Implementing a Clinical Pathway for Needs Assessment and Supportive Care Interventions.

Despite advances in clinical cancer care, cancer survivors frequently report a range of persisting issues, unmet needs, and concerns that limit their ability to participate in life roles and reduce quality of life. Needs assessment is recognized as an important component of cancer care delivery, ideally beginning during active treatment to connect patients with supportive services that address these issues in a timely manner. Despite the recognized importance of this process, many health care systems have struggled to implement a feasible and sustainable needs assessment and management system. This article uses an implementation science framework to guide pragmatic implementation of a needs assessment clinical system in cancer care. According to this framework, successful implementation requires four steps including (1) choosing a needs assessment tool; (2) carefully considering the provider level, clinic level, and health care system-level strengths and barriers to implementation and creating a pilot system that addresses these factors; (3) making the assessment system actionable by matching needs with clinical workflow; and (4) demonstrating the value of the system to support sustainability.

Gaps in Access to Medically Necessary Dental Care for Patients Living With and Beyond Cancer: We Must Do Better.

Delivery of high-quality, evidence-based oral care for those living with and beyond cancer needed!

Unmet Needs and Care Delivery Gaps Among Rural Cancer Survivors.

Community-based healthcare delivery systems frequently lack cancer-specific survivorship support services. This leads to a burden of unmet needs that is magnified in rural areas. Using sequential mixed methods we assessed unmet needs among rural cancer survivors diagnosed between 2015 and 2021. The Supportive Care Needs Survey (SCNS) assessed 5 domains; Physical and Daily Living, Psychological, Support and Supportive Services, Sexual, and Health Information. Needs were analyzed across domains by cancer type. Survey respondents were recruited for qualitative interviews to identify care gaps. Three hundred and sixty two surveys were analyzed. Participants were 85% White (n = 349) 65% (n = 234) female and averaged 2.03 years beyond cancer diagnosis. Nearly half (49.5%) of respondents reported unmet needs, predominantly in physical, psychological, and health information domains. Needs differed by stage of disease. Eleven interviews identified care gap themes regarding; Finding Support and Supportive Services and Health Information regarding Care Delivery and Continuity of Care. Patients experience persistent unmet needs after a cancer diagnosis across multiple functional domains. Access to community-based support services and health information is lacking. Community based resources are needed to improve access to care for long-term cancer survivors.

Implementing process improvements to enhance distress screening and management.

INTRODUCTION: While distress is prevalent among individuals living with cancer, distress management has not been optimized across cancer care delivery despite standards for screening. This manuscript describes the development of an enhanced Distress Thermometer (eDT) and shares the process for deploying the (eDT) across a cancer institute by highlighting improvements at the provider, system, and clinic levels. METHODS: Focus groups and surveys were used at the provider-level to outline the problem space and to identify solutions to improve distress screening and management. Through stakeholder engagement, an eDT was developed and rolled out across the cancer institute. Technical EHR infrastructure changes were implemented at the system-level to improve the use of the distress screening findings and generate automated referrals for specialty services. Clinic workflows were adapted to improve screening and distress management using the eDT. RESULTS: Stakeholder focus group participants (n=17) and survey respondents (n=13) found the eDT to be feasible and acceptable for distress identification and management. System-level technical EHR changes resulted in high accuracy with patient identification for distress management, and 100% of patients with moderate to severe distress were connected directly to an appropriate specialty provider. Clinic-level workflow changes to expand eDT use improved compliance rates with distress screening from 85% to 96% over a 1-year period. CONCLUSIONS: An eDT that provides more context to patient-reported problems improved identification of referral pathways for patients experiencing moderate to high distress during cancer treatment. Combining process improvement interventions across multiple levels in the cancer care delivery system enhanced the success of this project. These processes and tools could support improved distress screening and management across cancer care delivery settings.

Implementation of a Cancer Rehabilitation Navigation Program: a qualitative analysis of implementation determinants and strategies.

BACKGROUND: Cancer rehabilitation navigation (CRNav) is a care delivery model that expedites identification and management of symptom-related functional morbidity for individuals undergoing cancer treatment. A CRNav program is unique in that it embeds a cancer rehabilitation professional in the cancer center for patient screening and assessment. The implementation of CRNav programs has not been studied and doing so could facilitate greater uptake of these programs. METHODS: Using implementation science frameworks, we conducted a qualitative, post-implementation analysis of a CRNav program that was implemented in 2019. Semi-structured, 1:1 interviews were guided by the Consolidated Framework for Implementation Research (CFIR) and a combination of deductive and inductive analyses, using a priori established codes, was used to assess the implementation context, and identify emergent themes of barriers and facilitators to implementation. Participant described implementation strategies were characterized and defined using the Expert Consensus Recommendations for Implementing Change (ERIC) taxonomy. RESULTS: Eleven stakeholders including physicians, administrators, clinical staff, and patients, involved with program development and the implementation effort, participated in interviews. Predominant barriers to implementation included developing the program infrastructure, and lack of awareness of rehabilitation services among oncology professionals, predominant facilitators of implementation included; physical co-location of the navigator in the cancer center, individual characteristics of the navigator, and unique characteristics of the program. Strategies described that supported implementation included developing stakeholder interrelationships, evaluating and iteratively adapting the program, creating infrastructure, training and education, and supporting clinicians. CONCLUSION: This analysis uses implementation science to methodically analyze and characterize factors that may contribute to successful implementation of a CRNav program. These findings could be used alongside a prospective context-specific analysis to tailor future implementation efforts. IMPLICATIONS FOR CANCER SURVIVORS: Implementing a CRNav program expedites a patient's direct contact with a rehabilitation provider complementing the cancer care delivery team, and providing an additive and often missing service.

Addressing Social Determinants of Health to Reduce Disparities Among Individuals with Cancer: Insights for Rehabilitation Professionals.

PURPOSE OF REVIEW: This report aims to provide a framework for cancer rehabilitation professionals to assess social determinants of health in individuals with cancer and discuss strategies that can be implemented in practice to overcome barriers to care. RECENT FINDINGS: There has been an increased focus in improving patient conditions that can affect access to cancer rehabilitation. Along with government and world health organization initiatives, healthcare professionals and institutions continue to work towards decreasing disparities. Several disparities exist in healthcare and education access and quality, patients' social and community context, neighborhood and built environments, and economic stability. The authors emphasized the challenges that patients who require cancer rehabilitation face that healthcare providers, institutions, and governments can mitigate with outlined strategies. Education and collaboration are essential to make true progress in decreasing disparities in the populations most in need.

Implementing and sustaining a breast cancer prospective surveillance rehabilitation program: an institutional perspective.

BACKGROUND: The prospective surveillance model (PSM) is an evidence-based rehabilitation care delivery model that facilitates functional screening and intervention for individuals undergoing cancer treatment. While PSM is empirically validated and feasible in practice, implementation into cancer care delivery has languished. The purpose of this manuscript is to characterize the barriers and facilitators to implementing PSM in a breast cancer center and to share policy and process outcomes that have sustained the model in practice. METHODS: The PSM implementation was undertaken as a quality improvement initiative of our cancer center. We retrospectively assessed barriers to implementation and define those according to the Consolidated Framework for Implementation Research (CFIR). Implementation strategies are defined based on the Expert Recommendations for Implementation Change (ERIC) taxonomy. Breast center policy changes and stakeholder-reported process improvement outcomes at the clinic and system level are described. RESULTS: PSM implementation facilitation was driven primarily by adapting the model to align with the cancer center workflow, engaging interdisciplinary stakeholders as program champions, enhancing knowledge and awareness among cancer care providers, and changing infrastructure to support the model. System and clinic-level policy and process changes included the development of clinical pathways, EHR order sets and automated referrals, new staffing models, and adapted clinical workflows. CONCLUSION: Our report provides insight on implementing the PSM at a single institution in a cancer care delivery setting. Successful implementation strategies addressed individual, clinic, and system-level barriers and facilitated process and policy changes that have enabled PSM sustainment. Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity. IMPLICATIONS FOR CANCER SURVIVORS: Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity.

The critical need to implement and utilize patient-reported measures of function in cancer care delivery.

The study by Smith et al. on the Patient-Reported Outcomes Measurement Information System (PROMIS) Cancer Function Brief 3D Profile shows that it can be used to measure how an individual functions and how his or her function changes during cancer treatments. This is important because most patients will experience a decline in function during cancer treatment and will struggle to fully participate in their life roles. Strong evidence demonstrates that rehabilitation improves function for individuals with cancer; rehabilitation is relatively underutilized. We suggest that using the PROMIS tool as a repeated measure throughout cancer treatment will help to identify those with functional decline who will benefit most from rehabilitation.

Effects of Multimodal Inpatient Rehabilitation vs Conventional Pulmonary Rehabilitation on Physical Recovery After Esophageal Cancer Surgery.

OBJECTIVE: To determine the effects of multimodal rehabilitation initiated immediately after esophageal cancer surgery on physical recovery compared with conventional pulmonary rehabilitation. DESIGN: Retrospective study. SETTING: Private quaternary care hospital. PARTICIPANTS: Fifty-nine inpatients (N=59) who participated in either conventional pulmonary rehabilitation (n=30) or in multimodal rehabilitation (n=29) after esophageal cancer surgery were included. INTERVENTIONS: Both groups performed pulmonary exercises, including deep breathing, chest expansion, inspiratory muscle training, coughing, and manual vibration. In the conventional pulmonary rehabilitation group, light-intensity mat exercise, stretching, and walking were performed. The multimodal rehabilitation group performed resistance exercises and moderate- to high-intensity aerobic interval exercises using a bicycle. MAIN OUTCOME MEASURES: The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 (EORTC QLQ-C30), pain, 6-minute walk test (6MWT), 30-second chair stand test, and grip strengths were assessed before and after the rehabilitation programs. RESULTS: Symptom scales of pain, dyspnea, and insomnia in the EORTC QLQ-C30 as well as 6MWT improved significantly after each program (P<.05). 6MWT (73.1±52.6 vs 28.4±14.3, P<.001, d=1.15), 30-second chair stand test (3.5±3.9 vs 0.35±2.0, P<.001, d=1.06), and left grip strength (1.2±1.3 vs 0.0±1.5, P=.002, d=0.42) improved significantly in the multimodal rehabilitation group compared with the pulmonary rehabilitation group. While right grip strength also showed more improvement for those undergoing the multimodal program, the mean strength difference was not clinically meaningful. CONCLUSIONS: A multimodal inpatient rehabilitation program instituted early after esophageal cancer surgery improved endurance for walking more than conventional pulmonary rehabilitation as measured by the 6MWT and the 30-second chair stand test.

Program Barriers and Facilitators in Virtual Cancer Exercise Implementation: A Qualitative Analysis.

Introduction/Purpose: Due to the coronavirus disease 2019 (COVID-19) pandemic, many in-person cancer exercise and rehabilitation programs necessarily transitioned to virtual formats to meet the needs of individuals living with and beyond cancer. The purpose of this study was to qualitatively assess program-level facilitators and barriers to virtual exercise program implementation and to identify preferred strategies to overcome implementation barriers. Methods: US-based virtual cancer exercise and rehabilitation programs were recruited from professional networks via an emailed screening questionnaire. Eligible programs identified a point of contact for a 1:1 semi-structured interview to discuss program-level barriers and facilitators to implementing virtual exercise programs. Interview transcript analysis was conducted via inductive coding techniques using NVivo software. Barriers were categorized according to the Consolidated Framework for Implementation Research and a prioritized list of strategies to support implementation was created by mapping barriers to a list of Expert Recommendations for Implementing Change. Results: Of the 41 unique responses received, 24 program representatives completed semi-structured interviews. Interviewees represented individual programs, community-based programs, and hospital-based cancer exercise/rehabilitation programs. Analysis showed high correlation between facilitators and barriers by program type, with both program- and individual-level strategies used to implement exercise programs virtually. Strategies that ranked highest to support implementation include promoting program adaptability, building a coalition of stakeholders and identifying program champions, developing an implementation blueprint, altering organizational incentives and allowances, providing education across stakeholder groups, and accessing funding. Conclusions: Learning from the transition of cancer exercise and rehabilitation programs to virtual formats due to the COVID-19 pandemic, we identify program-level barriers and facilitators encountered in the implementation of virtual programs and highlight implementation strategies that are most relevant to overcome common barriers. We present a roadmap for programs to use these strategies for future work in virtual exercise and rehabilitation program implementation.

Prehabilitation is the Gateway to Better Functional Outcomes for Individuals with Cancer.

Prehabilitation is a clinical model that introduces components of rehabilitation to patients prior to undergoing intensive medical interventions, such as surgery, in order to optimize function and improve tolerability to the intervention. Cancer care introduces a continuum of sequential or concurrent intensive anti-neoplastic medical interventions that are known to be detrimental to a patient's function. Prehabilitation evidence has grown across several areas of oncology care delivery demonstrating that a multi-modal rehabilitative intervention, delivered prior to oncology-direct therapies, leads to better functional outcomes and improves important endpoints associated with surgery and cancer treatment. This commentary article provides a brief history of the emergence of prehabilitation in cancer care delivery, reviews the current evidence base and guidelines for prehabilitation, and offers insights for future implementation of this model as a standard in oncology care. A prehabilitation program is an optimal starting point for most patients undergoing anti-neoplastic therapy as it serves as a gateway to improving functional outcomes throughout the cancer continuum. Future research in prehabilitation should aim to reach beyond measuring functional outcomes and to explore the impact of this model on important disease treatment endpoints such as tumor response to oncology-directed treatment, impact on treatment-related toxicities, and disease progression.

Moving through cancer: Setting the agenda to make exercise standard in oncology practice.

LAY SUMMARY: International evidence-based guidelines support the prescription of exercise for all individuals living with and beyond cancer. This article describes the agenda of the newly formed Moving Through Cancer initiative, which has a primary objective of making exercise standard practice in oncology by 2029.

A systematic review of rehabilitation and exercise recommendations in oncology guidelines.

Guidelines promote high quality cancer care. Rehabilitation recommendations in oncology guidelines have not been characterized and may provide insight to improve integration of rehabilitation into oncology care. This report was developed as a part of the World Health Organization (WHO) Rehabilitation 2030 initiative to identify rehabilitation-specific recommendations in guidelines for oncology care. A systematic review of guidelines was conducted. Only guidelines published in English, for adults with cancer, providing recommendations for rehabilitation referral and assessment or interventions between 2009 and 2019 were included. 13840 articles were identified. After duplicates and applied filters, 4897 articles were screened. 69 guidelines were identified with rehabilitation-specific recommendations. Thirty-seven of the 69 guidelines endorsed referral to rehabilitation services but provided no specific recommendations regarding assessment or interventions. Thirty-two of the 69 guidelines met the full inclusion criteria and were assessed using the AGREE II tool. Twenty-one of these guidelines achieved an AGREE II quality score of ≥ 45 and were fully extracted. Guidelines exclusive to pharmacologic interventions and complementary and alternative interventions were excluded. Findings identify guidelines that recommend rehabilitation services across many cancer types and for various consequences of cancer treatment signifying that rehabilitation is a recognized component of oncology care. However, these findings are at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked. Considering that functional morbidity negatively affects a majority of cancer survivors, improving guideline concordant rehabilitative care could have substantial impact on function and quality of life among cancer survivors.

Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management.

Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.

Clinically Integrated Physical Therapist Practice in Cancer Care: A New Comprehensive Approach.

Best practice recommendations in cancer care increasingly call for integrated rehabilitation services to address physical impairments and disability. These recommendations have languished primarily due to a lack of pragmatic, generalizable intervention models. This perspective paper proposes a clinically integrated physical therapist (CI-PT) model that enables flexible and scalable services for screening, triage, and intervention addressing functional mobility. The model is based on (1) a CI-PT embedded in cancer care provider clinics, and (2) rehabilitation across the care continuum determined by the patient's level of functional mobility. The CI-PT model includes regular screening of functional mobility in provider clinics via a patient-reported mobility measure-the Activity Measure for Post-Acute Care, a brief physical therapy evaluation tailored to the specific functional needs of the individual-and a tailored, skilled physical therapist intervention based on functional level. The CI-PT model provides a pragmatic, barrier-free, patient-centric, data-driven approach to integrating rehabilitation as part of standard care for survivors of cancer. The model standardizes CI-PT practice and may be sufficiently agile to provide targeted interventions in widely varying cancer settings and populations. Therefore, it may be ideal for wide implementation among outpatient oncological settings. Implementation of this model requires a shared approach to care that includes physical therapists, rehabilitation administrators, cancer care providers, and cancer center administrators.