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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 146-155

Cancer rehabilitation in Australia and New Zealand: A pilot cross-sectional survey


Department of Rehabilitation Medicine, Royal Melbourne Hospital, Victoria; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne; Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Victoria, Australia

Date of Submission28-May-2021
Date of Acceptance28-May-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Krystal Song
Department of Rehabilitation Medicine, Royal Melbourne Hospital, Royal Park Campus, 34-54 Poplar Road, Parkville, Victoria
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPRM-000131

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  Abstract 


Objective: Despite increasing evidence of the benefits of cancer rehabilitation worldwide, the nature of cancer rehabilitation programs is not well described in Australia and New Zealand. We report findings of a pilot survey highlighting the current service delivery of cancer rehabilitation programs and health professionals' perspectives on barriers and facilitators to implementation of cancer rehabilitation programs. Methods: A cross-sectional pilot survey of rehabilitation health professionals in hospital and ambulatory care settings in Australia and New Zealand, evaluating current availability of cancer rehabilitation programs, health professional workforce, core components delivered, and barriers and facilitators to provision and delivery of cancer rehabilitation programs. Results: Respondents (n = 60) included rehabilitation physicians and advanced trainees, with a majority of respondents working in non-dedicated cancer rehabilitation programs in Australia and New Zealand. Most rehabilitation programs being provided to cancer patients are led by rehabilitation physicians, followed by allied health. The most common tumor streams referred include central nervous system, hematological, and breast cancers. Patients are most frequently referred during posttreatment phase. The core components of rehabilitation programs include management of complications and provision of education (mood, exercise, and fatigue management), with exercise prescription comprising mainly strengthening exercises, mobilization, and gait training. Common barriers for adequate service delivery included inadequate funding and lack of appropriate staffing with expertise, while most common facilitators identified were encouraging better collaboration and integration of rehabilitation within acute cancer care services and specialty teams and increased enthusiasm and engagement of staff with leadership skills. Conclusion: The pilot survey identified current service provision among rehabilitation programs providing care to cancer patients and highlighted preliminary gaps and facilitators to the implementation of formal cancer rehabilitation programs. These findings need further confirmation in a larger study to assess further outcome measures and the impact of barriers and facilitators for care quality. Collaborative efforts between physicians, patients, policy makers, and related parties may assist in overcoming the barriers identified.

Keywords: Cancer, rehabilitation, survey


How to cite this article:
Song K, Amatya B, Khan F. Cancer rehabilitation in Australia and New Zealand: A pilot cross-sectional survey. J Int Soc Phys Rehabil Med 2021;4:146-55

How to cite this URL:
Song K, Amatya B, Khan F. Cancer rehabilitation in Australia and New Zealand: A pilot cross-sectional survey. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2022 May 20];4:146-55. Available from: https://www.jisprm.org/text.asp?2021/4/3/146/323564




  Introduction Top


In 2018, there were an estimated 17.0 million cases of cancer diagnosed and 9.5 million cancer deaths globally.[1] Cancer survival rates are rising worldwide, with approximately 16.9 million cancer survivors in the United States in 2019.[1] In Australia, there were an estimated 150,000 new cases of cancer diagnosed and 48,000 deaths in 2020, with lung and colorectal cancers being the more prominent types of diagnosed cancer.[2] The 5-year relative survival rate for all cancers combined is approximately 69% for 2012–2016 in Australia[2] and is expected to increase due to improvements in diagnostic methods, earlier detection, and advancement in oncology-directed treatment modalities. Studies have shown that up to two-thirds of cancer patients experience significant physical and psychosocial issues due to the disease and treatment, with high levels of unmet needs following treatment.[3],[4],[5] Further, various complications can arise following treatment regimens such as radiotherapy, chemotherapy, and surgery. One study evaluating physical and mental health-related outcomes in people with 13 various cancer types in Australia reported that cancer patients had significantly higher physical disability, distress, and reduced quality of life compared with counterparts without cancer.[6]

With increasing cancer survivorship rates, cancer rehabilitation remains an integral part of the continuum of care for survivors. Cancer rehabilitation is multicomponent and considered a complex intervention. It is a growing model of care and consists of interventions designed to help mitigate short- and long-term effects of cancer and cancer treatments (e.g., pain, fatigue, reduced mobility, weakness, depression, etc.).[7] Further, cancer rehabilitation aims to maximize patients' functional independence and improve their quality of life. Cancer rehabilitation employs a multidisciplinary team working in an interdisciplinary approach to deliver evidence-based elements of secondary prevention/core components (e.g., education, nutrition, sleep, and exercise) and medical supervision to assist with the physical and psychosocial needs of survivors. This is in the context of increasing evidence of the various benefits of cancer rehabilitation along the cancer care continuum, with increasing integration of rehabilitation within cancer care programs.[8],[9],[10],[11] Specialized rehabilitation interventions have also been highlighted for individual cancers such as shoulder exercises and lymphedema programs for breast cancer patients,[12],[13] pulmonary rehabilitation for lung cancer patients[14],[15] and dysphagia, and communication training post head-and-neck cancer surgery.[16]

Currently, cancer care has shifted beyond acute management to long-term management of patients in ambulatory and community settings. The interplay between patient, provider, and organizational factors continues to influence access to and the use of cancer rehabilitation services where available.[17],[18] The ideal model of cancer rehabilitation care is yet to be established, with current models focusing on postacute, home, and outpatient ambulatory care.[19] More comprehensive cancer care plans which integrate rehabilitation have been called for to address the multitude of rehabilitation needs experienced by cancer survivors, along with timely and systematic assessment of cancer patients and subsequent referrals to appropriate rehabilitation services across multiple sectors (primary/secondary care/community organizations). Skills and competencies of rehabilitation staff are also crucial to effective delivery of care.

The nature of cancer rehabilitation services tends to vary widely in different countries due to differences in health-care systems, geographical locations, availability of resources, infrastructure, and financial capabilities. Interventions, modalities used, and skill sets among the rehabilitation workforce are also diverse. To date, little is known about the nature of cancer rehabilitation programs worldwide and in Australia, with limited data available compared to other chronic conditions such as cardiac and pulmonary rehabilitation.[20],[21] To our knowledge, only one previous mixed method study described oncology rehabilitation programs in Australia.[9] This study explored barriers and facilitators to program implementation, and also focused mainly on determining whether the exercise component of programs is consistent with guidelines.[9] There is a need for more information regarding the current state of cancer rehabilitation in Australia and New Zealand including service provision, current rehabilitation workforce capabilities, and knowledge of specific barriers/facilitators, for guidelines to be further developed and to direct the implementation of comprehensive cancer rehabilitation programs in future.

Thus, the purpose of this pilot study is to characterize the nature of cancer rehabilitation programs in Australia and New Zealand, using a cross-sectional online survey of rehabilitation physicians and advanced trainees, and to provide insight into the availability and use of cancer rehabilitation programs. Information gathered includes (1) type of cancer patients served; (2) core components delivered; (3) types of health-care professionals providing service; and (4) barriers and facilitators to cancer rehabilitation programs.


  Methods Top


Design

This was an exploratory descriptive study with a cross-sectional online survey design.

Settings

The online survey (using the SurveyMonkey platform) was distributed to rehabilitation physicians and advanced trainees working in various health-care services in the hospital and ambulatory care settings in Australia and New Zealand from October to December 2020. The survey was approved by the Rehabilitation Medicine Society of Australia and New Zealand Society (RMSANZ), a professional body for rehabilitation physicians and trainees in Australia and New Zealand.

Participants

Participants included registered rehabilitation professionals currently working across Australia and New Zealand who are also members of the RMSANZ. All personal details and information of all members are already registered within the RMSANZ database. No further information was sought. Completion of the survey was voluntary, with filling and returning the survey itself implying consent. The inclusion criteria included rehabilitation physicians and advanced trainees working in hospitals and ambulatory care settings that offer rehabilitation to cancer patients, which include (1) initial assessment, (2) structured exercise (supervised or unsupervised; >1 week for outpatient programs or until discharge for inpatient programs), and (3) at least one other rehabilitation intervention.

Identified rehabilitation physicians and advanced trainees through the RMSANZ database were sent an e-mail in October 2020 requesting their assistance in completing the online survey. Data were collected through SurveyMonkey. A further e-mail reminder was sent after 2 and 4 weeks to all contacts to provide a response and return the survey form.

Data collection

As no previous comprehensive survey instrument is available to obtain the required information, a cancer rehabilitation survey tool was developed by the authors based on previous cancer rehabilitation surveys[9] and other similar surveys completed on cardiac and pulmonary rehabilitation.[20],[21] The survey tool was approved by the RMSANZ. This pilot survey was designed to provide a cross-sectional assessment of types of services, components of service delivery, and rehabilitation interventions delivered across cancer rehabilitation programs from rehabilitation health professionals' perspectives.

The survey content was organized into subsections, including participant demographics, education/training, components of the program (including rehabilitation interventions provided), cancer rehabilitation providers involved, and barriers and facilitators to service provision. The survey had various close and open-ended sections which provide respondents an opportunity to supply information on their cancer rehabilitation program within their service, as well as comments/personal views regarding the gaps relevant to their service [Appendix 1].

Data analysis

All institutional and respondent identification information remained confidential. The original and identifiable data are owned by RMSANZ. De-identifiable data were used by the authors for data analyses and publication. The survey data were secured and filed in the Department of Rehabilitation Medicine at Royal Park Campus, The Royal Melbourne Hospital. Access was available only to the primary investigators. An in-house password-protected database using an Excel program was used to store all information. Specific study ID codes were used for each participant and special coding strategies were developed by the research team to analyze participants' responses. All information was re-identifiable and double entered by the primary investigators.

All ordinal and numeric data on all items in the survey were analyzed and presented descriptively. Personal comments/views were collated using the content analytical technique, coding each response using a line-by-line process.


  Results Top


A total of 60 respondents completed the survey; these included 50 rehabilitation physicians (83.3%) and 10 rehabilitation registrars (16.7%).

Participant demographics

Survey participants were mostly from two main Australian states: Victoria (55%, n = 33) and New South Wales (18.3%, n = 11) [Figure 1], with the majority aged between 30 and 40 years old (41.7%, n = 25). Most worked within rehabilitation inpatient and outpatient hospital metropolitan settings (78.6% and 58.9%, respectively).
Figure 1: State/territory/country of participants

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Qualifications and experience

All rehabilitation physicians were accredited with the rehabilitation faculty in Australia, with approximately 10% (n = 6) respondents having other concurrent qualifications (e.g., pain or palliative care diplomas, Masters of Public Health). Approximately just over half (52%) felt that their formal fellowship training prepared to meet the rehabilitation needs of cancer patients. Majority (n = 37) reported only having informal training (e.g., workshops, courses, tutorials) as part of cancer rehabilitation training, without significant formal qualifications obtained.

Cancer rehabilitation

Over two-thirds (76.7%, n=46) of respondents reported to be involved in the management of the cancer patients, with a majority (n = 20) having <5 years of experience. Of the 51 respondents, only 17.7% (n = 9) worked in a dedicated cancer rehabilitation program, with others (82.4%, n = 42) working in rehabilitation units offering streams that look after cancer patients when referred. Out of 44 respondents, their rehabilitation programs were largely public funded (50%, n = 22) (others being either private or mixed funded), with neither specific nor formal established cancer rehabilitation stream.

Type of professionals

Of the 45 respondents, the findings indicated that most often, rehabilitation physicians (77.8%, n = 35) were overall responsible for the delivery of rehabilitation programs to cancer patients, followed by allied health (20%, n = 9). Of 44 respondents, the majority of health professionals in the multidisciplinary team were physiotherapists (95.5%, n = 42), occupational therapists (95.5%, n = 42), rehabilitation physicians (88.6%, n = 39), and dieticians (86.4%, n = 38) [Figure 2].
Figure 2: Multidisciplinary team members in rehabilitation program

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Referral patterns

Of the 45 respondents, the most common streams referred to cancer rehabilitation programs were central nervous system (66.7%, n = 30), hematological (60%, n = 27), and breast cancers (55.6%, n = 25) [Figure 3].
Figure 3: Tumour streams referred

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Patients were usually referred most during posttreatment phase (88.9%, n = 40), followed by treatment phase (60%, n = 27) and diagnosis and planning phase (20%, n = 9) [Figure 4]. Referrals often originate from cancer specialists (i.e., oncologists, hematologists, and radiation oncologists) (86.7%, n = 39).
Figure 4: Phases in cancer trajectory patients most commonly referred

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Core components of cancer rehabilitation delivered

Of the 45 respondents, core components of medical management in rehabilitation programs delivered to cancer patients mostly include management of complications (deep-vein thrombosis prophylaxis, pain, sarcopenia, and malnutrition) (n = 41), lifestyle modification education/strategies (n = 41), medication management (n = 40), and referrals/collaboration (care continuity) (n = 39), followed by medical disability assessment (n = 32). The most common patient education topics included mood (e. g depression, anxiety) (n = 42), exercise (n = 41), fatigue management (n = 41), management of symptoms/side effects (n = 39), and diet/nutrition (n = 39).

Exercise prescription within the rehabilitation programs comprised mainly strengthening exercise (n = 43), mobilization (n = 41), gait training (n = 41), transfers training (n = 39), and range of movement exercises (n = 39) [Figure 5].
Figure 5: Exercise prescription/use of modalities

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Other key components include activities of daily living retraining (n = 42), optimization of nutrition (n = 38), functional restoration of upper limb (n = 37), and psychology input (n = 36) [Figure 6].
Figure 6: Other components of rehabilitation programs delivered to cancer patients

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Most services evaluated functional independence scores (n = 36) and physical activity measurements scores (n = 27), as part of patients' functional outcomes. Majority of programs (73.3%, n = 33) do not provide specialized care for patients with advanced cancer or those requiring end-of-life care including advance care planning and symptom management.

Barriers to uptake of cancer rehabilitation programs

Of the 45 respondents, the most common barriers reported to the successful implementation of cancer rehabilitation programs included inadequate funding, lack of appropriate staffing with expertise (namely allied health, nursing care with lymphedema/breast cancer skills, and psychology), lack of collaboration, coordination, and integration of rehabilitation within acute cancer care services and models. The key barriers reported by participants are summarized in [Table 1].
Table 1: Top key barriers in uptake of cancer rehabilitation programs

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Factors identified as facilitators to cancer rehabilitation programs

Better collaboration and integration of rehabilitation within acute cancer care services and specialty teams, increased enthusiasm and staff engagement with leadership skills, availability of allied health/staffing with expertise, and increased funding for resources were highlighted by participants as most helpful to facilitating cancer rehabilitation programs. Key facilitators in the uptake of cancer rehabilitation programs are summarized in [Table 2].
Table 2: Key facilitators in the uptake of cancer rehabilitation programs

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  Discussion Top


This pilot study used an online survey tool to provide insight into the current state of cancer rehabilitation programs in Australia and New Zealand. The findings showed that the majority of rehabilitation health professionals work in non-dedicated cancer rehabilitation programs in Australia and New Zealand. This study also helped characterize some of the more common tumor streams being referred to rehabilitation programs and identified that patients are usually referred most during the posttreatment phase. The core components appear to be similar to previous findings by Dennett et al.[22] including provision of education (mood, exercise, fatigue and management) and self-management strategies, with exercise prescription comprising mainly strengthening exercises, mobilization, and gait training. Barriers and facilitators to implementation of cancer rehabilitation programs were also identified that tend to limit these programs becoming part of standard practice.

Nevertheless, cancer rehabilitation is becoming an integral part of the cancer continuum of care and the development of effective programs is important to address the needs of cancer patients, who often have unmet needs due to functional loss and disability as a result of the disease and its treatment.[3],[5],[23] However, to date, most rehabilitation programs in Australia and New Zealand appear to lack comprehensive guidelines recommending rehabilitation as part of standard care. This seems to have hindered many services in securing adequate funding to establish dedicated and well-resourced cancer rehabilitation programs, with general rehabilitation programs accommodating most needs of cancer patients.

The findings of this pilot study identified gaps in formal training in cancer rehabilitation among rehabilitation health professionals and their experience in this area, with insufficient skills learned to address the needs of cancer patients. While the awareness of cancer rehabilitation among health-care professionals has increased in recent years, there are currently limited options available for physicians and trainees to receive adequate exposure to cancer rehabilitation during training to develop skills, practice, and experience. Further, there is a lack of opportunities for graduate physicians for further subspecializing in this field with cancer rehabilitation fellowships, mainly due to the limited number of cancer rehabilitation programs across Australia and New Zealand. A previous study by Sharma et al.[24] found that career mentorship usually helps rehabilitation professionals advance into this field and informal training through national professional society meetings or alternative fellowships in palliative care and pain medicine.

The perceived lack of collaboration between acute cancer services and rehabilitation, with a limited coordinated approach to the care of cancer patients and low referral rates to rehabilitation, may highlight possible contributing factors such as reduced awareness of the benefits and value of rehabilitation among oncologists, acute specialty teams, patients, and families.[25],[26] Evidence suggests discrepancies between prior training and education of medical oncologists and rehabilitation physicians,[27] with only 20% of medical oncologists having any education about rehabilitation medicine, and more rehabilitation physicians have had some education in rehabilitation-palliative care. Cross-disciplinary education regarding the expected benefits of rehabilitation would help both oncologists and specialty teams to know to understand rehabilitation physicians' role in caring for cancer patients, including those with advanced cancer stages. In addition, timely, comprehensive, and coordinated cancer rehabilitation necessitates available and accessible high-quality services being available to all patients for improved patient, provider, and organizational outcomes.

The implications of the findings of this study will optimistically increase attention to the current gaps cancer rehabilitation programs delivery and how such programs to be integrated into the health-care systems to address the complex physical, psychological, and social needs of patients with cancer. The importance of increasing awareness of the value and benefits of cancer rehabilitation among acute cancer care services, acute specialty teams, oncologists, patients, and families, as well as integrating rehabilitation within current cancer care models is needed. The need for the allocation of additional funding and services for the rehabilitation and community support of public (uninsured) patients need to be highlighted. Further, resources such as trained staff, infrastructure, access to education and training, specialized outpatient cancer rehabilitation services, and collaboration with primary care providers and consumer organizations are crucial to achieving the successful implementation of cancer rehabilitation programs.

This study has several limitations. First, response rates to online surveys were low which are generally attributable to the nature of online surveys. The survey tool was developed by the authors and yet to be validated. However, the authors are experienced rehabilitation health professionals in cancer rehabilitation care and various other currently available tools in literature were considered. Further, this is a cross-sectional study and all responses were based on participants' own views, rather than objective data. Participants represent only a small proportion of health professionals working in only key states of Australia and New Zealand; hence, this uneven geographical distribution of the respondents may have resulted in missed views from rehabilitation professionals stationed in other parts of the countries. This may limit the generalizability and validity of findings. A larger cohort of rehabilitation professionals from a wide range of geographical locations using random sampling methods would have been ideal to minimize the selection and respondent bias; however, this was beyond the authors' authority and the scope of this pilot study. Furthermore, the participants in this study represent a wide sample of rehabilitation professionals dedicated to the care of cancer patients working in different settings (public/private settings, inpatient/ambulatory/community settings). Therefore, the findings should reflect the current situation and state of cancer rehabilitation in Australia and New Zealand. The authors are unaware of any similar study conducted in these settings that address these issues.


  Conclusion Top


The findings of the pilot survey highlight the currently low uptake and implementation of cancer rehabilitation programs in Australia and New Zealand. However, with growing awareness of the value and benefits of cancer rehabilitation, multicomponent review of barriers to its uptake can be addressed including building on links with oncologists, securing increased funding and resource allocation, and tackling organization barriers. Future research will hopefully focus on a larger study to further assess our capacity to provide cancer rehabilitation programs, evaluation outcome measurement tools available, and the impact of barriers and facilitators for care quality. This is also to ensure to effectively meet the demands of our escalating cancer population and to build mechanisms for increased awareness, training, funding, infrastructure, and advocacy.

Financial support and sponsorship

The authors thank RMSANZ for their support of this study.

Conflicts of interest

There are no conflicts of interest.


  Appendix Top


Appendix 1: Survey

Cancer rehabilitation survey

This survey is about your service and provision of cancer rehabilitation program.

Taking part in this survey is voluntary. Your responses are confidential. They will be combined with the responses of others in reports.

Completing this survey

For most questions, there is a choice of answers. Pick the response/s that suit best for you.

There are areas throughout the survey for you to make comments about your program and the health care aspects that your service provides.

The survey may take 15 min to complete.

Survey – Cancer rehabilitation in Australia and New Zealand

  1. Participant Demographics




  2. Type of health professionals




  3. Referral patterns




  4. Core components delivered - Please select all relevant core component(s) if this is provided by your cancer rehabilitation program:




  5. Barriers and facilitators to provision and delivery of rehabilitation services to cancer patients




If you have any other comments, please use the following box below.



Thank you for completing the survey.



 
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American Cancer Society 2021. Cancer Facts and Figures. Available from: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf. [Last accessed on 2021 May 15].  Back to cited text no. 1
    
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Khan F, Amatya B, Ng L, Demetrios M, Zhang NY, Turner-Stokes L. Multidisciplinary rehabilitation for follow-up of women treated for breast cancer. Cochrane Database Syst Rev 2012;12:CD009553.  Back to cited text no. 11
    
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Shannon VR. Role of pulmonary rehabilitation in the management of patients with lung cancer. Curr Opin Pulm Med 2010;16:334-9.  Back to cited text no. 14
    
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Sharma R, Molinares-Mejia D, Khanna A, Maltser S, Ruppert L, Wittry S, et al. Training and practice patterns in cancer rehabilitation: A survey of physiatrists specializing in oncology care. PM R 2020;12:180-5.  Back to cited text no. 24
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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