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Surviving and Thriving Post Head and Neck Cancer (HNC)

 

L-R: Dr. Sara McEwen, Colleen Dunphy, Dr. Jolie Ringash

by Colleen Dunphy, BScPT, MSc; Sara McEwen,BSc(PT), MSc, PhD; and Jolie Ringash, MD, FRCPC, MSc

 

Cancer rehabilitation is slowly gaining recognition as a prominent field in cancer survivorship. The needs of cancer patients do not stop when the cancer is gone.

 

Certain cancers can result in high healthcare usage amongst survivors. Though head and neck cancers (HNCs) make up only about 3% of all cancer types, damage from the disease itself and its treatment can leave survivors with significant impairments ranging from trouble speaking and swallowing, to changes in appearance and memory or thinking.  A team based at Princess Margaret Cancer Centre (PM) and the Sunnybrook Research Institute (SRI) have been working to bring these issues to the forefront, and close the gap between finishing treatment for head and neck cancer and getting back to doing important activities.

 

In 2014, Co-principal investigators Dr. Jolie Ringash (PM) and Dr. Sara McEwen (SRI) received a two year Canadian Cancer Society Research Institute Innovation grant to develop an efficient way to integrate evaluation of rehabilitation needs into routine cancer care for HNC survivors.   In the first phase of this study, a group of patients, family members and providers from both facilities helped to create a rehabilitation consultation, in which survivors met with a rehabilitation professional to discuss their rehabilitation needs, create personal goals, and jointly develop an action plan to achieve these goals. The approach was trialled with a small group of patients first, before being revised and piloted with 35 patients from the Wharton Head and Neck Cancer Centre at the PM. This study is in the final phase of data collection, but has already produced a number of materials that may be helpful to patients, family members, and clinicians working with HNC survivors.

 

So far, one of the most significant achievements of the study has been the creation of the Head and Neck Cancer Rehabilitation Resources website, www.hncrehab.ca. This site was created with funding from the CCSRI Innovation grant as a tool for direct use during the rehabilitation consult, but is an openly available source of HNC rehabilitation resources for all survivors and rehabilitation providers whether or not they were involved in the pilot project. The site features reading material, research articles, videos, and links to other sites that deal with HNC rehabilitation. The main features of the site are a Survivor Resources information section, a section for Health Professionals, and a “Find a Program or Therapist” option. Though these resources were compiled primarily for HNC patients living in Southern/South Western Ontario, much of the information is relevant to those residing elsewhere, and even those with other types of cancer. For example, Survivor Resources includes information on cancer-related fatigue, general exercise, and changes in mood that can occur with any type of cancer. Other sections on speech and voice, body image, and swallowing are more specific to the needs of HNC survivors. We invite you to visit the site and feel free to download materials or use the “Contact The Authors” link if you have other resources to suggest including.

 

More information on the Rehabilitation Consultation study can be found on the site, or in the following publications:

McEwen SE, Davis AM, Jones JM, Martino R, Poon I, Rodriguez AM, Ringash J. Development and preliminary evaluation of rehabilitation consult for 1 survivors of head and neck cancer: An intervention mapping protocol. Implementation Science (2015) 10:6 DOI: 10.1186/s13012-014-0191-z

McEwen S, Rodriguez AM, Martino R, Poon I, Dunphy C, Rios JN, Ringash J. I didn’t actually know there was such a thing as rehab: survivor, family, and clinician perceptions of rehabilitation following treatment for head and neck cancer. Support Care Cancer (2016) 24:1449–1453. DOI 10.1007/s00520-015-3021-1

 


 

Colleen Dunphy is a physiotherapist with almost 10 years’ experience treating patients with cancer. She obtained her Physiotherapy degree from Dalhousie University in 2006 and just completed an MSc with a concentration in Quality Improvement and Patient Safety at the University of Toronto. She sits on the executive of the Oncology Division of the Canadian Physiotherapy Association and holds a status-only appointment with the University of Toronto where she lectures on palliative care in the Department of Physical Therapy.

 

Dr. Sara McEwen is a scientist at the Sunnybrook Research Institute, St. John’s Rehab Research Program. She also holds appointments as Assistant Professor in the Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto. She obtained her B.Sc. in Physical Therapy and M.Sc. in Rehabilitation Science from McGill University, and PhD in Rehabilitation Science from the University of Toronto. Broadly, she is interested in investigating long-term meaningful outcomes in people living with chronic conditions.

 

Dr. Jolie Ringash is a Professor of Radiation Oncology at the University of Toronto.  She is cross appointed to the Department of Otolaryngology Head Neck Surgery and to the Institute of Health Policy, Management and Evaluation at the University of Toronto.  She is the Site Leader for the Gastrointestinal Radiation Oncology Site Group, Co-Chair and medical lead of the Head and Neck Cancer Survivorship Programme supported by the Discovery Fund, and a staff radiation oncologist, at the Princess Margaret Cancer Centre.

 


 

 

Moving Forward with Cancer Rehabilitation

Cancerrehabby Sara E.  McEwen, PT, PhD

What is cancer rehabilitation? Cancer rehabilitation enables people living with cancer or the effects of cancer treatments to maximize physical, social and psychological function within the limits imposed by the disease, and subsequently to engage in personally valued activities in their home, community, and work environments.  One could say that cancer rehabilitation is concerned about mitigating the consequences of the disease and restoring function. Cancer rehabilitation services are as diverse as the disease itself – they could include a swallowing exercise program administered by a speech-language pathologist for a patient with head and neck cancer, lymphedema treatment by a physiotherapist for a patient with breast cancer, or perhaps a driving assessment by an occupational therapist for a patient with a brain tumour, to name just a few of the many professional disciplines involved and the profuse potential clinical scenarios.

 

What is the current state of cancer rehabilitation in Canada? Despite the need for these services, they are fragmented and inconsistently available in Canada.  To move the agenda forward, the Partners in Cancer Rehabilitation Research (PCRR) group held a 3-day invitational working meeting last spring aimed at defining the state of the science and identifying key areas for development of research and education. Twenty-nine clinicians, patients, and researchers gathered and the results included consensus statements on research and education priorities that were published in Current Oncology, Volume 20, No. 1, February 2013.  The group concluded that a main research priority is to develop and test personalized rehabilitation interventions and short form instruments to detect the presence and severity of disabling symptoms specific to different types of cancer and different times in the trajectory, and to mesh with the personal characteristics of individual patients, such as age, comorbidities, and personal preferences.   We established two main education priorities: 1. Develop and disseminate a clear, interdisciplinary description of the nature of cancer rehabilitation and its mandate; 2. Increase awareness among health care providers and patients of the need for and general effectiveness of cancer rehabilitation.

 

What is the evidence supporting the efficacy of cancer rehabilitation? Also stemming from last spring’s meeting was a best evidence synthesis to summarize current evidence regarding rehabilitation interventions to address problems during survivorship.[i] We identified post-cancer treatment needs that could be addressed by rehabilitation and summarized the strongest evidence from systematic reviews and randomized controlled trials. Evidence regarding the effectiveness of rehabilitation interventions was reviewed for physical functioning, fatigue, pain, sexual functioning, cognitive functioning, depression, employment, nutrition and participation. We concluded that:

  • Good evidence exists for the use of exercise/physical rehabilitation in reducing fatigue after treatment for most cancers, and improving upper extremity functioning following treatment for breast cancer. Of particular interest is the extensive literature regarding rehabilitation interventions for breast cancer which has resulted in a comprehensive guideline for prevention and intervention for mobility, pain, swelling and function.[ii]
  • There is preliminary evidence that pain, sexual functioning, cognitive functioning and return to work may be improved by rehabilitation interventions, but further research is needed.

What cancer rehabilitation services exist in your clinical setting? Are there gaps? Are there innovations?  This is a small but growing field, so please share your successes and challenges so that we can work together to improve the functional health for survivors of cancer.

 

 


 

References

[i] Egan MY, McEwen SE, Sikora L, Chasen M, Fitch M, Eldred S. Rehabilitation following cancer treatment. Disability and Rehabilitation. Published early online, March 15, 2013.

[ii] Harris SR, Schmitz KH, Campbell KL, McNeely ML. Clinical practice guidelines for breast cancer rehabilitation: syntheses of guideline recommendations and qualitative appraisals. Cancer 2012; 118:2312–24.


saramcewenDr. Sara McEwen is a physiotherapist and a scientist at the Sunnybrook Research Institute, St. John’s Rehab Research Program.  She also holds appointments as Assistant Professor, Department of Physical Therapy, University of Toronto, Associate Member, Graduate Department of Rehabilitation Science, University of Toronto, and Research Associate with the Cognitive Rehabilitation Research Group, Washington University, St. Louis, MO. Broadly.  She is interested in investigating long-term meaningful outcomes in people living with chronic conditions. Her specific interests include exploring the links among cognition, motivation, and motor skill acquisition, and facilitating knowledge exchange between front-line health professionals and researchers.  Her current projects include two randomized controlled trials investigating cognitive strategy based interventions in people living with stroke, as well as foundational work to develop new oncology rehabilitation interventions. She obtained her B.Sc. in Physical Therapy and M.Sc. in Rehabilitation Science from McGill University, and PhD in Rehabilitation Science from the University of Toronto. In addition to her role as a researcher, Dr. McEwen has worked as a clinical physiotherapist, educator, and project coordinator. She is an avid skier, cyclist, and runner, and lives near Orillia, Ontario, with her husband and children.