There are more than 16.9 million cancer survivors in the United States as of 2019 and the number is projected to reach to more than 22 million by year 2030, with the global burden expected to rise to nearly 27 million by year 2040. At the same time, the 5-year relative survival rate for all cancers combined continues to rise in the United States, which reflects the aging population, advances in treatments, and improvements in screening and detection.
Research has demonstrated that cancer survivors experience a complex variety of functional impairments as a consequence of disease burden and treatment toxicity. These impairments can lead to long-term functional decline, precipitate psychological distress, and negatively impact quality of life if left untreated. The growing number of elderly cancer survivors highlights the need for better access to rehabilitative services, as well as developing alternative models of care to overcome critical shortages of rehabilitation providers in order to improve outcomes in cancer patients.
Advances in technology have pushed the boundaries of medicine, shifting the way care is being delivered. Telemedicine uses a variety of technological applications to support clinical practice by enhancing communication and expanding accessibility. It has reached multiple medical disciplines and has recently expanded to the fields of oncology and rehabilitation, referred to as “teleoncology” and “telerehabilitation,” respectively. This chapter discusses the practical applications of telerehabilitation in the rehabilitation of cancer patients with emphasis on impairment screening, diagnosis of complications, exercise considerations, symptom monitoring, and multidisciplinary collaboration.
The Current State of Cancer Rehabilitation
The term “cancer survivor” is defined by the National Coalition for Cancer Survivorship as individuals living with, through, and beyond cancer. Whether it is at the time of diagnosis, during active treatment, in remission, or nearing end-of-life, the cancer survivor experience encompasses the entire scope of the care continuum. As the number of cancer survivors continues to rise internationally, there is increased attention to the health and well-being of this population. Further, the prevalence of elderly cancer survivors (65 and older) currently reaches 60% of the cancer patients and is expected to increase respectively with the aging of the US population, significantly contributing to the number of expected survivors.
Cancer survivors experience a variety of treatment or disease-related adverse effects at any point of their journey, which may disrupt essentially any organ system and manifest as profound physical impairments. Elderly survivors may have preexisting comorbidities with unique survivorship needs, further adding to the demand and complexity of care. To meet these demands, survivorship care models have shifted focus to a more holistic, patient-centered approach, providing comprehensive and multidisciplinary services to effectively address the needs of cancer survivors of all ages and stages of care. As a result, cancer rehabilitation has had increased recognition in light of the rising demands for screening, identifying, and mitigating potential side effects in individuals living with cancer. The field is supported by a growing body of research that has demonstrated the positive effects of cancer rehabilitation and physical activity on functional prognosis and cancer-specific mortality as well as improvements in quality of life and reported pain scores. For this reason, new comprehensive cancer rehabilitation care models are being implemented throughout the course of cancer treatment in efforts to optimize physical function and prevent disability among cancer survivors.
Despite ongoing evidence demonstrating efficacy and safety of cancer rehabilitation, cancer patients continue to have unmet needs due to underutilization of services. A study by Cheville et al. found that outpatient oncologists were less likely to address functional deficits such as gait or balance dysfunction. The study underscores the importance of integrating cancer rehabilitation specialists into oncology care in order to properly screen for impairments and better identify rehabilitation needs before dysfunction escalates to disability. This evolving model of survivorship care has raised interest in improving health care delivery to allow for this integration to occur. One of those efforts involves incorporating telerehabilitation into traditional cancer care.
Teleoncology
Telemedicine was initially implemented in cancer care with the aim of redistributing the workforce of oncology specialists to areas that lack specific services. With immediate access to care, teleoncology can improve patient health outcomes, allowing for early detection of anticipated complications, decreased time and cost of transportation, lessened caregiver burden, and better adherence to therapies.
The growth of teleoncology has resulted in multiple changes to cancer care as summarized in Table 6.1 . Despite these benefits, the adaptation of telerehabilitation into clinical practice has remained a challenge as a result of clinical, technical, legal, and administrative consequences.
| Remote office visits | Primary oncologist meets with patients using synchronous (real-time communication) methods via telephone or virtual videoconferencing. Can reduce transportation costs and time. Extends services to rural sites. |
| Patient communication | The physician is able to communicate with patients asynchronously (in between visits) to transmit data such as lab results, images, and other reports, as well as answer patient inquiries and triage complaints. |
| Tele-education | Provides remote continuing education opportunities for rural oncology practitioners. Promotes multidisciplinary collaboration. For patients, virtual education sessions may include lifestyle modification, smoking cessation, psychosocial support, presurgical information sessions, wound care, and pre-habilitation. |
| Chemotherapy supervision | Wearable technologies such as heart monitors and skin sensors provide periodic monitoring of vital signs during active treatment. |
| Symptom monitoring | Mobile applications and portable interactive tools can provide more frequent engagement and monitoring of symptoms that may otherwise be overlooked and underdiagnosed. |
| Interprofessional care | Bundling of services such as radiology, pathology, oncology in a visit to enhance the patient experience and access to care in a timely manner with less frequent office visits. |
| Telegenetics | Provide virtual genetic counseling for patient and families to identify possible carriers. With telemedicine, more family members are able to be engaged in the visit. |
| Telepathology | Remote viewing of tissue pathology and cytology. Pathologists and cytologists do not have to remain onsite during long procedures, making them more available for remote reviewing of specimens in multiple sites. Can provide real-time feedback on molecular analysis and histochemical testing. |
| Clinical trial engagement | Extending access to those living in distant areas. Improve interest, eligibility, participation, engagement, adherence, and follow-up for clinical trials. |
| Multidisciplinary tumor board | Increase interprofessional participation in tumor board meetings by overcoming distance barriers. Facilitate engagement from multiple health professionals to discuss treatment plans for patients. |
| Telerehabilitation |
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Impact of COVID-19 on Cancer Care
In December 2019, the outbreak of the novel coronavirus Sars-CoV-2, referred to as COVID-19, resulted in a state of global emergency affecting over 200 countries and classified as pandemic by the World Health Organization (WHO). This highly virulent disease characterized by rapid spread, multiorgan dysfunction, and varying degrees of illness raised concern for those who are immunocompromised or have multiple comorbidities, such as individuals with active cancer.
Emerging evidence has shown that patients with cancer have an increased risk for contracting COVID-19 and, if infected, are more likely to develop severe symptoms (acute respiratory distress requiring ventilation) with a higher 30-day mortality rate. Government-mandated physical distancing, diversion of medical resources, lack of preparedness plans, and concern for inadvertently spreading infection made it increasingly difficult for cancer patients to receive care. Physicians were compelled to adapt to telemedicine models in an attempt to mitigate viral transmission and preserve health care resources while minimizing disruption of cancer care.
As a response to the COVID-19 pandemic, the US federal government set forth emergency waivers and stimulus packages to allow for ease of care delivery in the midst of a health crisis. Centers for Medicare & Medicaid Services (CMS) made several changes to improve virtual health care access by allowing more flexibility with regulations and better reimbursement rates. These changes allowed for prompt adaptation of telemedicine in the setting of cancer care.
Similar to acute cancer management, rehabilitation and survivorship care services were significantly impacted as a result of the COVID-19 pandemic. Various cancer rehabilitation strategies used to screen, diagnose, and manage cancer-related impairments often require physical, in-person visits such as a physical evaluation of functional deficits, manual therapies for lymphedema, electrodiagnostic testing to investigate neurological symptoms, and various interventional procedures to address cancer-related pain. The benefits of these rehabilitation interventions had to be weighed against risk for contracting COVID-19, and although telerehabilitation has its setbacks, it offers an opportunity to meet the rehabilitative needs of patients living with cancer.
Evidence and Implications for Telerehabilitation in Cancer Management
Over the years, telerehabilitation has mostly existed in the context of neurological rehabilitation, providing remote therapies and monitoring progress in stroke patients. In this setting, telerehabilitation was shown to be an effective, alternative way of providing therapy and improving patient outcomes after stroke. Similar to stroke patients, physical activity levels in cancer patients are significantly reduced (33%–60% decline) after diagnosis, necessitating ongoing therapeutic intervention.
The use of telerehabilitation services in cancer care remains limited. This can be attributed to the fact that, in general, exercise-based rehabilitation programs are not yet part of the standard of care for cancer patients, and, therefore, are not regularly recommended by oncologists. Additionally, there may be hesitancy to refer a patient to remote rehabilitation programs versus supervised face-to-face programs due to the perceived fragility and medical complexity of this population. Nevertheless, there is emerging evidence to support the use of telerehabilitation in cancer rehabilitation as an effective, accessible, feasible, and cost-effective alternative to traditional care.
Efficacy
Improvements in function, patient-reported symptoms, satisfaction surrounding care, and quality of life measures support the efficacy of telerehabilitation in oncology. About one-fifth of the elderly population undergoing chemotherapy can experience a decline in activities of daily living (ADLs). Further, the functional decline trajectory in a patient with advanced disease in the last year of life is much steeper compared to other diseases. Collaborative telerehabilitation, such as remote monitoring and web-based exercises, is useful in minimizing functional regression and improving overall functional capacity in cancer patients. These interventions have been successfully applied in individuals with advanced cancer and those undergoing chemotherapy. Additionally, the functional improvements derived from remote therapies have been shown to be maintained months after completion of a program. Another advantageof telerehabilitation for the purpose of improving function is the ability to observe the home environment. By doing so, rehabilitation specialists can better assess equipment needs and address barriers to ADLs.
Despite improvements in treatments, cancer patients continue to experience a high symptom burden long after completing treatments. Symptoms are highly variable, with the most common symptoms being pain, fatigue, and depression. Due to the multifactorial nature of these symptoms, frequent assessment and patient engagement is imperative. A collaborative telerehabilitation care model with a principle physician, nursing staff, and therapists can be advantageous for making these assessments. These comprehensive and multidisciplinary assessments have resulted in improvements in pain and depression scores. For patients undergoing chemotherapy, symptom monitoring can screen for toxicity-related side effects. Automated symptom monitoring and remote support in between follow-up visits has resulted in reduced symptom burden and improved symptom outcomes for patients undergoing chemotherapy.
Telerehabilitation enhances the quality of care received by cancer patients. One metaanalysis by Chen et al. looked into the effect of telehealth interventions on quality of life and psychological outcomes in breast cancer patients and found that patients who received telehealth interventions had improved quality of life scores, less depression, and less perceived stress compared to usual care. These results have been replicated in patients with head and neck cancer who experience significantly reduced quality of life due to treatments resulting in facial disfigurement, speech complications, and swallowing dysfunction.
Patient health care experience, including satisfaction with care, is a core focus of interest in medicine and is part of the Institute for Health Care Improvement “Triple Aim” initiative for optimizing health system performance. As the use of telerehabilitation emerges in oncology, patient satisfaction outcomes assume the upmost importance in order to support and maintain delivery of care through these platforms. From a patient perspective, telehealth has been found to be well accepted and satisfactory due to its relative ease of use and ability to improve communication between providers.
Accessibility
According to the WHO, issues with treatment adherence in cancer care are multifaceted and often occur as a result of patient-related, condition-related, treatment-related, socioeconomic-related, and health system–related factors. Patients with physical disability related to cancer benefit from easier access to care. Telerehabilitation addresses access barriers by providing opportunities to conduct visits and therapies remotely. Ease of follow-up with telerehabilitation also influences treatment and exercise adherence. Telerehabilitation appears to be an ideal solution to meet the accessibility needs of cancer patients by promoting compliance with clinic visits, exercise programs, and treatment regimens. For example, reducing the frequency of travel to treatment or clinic settings will not only improve follow-up compliance but also ease caregiver burden. Inconsistencies with medication administration due to the complexity of treatment or presence of uncontrolled side effects can be addressed through remote education and symptom monitoring.
From an exercise perspective, the ideal exercise program for this population is one that is well tolerated, safe, and sustainable. Telerehabilitation can improve adherence to exercise due to the inherent flexibility of delivering programs to best fit a patient’s lifestyle. The added benefit of symptom monitoring can allow for exercise prescription adjustments based on tolerability.
Feasibility and Safety
Although telerehabilitation has been recognized as a valuable and effective method of delivering care, little is known about the feasibility of these interventions in clinical practice. A systematic review investigating the use of videoconferencing (a form of telemedicine) in clinical oncology supports the feasibility for assessing, monitoring, and managing oncology patients through this intervention. In fact, patients with advanced cancer with moderate functional impairments were able to tolerate an individualized walking and resistance training program delivered via telephone for 6 months with good tolerability and no reported adverse events. Other administrative, clinical, technical, and ethical-related factors need to be considered for delivering telerehabilitation services as outlined by the American Telemedicine Association.
Health Care Utilization and Cost-Effectiveness
The cost of cancer care in the United States is projected to increase by 34% by 2030 and is estimated to reach nearly $246 billion based on population aging and cancer survivor prevalence. According to Commonwealth 2019 analysis of Organisation for Economic Co-operation and Development data, the United States spends nearly twice as much on health care compared to other high-income countries. In the United States, health care costs are nearly four times greater compared to non-cancer cohorts, especially in the elderly population and those with more advanced disease. It is difficult to compare health care utilization and hospital expenditures among individuals with cancer across nations given the heterogeneity of cancer cohorts, inconsistency with international data sources, and differences in health policies and payment models. With that being said, some data suggest that health care expenditures for individuals with cancer and nearing the end of life were highest in the United States, Norway, and Canada.
Patients with advanced cancer may contribute to rising health care costs due to hospitalization readmissions and frequent emergency room visits for uncontrolled adverse symptoms and functional loss related to disease or treatments. Telerehabilitation can be useful for facilitating transition care of cancer patients after hospitalization by providing a more suitable method of postacute care follow-up and ensuring rehabilitative services are in place. The results from the Collaborative Care to Preserve Performance in Cancer (COPE) trial support telerehabilitation and its efforts to reduce the economic burden of cancer by addressing pain and functional loss early on as a means to decrease hospital lengths of stay and restore function in this highly symptomatic population.
Practical Applications of Telerehabilitation in Cancer Rehabilitation
Cancer rehabilitation has become an increasingly relevant field, playing an integral role in survivorship care. This section discusses the practical applications of telerehabilitation into the clinical practice of cancer rehabilitation such as addressing preexisting barriers, conducting virtual visits, and integration of a telerehabilitation model throughout the course of cancer care.
Addressing Cancer Rehabilitation Barriers with Telerehabilitation
Despite all the benefits, expansion of cancer rehabilitation across diverse clinical settings has met considerable challenges. Current advocates of cancer rehabilitation have explored these barriers and suggested they may occur as a result of deficits in knowledge, access, and adherence. The emerging use of telerehabilitation provides unique opportunities to overcome these barriers and enhance the impact of cancer rehabilitation in the field of oncology.
Knowledge barriers result from the lack of awareness of rehabilitative services by oncologists and patients, ambiguity of referral practices, and uncertainty of roles. Telerehabilitation can fill knowledge gaps by extending educational services from already established cancer rehabilitation programs to health systems, clinicians, and community clinics regarding current, evidence-based practices of the field.
Incorporating telerehabilitation services can relieve financial and time constraints associated with traveling and, as a result, relieve the burden of multiple clinic and therapy visits. Moreover, the cancer rehabilitation workforce has an exclusive presence in mostly large academic, tertiary care centers. Telerehabilitation can be used to expand this limited workforce to serve in areas in need of such programs.
Lastly, other barriers to cancer rehabilitation fall under issues with adherence. Examples include patient motivation to participate, activity intolerance, and lack of support and oversight. Remote technology, such as the use of wearable sensors for activity tolerance, mobile applications for symptom monitoring, and web-based exercise programs for support and accountability for home exercises, has been shown to address these issues and promote positive behavior change.
The Virtual Visit: From Consultation to Disease Management
Virtual visits can be conducted synchronously (physician and patient engage in real-time communication via live video or audio platforms) or asynchronously (transmitting, reviewing, and storing clinical data such as images, results, or reports reviewed at later times). Although in practice both approaches are used interchangeably, recent attention on telerehabilitation has focused on synchronous visits since they maintain the patient-physician relationship reminiscent of an in-person clinic visit. Maintaining good patient rapport is imperative in the cancer population as it facilitates an environment where patients feel comfortable asking questions and are open to reporting adverse symptoms.
The virtual visit, conducted through video interface, is essentially identical to in-person visits in terms of flow and content of the encounter, except the inability to use tactile techniques for a physical examination. Virtual adaptations to the conventional physical examination have been proposed in the setting of telerehabilitation in the outpatient setting that allow physicians to provide a comprehensive evaluation. Physical examination of a patient with cancer may vary significantly depending on tumor type, stage, treatments endured, and presence of comorbidities. Although examination of multiple systems is critical in this population, the cancer rehabilitation evaluation tends to put more focus on neurological, musculoskeletal, and functional aspects of the examination. Table 6.2 provides examples of virtual examination modifications with respect to common cancer rehabilitation conditions. Table 6.3 describes various functional assessment scales and measurement tools that may aide in the virtual examination.
| System | Specific Condition | Virtual Evaluation and Assessment Tools | Virtual Management and Follow-up Plan |
| Functional | General performance | KPS, ECOG | Communication with oncology regarding treatment plan, referral for nutrition for weight management, referral for pre-habilitation if indicated. Provide durable medical equipment (DME). OT and PT prescriptions |
| Mobility | TUG test | ||
| Self-care and ADLs | Barthel index, home assessment | ||
| Systemic | Cancer-related fatigue | BFI, FACIT-F | Education, exercise program, medications |
| Dyspnea/deconditioning | RPE, CDS | Rule out PE, metastasis. Refer to pulmonary rehabilitation and PFT measurements | |
| Head and neck (H&N) | Trismus | Direct observation, mouth opening measurement (patient can use fingers and document in “finger breadths”). Inquire about food intake and weight loss. | Trismus exercises, referral to SLP, prescription for jaw stretching device |
| Dystonia | Direct observation for muscle contraction, instruct patient to perform neck range of motion (ROM), and palpation of tender areas | Stretching exercises, evaluate for trigger point, and Botulinum toxin injections | |
| Musculoskeletal | Bone metastasis | Assessment of new pain, observation of functional pain | Referral for imaging. Communication with primary oncology team. If known metastasis, referral for appropriate exercise interventions and bracing as needed. Orthopedic assessment for long bone metastasis |
| Amputation | Wound inspection, ROM of limb, mobility observation | Therapy and prosthetic prescription | |
| Shoulder tendonitis | ROM, shoulder and arm special tests | PT prescriptions, medications as appropriate, referral for imaging if no improvement | |
| Adhesive capsulitis | Shoulder ROM, shoulder and arm special tests | PT prescriptions, medications, referral for injection as appropriate | |
| Myopathy | Direct observation for atrophy, strength testing with squat and wall push up | Review steroid use, PT prescriptions, DME as appropriate | |
| Post-mastectomy/thoracotomy pain | Incision evaluation, assessment for scar dysfunction/pain, muscle atrophy observation, evaluate for axillary cording by instructing patient to palpate axilla | PT prescriptions, medications, and injection as appropriate | |
| Scapular winging | Direct observation of scapula and shoulder girdle during wall push up | PT prescription, referral for NCS/EMG as appropriate | |
| Soft tissue | Lymphedema | Direct observation for edema, skin color, and texture. Measurement by patient comparing to contralateral limb if measuring tape available. Facial lymphedema in H&N cancer | Venous duplex as needed, prescription for manual lymphatic drainage (MLD) as needed, garment prescriptions |
| Radiation fibrosis syndrome | Direct observation for atrophy, skin changes, muscle contraction, ROM restrictions. Progressive dysphagia in H&N cancer | PT prescriptions, medications, and injection as appropriate, bracing as appropriate. SLP for swallow dysfunction | |
| Graft vs. host disease | Assess for maculopapular rash, abdominal cramps with diarrhea | Refer to oncology for management | |
| Neurological | Chemotherapy-induced peripheral neuropathy | Instruct patient to assess sensation and strength, CIPNAT, FACT/GOG-Ntx | Education on neuropathy, compensatory strategies, PT/OT prescription, bracing as needed, DME |
| Compression neuropathy/plexopathy | Instruct patient to assess sensation and strength, special tests. | Education, referral for NCS/EMG, compensatory strategies, PT/OT prescription, bracing as needed, referral to surgery as needed | |
| Cognitive impairment | FACT-COG, MOCA, assess IADLs, home assessment | Referral to neuropsychology, compensatory strategies, medications when appropriate | |
| Speech and swallow dysfunction | Language evaluation, screen for dysphagia | Referral to speech and language pathology; consider imaging if symptom is new complaint |
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