outpatient settings. Physiatrists may order electrodiagnostic testing to rule out any other peripheral nerve injuries that could be impacting a person’s ability to function. Therapists may also utilize modalities such as fluidotherapy or scrambler therapy to treat pain in patients with CIPN.
Lymphedema
The pathophysiology of lymphedema is not well understood; however, any disruption to a normal functioning lymphatic system can predispose a person to the development of lymphedema. With any disruption (surgery, radiation, injury, etc.), there is an increase in intralymphatic fluid pressure distal to the obstruction, which causes lymphatic vessels to dilate, making the valves incompetent. This in turn makes the cellular junctions incompetent and causes the development of lymphedema. Patients who undergo ALND, regional radiation therapy, and/or sentinel lymph node biopsy for breast cancer diagnosis and treatment are at an increased lifetime risk for developing lymphedema. The exact incidence is hard to determine due to the many types of surgical and radiation treatment protocols; however, it is thought to be between 5% and 50%. The average time to the onset of symptoms is 14.4 months after the completion of treatment. In addition to treatment-related effects, patients with a body mass index ≥25 kg/m 2 are at increased risk of developing lymphedema.
Patients with gynecologic malignancies are also at risk for developing lymphedema. Surgical treatment for patients with ovarian cancer often involves sampling or resection of lymph vessels and lymph nodes in the pelvic sidewall and the para-aortic area, increasing the risk for the development of lower extremity lymphedema. Since surgical intervention for gynecologic cancer involves bilateral lymph node dissection, patients often have bilateral lower limb lymphedema. The prevalence of lower extremity lymphedema in this population is thought to be between 7% and 38%.
In an IRF, physicians, therapists, and nurses may encounter patients with lymphedema. It is important for rehabilitation professionals to be able to identify lymphedema and determine how it can potentially impact the patient’s ability to maximize functional progress. Other causes of peripheral edema should also be ruled out, including, but not limited to, venous thrombosis, edema related to renal or hepatic dysfunction, or hypoalbuminemia. The gold standard for measuring lymphedema is to be either performed by a trained lymphedema specialist or by a perometer. Lymphedema massage and kinesiology taping can be performed in IRFs, which have shown to decrease limb volume. Patients may also utilize compression garments, including thromboembolic disease hose or Tubigrip to minimize edema in inpatient rehabilitation settings. By reducing limb volume, patients can experience improvement in gait quality, minimize fall risk, and make safe stair navigation more feasible.
Patients and the rehabilitation team may have questions about specialized precautions for the affected limb. Weight training has not been shown to exacerbate or improve lymphedema in breast cancer survivors. Similarly, exercise does not exacerbate lower limb lymphedema in patients with ovarian cancer. The nursing staff often restricts blood pressure measurements or blood draws on a lymphedematous limb over concerns about exacerbating the swelling. Two recent analyses showed that neither ipsilateral blood pressure checks, venipuncture, air travel nor extreme temperatures increased the risk of lymphedema in patients with breast cancer. Patient education regarding limb hygiene and infection prevention should be provided as cellulitis can exacerbate or increase the risk of developing lymphedema.
Additional Symptoms/Conditions
Rehabilitation professionals may also provide other supportive services for the cancer survivor. Opioid-induced constipation can be present in 70%–100% or patients with cancer-related pain. Bowel management with medications such as stool softeners, colonic irritants, osmotic agents, promotility agents, suppositories, or enemas in combination or individually can improve these symptoms. In addition, 25% of patients who received radiation therapy for cervical cancer complain of urinary frequency for up to 2 years after treatment. Timed toileting programs with the addition of anticholinergic mediations or α-blockers may help improve continence. Indwelling Foley catheters may be utilized for medically complex patients or for those transitioning to the end-of-life comfort care. Patients receiving anthracyclines for treatment of breast cancer or those undergoing chest radiation therapy may have cardio/pulmonary toxicity; however, active breath coordination during radiation may minimize this risk. Active breath coordination involves using the deep inspiration breath hold technique when a person is getting chest radiation for breast cancer. When a patient takes a deep breath, the diaphragm flattens, expands the chest cavity, and moves the heart out of the radiation field thus limiting damage to cardiac tissue. Early identification and management of these treatment sequelae can help the patient maximize function during rehabilitation stay. Herceptin (trastuzumab), which can be used in the treatment of certain types of breast cancer, and certain taxanes have been known to cause pancytopenia. Transfusion parameters to minimize bleeding risk should be discussed with the primary oncology team prior to transfer to IRF. Granulocyte colony–stimulating factors can be administered to combat leukopenia and neutropenia. Therapists should be mindful of blood counts and adjust plan of care accordingly ( Table 23.3 ). Fatigue is also seen in 60%–90% of cancer survivors and is multifactorial in nature. Dopamine agonists have been shown to be effective in managing fatigue. Methylphenidate is the drug of choice to improve opioid-induced sedation, cognitive decline, and fatigue.
