Introduction
The cancer care continuum is a protracted time period with multiple medical treatments introduced at varying time points through that continuum. Each medical treatment brings with it the risk for different side effects that impact various body systems. Implementing a model of care that optimally serves women during and after cancer treatment requires an understanding of the timing of onset of common impairments through the continuum of care and recognition of the measurement tools that are most appropriate for screening and assessment to identify impairment and ensure that evidence-based interventions are then introduced. This chapter will present the framework of the prospective surveillance model (PSM) as a construct for rehabilitation of patients with breast and gynecological cancers and will review the evidence for screening and assessment measures most appropriate for these populations.
Prospective Surveillance Model
Breast and gynecological cancer treatments–related impairments are prevalent and commonly incite functional morbidity. Due to the high risk of impairment throughout the continuum of cancer care, it is reasonable that a rehabilitation model of care should parallel medically directed treatment. The PSM encourages the implementation of rehabilitation services into the cancer care continuum from the point of diagnosis to encourage ongoing interval surveillance of function, identify impairment early, and introduce intervention to ameliorate functional decline. Fig. 2.1 illustrates the PSM and its natural parallel with the cancer continuum.
Prior to the onset of cancer treatments, the PSM encourages the assessment of an individual’s baseline level of function. Assessing comorbidities also provides insight on functional capabilities at baseline. For some populations a prehabilitation plan of care may be indicated. Prehabilitation provides targeted interventions to prepare an individual for cancer treatments with the goal of optimizing physical function prior to the initiation of treatment. The PSM then proceeds with follow-up assessments at intervals throughout the care continuum. The premise of the PSM is that repeated interval assessment will enable early identification of clinically meaningful changes in functional measures, compared to the baseline, that will promote early identification of emerging impairments and enables introduction of rehabilitation services proactively.
Upon completion of cancer therapies, ongoing follow-up, screening, and monitoring for emerging late effects of treatment is warranted. Late effects may present months or years following the completion of medical treatments and incite functional decline. The PSM is a highly regarded, evidence-based model that provides a clinical pathway for optimal integration of rehabilitation services into the cancer care continuum. Use of proactive rehabilitation services, as enabled by the PSM, is considered to be an important component of high-quality cancer care.
Screening and Assessment Measures
Inherent in a surveillance model is the need for ongoing interval screening for treatment-related symptoms indicative of emerging impairment and assessment of various domains of physical function. These measures promote identification of clinically meaningful change and provide important insights to functional status. Screening tests are used when a high-risk population is identified, a variety of tests and measures exist that can identify important and meaningful changes that indicate a disease state or condition. Screening typically is quick, unidimensional, easy to perform, and easy to interpret. In contrast, assessments provide a richer understanding of impairments in order to drive rehabilitation strategies. An assessment is conducted once symptoms consistent with impairment are identified and evaluates their severity and impact on function and quality of life. Assessments are multidimensional, and more comprehensive to identify not just that a problem exists but, more importantly, the extent to which it exists, and what the source of the problem may be. Assessment findings are the basis for the rehabilitation plan of care. Assessment findings are also the baseline from which outcomes of intervention can be evaluated, providing insight on overall effectiveness of a rehabilitation plan of care.
The PSM uses screening and repeat assessment to drive the referral to rehabilitation services and to inform the plan of care. Whether screens or more detailed assessments are conducted depend on a variety of factors, including setting of cancer care delivery, timing of assessments, and access to specific providers as well as burden to the patient. Screening for cancer treatment–related impairments will commonly be symptom based and undertaken by oncology health-care professionals (i.e., nurse navigators) and ideally occur prior to and during active treatments.
Implementing the PSM for breast and gynecological cancers may follow the basic framework as described previously; however, there are specific nuances to each of these populations that should be further contextualized to optimize rehabilitation interventions.
Breast
Breast cancer treatment–related impairments occur based on the timing and type of cancer treatments. Most commonly, the upper quadrant is at risk for functional loss throughout the duration of cancer care and may result from surgical interventions and is often further exacerbated by radiation therapy. For the majority of individuals with breast cancer, surgery is the first intervention in the continuum of care. Breast surgery and lymph node removal may result in postoperative impairments affecting soft tissue and joint structure and function surrounding the surgical site. These sequelae may lead to upper limb impairments, such as local postoperative pain and a subsequent decrease in range of motion. In the postoperative subacute period, pain and impaired shoulder mobility may be due to adhesive capsulitis, myofascial dysfunctions, and/or nerve dysfunctions.
In later phases of cancer treatments, radiation therapy introduces further upper quadrant impairment risk due to scar tissue formation, wound development, fibrosis, as well as shortening of soft tissues on the anterolateral chest wall, such as the pectoral muscles. Shortened pectoral muscles, often exacerbated by forward shoulder position, may cause narrowing of the subacromial space leading to rotator cuff diseases that can be painful and may limit upper limb movements. In addition, a history of previous shoulder pathology is a risk factor for developing shoulder and arm–shoulder morbidity.
In addition to the upper quadrant impairments fatigue, chemotherapy-induced peripheral neuropathy (CIPN), joint arthralgia, cognitive dysfunction, anxiety, depression, and bone density loss are prevalent throughout the continuum of care due to chemotherapy, hormonal therapy, and radiation therapy. Evidence indicates that many women with breast cancer will experience ≥1 of these physical impairments and suffer from the cumulative burden of impairments, disease treatment, and comorbidities. These impairments lead to difficulties in performing activities of daily living and negatively affect quality of life. In addition, women often report being uninformed regarding the side effects related to their breast cancer treatment and are often surprised that they do not resolve after treatment. Side effects of many of these treatments are amenable to rehabilitation interventions when identified early during treatment for breast cancer.
Specific recommendations regarding impairments that should be assessed at baseline can be viewed in Table 2.1 .
| Domain | Recommendations |
|---|---|
| Range of Motion | Goniometry—passive range of motion |
| At minimum: shoulder flexion and 90 degrees of external rotation | |
| Volume | Circumferential measures with volume calculation |
| Upper Extremity Strength | Handheld dynamometry |
| At minimum: shoulder horizontal adduction, internal and external rotators, and scaption | |
| Upper Extremity Function | Patient-reported outcomes |
| DASH or | |
| University of PSS | |
| Fatigue | Screening measures |
| Ten-point rating scale for fatigue | |
| Patient-reported outcomes: | |
| PROMIS Cancer Fatigue Short Form or PROMIS Cancer Fatigue | |
| Functional Mobility | Clinical measures |
| 6MWT, TUG | |
| Patient-reported outcomes: | |
| AMPAC |
Along with conducting a baseline assessment, timing of future assessments depends on a variety of factors, including, but not limited to, stage of cancer; type of surgery, including reconstruction, chemotherapy, radiation, adjuvant hormone therapy such as aromatase inhibitor use; and a new onset of lymphedema. The interval time points along the PSM trajectory enable providers to evaluate the impact of newly introduced antineoplastic therapies and assess for symptom impact on function.
Pelvic Floor
Patients with urogynecologic cancers experience higher rates of urinary and fecal incontinence as a result of their cancer treatment, and up to 50% report some level of incontinence prior to treatment, with age and body mass index as identifiable risk factors for preexisting incontinence. Urinary incontinence, fecal incontinence, and painful intercourse are prevalent in women with cervical, uterine, vulvar, and ovarian cancers. Pelvic pain and sexual dysfunction are also common sequelae of gynecological cancer treatments. Pelvic pain refers to pain in any structures of the pelvis, and when this pain persists, it can be associated with negative behavioral side effects. Sexual dysfunction represents a heterogeneous group of disorders characterized by a clinically significant disturbance in an individual’s ability to respond sexually or to experience sexual pleasure. These disorders may include both arousal/interest disorders and/or sexual pain.
The prevalence of sexual dysfunction in women with gynecologic cancers is estimated at up to 90%, compared to 40% in the general population. Sexual pain is associated with higher levels of depression and anxiety and lower levels of sexual enjoyment and satisfaction. Additional impairments identified during and after treatment include increased vaginal dryness, decreased sexual desire and arousability, and dyspareunia associated with decreased vaginal diameter after surgical and radiation therapy.
Collectively, the onset of these impairments negatively impacts functioning throughout the trajectory of cancer treatments, warranting a prospective approach to screening and assessment. Furthermore, the persistent nature of these issues requires ongoing long-term surveillance and management through rehabilitative interventions. In the preoperative period, pelvic floor functional assessment should be conducted to understand baseline level of function and to introduce interventions designed to optimize preexisting pelvic floor strength and continence deficits through supervised rehabilitation interventions as indicated. Prehabilitaiton for pelvic floor strengthening improves postoperative return to continence and overall pelvic function.
Despite the high prevalence of sexual dysfunction and pelvic floor disorders in women following cancer treatments, these issues are infrequently addressed until they become substantially disabling to the individual. Sixty percent of gynecologic cancer survivors report that physicians did not discuss the impacts of cancer treatments on sexual function.
While these side effects commonly present or worsen during active cancer treatments, they may persist for several years after the immediate posttreatment phase. Furthermore, these impairments typically cooccur suggesting that multimorbidity should be considered and assessed. The delay of treatment occurs for many reasons: individuals may be embarrassed or uncomfortable initiating discussion on issues such as painful sex or incontinence with their providers, providers may be focused on the urgent, medically specific treatment-related issues rather than on supportive care. Therefore it is imperative for ongoing prospective surveillance at intervals during treatment to allow for a dialogue that provides the individual with an opportunity to discuss these issues as well as to enable a clinical assessment of pelvic floor function and to assess change since baseline.
Beyond the completion of cancer treatments, providers should be aware that these issues may be present given the cancer history and should ask important screening questions and use standardized, validated questionnaires to (1) assess the presence of symptoms and (2) refer to appropriately trained providers who can deliver treatment aimed at pelvic floor dysfunction.
The PSM is the gold standard for multidisciplinary, patient-centered care that involves regular assessment of potential impairments during and after cancer treatment in order to detect issues and intervene early. Providers should consider administering evidence-based screening and assessment measures to evaluate the presence and impact of urinary and fecal incontinence and sexual dysfunction before, during, and after treatment. Table 2.2 outlines the recommended measures assessing gynecological cancer treatment–related impairments.
| Domain | Recommendation |
|---|---|
| Urinary and Fecal Incontinence | Screening: “Have you leaked any [urine or feces], even a small amount, in the last three months?” This screening question is adapted from the 3IQ measure providing a general indication if incontinence has occurred in the last 3 months |
| Interval: Baseline, pretreatment, and at regular intervals (every 4–6 weeks) to assess pre, during, and posttreatment severity and impact of incontinence | |
Patient-reported outcomes:
| |
Patient-reported outcomes for combined urinary and fecal incontinence:
| |
Patient-reported outcomes for fecal incontinence:
| |
| Pelvic Pain and Sexual Dysfunction | Screening: A single screening question: “Do you experience pain with intercourse?” Patients who endorse sexual pain may then require a more in-depth assessment of their sexual function and pain experience |
Patient-reported outcomes:
|
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