The Lynx Group

Cancer Prehabilitation May Reduce Healthcare Costs and Improve Outcomes

October 2013, Vol 4, No 8
Julie K. Silver, MD
Associate Professor and Associate Chair for Strategic Initiatives
Department of Physical Medicine and Rehabilitation
Harvard Medical School
Boston, MA

Prehabilitation (or “prehab”) has a long history as an important part of the rehabilitation care continuum. For example, patients who are electing to have a total hip or knee arthroplasty may have preoperative assessments and interventions that are sometimes grouped together and called “joint camp.” Prehabilitation has also been gaining traction in the oncology community, because of the potential it may have to improve cancer care. In general, prehabilitation is used in anticipation of an upcoming stressor to improve outcomes; it typically should not delay the start of cancer treatment but rather use the available time between diagnosis and surgery or other therapies. There is no doubt that the time between a cancer diagnosis and the start of treatment may offer a unique opportunity to assist newly diagnosed patients to become more physically and emotionally ready for whatever comes next.

What Is Cancer Prehabilitation?
In a recent article on cancer rehabilitation, my colleagues and I defined prehabilitation as “a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments.”1

Although prehabilitation has been around for more than half a century, cancer prehabilitation is in its infancy. I recently wrote with my colleague Jennifer Baima, MD, the first ever review on this topic, titled “Cancer Prehabilitation: An Opportunity to Decrease Treatment-Related Morbid­ity, Increase Cancer Treatment Op­tions, and Improve Physical and Psychological Health Outcomes.”2 We included a list of the many articles we identified in PubMed related to this topic. This list shows that prehabilitation interventions are not always identified as such in the scientific literature. A sampling of the terms we found includes “cancer prehab” (2 articles), “preoperative cancer exercise” (257 articles), “preoperative cancer rehabilitation” (570 articles), and “preoperative rehabilitation” (4502 articles).

Cancer Prehabilitation
The scientific literature regarding prehabilitation interventions can be confusing. Understanding this concept in clinical practice is equally challenging. I work with hospitals throughout the United States and have come to realize that some form of prehabilitation is offered at many, probably most, institutions that deliver oncology services. Practices include preoperative or other pretreatment assessments and interventions that may not necessarily be well coordinated or involve a scientific approach to improving outcomes. For example, one nurse told me that at her hospital, the nurses teach patients “mind-body strategies” to help them relax before starting chemotherapy. When asked if they had any type of protocol, or if the nurses had any special training, she said, “No, we just knew we had to do more to help our patients.”

Another example is prostate cancer. Numerous studies have shown that teaching men to do pelvic floor exercises before prostate cancer surgery may improve their urinary continence outcomes. It is therefore reasonable to offer preoperative instruction on pelvic floor strengthening exercises to all men who will undergo such surgery. However, after dozens of conversations with physicians who treat prostate cancer regarding what protocols they are using in newly diagnosed men, I have found that this approach is utilized inconsistently.

As we learn more about cancer prehabilitation, the goal is to shift away from fragmented pretreatment assessments and interventions and toward a more thoughtful and scientifically based approach using coordinated prehabilitation that is designed to improve outcomes.

Is Cancer Prehabilitation Covered Care?
There are many barriers to effective prehabilitation care, including third-party payer coverage. However, some prehabilitation is covered and should be appropriately utilized. The following 3 examples, in which prehabilitation assessments and/or interventions may be covered by health insurers, including Medicare, highlight opportunities to provide reimbursable care.

1. Smoking Cessation
Smoking-cessation counseling is typically a covered service and is often considered an important modifiable lifestyle behavior that can impact many health issues. In the context of a patient with newly diagnosed cancer who undergoes smoking cessation as a part of a prehabilitation protocol, the relatively immediate goal is to reduce potential morbidity related to cancer treatments. The obvious population to target is patients with lung cancer who will be undergoing surgical resection and are active smokers. But based on the evidence, other at-risk populations may also benefit from a prehabilitation protocol that includes smoking cessation. For instance, women who are electing to have breast reconstruction tend to have worse cosmetic outcomes if they are current smokers. Not surprising, many plastic surgeons recommend discontinuing smoking before breast reconstruction, even if the surgery will be performed soon.

2. Physical/Occupational Therapy
Physical or occupational therapy would typically be covered before upcoming oncology treatments in patients with head and neck cancer who are screened and are found to have limitations and/or pain with cervical range of motion. This population is at risk for further loss of cervical range of motion that results in significant disability, such as an inability to safely see oncoming traffic while driving.

Similarly, physical or occupational therapy would usually be covered for patients with breast cancer who are screened and are found to have preexisting musculoskeletal issues that involve the shoulder, neck, or chest. These preexisting problems can interfere with the delivery of upcoming cancer treatments and/or be exacerbated by cancer interventions, leading to significant disability. For instance, a shoulder problem, such as rotator cuff impingement syndrome, in a woman newly diagnosed with breast cancer may cause problems during radiation therapy when trying to position her arm. Even if she has no positioning problems initially, a mild rotator cuff impingement syndrome may progress to a more severe and disabling condition, such as adhesive capsulitis (or “frozen shoulder”), if it is not identified and addressed before starting cancer treatments

Figure
 Opportunities for Dual Screening at Pivotal Medical Visits.
View larger version

3. Psychosocial Assessment
Psychosocial assessments and/or interventions may be covered. The period between diagnosis and the beginning of cancer treatments is an opportune time to do an initial distress screening and consider whether prehabilitation interventions may improve a patient’s psychological health outcomes. Moreover, because a leading cause of distress in cancer survivors is physical disability, it is ideal to perform dual screening for physical and psychological problems during the prehabilitation period (Figure).

Conclusion
Many other examples of prehabilitation assessments and interventions may be covered now or will be in the future. Interest in cancer prehabilitation from clinicians and researchers will undoubtedly drive changes in the delivery of oncology care and reimbursement for the services. Cancer prehabilitation may also have an impact on the market share for various oncology practices. For example, theoretically it makes sense that a newly diagnosed patient who is scared and anxious would respond very favorably to a high-quality cancer prehabilitation program designed to prepare him or her for upcoming treatments. Would this favorable response decrease the likelihood of seeking care elsewhere (eg, decreasing outmigration)? It is too soon to tell, but clearly prehabilitation is something that every oncologist should be paying close attention to now and in the future.

References

  1. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. 2013;63:295-317.
  2. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil. 2013;92:715-727.

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