Tuesday 12th June 2012
Sue Acreman, Consultant Practitioner in cancer rehabilitation, appraises the current available literature relating to the pilot programme.
People with cancer can experience difficulties before, during and after their treatment. Rehabilitation can enable them to manage these problems and to live well with their cancer. This review highlights the effective rehabilitation interventions provided by allied health professionals and others.
Almost all people with cancer will require rehabilitation at some point along the care pathway, and an increasing number of people living with cancer means there will be an inevitable increase in demand for rehabilitation services.
According to Dietz, there are four stages of rehabilitation in cancer:
- prevention (preventing disability)
- restoration (returning to pre-illness health status)
- support (minimising functional loss)
- palliation (symptom management).
Additionally, acknowledgement of the eight domains of care (physical, nutritional, psychological, spiritual, practical, informational, financial and social/relationships) in the provision of holistic care is important in the planning and delivery of rehabilitation.
This review is divided into sections that reflect either the intervention or the tumour site used in the Scottish pilot cancer rehabilitation programme.
Physical activity and exercise
Pinto et al provided a single, face-to-face exercise session followed by a telephone review to provide further encouragement. This resulted in reported improvements in vigour and fatigue.
A review by Beaton et al found a possible benefit of exercise in people with metastatic disease, while Morey et al reported that exercise, dietary improvements and weight loss had a positive effect in people with colorectal, breast or prostate cancer.
Bird et al conducted a randomised control trial (RCT) using both a professionally-led rehabilitation programme and a self-managed one. The self-managed group was provided with identical information as the professional programme. They found improvements in both groups.
Korstjens et al found that a 12-week physical training programme with cognitive behaviour problem solving training, or a physical training programme alone, led to improvements in anxiety. Cognitive behavioural therapy (CBT) added little additional benefit.
In their Cochrane review, Goedendop et al found limited but promising evidence that psychosocial interventions during cancer treatment are effective in reducing fatigue.
Ibfelt et al provided information and advice sessions for people with cancer on topics such as: cancer treatments, psychological issues, spirituality, sexuality, lifestyle, and employment issues. They used lectures, discussions and group work. These led to improvements in BMI but none in self-rated health. Though there was some benefit, it was not statistically significant.
Diet and nutrition
A systematic review by Baldwin and Weekes found that dietary advice in conjunction with oral nutritional support produced better rehabilitation outcomes for people with cancer, while the National Collaborating Centre for Acute Care reported similar improvements.
Ma et al conducted a systematic review on people diagnosed with urological cancers in which diet, exercise and stress reduction techniques showed possible beneficial effect on the progression of prostate cancer.
A group study by Campbell et al used relaxation as the intervention and measured its effect on fatigue and body weight. Though no positive effects were reported, work by Leon-Pizzero et al found that it improved mental health status.
An RCT by Van Weert et al found physical training had a significant effect on fatigue levels in people with a range of cancers. While Fillion et al showed positive results from supervised walking training and psycho-educational stress management.
Breast cancer is an area where much of the research in cancer rehabilitation has been undertaken. Duijts et al conducted a meta analysis of over 50 RCTs evaluating the effect of physical activity, among other interventions, on psychosocial functioning and quality of life. Statistically significant effects were reported for fatigue, depression, body image and quality of life.
Regarding nutrition, Thompson et al found that diet counselling, using either low fat or low carbohydrate regimes, was effective for weight loss and led to improvements in a range of nutritional biochemical markers in women with breast cancer.
Courneya et al reported an enduring positive effect of exercise on physical functioning in people with lymphoma.
Peat et al used circuit training as a means of improving functional performance and stamina in a mixed tumour group, which included ovarian cancer. The results were unclear but this may have been due to the sample size, which was very small.
Strong et al reviewed 20 studies. These reported a positive effect on cancer-related fatigue and preservation of skeletal muscle mass with aerobic exercise, resistance training and a combination of both.
Coleman et al reported an increase in lean body mass, improved mood and sleep quality following the use of individualised exercise prescriptions.
Bourke et al found significantly positive effects on dietary behaviour, fatigue, functional capacity and aerobic exercise tolerance with a combined intervention of exercise and dietary advice.
An updated Cochrane review by Rueda et al of non-invasive interventions to improve well-being and quality of life, found that exercise programmes resulted in short-term benefit.
An RCT conducted by von-Gruenigen et al, which provided lifestyle interventions, resulted in reduced body weight.
This review shows that there is a body of evidence to support the interventions provided by allied health professionals and others, which assist people with cancer to manage their illness and its side effects. Other existing research, while not RCTs or systematic reviews, can help inform practice and should be critically appraised to assess its relevance in planning and developing services. Further research is required to ensure all interventions are evidence based and effective.
See References - Sharing Good Practice, Summer 2012.
Evidence for the effectiveness of rehabilitation approaches has been reviewed by the National Cancer Rehabilitation Advisory Board with the support of the National Cancer Action Team in England. The first review in 2009 was recently followed by a further piece of work launched in January this year.[25–26]
The context of both reviews have focused around a range of tumour sites and a variety of interventions that may form effective practice for dietitians, occupational therapists, physiotherapists, speech and language therapy and lymphoedema practitioners. These two extensive reviews focused on the evidence from RCTs and systematic reviews, though the search revealed a rich seam of evidence which did not fulfil this criteria. The reader is urged to access the review and all the references.
Email Sue Acreman, Consultant Practitioner in cancer rehabilitation.
About the author
Sue is a consultant practitioner in cancer rehabilitation and is currently developing rehabilitation programmes for people with cancer in south Wales. She is chair of the National Cancer Rehabilitation Advisory Board under the auspices of the English National Cancer Action Team and is a Fellow of the British Dietetic Association.
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