Future
Directions
in Cancer Rehabilitation
Susan J. Mellette and Gwendolyn
T
HE KEYSTONE for the future of cancer rehabilitation is widespreadrecognition of the importance of providing creative and wellresearchedrehabilitation measuresin addition to specific antitumor treatment for personswith cancer. The patient deservesthe opportunity for functioning at an optimal level within the limits imposed by the cancer or its treatment. The recognition of the needfor rehabilitation as well as specific treatment can lead to better rehabilitation techniquesand procedures.The nursing profession hasoften led the way in emphasizingquality of life issuesand can be expected to continue to do so in fostering appropriate physical, psychosocial, and vocational rehabilitation for all cancer patients. These concerns are addressedin a position statement of the Oncology Nursing Society.’ The recent increasedinterest in medical rehabilitation is encouraging. In June 1990, the National Institutes of Health convened a Task Force on Medical Rehabilitation Research. Four panels focused on major areas of scientific concentration. These were neurophysiological dysfunction, musculoskeletal disorders, cancer rehabilitation, and geriatric rehabilitation. The Cancer Rehabilitation Panel consisted of 12 members.Those serving on this panel representedvarious areasranging from specific expertise in particular cancer sites to community oncology, nursing, physiatry , and pediatric oncology. Many of the recommendations of the Panel will be incorporated into this article. The full report has been published.2 Progress in Cancer Rehabilitation requires appropriate and continuing assessmentof the patient’s rehabilitation needs. The development of a good databaseis essential. Assessmenttools must have the capacity for quantitating improvement in specific functional parameters. The mechanisms for optimal service delivery need to be better defined. The development of multidisciplinary Cancer Rehabilitation Programs should be fostered; but the efficacy of such programs requires documentation in the literature. CANCER SITES WITH SPECIAL REHABILITATION NEEDS
The rehabilitation requirementsof particular patients are determined to a great extent by the priSeminars
in Oncology Nursing, Vol 8. No 3 (August), 1992: pp 219-223
G. Parker
mary site of the cancerand the disabilities that may result from the cancer or its treatment. The physical rehabilitation needsof the ostomy patient are obviously quite different from those of the person who has undergone amputation or a limb salvage procedurefor a soft-tissue sarcoma.Similarly, the psychosocial impact of a major craniofacial resection differs from that after treatment for a “hidden tumor” such as that of the right colon or ovary. The emotional connotation of a cancer diagnosis crossesall sites and appropriatepsychosocialmeasures must be included along with site-specific needs. Future progress must encompassall these considerations. Head and Neck Cancer
New directions in rehabilitation for personswith cancer of the oral cavity, larynx, and accessory sinuses include technical improvements in prosthetic devices. New materials for extraoral prosthesesneed to be developed which will allow for better skin-color matching and better approximation of the prosthesisto the margins of the defect. Anchoring of prosthesesto bone is being studied.3*4 Intraoral prosthesesnot only provide for closure of defects but may be built up or augmentedto allow better approximation of a partially resectedtongue to the roof of the mouth which will facilitate speech.5Someprostheseshave also been developed to serve as reservoirs with a tonguetouch releasefor a saliva-substitute for patients in whom the normal salivary flow has been impaired, usually by radiation therapy.6 Further improvements are needed. Explanation of the functional From the Departments of Internal Medicine, and Rehabilitation Medicine, the Cancer Rehabilitation and Continuing Care Program, and the Massey Cancer Center, Medical College of Virginia, Virginia Commonwealth University. Richmond, VA. Susan J. Mellette, MD: Professor, Medical Oncology and Rehabilitation Medicine, and Director, Cancer Rehabilitation and Continuing Care Program, Gwendolyn G. Parker, RN, MS, OCN: Clinical Nurse Specialist, Massey Cancer Center. Address reprint requests to Susan J. Mellette, MD, Professor, Medical Oncology and Rehabilitation Medicine, Medical College of Virginia, Virginia Commonwealth University, Box 207, Richmond, VA 23298. Copyright 0 1992 by W.B. Saunders Company 0749-2081192/0803-0009$5.0010 219
MELLE-I-I-E AND PARKER
and esthetic limitations of prosthesesand help in adjustment are needed.’ The number of total laryngectomies has decreasedin recent years due to better radiation therapy and tissue-sparing procedures for early lesions. Some change in the quality of speechmay be present even with more limited procedures.8 Those personswho require a laryngectomy can often be benefitted by the tracheoesophagealfistula or Singer-Blom procedure.’ Further improvements in such techniques and in devices such as the electrolarynx are needed. Speechtherapy needsto be improved and to be made more widely available. Considerableresearchhasbeenunderway on the physiopathology of swallowing and its disruption by cancer surgery.” Techniques to evaluate and facilitate swallowing need to be more widely disseminated. Studies on impairments of taste and smell are less well advanced and more work is needed. Little progresshas been madein the treatment of shoulder dysfunction following radical neck dissection,” but this can be a debilitating complication of surgical treatment.
type should be recommended.Someconsensusalso needsto be reachedon appropriateexercisesfollowing mastectomywith immediate reconstruction, Lymphedemaof the arm may occur after lumpectomy as well as after mastectomyif axillary dissection is performed and, particularly, when radiation therapy is also administered. The treatment of lymphedemaremains unsatisfactory. Compression pumps are of some benefit and sequential compressionmay be better for some patients; but no great difference in results has been shown for the various types of pumps available. t2 Great strides are being made in meeting the psychosocial, as well as the physical rehabilitation needs of breast cancer patients. Support groups abound. Various programsaimed at physical needs and side effects of chemotherapy and including such activities as dance and aerobic conditioning have been instituted.13 Further research, with appropriate control groups and quality-of-life measures, is needed to evaluate many of these programs, particularly the various types of support groups.
Breast Cancer
Bone and Soft Tissue Tumors
Rehabilitation after breastcancer treatment is of great interest because of the large number of women (more than one tenth of US women) who will develop this disease. Breast cancer poses a threat to self-image and sexuality; and its treatment may entail not only surgery but radiation therapy and chemotherapy or hormonal therapy with their resultant side effects. Long-term sequelaesuch as lymphedema of the arm are also a consideration. The decreasein the performanceof mastectomy, which has recently occurred, can be expected to continue, basedon data indicating comparableoutcomes for either more extensive surgery or lumpectomy and radiation therapy. Reconstructionafter mastectomymay also be expected to increasedespite the recent, as yet unsubstantiated, concerns about the safety of silicone implants. The “tummy tuck” abdominal graft or the thoracic wall grafting procedureshave their own morbidity. Optimal rehabilitation of breast carcinoma patients requires further development and refinement of reconstructive techniquesand researchin prostheticmaterials. Limitation of shoulder motion secondaryto capsulitis occurs lessfrequently with more limited surgery, but further research is needed to determine the value of posttreatmentarm exercisesand which
Long-term survival and cures are increasing in patients with sarcomasof soft tissue and bone. When technically feasible, limb salvage procedurescan result in survival data comparableto that following amputation.I4715Multimodality therapy is common for these patients. Much research remains to be conducted in basic science areas,particularly in prosthetic materials and in the use of allografts. Porous implant materials that allow for bone growth into the new material need further study. The use of modular componentsthat can be tailored to the individual’s needs are a promising development. An adjustableand expandableinternal prosthesisthat allows for growth in young patients by means of a small surgical procedure at appropriate intervals is an innovative development.l6 Limb salvage procedures require new approaches in physical and psychosocial rehabilitation because changes in lifestyle may be required. l7 Somepatients function well; others have complications or defects which may make them less mobile or functional than a comparableamputee. The desired lifestyle of the whole individual needsattention, as well as the mechanicalfeasibility of an orthopedic procedure.
FUTURE
DIRECTIONS
IN CANCER
REHABILITATION
Gastrointestinal Cancer
Gastrointestinal cancer continues to be the second leading type of cancer in the United States.i8 Surgery is the treatment of choice for cancers of the colon and rectum. Surgical intervention can result in resection of the tumor with reanastomosis; a colostomy (temporary or permanent); or an abdominal-peritoneal resection (APR). Improved surgical techniques such as the use of the end-toend anastomosis(EEA) and stapling devices have decreased the incidence of colostomies, and sphincter-saving approacheshave helped decrease the functional disability associatedwith treatment of these types of cancers.‘9*2oFurther refinements in surgical approachesand in the use of adjuvant chemotherapy are needed. For patients who must have an ostomy, the need for odor management, methods to prevent flatus, leak-proof pouching systems,better skin care management,and pouching systemsthat do not interfere with sexual activity continue to be identified.‘932’722Addressing these issues in a cost-effective manner will continue to be a challenge. The psychological adaptionto the presenceof an ostomy will continue to be an issuethathealth care professionals will need to addressto promote the total rehabilitation of the colorectal cancerpatient. Extensive research has been conducted which identifies the psychological disturbancesthese patients may encounter as a result of a cancer diagnosis; loss of a body part and bodily function; loss of control over excretory processesand insult to one’s sexuality.2iW24 Further researchis neededto develop and evaluate efficient interventions to address these issues. Genitourinary
and Gynecological Cancer
Urological malignancies, which include cancers of the urinary and genital organs in males and urinary organs in women, will make up 14% of new cancer casesin 1991.l8 The availability and use of newer treatment modalities such as laser therapy and biological responsemodifiers such as Bacillus Calmette-Guerin have produced results that are as effective with minimal associateddisability.25 The recognition that radical surgical approaches for these cancers, particularly prostate cancer, have led to impotence and urinary incontinence has fueled the development for less-debilitating treatment options. The challenge for the future in gynecological
221
cancer care will be the development of conservative surgical approachesand, in cases in which aggressiveintervention is indicated, the development of innovative surgical techniquesto minimize the disability. This need has already been identified in the literature. A more conservative surgical approach to treating early vulvar carcinoma may bejust as effective as a radical vulvectomy.z6 Clinical trials in this areaare neededto evaluate patient outcomes and quality-of-life issues for various types of surgical interventions. Current treatments used to treat gynecological cancer may result in other types of dysfunction. More than 60% of patients treated for vulvar carcinoma with lymph node dissection experience varying degrees of peripheral edema.‘” Techniques used to treat lymphedema in breast cancer patients needto be applied to gynecological cancer patientsto determineeffectiveness.Patientsundergoing a partial or total pelvic exenteration may require the creation of some method of urinary diversion, colostomy, or vagina. Additional researchis neededto determine the most appropriate method of urinary diversion. Vaginal reconstruction hasbeenperformedusing the sigmoid colon as well as the myocutaneousgracilis graft approach, but promising results have been noted with the use of amnion grafts.27 More research is needed in reconstructive surgery to develop artificial organs that are acceptableto women. Gynecological cancers have not received as much national attention as breast cancer. Consequently, an organized psychosocial support network for these women does not exist. Although it is not usually feasible nor advisable to have specialized, site-specific support networks, this group may benefit from the attention that would be given to their needs. Sexual dysfunction will continue to be one of the more challenging rehabilitation issues. There are two domainsof this issuethat require attention. The first is continued education of health professionals to recognize and addresssexuality and sexual functioning in the treatment plans of cancer patients. Studies show that health professionals lack the knowledge and are not comfortable discussing sexual issues with their patients.23.28.29 Health organizations, such as the Oncology Nursing Society and American Nurses’ Association, will need to continue to advocate that this is an expected level of care.
222
MELLETTE
The development of methods to preserve fertility and refinement of surgical interventions and prosthesesto ensure sexual functioning needs to continue. Cryopreservation of semenbefore treatment has preserved the reproductive abilities of men. However, for women reproductive options are limited as the preservation of ova has not been fully used. As acceptanceof high-technological reproductive methods grows, this should become more common. The use of estrogen replacement therapy to relieve menopausal symptoms and osteoporosis in female cancer patients has not been fully researchedand requires further evaluation. REHABILITATION OF PATIENTS WITH METASTATIC DISEASE
Considerable effort is being directed toward the development of measureswhich will enable the patient with metastaticdiseaseto continue to function as optimally as possible for as long as possible. Many patients, particularly those with cancer of the breast, prostate, thyroid, and somehematologic malignancies may continue their usual activities for years after the diseasehas become widespread. Pain control may be the key to function, particularly for patients with bony metastases.Newer long-acting pain medications are available in oral and transdermalpreparations. Generally speaking, pain control is best achieved by specific antitumor measuressuch as radiation therapy or stabilization of affected bones. Further progress needs to be made in techniques for vertebral replacement30.31 and stabilization of the spine. Prosthetic modular componentscan be introduced and fixed with bone cement for some patients with destructive long bone lesions.32 The emotional needs of the person with metastatic disease also demand continued attention. Support groups appropriate for the person with early breastcancer are often inappropriate for such persons. Similarly, groups that emphasizepreparation for death are inappropriate for people who may remain functional for years. Much more work needsto be performed in this area. VOCATIONAL REHABILITATION CANCER PATIENT
OF THE
The aim for the future is to ensure that all patients treated for cancer are able to be employed in
AND PARKER
Table 1. Promising Avenues for Research Cancer Rehabilitation
in
1. Development of better methods for assessment of rehabilitation needs and delivery of rehabilitation services. of taste, 2. Basic and clinical research in impairments smell, swallowing, and muscle function. 3. Development of better prosthetic materials for facial, breast, and limb prostheses. 4. Work on improvements in continent ostomies, better ostomy care. 5. Determination of the role and type of exercise programs after breast cancer treatment and limb salvage. 6. Research in psychosocial components and rehabilitation: support groups, vocational needs, public health policy.
positions consistentwith their desiresand abilities. Problems in this area include not only physical disabilities which require accomodation, but fear of loss of insurance if a job change is made. Federal and state laws require that employers make reasonable accommodations for handicapped individuals. A compilation of applicable laws has been made by the National Cancer Employment Law Project sponsored by the American Cancer Society33 and information may be obtained from state offices of the American Cancer Society. Cancer patients have not generally taken advantage of the legal resources available to them.34 Another areain which more progressneedsto be made is in use of the services of state or other Vocational Rehabilitation agencies.35 Other ways in which employment problems of the cancer patient can be approachedare included in studies by Mellette and Franco.36v37 SUMMARY AND CONCLUSION
Many of the current and future directions in cancer rehabilitation have been briefly discussed;and some of the important areas for development are outlined in Table 1. Implementation of rehabilitation measuresmay be facilitated by organized and creative multidisciplinary rehabilitation programs. Advancesare also dependenton health carepolicy, particularly in reimbursement for rehabilitation services and in the funding of rehabilitation research.38Much progress can be expected in the years ahead.
FUTURE
DIRECTIONS
IN CANCER
223
REHABILITATION
REFERENCES 1, Mayer D, O’Connor L: Rehabilitation of persons with cancer: An ONS position statement. Oncol Nurs Forum 16:433, 1989 2. Report of the Task Force on Medical Rehabilitation Research, Hunt Valley, MD, June 28-29, 1990 3. Tjellstrom A, Lindstrom J, Nylen 0, et al: The bone anchored auricular epithesis. Laryngoscope 91:811-815, 1981 4. Pare1 SM, Branemark PI, Jansson T: Osseointegration in maxillofacial prosthetics. Part I: Intraoral application. I Prosthet Dent 55:490-494, 1986 5. Robbins KT, Bowman JB, Jacob RF: Postglossectomy deglutitory and articulatory rehabilitation with palatal augmentation prostheses. Arch Otolaryngol Head Neck Surg 113:12141218, 1987 6. Toljanic JA, Zacuskie TG: Use of a palatal reservoir in denture patients with xerostomia. J Prosthet Dent 52:540-544, 1984 7. Bimbach S, Herman GL: Coordinated intraoral and extraoral prostheses in the rehabilitation of the orofacial patient. J Prosthet Dent 58:343-348, 1987 8. Sessions DG: Functional results following partial laryngetctomy, in Myers EN, Barofsky I, Yates JW (eds): Rehabilitation and Treatment of Head and Neck Cancer, Washington, DC, US Department of Health and Human Services, NIH Publication No. 86-2762, 1986, pp 35-39 9. Singer MI, Blom ED: An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhino1 Laryngol 89:528-533, 1980 10. Logemann JA: Swallowing and communication rehabilitation. Semin Oncol Nurs 5:205-212, 1989 II DeLisa JA, Miller RM, Melnick RR, et al: Rehabilitation of the cancer patient, in DeVita VT Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice of Oncology. Philadelphia, PA, Lippincott, 1989, pp 1730-1763 12. Stone MA, Lustig J, Mellette SJ: Relative effectiveness of three pneumatic pumps for treatment of lymphedema. Arch Phys Med Rehabil 72:769, 1991 (abstr) 13. McVicar MG, Winningham ML, Nickel JL: Effects of aerobic interval training on cancer patients functional capacity. Nurs Res 38:348-35 1, 1989 14. Yang JC, Rosenberg SA: Surgery for adult patients with soft tissue sarcomas. Semin Oncol 16:289-296, 1989 15. Eilber FR, Rosen G: Adjuvant chemotherapy for osteosarcoma. Semin Oncol 16:313-322, 1989 16. Lewis MM: The use of an expandable and adjustable prosthesis in the treatment of childhood malignant bone tumors of the extremity. Cancer 57:499-502, 1986 17. Lampert MH, Gerber H, Glatstein E, et al: Soft tissue sarcoma: Functional outcome after wide local excision and radiation therapy. Arch Phys Med Rehabil 65:477-480, 1984 18. Boring CC, Squires TS, Tong T: Cancer Statistics. CA 42:19-38, 1992 19. Otte DE: Nursing management of the patient with colon and rectal cancer. Semin Oncol Nurs 14:235-292, 1988
20. Lind J: Colorectal cancer, in Ziegfield CR (ed): Core Curriculum for Oncology Nursing. Philadelphia. PA. Saunders, 1987, pp 163-171 21. Coe M: Comparison of concerns of clients and spouses regarding ostomy surgery for treatment of cancer. J Enterostom Ther 17:106-111, 1990 22. Cohen A: Body image changes in the person with a stoma. J Enterostom Therapy 18:68-71, 1991 23. Smith DB: Sexual rehabilitation of the cancer patient. Cancer Nurs 12:10-15, 1989 24. Gawron C: Body image changes in the patient requiring ostomy revision. J Enterstom Therapy 17: 106-l 11, 1990 25. Davis M: Genitourinary cancers, in Otto S (ed): Oncology Nursing. St. Louis, MO, Mosby, 1991, pp 97-113 26. Chamarro T: Cancer of the vulva and vagina. Semin Oncol Nurs 6:198-205, 1990 27. Thompson LJ: Cancer of the cervix. Semin Oncol Nurs 6:190-197, 1990 28. Williams HA, Wilson ME, Hongladoran G, et al: Nurses attitudes toward sexuality in cancer patients. Oncol Nurs Forum 13:39-43, 1986 29. Wilson ME, Williams HA: Oncology nurses’ attitudes and behavior related to sexuality of patients with cancer. Oncol Nurs Forum 15:49-53, 1988 30. Ono K, Yonenobu K, Ebara S, et al: Prosthetic replacement surgery for cervical spine metastasis. Spine 13:817-822, 1988 3 1. Moore AJ, Uttley D: Anterior decompression and stabilization of the spine in malignant disease. Neurosurgery 24: 713-717, 1989 32. Chao EY, Sim FH, Shives TC, et al: Diagnosis and Management of Metastatic Bone Disease: A Multidisciplinary Approach, in Sim FH (ed): New York, NY, Raven, 1988. pp 171-181 33. Frankfort IA: Employment problems of the cancer survivor, Proceedings of the Fifth National Conference on Human Values and Cancer. Atlanta, GA, American Cancer Society, 1987, pp 88-92 34. Barofsky I: Job discrimination: A measure of the social death of the cancer patient, Proceedings of the Western States Conference on Cancer Rehabilitation. Palo Alto. CA, Bull, 1982, pp 145-153 35. Goldberg RT, Habeck R: Vocational rehabilitation of cancer clients: Review and implications for the future. Rehab Counsel Bull 26: 18-27, 1982 36. Mellette SJ: The cancer patient at work. CA 35:360-375, 1985 37. Mellette SJ, Franc0 PC: Psychosocial barriers to employment of the cancer survivor. J Psychosoc Oncol 5.97- 115. 1987 38. Mayer DK: The healthcare implications of cancer rehabilitation in the twenty-first century. Oncol Nurs Forum 19:2327, 1992
Directions
in Cancer Rehabilitation
Susan J. Mellette and Gwendolyn
T
HE KEYSTONE for the future of cancer rehabilitation is widespreadrecognition of the importance of providing creative and wellresearchedrehabilitation measuresin addition to specific antitumor treatment for personswith cancer. The patient deservesthe opportunity for functioning at an optimal level within the limits imposed by the cancer or its treatment. The recognition of the needfor rehabilitation as well as specific treatment can lead to better rehabilitation techniquesand procedures.The nursing profession hasoften led the way in emphasizingquality of life issuesand can be expected to continue to do so in fostering appropriate physical, psychosocial, and vocational rehabilitation for all cancer patients. These concerns are addressedin a position statement of the Oncology Nursing Society.’ The recent increasedinterest in medical rehabilitation is encouraging. In June 1990, the National Institutes of Health convened a Task Force on Medical Rehabilitation Research. Four panels focused on major areas of scientific concentration. These were neurophysiological dysfunction, musculoskeletal disorders, cancer rehabilitation, and geriatric rehabilitation. The Cancer Rehabilitation Panel consisted of 12 members.Those serving on this panel representedvarious areasranging from specific expertise in particular cancer sites to community oncology, nursing, physiatry , and pediatric oncology. Many of the recommendations of the Panel will be incorporated into this article. The full report has been published.2 Progress in Cancer Rehabilitation requires appropriate and continuing assessmentof the patient’s rehabilitation needs. The development of a good databaseis essential. Assessmenttools must have the capacity for quantitating improvement in specific functional parameters. The mechanisms for optimal service delivery need to be better defined. The development of multidisciplinary Cancer Rehabilitation Programs should be fostered; but the efficacy of such programs requires documentation in the literature. CANCER SITES WITH SPECIAL REHABILITATION NEEDS
The rehabilitation requirementsof particular patients are determined to a great extent by the priSeminars
in Oncology Nursing, Vol 8. No 3 (August), 1992: pp 219-223
G. Parker
mary site of the cancerand the disabilities that may result from the cancer or its treatment. The physical rehabilitation needsof the ostomy patient are obviously quite different from those of the person who has undergone amputation or a limb salvage procedurefor a soft-tissue sarcoma.Similarly, the psychosocial impact of a major craniofacial resection differs from that after treatment for a “hidden tumor” such as that of the right colon or ovary. The emotional connotation of a cancer diagnosis crossesall sites and appropriatepsychosocialmeasures must be included along with site-specific needs. Future progress must encompassall these considerations. Head and Neck Cancer
New directions in rehabilitation for personswith cancer of the oral cavity, larynx, and accessory sinuses include technical improvements in prosthetic devices. New materials for extraoral prosthesesneed to be developed which will allow for better skin-color matching and better approximation of the prosthesisto the margins of the defect. Anchoring of prosthesesto bone is being studied.3*4 Intraoral prosthesesnot only provide for closure of defects but may be built up or augmentedto allow better approximation of a partially resectedtongue to the roof of the mouth which will facilitate speech.5Someprostheseshave also been developed to serve as reservoirs with a tonguetouch releasefor a saliva-substitute for patients in whom the normal salivary flow has been impaired, usually by radiation therapy.6 Further improvements are needed. Explanation of the functional From the Departments of Internal Medicine, and Rehabilitation Medicine, the Cancer Rehabilitation and Continuing Care Program, and the Massey Cancer Center, Medical College of Virginia, Virginia Commonwealth University. Richmond, VA. Susan J. Mellette, MD: Professor, Medical Oncology and Rehabilitation Medicine, and Director, Cancer Rehabilitation and Continuing Care Program, Gwendolyn G. Parker, RN, MS, OCN: Clinical Nurse Specialist, Massey Cancer Center. Address reprint requests to Susan J. Mellette, MD, Professor, Medical Oncology and Rehabilitation Medicine, Medical College of Virginia, Virginia Commonwealth University, Box 207, Richmond, VA 23298. Copyright 0 1992 by W.B. Saunders Company 0749-2081192/0803-0009$5.0010 219
MELLE-I-I-E AND PARKER
and esthetic limitations of prosthesesand help in adjustment are needed.’ The number of total laryngectomies has decreasedin recent years due to better radiation therapy and tissue-sparing procedures for early lesions. Some change in the quality of speechmay be present even with more limited procedures.8 Those personswho require a laryngectomy can often be benefitted by the tracheoesophagealfistula or Singer-Blom procedure.’ Further improvements in such techniques and in devices such as the electrolarynx are needed. Speechtherapy needsto be improved and to be made more widely available. Considerableresearchhasbeenunderway on the physiopathology of swallowing and its disruption by cancer surgery.” Techniques to evaluate and facilitate swallowing need to be more widely disseminated. Studies on impairments of taste and smell are less well advanced and more work is needed. Little progresshas been madein the treatment of shoulder dysfunction following radical neck dissection,” but this can be a debilitating complication of surgical treatment.
type should be recommended.Someconsensusalso needsto be reachedon appropriateexercisesfollowing mastectomywith immediate reconstruction, Lymphedemaof the arm may occur after lumpectomy as well as after mastectomyif axillary dissection is performed and, particularly, when radiation therapy is also administered. The treatment of lymphedemaremains unsatisfactory. Compression pumps are of some benefit and sequential compressionmay be better for some patients; but no great difference in results has been shown for the various types of pumps available. t2 Great strides are being made in meeting the psychosocial, as well as the physical rehabilitation needs of breast cancer patients. Support groups abound. Various programsaimed at physical needs and side effects of chemotherapy and including such activities as dance and aerobic conditioning have been instituted.13 Further research, with appropriate control groups and quality-of-life measures, is needed to evaluate many of these programs, particularly the various types of support groups.
Breast Cancer
Bone and Soft Tissue Tumors
Rehabilitation after breastcancer treatment is of great interest because of the large number of women (more than one tenth of US women) who will develop this disease. Breast cancer poses a threat to self-image and sexuality; and its treatment may entail not only surgery but radiation therapy and chemotherapy or hormonal therapy with their resultant side effects. Long-term sequelaesuch as lymphedema of the arm are also a consideration. The decreasein the performanceof mastectomy, which has recently occurred, can be expected to continue, basedon data indicating comparableoutcomes for either more extensive surgery or lumpectomy and radiation therapy. Reconstructionafter mastectomymay also be expected to increasedespite the recent, as yet unsubstantiated, concerns about the safety of silicone implants. The “tummy tuck” abdominal graft or the thoracic wall grafting procedureshave their own morbidity. Optimal rehabilitation of breast carcinoma patients requires further development and refinement of reconstructive techniquesand researchin prostheticmaterials. Limitation of shoulder motion secondaryto capsulitis occurs lessfrequently with more limited surgery, but further research is needed to determine the value of posttreatmentarm exercisesand which
Long-term survival and cures are increasing in patients with sarcomasof soft tissue and bone. When technically feasible, limb salvage procedurescan result in survival data comparableto that following amputation.I4715Multimodality therapy is common for these patients. Much research remains to be conducted in basic science areas,particularly in prosthetic materials and in the use of allografts. Porous implant materials that allow for bone growth into the new material need further study. The use of modular componentsthat can be tailored to the individual’s needs are a promising development. An adjustableand expandableinternal prosthesisthat allows for growth in young patients by means of a small surgical procedure at appropriate intervals is an innovative development.l6 Limb salvage procedures require new approaches in physical and psychosocial rehabilitation because changes in lifestyle may be required. l7 Somepatients function well; others have complications or defects which may make them less mobile or functional than a comparableamputee. The desired lifestyle of the whole individual needsattention, as well as the mechanicalfeasibility of an orthopedic procedure.
FUTURE
DIRECTIONS
IN CANCER
REHABILITATION
Gastrointestinal Cancer
Gastrointestinal cancer continues to be the second leading type of cancer in the United States.i8 Surgery is the treatment of choice for cancers of the colon and rectum. Surgical intervention can result in resection of the tumor with reanastomosis; a colostomy (temporary or permanent); or an abdominal-peritoneal resection (APR). Improved surgical techniques such as the use of the end-toend anastomosis(EEA) and stapling devices have decreased the incidence of colostomies, and sphincter-saving approacheshave helped decrease the functional disability associatedwith treatment of these types of cancers.‘9*2oFurther refinements in surgical approachesand in the use of adjuvant chemotherapy are needed. For patients who must have an ostomy, the need for odor management, methods to prevent flatus, leak-proof pouching systems,better skin care management,and pouching systemsthat do not interfere with sexual activity continue to be identified.‘932’722Addressing these issues in a cost-effective manner will continue to be a challenge. The psychological adaptionto the presenceof an ostomy will continue to be an issuethathealth care professionals will need to addressto promote the total rehabilitation of the colorectal cancerpatient. Extensive research has been conducted which identifies the psychological disturbancesthese patients may encounter as a result of a cancer diagnosis; loss of a body part and bodily function; loss of control over excretory processesand insult to one’s sexuality.2iW24 Further researchis neededto develop and evaluate efficient interventions to address these issues. Genitourinary
and Gynecological Cancer
Urological malignancies, which include cancers of the urinary and genital organs in males and urinary organs in women, will make up 14% of new cancer casesin 1991.l8 The availability and use of newer treatment modalities such as laser therapy and biological responsemodifiers such as Bacillus Calmette-Guerin have produced results that are as effective with minimal associateddisability.25 The recognition that radical surgical approaches for these cancers, particularly prostate cancer, have led to impotence and urinary incontinence has fueled the development for less-debilitating treatment options. The challenge for the future in gynecological
221
cancer care will be the development of conservative surgical approachesand, in cases in which aggressiveintervention is indicated, the development of innovative surgical techniquesto minimize the disability. This need has already been identified in the literature. A more conservative surgical approach to treating early vulvar carcinoma may bejust as effective as a radical vulvectomy.z6 Clinical trials in this areaare neededto evaluate patient outcomes and quality-of-life issues for various types of surgical interventions. Current treatments used to treat gynecological cancer may result in other types of dysfunction. More than 60% of patients treated for vulvar carcinoma with lymph node dissection experience varying degrees of peripheral edema.‘” Techniques used to treat lymphedema in breast cancer patients needto be applied to gynecological cancer patientsto determineeffectiveness.Patientsundergoing a partial or total pelvic exenteration may require the creation of some method of urinary diversion, colostomy, or vagina. Additional researchis neededto determine the most appropriate method of urinary diversion. Vaginal reconstruction hasbeenperformedusing the sigmoid colon as well as the myocutaneousgracilis graft approach, but promising results have been noted with the use of amnion grafts.27 More research is needed in reconstructive surgery to develop artificial organs that are acceptableto women. Gynecological cancers have not received as much national attention as breast cancer. Consequently, an organized psychosocial support network for these women does not exist. Although it is not usually feasible nor advisable to have specialized, site-specific support networks, this group may benefit from the attention that would be given to their needs. Sexual dysfunction will continue to be one of the more challenging rehabilitation issues. There are two domainsof this issuethat require attention. The first is continued education of health professionals to recognize and addresssexuality and sexual functioning in the treatment plans of cancer patients. Studies show that health professionals lack the knowledge and are not comfortable discussing sexual issues with their patients.23.28.29 Health organizations, such as the Oncology Nursing Society and American Nurses’ Association, will need to continue to advocate that this is an expected level of care.
222
MELLETTE
The development of methods to preserve fertility and refinement of surgical interventions and prosthesesto ensure sexual functioning needs to continue. Cryopreservation of semenbefore treatment has preserved the reproductive abilities of men. However, for women reproductive options are limited as the preservation of ova has not been fully used. As acceptanceof high-technological reproductive methods grows, this should become more common. The use of estrogen replacement therapy to relieve menopausal symptoms and osteoporosis in female cancer patients has not been fully researchedand requires further evaluation. REHABILITATION OF PATIENTS WITH METASTATIC DISEASE
Considerable effort is being directed toward the development of measureswhich will enable the patient with metastaticdiseaseto continue to function as optimally as possible for as long as possible. Many patients, particularly those with cancer of the breast, prostate, thyroid, and somehematologic malignancies may continue their usual activities for years after the diseasehas become widespread. Pain control may be the key to function, particularly for patients with bony metastases.Newer long-acting pain medications are available in oral and transdermalpreparations. Generally speaking, pain control is best achieved by specific antitumor measuressuch as radiation therapy or stabilization of affected bones. Further progress needs to be made in techniques for vertebral replacement30.31 and stabilization of the spine. Prosthetic modular componentscan be introduced and fixed with bone cement for some patients with destructive long bone lesions.32 The emotional needs of the person with metastatic disease also demand continued attention. Support groups appropriate for the person with early breastcancer are often inappropriate for such persons. Similarly, groups that emphasizepreparation for death are inappropriate for people who may remain functional for years. Much more work needsto be performed in this area. VOCATIONAL REHABILITATION CANCER PATIENT
OF THE
The aim for the future is to ensure that all patients treated for cancer are able to be employed in
AND PARKER
Table 1. Promising Avenues for Research Cancer Rehabilitation
in
1. Development of better methods for assessment of rehabilitation needs and delivery of rehabilitation services. of taste, 2. Basic and clinical research in impairments smell, swallowing, and muscle function. 3. Development of better prosthetic materials for facial, breast, and limb prostheses. 4. Work on improvements in continent ostomies, better ostomy care. 5. Determination of the role and type of exercise programs after breast cancer treatment and limb salvage. 6. Research in psychosocial components and rehabilitation: support groups, vocational needs, public health policy.
positions consistentwith their desiresand abilities. Problems in this area include not only physical disabilities which require accomodation, but fear of loss of insurance if a job change is made. Federal and state laws require that employers make reasonable accommodations for handicapped individuals. A compilation of applicable laws has been made by the National Cancer Employment Law Project sponsored by the American Cancer Society33 and information may be obtained from state offices of the American Cancer Society. Cancer patients have not generally taken advantage of the legal resources available to them.34 Another areain which more progressneedsto be made is in use of the services of state or other Vocational Rehabilitation agencies.35 Other ways in which employment problems of the cancer patient can be approachedare included in studies by Mellette and Franco.36v37 SUMMARY AND CONCLUSION
Many of the current and future directions in cancer rehabilitation have been briefly discussed;and some of the important areas for development are outlined in Table 1. Implementation of rehabilitation measuresmay be facilitated by organized and creative multidisciplinary rehabilitation programs. Advancesare also dependenton health carepolicy, particularly in reimbursement for rehabilitation services and in the funding of rehabilitation research.38Much progress can be expected in the years ahead.
FUTURE
DIRECTIONS
IN CANCER
223
REHABILITATION
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20. Lind J: Colorectal cancer, in Ziegfield CR (ed): Core Curriculum for Oncology Nursing. Philadelphia. PA. Saunders, 1987, pp 163-171 21. Coe M: Comparison of concerns of clients and spouses regarding ostomy surgery for treatment of cancer. J Enterostom Ther 17:106-111, 1990 22. Cohen A: Body image changes in the person with a stoma. J Enterostom Therapy 18:68-71, 1991 23. Smith DB: Sexual rehabilitation of the cancer patient. Cancer Nurs 12:10-15, 1989 24. Gawron C: Body image changes in the patient requiring ostomy revision. J Enterstom Therapy 17: 106-l 11, 1990 25. Davis M: Genitourinary cancers, in Otto S (ed): Oncology Nursing. St. Louis, MO, Mosby, 1991, pp 97-113 26. Chamarro T: Cancer of the vulva and vagina. Semin Oncol Nurs 6:198-205, 1990 27. Thompson LJ: Cancer of the cervix. Semin Oncol Nurs 6:190-197, 1990 28. Williams HA, Wilson ME, Hongladoran G, et al: Nurses attitudes toward sexuality in cancer patients. Oncol Nurs Forum 13:39-43, 1986 29. Wilson ME, Williams HA: Oncology nurses’ attitudes and behavior related to sexuality of patients with cancer. Oncol Nurs Forum 15:49-53, 1988 30. Ono K, Yonenobu K, Ebara S, et al: Prosthetic replacement surgery for cervical spine metastasis. Spine 13:817-822, 1988 3 1. Moore AJ, Uttley D: Anterior decompression and stabilization of the spine in malignant disease. Neurosurgery 24: 713-717, 1989 32. Chao EY, Sim FH, Shives TC, et al: Diagnosis and Management of Metastatic Bone Disease: A Multidisciplinary Approach, in Sim FH (ed): New York, NY, Raven, 1988. pp 171-181 33. Frankfort IA: Employment problems of the cancer survivor, Proceedings of the Fifth National Conference on Human Values and Cancer. Atlanta, GA, American Cancer Society, 1987, pp 88-92 34. Barofsky I: Job discrimination: A measure of the social death of the cancer patient, Proceedings of the Western States Conference on Cancer Rehabilitation. Palo Alto. CA, Bull, 1982, pp 145-153 35. Goldberg RT, Habeck R: Vocational rehabilitation of cancer clients: Review and implications for the future. Rehab Counsel Bull 26: 18-27, 1982 36. Mellette SJ: The cancer patient at work. CA 35:360-375, 1985 37. Mellette SJ, Franc0 PC: Psychosocial barriers to employment of the cancer survivor. J Psychosoc Oncol 5.97- 115. 1987 38. Mayer DK: The healthcare implications of cancer rehabilitation in the twenty-first century. Oncol Nurs Forum 19:2327, 1992
