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CASE REPORT

Meeting the Rehabilitation and Support Needs of Patients With Breast Cancer During COVID-19: Opening New Frontiers in Models of Care

Binkley, Jill PT, MSc1; Mark, Mallory PT, DPT2; Finley, Janae PT, DPT3; Brazelton, Allison PTA, BS4; Pink, Marilyn PT, PhD, MBA5

Author Information
doi: 10.1097/01.REO.0000000000000237
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Abstract

INTRODUCTION AND PURPOSE

While the COVID-19 pandemic presents health and economic challenges to individuals around the world, additional challenges are faced by patients with cancer, particularly those recently diagnosed and/or receiving treatment. Many patients are immunosuppressed and therefore are considered high risk for COVID-19. In March 2020, surgery for breast cancer was deemed nonessential and often postponed.1 When surgery was scheduled, surgical options such as reconstruction or prophylactic second mastectomies were often restricted.

Patients with cancer faced psychosocial and emotional challenges and effect on quality of life during COVID-19.2,3 Patients with breast cancer reported increased anxiety due to delayed surgical procedures, fear of attending medical offices and hospitals for treatment, reduced access to rehabilitation, job loss, working from home, homeschooling children, and partners who are working from home. COVID-19 presented a significant challenge to safe provision of specialized rehabilitation and exercise for patients with breast cancer.

Telehealth” is a broad term used to describe the use of electronic information and communication technologies (ICT) to support clinical health care, patient and professional health-related education, and public health and health administration activities.4,5 Telerehabilitation (TR), a branch of telemedicine,6 is defined as the use of ICT to provide rehabilitation services to people remotely in their homes or other environments4,6–9 In this article, TR specifically refers to the delivery of one-on-one physical therapy evaluation and intervention using a live video and audio connection between a patient and a clinician. TR met the need to provide oncology rehabilitation and exercise safely,10 but implementation strategies and funding required consideration. Implementation of TR requires planning, training, and iterative improvement of process and procedures based on experience.10 Widespread access to technology and payment for TR vary internationally.10 In the United States, the Centers for Disease Control and Prevention deemed physical therapy an essential service for high-need patients during COVID-19.10 Reimbursement for physical therapy services was only fully in place once Medicare allowed reimbursement for TR services by physical therapists (PTs) on April 30, 2020. It is not known whether reimbursement will be terminated by commercial insurance and Medicare.

There are many Web-based applications targeting quality of life and function for survivors of cancer. Numerous studies have demonstrated the effectiveness of a variety of Web- and app-based strategies to reduce symptom distress and improve quality of life, self-efficacy, and psychological well-being in patients with breast cancer.11–15 There is evidence to support currently available online and app-based delivery of exercise programs for individuals during and after breast cancer treatment.16–19 Online interventions to meet the information and psychosocial needs of patients and families with advanced breast cancer have shown promise and received good feedback from patients.20,21 Telehealth management has been shown to be effective in reducing pain and depression in patients with cancer.22,23 One example is the Breast Cancer Online Rehabilitation Program that was developed by expert PTs and is individualized on the basis of an initial physical therapy assessment.19 Many apps and Internet-based programs are not individualized and may be of most benefit when integrated with supervised rehabilitation.24,25

While there is evidence to support various Web-based support applications for individuals with breast cancer, there is less evidence related to the effectiveness of one-on-one physical therapy provided via TR. A randomized controlled trial demonstrated improved function and decreased pain and hospital stay in patients with advanced cancer when TR was provided by a PT-physician team.26 A retrospective report of TR for rural-based veterans with various health conditions reported improved function, health-related quality of life, and good patient satisfaction.9

Prior to COVID-19, there was growing evidence that current models of cancer survivorship support may be unsustainable and fail to meet the diverse needs of cancer survivors.27 Incorporating technology may be part of the solution.27 TR and interactive Web-based education formats may provide an adjunct to in-person breast cancer rehabilitation care that will improve access and delivery to underserved populations.

The purpose of this report is to describe the implementation of TR for one-on-one patient care and interactive, live, Web-based formats for group patient education, exercise, and support programs during the COVID-19 pandemic. Brief patient cases are included to describe the process of TR and provide patient and family perspectives.

METHODS

Setting and Personnel

The setting was a nonprofit community-based health care organization in Atlanta, Georgia, that provides specialized physical therapy, counseling, massage therapy, and nutrition counseling for patients during and after breast cancer treatment. Patient survivorship education programs and a support group for patients with metastatic breast cancer are offered monthly. The organization's response to COVID-19 was designed and implemented in March 2020 and refined as patients' needs were identified. A model of “completing the support need puzzle” was developed to guide the development and modification of new and existing programs to meet the complex needs and challenges facing patients while keeping the patient and staff in mind (Figure 1). The puzzle was shared with patients via social media, e-mail, and our Web site. New programs included TR, patient check-ins by phone, and virtual exercise “snacks.” The exercise “snacks” are 5-minute light aerobic programs led by the physical therapy staff that are posted on social media. Modifications of existing programs included shifting in-person weekly exercise classes and monthly patient group education programs to interactive, live, Web-based events. A monthly in-person support group for patients with metastatic breast cancer shifted to virtual meetings on Zoom. The financial effect of COVID-19 on patients was also considered. Many existing and newly referred patients have been furloughed, laid off permanently, or felt it was not safe to continue in their workplace. To reduce the financial barrier to care, out-of-pocket fees were waived for any services or programs provided.

Fig. 1.
Fig. 1.:
COVID-19 support response puzzle for patients with breast cancer. This figure is available in color online (www.rehabonc.com).
Fig. 2.
Fig. 2.:
Case 1: Evaluation of mastectomy incision and skin response during radiation therapy. This figure is available in color online (www.rehabonc.com).
Fig. 3.
Fig. 3.:
Case 1: Evaluation of range of motion during radiation therapy. This figure is available in color online (www.rehabonc.com).

While the majority of patient care was shifted to TR, allowance was made for necessary in-person treatment(s) during this time. The decision to provide in-person treatments was based on clinical judgment, but broad criteria included the need for instruction in bandaging, complex garment fitting, and slower than expected progression in goal achievement.

Three PTs and 1 PT assistant specialized in breast cancer oncology rehabilitation provided TR visits between March 16 and June 15, 2020. TR visits ranged from 45 minutes to 1 hour. PTs, a PT assistant, a licensed clinical social worker, and a licensed dietitian provided the Web-based education events. The social worker facilitated the Web-based support group.

Platform and Materials

Individual TR visits and all patient Web-based events were provided on a Zoom platform that is compliant with the Health Insurance Portability and Accountability Act. Initial TR appointments for new patients were scheduled by the administrative staff, and follow-up appointments were scheduled directly by the treating clinician. The following support materials and procedures were developed specifically to support the TR program:

  1. Initial e-mail communication for patients describing what to expect and how to access their Zoom appointments. Recommendations related to optimal lighting, monitor and sound setup, and the need for a private room were provided. Patients were also provided with guidelines on appropriate clothing and the need to be able to expose the upper body and arms during the examination, if acceptable. Finally, patients were instructed to have a few basic supplies available, including a chair, floor surface or bed for supine work, notepad and paper, pillow, and a pole for exercise.
  2. Updated support materials for patients, including customizable patient exercise handouts.
  3. Education materials for use during TR appointments, including evidence-based PowerPoint presentations on:
    1. Overview of common treatment side effects, role of rehabilitation in breast cancer, concept of prospective surveillance for treatment side effects, and orientation to programs and services, including financial assistance if needed.
    2. Lymphedema risk factors, risk reduction, early detection, and management.
  4. Arm circumference self-measurement protocol was implemented to allow remote monitoring of patients at risk for and with lymphedema.28,29 Home kits to support self-measure and implementation of resistance exercise, when applicable, are mailed to patients and include caliper-type metric measuring tape with lock pin and push-button retraction (Phinus Group, Amazon.com), a 10-cm stick, skin pencil, and yellow TheraBand. Patients were instructed in self-measure of arm circumference during a TR appointment. Volumes were calculated by the PT during or after the visit.28,29

An online system to collect patient intake data as well as admission and discharge Upper Extremity Functional Index (UEFI)30 and Functional Assessment of Cancer Therapy–Breast (FACT-B)31,32 scores was already in place.

RESULTS

Between March 16 and June 15, 2020, 34 new patients and 9 returning patients were seen and a total of 256 TR visits were provided for these patients. Returning patients are individuals who have been cared for in the past and return with new issues, as part of ongoing surveillance or for ongoing intervention for chronic issues, such as lymphedema. Approximately 90% of individual patient visits during this period were via TR. Prior to COVID-19, an average of 35 new patients were seen each month. The reduction in new patients was due to the postponement of elective surgery in March and April, and numbers have since returned to normal levels. The weekly virtual exercise program for patients had an average of 132 views weekly and 1594 total views. The brief “exercise snacks” were offered on Instagram and Facebook, and each had an average of 185 views.

There was a substantial increase in participation in monthly survivorship education programs. Prior to COVID-19, the average attendance at in-person group monthly patient education events was 15 per event. There were 3 interactive Web-based patient education events between March 15 and June 16, 2020. Two of the events focused on nutrition for breast cancer survivors provided by an oncology-specialized registered dietitian. The other education event was presented by PTs and focused on exercise options for patients during COVID-19. These were available to active and former patients. The average attendance was 51 for the interactive, live, Web-based events, with an average of 125 views on Facebook and YouTube following the events. Participation in the monthly support group for patients with metastatic breast cancer, facilitated by a licensed social worker, increased from an average of 5 participants for in-person support groups in the prior 12 months to 11 participants per month when it shifted to the virtual format.

Patient Outcomes and Experiences

The following are brief summaries of 3 patient cases selected to illustrate the TR process. The physical therapy visits, including the initial evaluation, were carried out via TR. Informed consent was obtained from patients for the reporting of their cases. The authors gathered patient feedback via phone and e-mail communication.

Case 1. The patient was a 34-year-old woman referred for physical therapy 3 weeks following a right mastectomy with 6 axillary nodes removed, of which 5 were positive. She was diagnosed with stage III invasive ductile carcinoma in November 2019. The tumor was estrogen, progesterone, and Her2-neu positive. She received neoadjuvant chemotherapy, including carboplatin, Taxol (paclitaxel), and Herceptin (trastuzumab), between December 2019 and March 2020. The response to chemotherapy was incomplete and radiation therapy as well as Kadcyla (ado-trastuzumab emtansine) were planned to start 4 weeks after surgery. While she was able to have her right mastectomy, her immediate right breast reconstruction and prophylactic left mastectomy were postponed by her surgeon due to COVID-19. She usually worked full-time as an ultrasound technician in a high-risk obstetrics practice, but she was currently off work due to surgery and COVID-19. The patient was married with 2 children, aged 4 and 6 years, and the children were homeschooling due to COVID-19. She had good extended family support close by. She had no other significant health issues and usually exercised regularly. The patient was provided with information on the support puzzle (Figure 1) and engaged in 3 exercise and group education events. The patient's key initial assessment findings and treatment goals are provided in Table 1.

TABLE 1 - Case 1: Key Initial Assessment Findings, Treatment Goals, and Summary of TR Physical Therapy Treatments
Key initial findings at visit 1
Pain and function: (Pain and Patient Specific Functional Scales assessed via screen share)
 Pain: 5/10 in the right axilla, medial upper arm, cubital fossa, anterior forearm
 PSFS score:
  1. Reaching into microwave 7/10

  2. Ultrasound scanning over larger abdomens 7/10

  3. Throwing a ball with kids 6/10

 PSFS scorer average: 6.3/10
 UEFI score: 65/80 (full function = 80)
 FACT-B scores: Physical well-being: 22/28; social/family well-being: 28/28; emotional well-being: 17/24; functional well-being: 21/28; additional breast cancer concerns: 29/40; additional +4 upper extremity concerns: 10/20
Inspection and posture: Mild protracted shoulders, otherwise good. Well-healed right mastectomy and drain site incisions. Mild swelling in areas
of incisions; no evidence of swelling in upper extremities.
Shoulder and cervical active range of motion: (estimated via TR)
 Flexion: Right: 150° (pain at end range in the mastectomy incision region, axilla, and medial upper arm region)
 Left: 170°
 Abduction: Right 120° (limited by painful pull extending from the axilla to cubital fossa to anterior wrist area with abnormal scapula-humeral rhythm and visible axillary cording in the axilla and medial upper arm at 90°)
 Left: 160°
 Hand behind back motion: To L1 bilaterally, no pain
 Cervical range of motion: Within normal limits
Self-palpation of soft tissue: Gentle, guided soft-tissue palpation reveals pain on palpation of cording and drain site.
Plan of care
Planed frequency of treatment: Once per week
 Short-term goals: 4 wk
  1. Increase shoulder abduction >160°

  2. Decrease pain <2/10

  3. Understands lymphedema risk, risk reduction, and baseline arm volume measure completed

  4. Return to regular walking program

 Long-term goals: 8 wk
  1. Upper extremity and core strengthening program in place

  2. Increase UEFI score >75/80

  3. Increase average PSFS score ≥9/10

  4. Prospective surveillance in place through radiation therapy and ongoing chemotherapy

Visit 1 key physical therapy interventions
  1. Self-massage of cording from the axilla to upper medial arm, with the arm supported in 90° abduction in sitting

  2. Home exercise program of diaphragmatic breathing, posterior shoulder rolls, overhead stretch with stick, and butterfly stretch in supine hook-lying position

Visit 2
Baseline self-measures of upper extremity volume: Right = 1662.2 mL; left = 1553.3 mL (right affected dominant arm is 7% larger than the left)
Visit 3
Pain decreased to 3/10; visible and painful cording in the right axilla to anterior elbow; full shoulder range of motion bilaterally. Key physical
therapy interventions:
  1. Added targeted single-arm doorway with self-massage of cording

  2. Self-massage for tightness of mastectomy incision added

Visits 4-6
Radiation therapy of the right chest wall and axilla initiated along with Kadcyla every 3 wk. Moderate erythema in the radiation field was noted on
the sixth visit (Figure 2). Range of motion was full and pain-free, and no cording was noted (Figure 3).
Key physical therapy interventions
  1. Progressed shoulder and trunk stretching exercises

  2. Added light upper extremity resistance exercise with yellow TheraBand

  3. Added and progressed core engagement and stability exercises

Abbreviations: FACT-B, Functional Assessment of Cancer Therapy–Breast; PSFS, Patient Specific Functional Scale; TR, telerehabilitation; UEFI, Upper Extremity Functional Index.

Impression. The patient was a fit 34-year-old woman facing stage III breast cancer with incomplete response to neoadjuvant chemotherapy and upcoming radiation therapy and further chemotherapy. She expressed significant anxiety related to her incomplete response to chemotherapy and the postponement of her reconstruction and left prophylactic mastectomy. She was homeschooling her young children due to COVID-19. She had moderate pain as measured on a visual analog pain scale33 and moderate functional limitation as seen on the Patient Specific Functional Scale (PSFS)34–36 and UEFI.30 She had painful cording that limited her right shoulder range of motion and had mild fatigue. She was at moderate risk for lymphedema with 5 axillary nodes removed and planned radiation therapy, but her normal body mass index mitigated risk. The patient's FACT-B scores indicated physical, functional, and psychosocial concerns, and she had significant stress in her life. This was discussed, and the patient considered counseling that was offered.

Plan of Care. The first TR appointment included the physical therapy evaluation and initiation of the physical therapy plan of care. The patient was educated regarding postoperative expectations and axillary cording. She was instructed in self-treatment of cording and a home exercise program that included breathing, posture work, and gentle shoulder stretches (Table 1). She was encouraged to begin an outside daily walking program.

During the second visit, baseline arm volume measures were obtained using self-measurement28,29 and the patient was provided with an interactive patient presentation on lymphedema risk factors, risk reduction, early detection, and ongoing surveillance. At visit 3, the patient reported significant fatigue, particularly during her chemotherapy weeks. The importance of energy conservation and daily walking was reinforced. Once her range of motion was full, upper extremity resistance exercises were added for strengthening, fatigue37 management, and lymphedema risk reduction38–40 A summary of treatment visits 2 through 6 is outlined in Table 1.

Impression and Ongoing Plan of Care. At the sixth visit, the patient had full range of motion and no significant pain or cording. Her average PSFS score increased to 9/10 and her UEFI score increased to 75/80. She will be followed through the end of radiation therapy. She will receive guidance to reestablish her full regular exercise program to address increasing fatigue and continue with ongoing surveillance program through the end of her chemotherapy. There is ongoing inquiry related to psychosocial issues and encouragement to see a counselor if needed.

Patient Feedback on TR Experience

Recovering from a unilateral mastectomy, the telerehabilitation experience was definitely valuable to my breast cancer recovery during COVID-19. Without the telerehabilitation option, I would not have gained back my flexibility and strength as quickly. Some points that made telerehabilitation a little more challenging was having occasional Internet interruptions and when the physical therapists were unable to fully visualize my scar. I felt that I was able to connect and establish a good rapport with my physical therapists.

Case 2. This patient was a 75-year-old woman referred to physical therapy 7 weeks following a right mastectomy and latissimus dorsi flap reconstruction procedure performed in March 2020. She had a right-sided lumpectomy and removal of 4 lymph nodes, adjuvant chemotherapy, and radiation therapy in 2017. Her postoperative course was complicated by an infection requiring multiple surgical debridements and hyperbaric oxygen treatments between August 2019 and June 2020. Ultimately, the mastectomy and latissimus dorsi flap reconstruction were performed to close the wound. The patient expressed hesitancy over the use of her right upper extremity after surgery and concern that she would disrupt an area of incomplete healing in her right breast. She was unable to attend in-person physical therapy as she and her husband were considered at high risk related to COVID-19. The couple lived with their daughter who played a very active role in the patient's care. The patient had no other significant medical issues. She had a sensation of heaviness and puffiness of her right upper arm and significant discomfort in her right lateral chest wall region. She stayed active by performing daily household chores and walking regularly as she was able. The patient and her daughter were provided with information on the support puzzle (Figure 1). The patient's key initial assessment findings and treatment goals and are outlined in Table 2.

TABLE 2 - Case 2: Key Initial Assessment Findings, Treatment Goals, and Summary of TR Physical Therapy Treatments
Key initial findings at visit 1
Pain and function: (Pain and Patient Specific Functional Scales assessed via screen share)
 Pain: 5/10 at the right latissimus flap tunneling site and the right lateral scar site
 PSFS score:
  1. Sweeping floor with battery Swiffer 2/10

  2. Folding laundry 3/10

  3. Washing dishes 2/10

  4. PSFS score average: 2.3/10

 UEFI score: 19/80
FACT-B scores: Physical well-being: 23/28; social/family well-being: 25/28; emotional well-being: 18/24; functional well-being: 16/28; additional breast cancer concerns: 25/40; additional +4 upper extremity concerns: 9/20
Inspection/posture: Marked forward head posture, protracted shoulders, and increased thoracic kyphosis. Mild increase in girth to the right posterior upper arm and the right lateral chest wall. Right latissimus flap donor scar site closed and healing well.
Shoulder and cervical active range of motion: (estimated via TR)
 Flexion: Right: 120° (pressure noted at the anterior chest wall; the patient was fearful of movement)
 Left: 150°
 Abduction: Right: 115° (decreased upward rotation of the scapula)
 Left: 130°
 Cervical range of motion: Within normal limits
Self-palpation of soft tissue: Gentle, guided soft-tissue palpation completed by the patient's daughter. The patient reported tenderness to palpation along the right latissimus flap tunneling site on the lateral chest wall and the lateral latissimus flap scar site; good mobility observed along the right latissimus flap scar site.
Plan of care: Treatment goals and frequency
Planed frequency of treatment: Once per week
 Short-term goals: 4 wk
  1. Increase UEFI score to ≥55/80

  2. Increase aerobic activity level

  3. Increase shoulder flexion to >160°

  4. Improve postural awareness

 Long-term goals: 8 wk
  1. Increase average PSFS score to ≥8/10

  2. Increase UEFI score to ≥70/80

  3. Strengthening program in place

  4. Discharge to ongoing lymphedema surveillance

Visits 1-3
Key physical therapy interventions
  1. Instructed in gentle, pain-free range of motion and postural exercises, including overhead stretch with stick in supine position, butterfly stretch in supine position, and scapular retraction

  2. Educated in safe return to activities of daily living

  3. Instruction of the patient and her daughter in gentle soft-tissue massage to the right lateral and posterior chest wall, as well as gentle scar massage to the right latissimus flap donor site

  4. Importance of daily exercise and initiation of personal walking log

Visits 4 and 5
Upper extremity volume: Right = 1968.9 mL; left = 1990.3 mL. Right affected dominant arm is 1% smaller than left (Figure 4). Shoulder flexion and abduction 150° bilaterally (estimated).
Key physical therapy interventions
  1. Added upper extremity resistance exercises with yellow TheraBand for increased strength and reduced risk of lymphedema

  2. Progressed upper-quadrant stretches to include pectoralis major stretch in the doorway

Abbreviations: FACT-B, Functional Assessment of Cancer Therapy–Breast; PSFS, Patient Specific Functional Scale; TR, telerehabilitation; UEFI, Upper Extremity Functional Index.

Impression. The patient was a 75-year-old woman recovering from significant wound-healing complications and a right mastectomy and latissimus flap reconstruction. Because of COVID-19, the patient was self-quarantined at her daughter's home and she and her husband were at high risk. The patient's daughter planned to attend all sessions to assist with the technology aspects of TR. The patient had very significant functional impairments based on her PSFS and UEFI scores. She was hesitant to move her right arm. She had moderate lymphedema risk in the right upper extremity with 4 lymph nodes removed, a history of radiation therapy to the right breast, and increased body mass index.

Plan of Care. The first 3 TR visits focused on decreasing the patient's fear of moving and improving her posture and range of motion. Lymphedema education and baseline measures were deferred to focus on reducing the patient's fear of moving her arm. A summary of visits 2 through 6 is outlined in Table 2.

At the fourth and fifth visits, the patient had significant improvement in bilateral shoulder range of motion and demonstrated greater confidence with use of her arms. She noted that the heaviness in her upper arm had subsided. She was provided with an interactive patient presentation on lymphedema risk factors, risk reduction, early detection, and ongoing surveillance. Baseline volume measures were obtained (Figure 4) and are included in Table 2.

Fig. 4.
Fig. 4.:
Case 2: Markings for home measurement of arm circumference. This figure is available in color online (www.rehabonc.com).

Impression and Ongoing Plan of Care. By visit 6, the patient had full range of motion bilaterally. There was no evidence of visible or measurable lymphedema, but she remained at moderate risk and had noted heaviness since her surgery. In the next 3 visits, the patient's exercise program will be progressed and she will be discharged from regular physical therapy. She will continue on an ongoing surveillance program as needed for lymphedema and other long-term treatment side effects.

Feedback on TR Experience From the Patient's Daughter

Telerehabilitation has been the perfect solution for mom and our family! Telerehabilitation made rehab possible. I don't think mom could have had the success that she has had thus far without this platform.

Case 3. The patient was a 68-year-old woman who had breast cancer in 2015 with secondary lymphedema of the left upper extremity. She returned for a lymphedema recheck. Her lymphedema was detected early 4 years ago, and she continues on a surveillance and management program. The volume of her affected left nondominant arm had been maintained at less than 8% greater than her unaffected arm over the years. She was using a class I compression sleeve approximately 6 hours per day.

Self-measures taken by patient during her TR visit demonstrated that the nondominant affected left upper extremity is 1% larger than right (Figure 5). She had no pain, her range of shoulder motion was full, and she had no functional limitation. The patient's upper extremity resisted exercise program was reviewed and updated. A new sleeve was ordered, and the fit was confirmed with the PT on a subsequent TR visit.

Fig. 5.
Fig. 5.:
Case 3: Home self-measurement of arm circumference. This figure is available in color online (www.rehabonc.com).

Impression and Ongoing Plan of Care. The patient will continue with self-management of her mild lymphedema with a compression sleeve and upper extremity resistance exercise. She will return for a recheck in 3 to 4 months or as needed.

Patient Feedback on TR Experience

I have lymphedema and check in every several months to make sure it doesn't get worse. With the advent of COVID-19, I assumed I would have to place my lymphedema check-ups on hold. The process of measuring my arm at home was a unique solution! The physical therapist was able to assess the quality of my current sleeve, order a new one, and provide some new exercises to assist me with core strengthening. Telerehabilitation has been great solution.

Some aspects of a TR-only approach to one-on-one care are challenging. An initial hesitancy is sometimes expressed by patients regarding the TR process versus in-person, hands-on care. It can take more time to establish a trusted and compassionate therapeutic relationship without in-person patient contact. In our experience, this took 2 or 3 TR appointments to establish this relationship. There are clinical scenarios where patients may benefit more from in-person care, such as for skilled manual therapy for cording and soft-tissue and joint restriction and more complex garment fitting and instruction in bandaging for lymphedema.

DISCUSSION

There were numerous challenges to implementing TR and Web-based patient education, exercise, and support programs. Technology access and technical skill can be a barrier to TR care, as shown in case 2, where the patient needed assistance from a family member related to the technology. Technical, administrative, and scheduling processes and the development of best practices for new procedures, such as self-measurement of volume, were improved upon over the 3-month time period. PTs and the public in general are increasingly adept and comfortable with virtual communication, enhancing the establishment of a therapeutic relationship without in-person contact.

PTs were required to be creative in guiding patients through examination procedures, such as examination of tissue extensibility, incision healing and mobility, axillary cording, and swelling. Manual therapy techniques for conditions such as soft-tissue and joint mobility and axillary cording needed to be replaced with guided targeted stretching and self-mobilization. In some cases, the inability to provide manual techniques may have resulted in slower resolution of symptoms.

TR and online education and support groups provided a safe alternative for patient care during COVID-19. Several advantages were realized, including increased flexibility for patients related to scheduling and the potential for caregiver involvement in patient care. Observing patients in their home provided unexpected benefits when PTs were able to observe an exercise program as it was being carried out at home. PTs were able to evaluate and advise on issues such as home office space ergonomics and sleep position in a patient's home environment. The success of the interactive, live, Web-based format for patient education, group exercise, and support groups demonstrates an opportunity for PTs to lead broad community cancer survivorship education and exercise initiatives.

Implementation of TR, virtual education, and support programs offered by specialized oncology PTs and other oncology rehabilitation professionals has opened frontiers in patient care that will continue to expand. Patients are now offered the options of in-person, TR, and a hybrid model of care. These care options will reduce barriers to the prospective model of care for preoperative and long-term surveillance by increasing access to care remotely. This model can be applied to other cancer populations.

TR and interactive Web-based patient education and exercise are improving access to care to breast cancer rehabilitation care. By extension, barriers to care can be reduced in underserved populations, including minority, rural-based, and immune-suppressed patients and patients with metastatic breast cancer.26 For example, there are significant racial disparities in breast cancer care,41 including a greater effect of breast cancer on African American women with respect to physical and functional morbidity.42,43 Targeted programs that expand rehabilitation, survivorship education, and exercise opportunities by providing multiple access options are needed to address racial disparity in breast cancer survivorship care.

Breast cancer survivors living in rural areas experience unique challenges due to additional burdens, such as travel and limited access to specialists. Rural survivors of breast cancer have reported poorer outcomes, poorer mental health and physical functioning, lower-than-average quality of life, and less access to exercise programs, compared with urban survivors.44,45 A telemedicine intervention was shown to be effective in improving quality of life in breast cancer survivors living in remote areas.46 TR provides an immediate opportunity to provide rehabilitation and exercise for patients with breast cancer in rural and remote settings.

Prior to COVID-19, physical therapy care provided via telemedicine was not reimbursed by Medicare or most commercial insurance companies in the United States. This rule was waived during COVID-19, and patient co-pays were funded by insurance companies. It is not clear how long this will continue. If insurance reimbursement for TR provided by PTs ends, there will be significant setback to this new frontier in providing cancer rehabilitation care more universally. As a nonprofit, community grant and donor funding and partnerships help sustain these programs that serve the unmet needs of breast cancer survivors.

There are several limitations to this report. It is descriptive and does not include group outcomes. Further research is needed to compare outcomes of TR versus in-person delivery of breast cancer rehabilitation care.

CONCLUSION

The delivery of cancer survivorship care has been increasingly recognized as an area of health care in need of improvement.27 Prior to COVID-19, there was growing evidence that current models are both unsustainable for the future and fail to meet the diverse needs of cancer survivors.27 COVID-19 has accelerated the growth of TR and general patient acceptance of this care model. There is a need for ongoing development of innovative models of oncology rehabilitation and exercise care that meet both patient need and safety concerns while improving accessibility to care and outcomes. TR and interactive Web-based education formats provide an alternative to in-person breast cancer rehabilitation care during COVID-19 and have significant future application for improving delivery of care to underserved populations.

ACKNOWLEDGMENTS

The authors acknowledge contributions of the following to the development and implementation of the TR model of care for patients with breast cancer at TurningPoint: Judith Mill, PhD, RN, Professor Emeritus, Faculty of Nursing, University of Alberta, Edmonton, Canada; Kristin L. Campbell, PT, PhD, Associate Professor, University of British Columbia, Vancouver, Canada; and Bolette Skjødt Rafn, PT, PhD, Department of Oncology, Copenhagen University Hospital Rigshospitalet, CASTLE—The Danish Cancer Societyʼs National Research Center for Late Effects Among Cancer Survivors, Copenhagen, Denmark.

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Keywords:

breast cancer rehabilitation; physical therapy; telehealth; telerehabilitation

© 2020 Academy of Oncologic Physical Therapy, APTA.