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Living well after cancer

With more people surviving after having cancer, what can physiotherapists do to boost the quality of their lives? Louise Hunt reports

As our understanding of the long-term effects of cancer and the treatment of the condition grows, physiotherapists will play an increasingly important role in helping survivors to maintain a good quality of life.

This prediction is made in the National Cancer Survivorship Initiative (NCSI), which, through its Consequences of Cancer and its Treatment (CCaT) work stream, aims to improve the long-term care delivered to all cancer patients, with a particular emphasis on vocational rehabilitation.

The NCSI was formed in 2007 by the Department of Health and the charity Macmillan Cancer Support, as part of the Cancer Reform Strategy for England.

The precise scale of the problem is not yet fully appreciated, the NCSI notes, pointing out that data about the consequences of patients’ treatment are not collected as routine.

In addition, health professionals have difficulties in making the link between patients’ symptoms and earlier diagnoses of cancer.

However, the NCSI estimates that 60 per cent of cancer survivors have unmet physical or psychological needs following treatment.

For example, one person in two who has received pelvic radiotherapy reports having bowel problems that affect his or her quality of life.

And more than one third report problems with close relationships, an inability to pursue their chosen career, or difficulties in carrying out daily household duties.

Crucial intervention

Early intervention rehabilitation could be crucial in preventing such problems from arising later on, according to consultant physiotherapist Karen Robb.

She is the sole allied health professional (AHP) on the 12-strong CCaT group; the rest are cancer nurse specialists. All the members are actively involved in research.

As part of one of her CCaT projects, Dr Robb is funded by Macmillan Cancer Support for two days a week to develop, oversee and evaluate an education and rehabilitation programme for cancer patients from the borough of Tower Hamlets.

She is based at the Barts and the London NHS Trust. The six-week programme is run by physiotherapist colleague Claus Buscher.

It is based on the American ‘cancer transitions’ model for people at the end of cancer treatment, although some participants may join several months later.

Patients, who can be referred by clinical nurse specialists, consultants, GPs or self-refer, attend weekly sessions lasting two hours and 30 minutes.

They are offered exercise routines and talks delivered by specialists on topics such as diet and nutrition, managing psychological issues, and medical aspects following treatment.

The physical activity part of the programme is aimed at improving people’s overall fitness using a circuit-style exercise programme, says Dr Robb.

 ‘We tell patients why exercise is beneficial for them and provide practical help. It is a safe environment, which is important for patients who may be experiencing significant consequences of treatment, such as pain or fatigue.

Every patient is looked at individually so even if they are not particularly mobile they can still do exercises sitting down.’

Importance of exercise

Dr Robb notes: ‘The programme’s ultimate aim is to improve patients’ ability to self-manage following treatment and, hopefully, to combat the consequences of cancer treatment and to lead a good quality of life.’

The programme, which has been running for just over a year, is funded by Tower Hamlets public health department as an ongoing service. Dr Robb works closely with the public health team to ensure that it’s used widely by local cancer patients.

While it is too early to report the results of the programme, Dr Robb hopes that through rigorous evaluation of outcome measures, including the numbers of participants who have been able to return to work, it will influence national policy and practice.

Making the link between early intervention rehab and a reduction in the consequences of cancer treatment will take time.

‘As patients survive cancer longer we are just starting to see the late effects of cancer. The NCSI is doing really good work in raising awareness of the issue, but it will be many years before late effects are routinely recorded.

‘We don’t have strong evidence now, but we know that exercise can help with problems such as fatigue. I believe if we can start early with good rehabilitation, physiotherapists can help to prevent consequences down the line.

It’s about giving patients the message that exercise is important during and after treatment and physiotherapists have a really important role in this.’

The ‘survivorship agenda’

Nationwide, access to cancer rehab services is not routinely available says Jane Rankin, chair of the Association of Chartered Physiotherapists in Oncology and Palliative Care (ACPOPC). It is, she says, a ‘key area of development’ for specialist physiotherapists.

Across the UK there has been a push to develop rehabilitation programmes that can prevent or lessen the impact of cancer and its treatment.

For example, a physio is leading Macmillan’s ‘Move More’ activity campaign, which is encouraging cancer survivors to be physically active to combat cancer-related fatigue and depression.

And many physios are working with councils to educate leisure centre fitness instructors to manage re-enablement activity classes for those with low-level fatigue.

More intensive AHP rehab input is being provided through schemes such as the Back on Track pilot – a Northern Ireland-based eight-week rehabilitation programme to beat cancer-related fatigue, for which Ms Rankin was a key adviser.

It is run by the University of Ulster, in partnership with Belfast Health and Social Care Trust and Ulster Cancer Foundation charity.

ACPOPC is working directly with the National Cancer Rehabilitation Advisory Board, and evidence from such pilot models as Back on Track is influencing the development of rehab services that support what some term the ‘survivorship agenda’.

Physio Jackie Turnpenney is the rehabilitation and survivorship lead for the Department of Health’s National Cancer Action Team.

She says that the work of key players such as Karen Robb and Jane Rankin, among others, is helping to give AHPs a firm footing in the cancer survivorship agenda.  

While rehab has always been about self-management, Ms Turnpenney says AHPs delivering cancer rehab as part of multidisciplinary teams should be seen as being integral to the survivorship agenda.

This, she says, is a relatively new area of policy development, driven by the acknowledgement that cancer is now a long-term condition.

Unless they put themselves forward, AHPs could be in danger of losing out on the zeitgeist to other health professionals.

Physios could be doing more to influence the National Institute for Health Research Cancer Research Network agenda,’ she says.

Cancer care pathways

This is partly being achieved through developing cancer care pathways based on evidence reviews that stipulate the role of rehab in different cancer patient groups; there are eight so far and three more in development.

Ms Turnpenney has also developed a workforce model based on the incidence of cancer that involves auditing the number of AHPs working in cancer rehab and palliative care and creating a model for the numbers needed.

‘We need to help commissioners to recognise the advantages in terms of cost and impact on patients of putting in cancer rehab earlier rather than later,‘ Ms Turnpenney adds. fl

Further reading

• For more information on the CCaT.To download copies of the Macmillan ‘Move More’ packs, visit: www.macmillan.org.uk and put ‘move more’ into the search engine

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