B.S. is a 77-year-old woman with a history of breast cancer, diagnosed at age 56 when she was found to have a right upper quadrant breast mass on screening mammogram, along with axillary lymphadenopathy on physical examination. She underwent right modified radical mastectomy and complete right axillary lymph node dissection. Pathologic examination confirmed right invasive cancer with lobular tubular features, well-differentiated, with six positive lymph nodes. The tumor was estrogen receptor and progesterone receptor-positive (ER/PR+). Imaging studies revealed no metastatic disease so the patient began radiation therapy and was placed on tamoxifen. She also developed right upper extremity lymphedema and arm dysfunction as a result of the surgery.
After remaining cancer-free for nearly 16 years, she presented to her physician complaining of radiating back pain, frequent falls, and increasing debilitation in the past 6 months from persistent right arm lymphedema and dysfunction. She was noted to have an elevated alkaline phosphatase and was found to have lumbar metastasis. Imaging studies revealed no further metastatic disease except for a new lesion in the left breast measuring 13 mm. She was treated with radiation to the lower back. While undergoing radiation she was offered subacute rehabilitation but refused it at first. Once she was educated on the benefits of “short-term” rehabilitation she agreed and was admitted to a skilled nursing facility (SNF), where she received physical and occupational therapy, pain management, and psychosocial therapy. Because B.S. was depressed and lacked adequate social support, she was adamant about not wanting to undergo another operation that would further debilitate her by also reducing her left arm function. After receiving radiation therapy, psychotherapy, and rehabilitation she agreed to undergo left modified radical mastectomy and modified lymph node dissection. Following her second operation, she returned to the SNF and received an additional 2 weeks of rehabilitation before she went home.
Rehabilitation services provide a multidisciplinary approach to preventive interventions that can enhance physical and psychosocial functioning; these interventions can be directed at limitations that may result from the diagnosis or treatment of cancer. The rehabilitation team begins by assessing and treating the whole patient and gaining an understanding of the individual’s limitations and his or her disease process, along with an awareness of his or her leisure and vocational activities and desire to maintain a healthy and productive lifestyle, regardless of age or disease severity.
Rehabilitation plays an important role for the older adult patient with cancer. With the aging of the population, there will be an expansion of the number of older adults with cancer, as nearly 60% of all cancer diagnoses are made in patients 65 years old and older. As a result of older age, many of these patients already have multiple coexisting chronic conditions and functional limitations. Therefore it may be important to maximize overall quality of life and emphasize both mental and physical preparation prior to cancer treatment in the older adult. Anticipation of patient needs prior to treatment, as well as intervention with rehabilitation services during and after cancer treatment, may be particularly important in maintaining function and stable health when cancer co-occurs with other chronic health conditions.
As in the aforementioned case, patients who receive rehabilitation before and during aggressive cancer treatments have a higher likelihood of regaining premorbid functional status. Therefore rehabilitation promotes long-term health and wellness, whether as part of curative or palliative care.
Rehabilitation Needs of the Older Patient with Cancer
Treatment and technological advancements in medicine have led to prolonged survival rates in patients diagnosed with cancer. In fact, it is estimated that nearly two thirds of patients treated for a cancer will survive the initial phase. However, the sequelae of cancer treatment, whether it be surgery, hormones, chemotherapy or radiation, may lead to significant distress and hence make cancer a chronic disease. For example, B.S. developed right upper extremity lymphedema and arm dysfunction from her initial surgery nearly 20 years ago. This impairment was physically and emotionally debilitating, leading her initially to decline additional surgical intervention for her recurring cancer in the left breast.
Rehabilitation needs of the older adult with cancer vary according to the phase of the disease, with physical needs being greatest in advanced cancer. Cancer in all age groups, but particularly in older patients, is very heterogeneous in its manifestations, biology, responses to treatment, and time course. Being aware of the rehabilitation needs of the older adult with cancer as associated with disease phase, site-specific cancer, and treatment options and/or toxicities will empower the oncologic team and patient to initiate preventive interventions in a timely fashion.
Common Related Rehabilitation Issues The most common rehabilitative problem faced by an older patient with cancer is physical. The extent of dysfunction ranges from none to severe depending on the disease, time of diagnosis, and cancer severity. Ideally, all patients who receive a cancer diagnosis should have some degree of rehabilitation at some point during the course of the disease and its treatment. The key is to identify the problem and intervene early. In many cases, being proactive and getting a physical therapy consultation before the symptoms present may improve the long-term functional outcome. The goal in obtaining physical therapy is to maximize quality of life by maintaining mobility and stamina and retaining the ability to perform basic activities of daily living. Consultation with the hospital rehabilitation service before a patient’s discharge from the hospital is invaluable, and maximizes the patient’s chance of maintaining physical function and independence while at home.
The next most common rehabilitative problem in cancer patients is psychosocial issues including depression, anxiety, fear, sexual difficulties, and social and interpersonal problems. Psychosocial concerns are usually not acknowledged or understood by the older adult and are frequently missed by the treating physician. Hence they are often overlooked and may remain untreated until the later part of the disease course. A needs assessment should be done at the time of diagnosis, at the time of any recurrence, or whenever the prognosis has changed or is poor, as these are the periods when patients are most likely to develop psychosocial problems and may need professional intervention. Some patients may benefit from early consultation with a psychologist or psychiatrist. Psychosocial issues will be discussed further in a later chapter. (See Table 22-1 .)Sexual difficulties are another area of rehabilitative need in some older patients with cancer. Depression, fatigue, distorted body image, hair loss, surgical scars, and weight loss can lead to decreased sexual desire and feelings of unattractiveness. Some surgical interventions and radiation therapies may lead to impairment in sexual function. Sexual problems are commonly overlooked by physicians and are frequently not discussed by the patient because of fears and embarrassment. It may help the patient and partner cope with posttreatment difficulties with sex and intimacy if the physician inquires about and discusses these issues with them. This may be particularly important for cancers that involve the pelvic organs, such as prostate cancer, rectal cancer, bladder cancer, and cervical cancer, especially when both surgery and radiation are used, and when stomas may be required. Sex therapy is warranted for some patients to help them recover.
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A fourth area of rehabilitative need is diet and nutrition. Older adults with cancer are at very high risk for developing malnutrition, often because many of them also have comorbidities in addition to their cancer. Patients who have excessive weight loss due to early satiety and anorexia may derive benefit from a nutrition consultation to identify problems with the current dietary pattern and aid with a supplemental plan. A speech therapy consultation may be beneficial for patients with dysphagia or difficulties swallowing. Some patients may need an appetite stimulant such as megestrol acetate, which has been shown to have some benefit in preventing cachexia. However, megestrol acetate also has many adverse effects and is contraindicated in many older patients. Mirtazepine is an antidepressant that has been used successfully as an appetite stimulant and which has a lower side effect profile. This drug may benefit a depressed patient with anorexia who is also struggling with insomnia. Patients who become very malnourished, especially those requiring prolonged periods of radiation and/or chemotherapy, may benefit from a short period of intravenous hyperalimentation or gastrostomy tube placement for supplemental nutrition.
Obesity and lack of physical activity may be a problem for some cancer patients. Weight gain after cancer and/or obesity puts patients at higher risk for recurrence of breast, colon, and prostate cancers. Maintaining physical activity and a prudent diet can be an important focus for rehabilitation.
Cancer-Specific Rehabilitation Issues
Breast CancerAs with the patient described at the beginning of the chapter, many women suffer both physically and emotionally from the diagnosis and treatment of breast cancer. Breast cancer is the most common cancer in women in the United States. Surgical treatments for breast cancer have evolved over the past 30 years, so that modified radical mastectomies are done less frequently (about 35% of cases), and most women receive a segmental mastectomy with whole breast irradiation. Removal of the axillary lymph nodes and radiation to the axilla can lead to complications of arm swelling and difficulties with range of motion. Fortunately, these procedures are being done less frequently; the current strategy is biopsy of a “sentinel node” to determine whether the breast tumor has spread outside the breast. When this does not show spread, surgery to the axilla can be avoided. Nevertheless, there are many older women who have had mastectomies at an earlier time and who may experience problems with arm swelling and function. The most common problems that occur with the surgical treatment of breast cancer are upper extremity edema, limited mobility, pain, tingling, numbness and weakness, fatigue, difficulty lifting, and trouble following through with housework. For B.S., this significantly affected her quality of life and she nearly refused surgical intervention when her breast cancer recurred in the other breast. She underwent occupational therapy including an exercise program, elevation, and a supportive sleeve, which collectively improved her right arm function and decreased the edematous swelling. During this period, she also received psychotherapy, was started on an antidepressant, learned about the new conservative surgical options and therefore agreed to have surgery to remove the left breast cancer.
Surgical reconstruction of the breast should be offered to all women who undergo mastectomy. However, surgical reconstruction poses its own risks for the older adult and many patients either choose not to undergo this intervention or are not considered candidates for surgical reconstruction.
Other rehabilitative problems that occur with breast cancer are, as mentioned earlier, sexual and body image problems. This may be worse in patients who undergo concomitant radiation and chemotherapy, as these treatments may lead to decreased sexual desire and impaired vaginal lubrication. Sexual problems that continue or become psychologically debilitating should be addressed in sexual therapy with a qualified psychotherapist, to include the patient and her partner.
Prostate Cancer
Prostate cancer treatment can range from radical prostatectomy to pelvic irradiation or watchful waiting. Any or all of these can lead to sexual, urinary, and/or bowel dysfunction. Focus on quality of life during rehabilitation is important because patients with this disease may survive many years after their diagnosis.Sexual impairment such as erectile dysfunction or impotence occurs in the early stages of prostate cancer and is frequently caused by surgery such as radical prostatectomy or from body image distortion due to castration and/or pelvic irradiation. It remains controversial whether nerve-sparing surgeries
C.W. is a 76-year old man with a 10-year history of prostate cancer. At the time of diagnosis, his serum prostate-specific antigen level was 4.9 ng/mL and the tumor’s Gleason score was 4+3. He was treated with external beam radiation therapy. He tolerated this therapy reasonably well except for some prominent urinary frequency and sexual dysfunction. This was emotionally distressing and he and his wife sought sexual therapy. His quality of life improved as a result and his PSA level dropped to 2.0 ng/mL (this suggests that the treatment did not eradicate his disease). However, his PSA level began to rise again, reaching 8.8 ng/mL about 3 years after treatment. A bone scan showed evidence of metastasis to a right seventh rib. He was placed on androgen deprivation therapy with a gonadotropin-releasing hormone analog and his PSA rapidly dropped to 3.0. He complained of worsening fatigue, urinary retention, and mid-to-lower back and right hip pain.
About 2 years later he had a third recurrence and received a series of endocrine therapies that eventually stabilized his PSA in the range of 3 ng/mL. However, he suffered a stroke with a left-sided hemiparesis about 2 years after the third recurrence and was hospitalized. As he recovered, he complained of fatigue, weakness, and depression. He was transferred to a skilled nursing facility where he underwent physical and occupational therapy and psychiatric evaluation and treatment. His prostate cancer symptoms of back and hip pain, urinary retention, and fatigue continued and his PSA rose to 9.1 ng/mL, so he was started on chemotherapy. However, after the first cycle of docetaxel chemotherapy he suffered considerable toxicity including diarrhea, stomatitis, and severe fatigue. It was at this time that he advised his oncologist that he did not wish to continue chemotherapy as it was impairing his quality of life. He agreed to undergo another course of rehabilitation before returning home to his family.
The patient in Case 22-2 suffered from urinary incontinence; however, bowel incontinence is also a very common problem following radical prostatectomies or pelvic irradiation, while urinary retention is common when watchful waiting is practiced. Bladder and bowel training programs can be helpful in coping with these impairments. Pain control, through use of sustained-release narcotic analgesics, nonsteroidal anti-inflammatory agents, and palliative radiation therapy, should be a focus in patients with advanced disease. Maintaining physical function through pain control can prolong independence and improve quality of life.
Colorectal Cancer
The rehabilitative needs of patients who undergo treatment for colon cancer often relate to bowel changes and, in the case of advanced disease, obstructing lesions. For patients with a stoma, consultation with an enterostomal therapist is critical for education and for the management of the ostomy. Unfortunately, because of the urgency of this patient’s need for surgery, he did not
F. H. is a 74-year-old man with end-stage colorectal cancer who was admitted to the hospital for nausea, vomiting, and abdominal pain. He was found to have colonic obstruction from a 5 cm cecal mass and two other lesions in the distal transverse and sigmoid colon. Review of systems revealed poorly controlled low back pain that began 3 months ago; poor sleep, which he attributed to pain; and several months of impaired concentration and anorexia, with a 40-pound weight loss.
F.H. underwent complete cecal excision and colectomy with subsequent right-sided colostomy. His hospitalization was complicated by prolonged intubation because of respiratory failure and hospital-acquired pneumonia, Clostridium difficile colitis, and deep vein thrombosis in the left leg. Anticoagulation had to be discontinued because of retroperitoneal bleeding; an inferior vena cava filter was placed. He was eventually extubated, but required placement of a gastrostomy tube because of severe dysphagia. Because of his debilitated state, he was deemed a poor candidate for chemotherapy; he was thus transferred to a skilled nursing facility for occupational and physical therapy.
The patient’s SNF course was marked by frustration that resulted from persistent pain and alternating constipation and diarrhea. Both palliative care and psychiatric services were consulted to help manage his pain and to evaluate his cognitive difficulties. His back pain was caused by a metastatic lesion at L3 and was treated with escalating doses of controlled-release oxycodone and as-needed doses of short-acting oxycodone. His psychiatric history was unremarkable. On mental status examination, F.H. was awake and amiable, but uncomfortable. He denied feeling depressed or guilty. However, he said that he was embarrassed by having colostomy and would no longer enjoy his hobbies or spending time with family or friends.
As his SNF stay progressed, he appeared more withdrawn, had no interest in learning ostomy care, refused therapy, and became less hopeful that his pain, his difficulty maintaining attention, and his bowel problems would resolve. He was started on an antidepressant and psychotherapy and eventually began cooperating with physical and occupational therapy, became receptive to ostomy education, and experienced a reduction in pain to a tolerable level.
Some patients also experience sexual dysfunction due to bodily distortion and function of elimination; erectile dysfunction is not uncommon in men who undergo invasive abdominorectal surgery. A patient’s partner may have some difficulties adjusting to the bodily changes; this may lead to discord, feelings of lack of support, and sexual impairment. Some patients and their partners may benefit from sexual therapy.
Rectal dysfunction including constipation, diarrhea, and incontinence frequently occurs in patients who undergo excision of localized bowel tumors, hemicolectomies, or irradiation therapy. These may be improved by bowel training programs and, in seriously debilitating cases, a referral to a proctologist or gastroenterologist may be warranted.
Lung Cancer
Lung cancer is the single most common cause of cancer mortality in the United States today. This is especially true in the older adult population. The lung cancer survival rate is low, perhaps because the disease is usually at an advanced stage when diagnosed, as was true for the aforementioned patient. The significant toxicities of both chemotherapy and radiation therapy may also contribute to morbidity and mortality.
L.D. is a 71-year-old woman, formerly a heavy smoker, who was hospitalized after a 2-month history of worsening dyspnea, anorexia, and an unintended weight loss of 40 pounds. A chest x-ray revealed a left hilar mass, and ultrasound of the abdomen showed liver lesions indicating metastatic disease. Bronchoscopy was diagnostic for small cell lung cancer. She received a protocol of combination chemotherapy on a 4-week schedule. Subsequently, she suffered significant side effects of worsening anorexia, nausea, vomiting, and extreme fatigue. She spent all of her waking time in bed. She was thus referred for outpatient rehabilitation and received 1 hour of physical therapy three times per week.
At 3-month follow-up, she was found to be in complete remission. However, she presented 5 months later with worsening low back pain, dyspnea, and new-onset seizure disorder. Second-line chemotherapy and steroid therapy were initiated. She suffered significant toxicities from the chemotherapy without much clinical improvement. She became severely debilitated and developed cognitive impairment as a result of the brain metastasis. According to the patient’s wishes, terminal supportive care was provided under the direction of her son who represented her interests with a durable power of attorney for health care.
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