Cancer Rehabilitation Medicine: “Bridging the Gap” With Supportive Care

Jessica Cheng, MD

City of Hope

Finding ways to improve quality of life outcomes is always a goal for oncologists. Those in the emerging field of cancer rehabilitation medicine have the opportunity to bridge a gap in oncology care.

Jessica Cheng, MD, described cancer rehabilitation as a strategy to improve function, whether that involves doing day-to-day activities or overcoming an unexpected challenge. She noted that finding solutions to these issues brings her joy.

Cheng, assistant clinical professor in the Department of Supportive Care Medicine at City of Hope, highlighted that cancer rehabilitation medicine is a subspecialty of physical medicine and rehabilitation (PM&R) and is a viable option for any patients who need to increase their strength or are experiencing toxicity-related events from treatment.

When speaking with CancerNetwork^®, Cheng discussed the importance of PM&R and cancer rehabilitation, those who may benefit from it, and how she hopes to spread the word regarding this up-and-coming field.

“My heart’s desire is that every institution that takes care of patients with cancer will recognize the importance of optimizing function and performance status from the beginning and throughout the cancer journey from prehabilitation to rehabilitation,” said Cheng.

CancerNetwork: What is cancer rehabilitation medicine?

Cheng: A lot of times when [patients have] cancer, they have thoughts like, “Will I be able to go back to work? Can I go to my son’s wedding? Can I keep golfing? My back hurts; it’s hard to get off a chair. How am I going to get through this?” What I do in my practice in cancer rehabilitation medicine is I then ask a lot more questions about where these thoughts are coming from. I do an extensive physical exam, and I come up with a comprehensive, tailored, practical, and coordinated plan that aims to give the patient a measure of control over their life; to live their life to the fullest no matter where they are in their cancer journey.

A key part of being able to function and do the activities that they want to do is exercise. There can be a lot of barriers to exercise. It could be that back pain, fatigue related to cancer, neuropathy, or [something that makes them say] “Why do I have to do that?” I seek to answer all those questions with my patients. That’s one example of what a visit might look like. The part that I’m passionate about is cancer prehabilitation, and that’s preparing for surgery, stem cell transplant, or whichever cancer treatment is coming up next. I had a patient who recently followed up with me after prehabilitation, and she followed everything I said in terms of exercise, nutrition, mental health, etc. [She said she] got out of the hospital faster, and she recovered much faster than she thought. The oncologist confirmed that was a quicker recovery than expected. That brings me joy.

How does PM&R relate to cancer rehabilitation medicine?

Cheng: It is not well known in the cancer space. This is my core specialty, and I sub-specialize in cancer rehabilitation medicine. [PM&R] often gets confused with physical therapy vs physical medicine, or psychiatry vs physiatry. These are all important collaborators, but [PM&R] is not exactly those specialties either. PM&R is the only medical specialty that focuses on function. That’s the keyword of everything I do: function.

Function is our ability to do things we care about, whether it’s high level like sports or someone’s job, or if it’s getting off the toilet. Those are all activities that people do day-to-day. The body systems of focus are the musculoskeletal system, or muscle, bone joints; and the nervous system, like the brain, spinal cord, and the nerves throughout the body, as those are the ones that impact someone’s function or ability to do things the most. We do a whole biological, psychological, social, whole-person approach, and I would add an environmental approach because if you imagine getting someone to exercise, move better, or get up after a fall, it requires knowing everything about the patient.

Although we focus on the musculoskeletal and neurological systems, those are not the only systems we look at. We look at their blood pressure. If they’re fainting, that’s not going to help their function. Imagine all of that applied to the cancer world. Historically, the cancer world and the physical medicine and rehabilitation world have not mixed very much. The cancer rehabilitation medicine subspecialty is one of the fastest-growing subspecialties within PM&R, and the population of people who are surviving cancer is growing exponentially. Our [oncologists] are doing such a great job. With physical medicine and rehabilitation, we can help empower patients to live longer with less disability and a better quality of life.

What made you interested in this field of study?

Cheng: I started my medical journey with this appreciation of the mystery of healing. As with many people on the pre-medical journey, you learn a lot about organic chemistry and a lot about mechanisms. I shadowed some doctors with more of a holistic approach, and it was just very mysterious to me how osteopathic manipulation might be able to promote deeper levels of healing, like psychological, emotional, and spiritual healing.

When I found the specialty of PM&R, it seemed like a natural fit in that I like these body systems. It’s focused on practical things. I love practical creative strategies married with medical complexities and the whole-person approach. It was innate to the physical medicine and rehabilitation field. The more I dug into the research about cancer rehabilitation, the more shocked I was at how high the unmet need was. A lot of people going into their cancer journey are already older and already have aches and pains or difficulty moving. For cancer treatment, oncologists look at their ability to move around and their performance status to see if they’ll be able to handle their cancer treatment. It weighed on me that there’s so much opportunity for my field to make a difference in someone’s ability to even get cancer treatment. There’s so much of a gap to bridge. There’s so much headway to make in bringing these 2 fields together.

Is there a specific area of oncology that cancer rehabilitation focuses on?

Cheng: Cancer rehabilitation applies to all patients with any type of cancer or anyone with a body. Overall, because this field is on the more recent side with not too many specialists, there’s a lot of room for research in every disease type and every stage of the disease. Personally, my interest is in cancer prehabilitation. The research has exploded exponentially and become an international phenomenon over the last 10 years.

I’m working on designing a trial for patients with breast cancer and gynecologic [cancers] who are undergoing chemotherapy before surgery so that we can catch them at the earliest time point. [This may allow us to] make them as fit as possible in their mind and body at the earliest point to give them the best chance with their cancer treatment. There has been a recent study that showed that in patients who are undergoing neoadjuvant chemotherapy for breast cancer, the [patients] who did an exercise and nutrition training program were able to achieve a good outcome with pathologic complete response in 53% of the cases vs 28% of people who did not do the program. [I had] a lot of times talking with patients about how chemotherapy is not an excuse to not do exercise. It should be your push to exercise with all that you have in you to help the chemotherapy potentially work better. It’s a way that they can have a measure of control over their cancer journey.

What are some techniques that you implement to help improve a patient’s quality of life?

Cheng: A patient example [may] help [better explain this]. On the rehabilitation end, a lot of times you have rehabilitation after an injury or something that causes some measure of disability. I had a patient with blood cancer who had a stem cell transplant. I saw her after treatment, and she was having difficulty eating and biting. She had pain in her masseter muscle, one of her chewing muscles. She had shoulder problems, range of motion, shoulder pain, and balance issues from the neuropathy. She couldn’t sleep. It’s this complex web [of symptoms], and they’re all in 1 person. They all affect each other. There’s lots of components to this because they all need to synergize to work. For that patient, it [involved] removing some medications and adding some medications for jaw pain, shoulder pain, and nerve issues. It [involved] doing some trigger point injections with [electromyography] guidance in the masseter muscle and working with outside physical therapy.

There are limitations in terms of how many things can be addressed at once. I would bridge the gap of rehabilitation care by giving some direction on exercises they can do at home in the meantime until they’re ready to transition to the next item with a physical therapist [PT]. I would direct them to a PT that would work for them in terms of specialty, logistics, and what’s feasible for them. If it’s too far, it’s just not going to work for them. [I also let] them know about any special precautions if they’re on cancer treatment and if their blood values, platelets, or white blood cell counts are fluctuating. I would arm the patient to understand how to stay safe with the PT and to keep communicating with me and connect with the therapist to make sure that we can optimize their recovery as best as possible.

How does cancer rehabilitation utilize the multidisciplinary care team?

Cheng: The core rehabilitation team consists of PM&R, PT, occupational therapy, and speech therapy. Those are the core rehabilitation team. With that said, because function and [patient’s] abilities to do things are so broad, my team includes everyone. Who is everyone? That could mean the rehabilitation team, recreational therapy, music therapy, acupuncture, supportive care, integrative medicine, interventional pain, neurology, orthopedics, and neurosurgery. It could mean the oncology team and communicating with them a lot. Every medical and supportive specialty is fair game. A lot of times, I am also trying to help the patient prioritize which referral in what timing makes the most sense, and then on the back end, also trying to coordinate and streamline care in collaboration with the whole team.

How do you hope this field grows and becomes implemented at more institutions across the country?

Cheng: I see the value of rehabilitation medicine as an integral part of the cancer space. My heart’s desire is that every institution that takes care of patients with cancer will recognize the importance of optimizing function and performance status from the beginning and throughout the cancer journey from prehabilitation to rehabilitation. There’s a lot of room for growth there.

Where do you hope to see this field headed?

Cheng: My catchphrase recently is “prehab for all”. I want everyone to be armed with this knowledge of what they can do that’s in their control to optimize their abilities for meaningful activities throughout the cancer journey. I hope that oncologists and rehabilitation physicians alike will see that there’s an opportunity with cancer prehabilitation to enable [patients] to get their cancer treatment, get through it better, and recover better. That’s my hope: that this will just spread even more like wildfire than it already is.

What do you hope your colleagues take away from this conversation?

Cheng: Engage in rehabilitation early. Give us a chance to optimize performance status, to help you do your work in oncology. To my PM&R colleagues, I would like them to know that you can impact cancer outcomes.

Reference

Sanft T, Harrigan M, McGowan C, et al. Randomized trial of exercise and nutrition on chemotherapy completion and pathologic complete response in women with breast cancer: the lifestyle, exercise, and nutrition early after diagnosis study. J Clin Oncol. 2023;41(34):5285-5295. doi:10.1200/JCO.23.00871