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RESEARCH REPORTS

Association of Outpatient Cancer Rehabilitation With Patient-Reported Outcomes and Performance-Based Measures of Function

Pergolotti, Mackenzi PhD1; Covington, Kelley R. MS2; Lightner, Ashley N. DPT3; Bertram, Jessica DPT4; Thess, Melissa PT5; Sharp, Julia PhD6; Spraker, Matthew MD, PhD7; Williams, Grant R. MD8; Manning, Peter MBA9

Author Information
doi: 10.1097/01.REO.0000000000000245
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Abstract

By 2026, more than 20 million Americans will be living with and beyond a cancer diagnosis (ie, cancer survivor).1 Cancer survivors often struggle with persistent symptom burden that may negatively impact quality of life, including physical, social, and/or cognitive functioning, and lead to disability.2 Cancer-related disability is associated with decreased patient health and satisfaction and greater overall societal and individual costs.3 As a whole, survivors report higher levels of distress than noncancer controls.4 An increased prevalence of distress has been observed for survivors who are not physically active or have functional limitations.4 Consequently, many survivors consider functional outcomes to be of equal or greater importance than overall survival.5 Optimizing function and quality of life throughout survivorship is critical to alleviate distress and enhance quality of life6 and requires timely clinical intervention.7

Cancer rehabilitation interventions, particularly physical therapy (PT) and occupational therapy (OT), are well positioned to improve cancer-related disability by addressing an individual's functional and quality-of-life needs.8 Physical and occupational therapists are uniquely trained to address persistent symptom burden and to help individuals maintain or improve physical and functional health.8 Broadly, the goals of rehabilitation interventions are to aid survivors' ability to reengage in work and life roles while decreasing distress.8 While cancer rehabilitation services are available in the outpatient setting, they are not a fully integrated component of standard cancer care.9 Lack of evidence regarding the effect of cancer rehabilitation for cancer-related disability outcomes in nonacademic outpatient settings is a major barrier to integration10; this evidence is critical to establish rehabilitation as a valued partner and an integral part of the cancer care team.11,12 Therefore, we examined the effect of community-based outpatient cancer-specific PT and OT on patient-reported outcomes (PROs) and performance-based outcomes for adults with cancer.

METHODS

We retrospectively evaluated PROs and performance-based measures of strength and function completed by adult cancer survivors (≥18 years old) during regularly scheduled PT or OT sessions at 2 outpatient rehabilitation clinics in the Southwestern United States (January-October 2019). All physical and occupational therapists had previously completed a minimum of 40 hours of CEU-accredited curriculum provided by ReVital Cancer Rehabilitation and received ongoing clinical support from ReVital's Medical Director and the National Research and Clinical Development team. Each therapy plan of care was developed by the treating therapist and based on discipline-specific, evidence-based protocols.

Survivors self-reported characteristics (ie, demographic information, cancer history, and treatment information) and completed PROs and performance-based measure at their initial PT/OT evaluation (ie, pretreatment). As part of standard-of-care practice, PROs and performance-based measures were repeated at regularly scheduled subsequent PT/OT appointments until discharge (ie, post).

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed consent was not needed, as all data were retrospective and de-identified before any analysis. This study was approved by the Institutional Review Board at Colorado State University.

Patient-Reported Outcomes

Health-related quality of life (HRQOL), ability to participate in social roles and activities (SRA), and physical function (PF) were measured using Patient-Reported Outcomes Measurement Information System (PROMIS) instruments.13 PROMIS measures were developed and validated with state-of-the-science methods to be reliable and valid14 and are available for researchers and clinicians to use in practice. All PROMIS measures use a T-score for scoring, with a mean of 50 and standard deviation of 10. The PROMIS global is a 10-item survey that measures HRQOL in 2 subdomains: global physical (GPH) and mental health (GMH),14,15 which include evaluations of pain, fatigue, and global quality of life. PROMIS PF and SRA measures each have 4 items. Higher scores on all measures indicate greater health or function.

Performance-Based Measures

Physical and occupational therapists measured hand grip strength (HGS) and administered the Timed Up and Go (TUG) test following the established clinical practice guidelines for each assessment.16,17 HGS was measured in pounds using the Jamar hydraulic handgrip dynamometer (Jamar by Lafayette Instruments, Lafayette, Indiana) and evaluated in this study as a proxy of upper-body strength.18,19 The TUG test is a performance test of physical mobility and fall risk.17,20,21 Therapists measured and recorded the TUG test in duration (seconds).

Data Abstraction and Analysis

From individual rehabilitation records, data abstracted included patient-reported characteristics, PROs, and performance-based outcomes that were collected during the rehabilitation evaluation (pretreatment) and at a second time point, either at last appointment seen or at discharge (post) PT or OT sessions. We calculated T-scores for all complete PROMIS measures and calculated average HGS using all 3 trials performed in the dominant hand. Descriptive statistics were used (frequencies, normalcy, and central tendency) to analyze patient-report characteristics and assumptions for statistical tests. Independent-samples t test and χ2 tests were used to compare continuous and categorical characteristics, respectively, between survivors who completed and did not complete a follow-up rehabilitation evaluation and between those who reported actively undergoing treatment (ie, active treatment) and those not receiving active treatment (ie, nonactive treatment). We used the paired-samples t test to compare PROs and performance-based outcomes from pre- to postrehabilitation and then calculated effect size (Cohen d). For all outcome measures, we completed a subgroup analysis using independent-samples t tests to evaluate differences between pre/posttreatment change between the active and posttreatment groups. A P value less than .05 was considered statistically significant for all analyses. All analyses were conducted in SPSS version 24 (released 2016; IBM SPSS Statistics for Windows, version 24.0; IBM Corp, Armonk, New York).

RESULTS

The characteristics of adults with cancer who completed an initial PT/OT evaluation during the study period (N = 185) are provided in Table 1. The majority of the sample reported actively receiving cancer treatment during rehabilitation (n = 98; 53%). Survivors in the sample who reported they were in active treatment compared with those who reported completion of cancer treatment before starting rehabilitation were diagnosed more recently (18.38 vs 36.70 months, P = .02, t = 2.50) and included a greater proportion of males (28.9% vs 11.9%, P = .01, χ2 = 6.63). Furthermore, those in active treatment were more likely to report having advanced cancer (26.5% vs 10.4% stage 4, P = .03, χ2 = 9.07) and less likely to have received radiation therapy (35.4% vs 65.7%, P = .00, χ2 = 14.46). There were no other significant differences for characteristics included in Table 1.

TABLE 1 - Patient Characteristics, Reported as Number (%) or Median and Interquartile Range (N = 185)
Characteristic n (%) or Median (Interquartile Range)
Age group
18-64 y 116 (62.7)
65-85+ y 58 (31.4)
Missing 11 (6.0)
Sex
Female 137 (74.1)
Male 45 (24.3)
Missing 3 (1.6)
Race/ethnicity
White 134 (72.4)
Non-Whitea 18 (9.7)
Missing 13 (8.1)
Highest education
High school degree or less 64 (34.6)
College degree 98 (53.0)
Missing 14 (7.6)
Marital status
Single, divorced, or widowed 41 (22.2)
Married 131 (70.8)
Missing 13 (7.0)
Employment statusb
Employed full- or part-time 70 (37.8)
Unemployed, retired, or other 101 (54.6)
Missing 14 (8.2)
Fallen in past 6 moc 31 (16.8)
Missing 15 (8.1)
Cancer diagnosis type
Breast 98 (53.0)
Head and neck 19 (11.2)
Leukemia, lymphoma, or myeloma 19 (10.3)
Otherd 34 (18.7)
Missing 15 (8.1)
Cancer stage
1-2 70 (37.8)
3-4 56 (30.3)
Unknown 32 (17.3)
Missing 28 (15.1)
Cancer treatment status
Pretreatment or active 103 (55.7)
Completed >1 mo ago 67 (36.2)
Missing 20 (10.8)
Cancer treatments receivede
Surgery 139 (75.1)
Systemic therapy 147 (79.5)
Radiation or stem cell transplant 89 (48.1)
Missing 5 (2.7)
Cancer-related emergency department or urgent care utilization in past year
No 123 (66.5)
Yes 49 (26.5)
Missing 13 (7.0)
Cancer-related unplanned hospitalization in the past year
No 123 (71.4)
Yes 48 (25.9)
Missing 14 (7.6)
Number of comorbid conditions 1.0 (0.00-2.00)
Missing 4 (2.2)
Number of daily medications 4.0 (2.0-6.0)
Missing 17 (9.2)
aNon-White includes Black or African American, Hispanic/Latino, mixed races, and Asian race/ethnicity.
bEmployment status: Full-time employment indicated by 32 or more hours of employed work per week. Other includes disabled, on medical leave, full- or part-time student and homemaker.
cNumber of falls: median = 0, range = 0-12.
dOther diagnoses include gynecological, genitourinary, or bladder, thyroid, skin, gastrointestinal, lung, and sarcoma.
eDoes not equal 100%, patients were able to answer more than 1 treatment. Systemic therapy includes chemotherapy, immune, or targeted therapy.

Of the 185 survivors who were evaluated by rehabilitation, 62 % (n = 115) returned for additional follow-up therapy visit(s) during which they completed at least one follow-up assessment. Survivors who had pre/posttreatment data were more diverse in diagnosis type (15.6% vs 3.3% with head and neck cancer diagnosis, 11 vs 7 different cancer diagnosis types, P = .02, χ2 = 22.32) and included a greater proportion of those diagnosed with advanced stage cancer (28% vs 4.5% stage 4, P = .01, χ2 = 10.99) than those with only evaluation data. There were no other significant differences for characteristics included in Table 1.

Survivors attended an average of 9 PT/OT visits over 6.1 ± 4.5 (range, 0.57-19.06) weeks. PRO and performance-based data are shown in Table 2. On average, a small yet significant effect was observed for mean change in the following: PROMIS GPH (+3.3 pts), PROMIS SRA (+2.6 pts), dominant HGS (+4.2 lb), and TUG duration (−1.5 seconds). Subgroup analysis revealed no significant difference in the mean change for any outcomes between patients receiving active treatment and those who had completed treatment. However, only the active treatment group achieved a small effect for HGS (d = 0.20) and only the nonactive treatment group achieved a small effect for GMH (d = 0.21).

TABLE 2 - Pre/Post, Patient-Reported and Performance-Based Outcomes, Mean ± Standard Deviation, Average Change, and Effect Size (Cohen d)a
All (N = 115) Active Treatment (N = 66) Nonactive treatment (N = 40)
n (%) Pre, Mean ± SD Post, Mean ± SD Mean, Pre-Post Δ Effect Size (d) n (%) Pre, Mean ± SD Post, Mean ± SD Mean Pre-Post Δ Effect Size (d) n (%) Pre, Mean ± SD Post, Mean ± SD Mean Pre-Post Δ Effect Size (d)
PROMIS outcomes
GPH 109 (94.8) 41.19 ± 9.23 44.44 ± 9.17 +3.26b 0.35c 63 (95.5) 40.62 ± 9.47 43.83 ± 9.46 +3.21b 0.34c 40 (100) 41.76 ± 9.08 45.24 ± 8.94 +3.49b 0.39c
GMH 110 (95.7) 48.50 ± 8.71 49.05 ± 9.18 +0.56 0.06 64 (97.0) 49.18 ± 9.36 49.24 ± 9.93 +0.06 0.01 40 (100) 47.20 ± 7.88 48.89 ± 8.34 +1.69 0.21c
PF 109 (94.8) 40.55 ± 9.38 41.70 ± 8.50 +1.15 0.13 61 (92.4) 39.87 ± 9.14 41.13 ± 8.89 +1.30 0.14 40 (100) 41.49 ± 10.40 42.50 ± 8.42 +1.01 0.11
SRA 109 (94.8) 46.91 ± 9.84 49.49 ± 8.98 +2.56b 0.27c 61 (92.4) 46.48 ± 9.03 48.81 ± 9.09 +2.33b 0.26c 40 (100) 48.27 ± 10.98 51.01 ± 9.26 +2.74b 0.27c
Performance-based measures
HGS 92 (80.0) 52.19 ± 18.42 56.39 ± 21.36 +4.20b 0.21c 54 (81.8) 53.58 ± 18.05 57.27 ± 19.69 +3.69 0.20c 32 (80.0) 47.91 ± 19.24 51.54 ± 22.02 +3.62 0.18
TUG 97 (84.4) 10.27 ± 7.27 8.78 ± 4.29 −1.49b 0.26c 56 (84.8) 10.01 ± 4.90 8.99 ± 3.86 −1.01b 0.23c 34 (85.0) 11.02 ± 10.53 8.79 ± 5.29 −2.20b 0.28c
Abbreviations: GMH, global mental health; GPH, global physical health; HGS, hand grip strength (pounds); PF, physical function; PROMIS, Patient-Reported Outcomes Measurement Information System; SRA, ability to participate in social roles and activities; TUG, Timed Up and Go test (seconds).
aN = number in each group who completed at least 2 outcome measures for pre- and postmeasure. Treatment status data missing for 7.8% (n = 9) and are reflected in each treatment group. For each respective outcome measure, missing data ranged from 4.3% to 20.0%. Corresponding number and percentages represent the number and proportion of individuals in each group for which complete data were available, for example, if one PROMIS item was left blank, it was considered missing and the measure was not scored on the basis of PROMIS scoring guidelines.
bP < .05.
cSmall effect size, d = 0.20-0.49.

DISCUSSION

To our knowledge, this study provides the first evaluation of the effect of PT/OT on multidimensional patient-reported and performance-based outcomes for patients who are referred to cancer rehabilitation in community settings. The adults who received PT/OT in this study experienced small but significant improvements in GPH, ability to participate in SRA, dominant HGS, and TUG test duration. Overall, a positive effect was observed independent of treatment status. HGS and TUG were used by therapists due to their association with disability and oncologic outcomes, such as frailty, chemotherapy toxicity, and unplanned hospitalization.22–27 Improvements in TUG score and HGS demonstrate promise in the ability of cancer rehabilitation to positively impact measures of function and build evidence toward ability to impact cancer-related disability.

Compared with the national average for adults (with and without cancer; ranging from 54 to 55),28 our sample reported significantly lower mental health, physical health, and PF scores when measured using PROMIS. Considering most patients with cancer decline in function after diagnosis and throughout treatment,29 and functional recovery can impact quality of life,7,30 our baseline evaluations suggest those who are accessing rehabilitation are already quite impaired. Potentially, if functional decline is found and addressed earlier, rehabilitation could be more effective and efficient.

Postrehabilitation, small significant improvements were achieved for physical health in this study and were accompanied by improved ability to participate in SRA. Although patient-reported PF did not improve, both performance-based measures of PF improved significantly. In addition, the nonactive treatment group experienced a small but nonsignificant effect on mental health. Taken together, these results provide real-world evidence to support the benefits of cancer rehabilitation for survivors with mental health, physical health, and physical functioning needs. Furthermore, because the nonactive treatment group reported poorer baseline mental health and saw greater average improvement, cancer rehabilitation may have enhanced positive effects for mental health following completion of active treatment, and/or potentially mental health could be maintained with prospective surveillance rehabilitation providing survivors with support throughout cancer care continuum.

Survivors who completed at least one follow-up evaluation were more heterogeneous in diagnosis type and included a greater proportion with advanced stage diagnosis. In addition, there was no significant difference in the proportion of those who completed a follow-up assessment when comparing the active and nonactive treatment groups. These results are encouraging because previous researchers have reported that advanced cancer diagnosis and complex health-related needs can be barriers to referral to rehabilitation,31 but are concerning because this may signal that only those with obvious disability are accessing care. Our study demonstrates the potential feasibility and effect of community-based cancer rehabilitation, regardless of cancer type, patient complexity, or treatment status.

Despite consistent improvements in TUG performance, 24.6% of the active treatment group and 32.5% of the posttreatment group reported reduced PROMIS PF scores postrehabilitation. Therapists in this study reported that patients often scored themselves lower on PROs as their strength and/or function improved. In a recent study examining patient report versus clinical report, patients tend to combine both mental and physical factors into their perceived functional ability. This could account for the decrease over time with this specific measure. However, studies examining functional trajectories with larger sample sizes to allow for detailed subgroup analyses could potentially better examine the reasons for decrease in PF 4-item score. We also hypothesize that as patients became more integrated into their social/work life (evidence by significant improvement on PROMIS SRA) and transitioned into a higher-demand setting, this revealed deficits the patient had not realized in lower-demand settings. Although anecdotal, this evidence was supported by the juxtaposition between improved scores on performance-based measures and PROMIS measures evaluating physical health and ability to participate in SRA and lack of consistent improvement in PROMIS PF or mental health.

Limitations

This study sought to understand the effect of cancer rehabilitation delivered in community-based outpatient clinics. Limitations to the rigor and generalizability of findings include retrospective design, lack of a control group, and heterogeneous sample. Limited access to detailed therapy and medical record information led to a reliance on patient-reported cancer diagnosis and treatment information and a lack of specific therapy intervention information. In addition, cancer-specific minimal clinically important difference (MCID) values have not yet been established for the therapy outcomes in this study, which prevented an evaluation of clinical significance. Future studies should consider a wait-list control group, recruit larger sample sizes, use electronic health records to confirm diagnosis and treatment information, use measures with establish MCID values, and review therapy records to better describe the specific rehabilitation interventions and diagnoses. Although this study examined the patient-reported use of unplanned hospitalization and emergency use as patient characteristics, retrospective design and patient-reported evaluation prevented pre/posttreatment analysis of these outcomes. There is pressing need to understand the effect of rehabilitation on health care utilization; this would be an appropriate next step for prospective studies and should be asked in all supportive care visits.

CONCLUSIONS

This study provides evidence supporting positive effects of community-based outpatient cancer rehabilitation (PT and OT) on HRQOL and functioning. Our results demonstrate that community-based outpatient cancer rehabilitation may be equally beneficial for patients with a range of cancer types and regardless of treatment status. Collaboration between community and academic cancer centers and rehabilitation clinics is required and urgently needed to fill evidence and access gaps for unmet cancer rehabilitation needs in the community.

ACKNOWLEDGMENTS

The authors thank the patients and their caregivers for participating in cancer rehabilitation. The authors also acknowledge the therapists, Bonnie Lucio and Karthick Jayaraman, and the leadership P. J. Gillard & Fabian Polo at Baylor Scott and White Rehabilitation for their support of this work.

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Keywords:

adults; cancer rehabilitation; community-based; outcomes; outpatient

© 2020 The Authors. Published by Wolters Kluwer Health, Inc.