We are grateful to the Association of Rehabilitation Nurses (ARN) Board of Directors (BOD) and the Rehabilitation Nursing Journal Editorial Board for providing the platform to voice the importance of cancer rehabilitation for the cancer survivor population. We are appreciative to our colleagues who authored the articles in this special issue and believe they have provided, through various venues, strong arguments for addressing the lack of and need for rehabilitation within the community of cancer survivors.
Many remember that not long ago the words “cancer” and “rehabilitation” were not used in the same sentence. Cancer was considered to be a terminal diagnosis (American Cancer Society, 2017), and as recent as the 1980s, patients diagnosed with cancer were viewed as victims rather than survivors (National Coalition for Cancer Survivorship, 2017). Today, with the advances in early detection and treatment, millions of individuals are surviving cancer (Miller et al., 2016). With increased longevity, the morbidities associated with treatment have become a major health concern in this population. For example, use of chemotherapeutic agents can lead to cardiotoxicity, nephrotoxicity, and neuropathy, among others; surgery is associated with effects such as adhesive capsulitis and lymphedema, and radiation can lead to fibrotic changes and damage to the organs within the parameters of treatment. Many of these treatment-related morbidities are amenable to rehabilitation, but few patients are referred for such care; thus, only a small percentage of survivors are reaping the benefits of cancer rehabilitation (Silver, 2015). In response to the dramatic rise in the number of cancer survivors and the accompanying treatment-related morbidities, many disciplines have developed cancer rehabilitation subspecialties, including physiatry, psychology, and physical therapy. Rehabilitation nursing, however, has struggled to delineate its role within cancer rehabilitation.
That said, rehabilitation nurses are becoming increasingly aware of and interested in the subspecialty of cancer rehabilitation due, in part, to the issues they have encountered when caring for cancer survivors in their various settings. Typically, rehabilitation nurses manage the care of patient populations with traumatic brain injury, spinal cord injury, stroke, and hip fractures. Thus, rehabilitation nurses may feel unprepared to manage the care of cancer survivors with treatment-related morbidities or to provide rehabilitation therapy to those who may have a terminal diagnosis.
ARN has moved forward with an initiative to increase awareness about cancer rehabilitation, provide educational venues about cancer rehabilitation for our members as well as other healthcare providers, and promote the integration of cancer rehabilitation into practice. Several seminal events have served to initiate this movement. During 2014 and early 2015, ARN participated in the National Institutes of Health Cancer Rehabilitation Subject Matter Expert Panel to identify the current state of clinical care in cancer rehabilitation and establish a research and clinical practice agenda for the future. This initiative culminated in a Cancer Rehabilitation Symposium attended by several rehabilitation disciplines such as physiatry, nursing, physical and occupational therapy, and rehabilitation psychology. The consensus of the panel and the symposium participants was that cancer rehabilitation is a clinical subspecialty.
Simultaneously, the ARN BOD and member advocates for cancer rehabilitation participated in activities that moved the cancer rehabilitation initiative forward. For example, an informal session was held at the 2015 ARN Conference to determine member interest in cancer rehabilitation. A large number of ARN members attended and expressed concern about the multiple cancer related issues they encounter in their rehabilitation settings and may not have the requisite knowledge or perhaps resources to adequately address these concerns. With these data, the ARN BOD initiated the writing of a white paper on cancer rehabilitation with the goal of updating the 1999 position statement Rehabilitation of People With Cancer. The completed white paper Cancer Rehabilitation and the Role of the Rehabilitation Nurse (Reigle, Campbell, & Murphy, 2017) was approved by the ARN BOD and posted on the ARN website. Congruent with the white paper, the Rehabilitation of People With Cancer Position Statement was revised and endorsed by the Oncology Nursing Society. Both documents propose a collaborative oncology-rehabilitation nursing model that recognizes the uniqueness of each nursing specialty while synthesizing the essential knowledge and skills needed to support competent rehabilitation care in the cancer population. The next step in moving the agenda forward was to dedicate an entire issue of the Rehabilitation Nursing Journal to the meaning of cancer rehabilitation for rehabilitation nurses and for all providers who care for cancer survivors. This focused issue provides a review of the history and goals of cancer rehabilitation and several examples of evidence-based cancer rehabilitation clinical and research initiatives.
Alfano and Pergolotti introduce the reader to the state of cancer rehabilitation science in their article, Next Generation Cancer Rehabilitation: A Giant Step Forward for Patient Care. As they present the evolution of cancer rehabilitation and its status in cancer care, they also issue a call to action. They call for developing innovative cancer rehabilitation care delivery models, expanding the team of providers and coordinating care, utilizing a precision medicine approach to cancer rehabilitation, and demonstrating the value of cancer rehabilitation for improved patient care outcomes. The authors note that treatment-related impairments amenable to rehabilitation are common among cancer survivors, but few survivors receive rehabilitation services.
Reigle and Zhang provide insight into the rehabilitation and exercise experiences of women who have undergone breast cancer surgery in their descriptive-correlational study, Women’s Rehabilitation Experiences Following Breast Cancer Surgery. This study reveals that breast cancer survivors, for the most part, self-managed their postsurgical rehabilitation using written instructions. Unfortunately, the same postsurgical morbidities exist in this population today (e.g., adhesive capsulitis), and yet, cancer rehabilitation provided by a therapist is still not the postoperative guideline for this population.
In Risk Factors for Falls in Adult Cancer Survivors: An Integrative Review, Campbell demonstrates the systematic process of synthesizing the literature, particularly findings from quantitative and qualitative studies that address factors associated with falls in the cancer survivor population. This review elucidates the complexity of identifying, extracting, critiquing, and synthesizing data from sources that differ significantly, such as using different instruments of measurement, having varied definitions for the same concept, enrolling diverse sample sizes, and exhibiting various levels of methodological robustness. This level of review provides the clinician with an understanding of the topic, in this case, antecedents to falls in cancer survivors, which can then provide a basis for intervention studies, and in turn such findings can underpin practice guidelines.
In Clinical Consultation: Collaboration Between Survivorship Cancer Program and Cancer Rehabilitation in the Care of Head and Neck Patient, Kirschner and Sherlock use a case study to highlight the lack of and need for cancer rehabilitation. They bring the reader into the world of a patient who suffers from the morbidities of head and neck cancer treatment. His experience is not uncommon, and unfortunately, more often than not, a formal referral to cancer rehabilitation is not made. His story emphasizes the importance of the oncology provider conducting a functional assessment using a screening tool that facilitates a referral to a cancer rehabilitation therapist. The positive patient outcome of this purposeful interdisciplinary partnership between the oncology provider and rehabilitation therapist is highlighted.
Authors Padgett, Asher, and Cheville eloquently present the rationale for providing rehabilitation care to seriously ill or end-of-life patients in The Intersection of Rehabilitation and Palliative Care: Patients With Advanced Cancer in the Inpatient Rehabilitation. Their thesis addresses the concern voiced by rehabilitation nurses about the appropriateness of providing rehabilitation care to patients with advanced cancer. They highlight the rehabilitative needs and appropriate goals of care for this population and recommend practical strategies for communicating with patients and families about their end-of-life wishes.
Hutchison engages the reader in differentiating between lymphedema and edema in Diagnosis and Treatment of Edema and Lymphedema in the Cancer Patient. She navigates through the complexity of lymphedema with an in-depth discussion of risk factors, preventative measures, diagnostic procedures, and current state-of-the-art treatment. Factors that differentiate edema, such as cardiovascular edema, from secondary lymphedema (associated with cancer treatment) are explained. The chronicity of lymphedema is highlighted, and Hutchison’s presentation reveals the significant negative impact it can have on a cancer survivor’s quality of life.
We encourage you to read each article in this issue and to reflect on the role you can play in advocating for cancer rehabilitation in practice, education, research, and your professional organizations. Share this issue with providers in your practice setting; dialogue with coworkers and other ARN members about the unique clinical needs of individuals with cancer and ways in which your setting might serve survivors with rehabilitation needs. Help us move the agenda forward.
Grace B. Campbell, PhD, MSW, RN, CRRN
Beverly S. Reigle, PhD, RN
School of Nursing, University of Pittsburgh,
Pittsburgh, PA, USA College of Nursing,
University of Cincinnati, Cincinnati, OH, USA.
The authors declare no conflict of interest.