key: cord-0856288-qatsptxk
authors: Chowdhury, Rabeya; Brennan, Frank P.; Gardiner, Matthew D.
title: Cancer Rehabilitation & Palliative Care – exploring the synergies.
date: 2020-08-06
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.07.030
sha: e723fde2e86aedce7a000abccb74bc66dbde0c1c
doc_id: 856288
cord_uid: qatsptxk

With perpetual research, management refinement and increasing survivorship, cancer care is steadily evolving into a chronic disease model. Rehabilitation Physicians are quite accustomed to managing chronic conditions, yet, in Australia, Cancer Rehabilitation remains under-explored. Palliative Care Physicians, along with Rehabilitationists, are true Generalists, who focus on the whole patient and their social context, in addition to the diseased organ system. This, together with Palliative Care’s expertise in managing the panoply of troubling symptoms that beset patients with malignancy, makes them natural allies in the comprehensive management of this patient group from the moment of diagnosis. This paper will explore the under-recognized and under-utilized parallels and synergies between the two specialties as well as identifying potential challenges and areas for future growth.

Cancer encompasses a group of disabling diseases and it's prevalence is growing rapidly worldwide. The lifetime prevalence of cancer in North America, from any site, is approximately 39.8%. 1 There are an estimated 1.1 million people living with a personal history of cancer in Australia, and this number is projected to increase to almost 1.9 million by 2040; thus 1 in 18 people will be diagnosed with cancer. 2 Owing to early detection, treatment, and ongoing supportive care, people are also living longer post diagnosis. Relative five-year survival rates for most cancers have risen from 49%, (1975 -1977) , to over 70%, (2016) (2017) , in the USA. 3 In Australia, five-year survival has risen from 50%, (1990) , to almost 70% in 2019. 4 Patients with cancer, before, during and after treatment, invariably experience physical symptoms due to the disease and its management -(see Tables 1 & 2) , psychological distress, functional impairment, and diminished quality of life. Often, this process has a profound effect on families and carers -(see Figure 1 ). Improvements in health awareness and an increase in timely cancer diagnosis, treatment and regular surveillance, has resulted in many people living longer with cancer. Their longterm health and wellbeing will need to be addressed adequately. The challenge for modern medicine is, therefore, the care of cancer patients from diagnosis to death, where the latter may occur years after the completion of treatment. Supportive cancer care strategies and cancer rehabilitation have been developed to reduce the impact of the disease and its treatment -(see Figure 2 ).

Cancer rehabilitation may be defined as medical care that should be integrated throughout the oncology care continuum and delivered by trained rehabilitation professionals who have it within their scope of practice to diagnose and treat patients' physical, psychological and cognitive impairments in an effort to maintain or restore function, reduce symptom burden, maximize independence and improve quality of life. 5 The most influential classification system for cancer rehabilitation, throughout the cancer trajectory, is the Dietz classification. 6 (see Table 3 ). Later in this article, we will use this structure to outline, in detail, the practice of, and evidence for, cancer rehabilitation in each of these stages.

From small beginnings, cancer rehabilitation is emerging as a discipline with a growing recognition by professional organizations within oncology, cancer surgery and rehabilitation medicine as a crucial, if not mandatory, component of cancer care. 7-10 A panel of experts, convened by the National Institutes of Health (NIH), have published practice recommendations. 11 A Cancer Rehabilitation Networking Group has been established within the American Congress of Rehabilitation Medicine (ACRM). The US Commission on Accreditation of Rehabilitation Facilities (CARF) have been accrediting inpatient cancer rehabilitation units for several years. Despite this activity, the discipline of cancer rehabilitation remains inadequately understood 12 , underutilized 13 and under-resourced. In this paper, we will describe the objectives and practice of cancer rehabilitation. We shall examine the barriers and challenges for the discipline, its interface with Palliative Care and shall argue that there are multiple synergies that could flow from an alliance of Cancer Rehabilitation, Palliative Care and Oncology in cancer care.

The goal of rehabilitation is contained in its etymology -from the Medieval Latin rehabilitationem = "restoration". From re -"again" + habitare -"make fit ".

The Rehabilitation Physician uses the traditional biopsychosocial framework to address impairment, with the broad goals of minimising disability and maximising function and independence, in all aspects of a patient's life.

The World Health Organisation, (WHO), defines Rehabilitation as "a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments." (WHO, 2011).

A Rehabilitation assessment always begins with a comprehensive history and physical examination, with particular focus on an extended social and functional history -(see Table  4 ). This may be supplemented by a broad array of specialised, validated, clinical assessment tools -(see Table 5 ). Certain investigations may be indicated, including pathology testing, imaging, nerve conduction studies (NCS), and electromyography (EMG).

Such evaluations assist rehabilitation physicians to identify current and potential physical and functional impairments affecting their daily life and to formulate a detailed rehabilitation 'prescription', as either an inpatient or outpatient, or both. The plan may include optimisation of medication management, various procedures for pain management, i.e. peripheral nerve blocks, intra-articular and peri-radicular injections and botulinum toxin injections. Patients may require referral to specialised services, (e.g. a prosthetist, orthotist, physical therapist, hydrotherapy, occupational therapist, speech pathologist, social worker, nutritionist or lymphedema therapist). Physiatrists may also develop a graded return to work program and assist with resumption of avocational pursuits.

The strength of Rehabilitation Medicine, as with Palliative Care, lies in the collective wisdom and clinical experience of its multidisciplinary structure -(see Figure 3 ).

Prehabilitation occurs when a treatment plan is developed post diagnosis and before the commencement of acute treatment. It 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." 14 With effective exercise prescription, prehabilitation is useful in reducing the length of hospital stay and postoperative complications as well as enhancing recovery and quality of life (QOL) after surgery. 16 Data exists for esophageal 17 colorectal, [18] [19] [20] [21] , lung, [22] [23] [24] [25] prostate 26 and head and neck cancer . 27 Prehabilitation interventions vary according to the diagnosis. Common modalities may include pulmonary prehabilitation, strengthening, stretching and endurance exercises, aerobic exercise, nutritional management, psychological counselling, oral and swallowing exercises for head and neck malignancies and pelvic floor exercises. Most prehabilitation occurs in an outpatient setting.

Some of the goals of prehabilitation are: 14 :

-Improvement in cardio-respiratory health.

-Improvement of musculoskeletal function and balance and reduced falls risk.

-Cognitive behavioural strategies to reduce anxiety and improve adaptation and sleep hygiene.

-Optimization of surgical outcomes via modification of risk factors, e.g. smoking cessation.

-Nutritional assessment.

-Preoperative exercise to improve postoperative potential, e.g. continence outcomes after perineal surgery, speaking and swallowing function after head and neck surgery.

-Strategies to return to school, work or home with adaptive equipment and structural modifications.

Restorative rehabilitation may be offered after surgery or when a patient is receiving chemotherapy, radiotherapy, or immunotherapy, with curative intent; rehabilitation often continues after completion of treatment. This intervention attempts to return patients to previous levels of physical, psychological, social, and vocational functioning. 15 Research suggests that a multidisciplinary approach may result in better outcomes and provide the opportunity and support for patients to cope with treatment modalities. 14 Multiple studies have revealed some benefit from restorative rehabilitation for certain cancer populations, e.g. esophagus, 28 colorectal, 21 29 lung, 24 30 pancreatic , 31 gastric, 32 prostate, 33 hematological 34 and laryngeal cancers 35 .

Restorative rehabilitation is usually multimodal with a combination of early mobilization and physical therapy, nutritional management, breathing exercises, with or without formal respiratory rehabilitation, relaxation techniques and lymphedema therapy. Most surgical and some non-surgical cancer patients commence therapy as an inpatient and continue therapy in an outpatient setting, supplemented by a home exercise program, in order to maintain the gains achieved earlier in the program.

Cavalheri et al published a Cochrane review in 2019 concluding that exercise training increased exercise capacity and quadriceps strength and improved general health related quality of life (HRQoL) as well as decreasing dyspnoea after lung resection for Non-Small Cell Lung Cancer. 36 When patients are receiving various cancer treatments, rehabilitation may be helpful in preventing the predicted decline in QOL related to the disease and treatment side effects.

The benefits of multimodal rehabilitation to maintain quality of life (QOL) during radiotherapy has been reported by Clark et al in 2013 37 and Rummans et al in 2006 38 . Monga et al demonstrated improved QOL and less fatigue with a unimodal, (physical exercise), rehabilitation approach for patients with prostate cancer in a retrospective study. 26 Multimodal rehabilitation has also been studied in patients with cancer during chemotherapy. Adamsen et al randomized 269 patients with 21 different cancer diagnoses, including solid tumors and hematological malignancies, into intervention and control groups. After 6 weeks, the intervention group demonstrated less fatigue, improved aerobic capacity, greater strength, improved vitality, and better emotional well-being, including significant improvement in depression. 39 

As the number of cancer survivors grows, there has been an increasing focus on survivorship as a distinct part of oncology care. This group has been the subject of a series of reports published by the US Institute of Medicine, highlighting the physical and psychological dimensions of survivorship [40] [41] and proposing a framework for patientcentered care. 42 Supportive rehabilitation involves rehabilitation for patients with cancer as a chronic condition. Interventions are designed to teach patients to accommodate fixed disability and minimize debilitating changes from ongoing disease. It increases self-care ability, (e.g. selfhelp devices), for patients whose cancer has progressed and whose functional impairments have worsened. Other goals include preventing disuse atrophy, contractures, loss of muscle strength and decubitus ulcers. 15 A Cochrane Database Review of 40 trials with 3694 participants, involving colorectal, head and neck, lymphoma and breast cancer patients, (1927 participants in an exercise group and 1764 in a comparison group), with exercise interventions after the completion of active cancer treatment, concluded that exercise may have beneficial effects on HRQoL and certain HRQoL domains for cancer-specific concerns such as body image, self-esteem, fatigue, and anxiety, in survivors of breast cancer. Exercise interventions included strength training, resistance training, walking, cycling, yoga, Qigong, or Tai Chi. 43 A review of survivors of prostate cancer revealed that supervised clinical exercise can improve continence, fitness, fatigue, body constitution and QoL. 44 Cancer related fatigue (CRF), along with QoL and function, have been shown in a randomized study in Germany to improve with a multimodal rehabilitation program consisting of physical therapy, patient education, group exercise, and psycho-oncologic counselling and the benefits were maintained for 3 months in the intervention group, compared to the control group receiving a conventional rehabilitation program. 45 Another smaller RCT of patients with gynecological cancers also showed similar benefit with aerobic exercise. 46 In a study of patients with treated lymphoma, Courneya et al concluded that strength and interval training is useful in maximizing return-to-work in cancer survivors. 47 In a recent review, Jamal et al concluded that with increases in survivorship for patients with head and neck cancer, our current attention is turning to QoL issues for which rehabilitation interventions, (speech pathology, physical therapy, social work, psychology, nutritional support, nursing care, etc), are required to prevent, restore, compensate and palliate symptoms and sequelae of treatment for optimal functioning. 48 A second category of supportive rehabilitation applies to people with slowly progressive disease, (e.g. prostate cancer, metastatic breast cancer) or chronic (usually hematological), malignancy. At this stage, the aim of rehabilitation is dependent on the patient's identified goals, taking into consideration symptoms related to cancer and ongoing treatment, remaining functional abilities and social circumstances. In the context of living with and beyond cancer, exercise intervention can improve cancer related fatigue, HRQoL and physical function, (Mishra 2014 49 , Stout 2017 50 ) -though maintaining motivation is the challenge and there is a lack of data available regarding how to improve motivation. 51 Two major studies are worth mentioning. Being currently undertaken in this area. The first is MENAC, (Multimodal intervention for Cachexia in advanced cancer patients undergoing chemotherapy), a randomized phase 3 interventional trial with the aim of preventing the development of cachexia, rather than providing treatment, late in the disease trajectory. 52 The second is a two arm, single institution, randomized controlled trial of outpatient Cancer Rehabilitation for patients over 65 years with functional impairment, (the CARE program), in the United States.

The intervention group receives individual physiotherapy (PT) and occupational therapy (OT) assessment in a tailored program, lasting up to 12 weeks, according to their needs. The other arm is a 'usual care' group who receive a brochure outlining services and contact information for supportive care programs, but not referral for PT / OT. At follow-up, both PT / OT (p = .02) and usual care (p=.03) groups experienced a decline in functional status. PactS, (physical function, and activity expectations and self-efficacy), scores between groups (p = 0.04) were significantly improved in the intervention group. Several barriers were noted regarding implementation of the intervention program and the authors suggested further research is needed to facilitate improved access to PT and OT. 54 

In this stage, interventions are focused on minimizing or eliminating complications and providing comfort and support in the terminal stages of disease, to improve QoL physically, psychologically and socially, while respecting the wishes of the patient and their loved ones. Such programs are designed to alleviate symptoms, such as pain, dyspnoea, fatigue, nausea and oedema and to prevent contractures and decubitus ulcers, using medication, heating modalities, positioning, breathing assistance, relaxation & the use of assistive devices.

Whereas palliative rehabilitation has been offered by rehabilitation physicians and the multidisciplinary team (MDT), palliative care physicians and their MDT may also provide a program of 'Rehabilitative Palliative care', which is well established in the hospice setting in the UK. Rehabilitative Palliative Care has been defined as a paradigm integrating rehabilitation, enablement, self-management, and self-care into the holistic model of palliative care to provide support to enjoy the fullest possible life until the patient's demise. 55 In both groups, proposed therapies and care plans are customised to the individual's needs and wishes.

A small number of uncontrolled, prospective studies comparing outcomes pre and post rehabilitation intervention, 56-57 as well as some randomized trials, [58] [59] show that general rehabilitation can improve function and QoL, and reduce symptom burden, (without worsening fatigue), in patients with cancer, even if the illness is at an advanced stage. [60] [61] Salakari et al. performed a systematic review of 13 randomized trials published between 2009 and 2014, (1169 participants), evaluating the benefits of general rehabilitation among patients with advanced cancer; seven were limited to physical exercise alone. The review was suggestive of significant improvement in general well-being and QoL with physical exercise. Rehabilitation delivered positive effects on fatigue, general conditioning, mood, and coping with cancer. Physical function was not addressed. 62 In a 2017 randomized controlled trial of advanced cancer patients (n = 60), one-half received a dedicated physiotherapy program whilst the other half, the control group, did not. The intervention group received a 30 minute physiotherapy session including active exercises, myofascial release, and proprioceptive neuromuscular facilitation (PNF) techniques, 3 times per week for two weeks. The intervention group demonstrated a significant reduction in the severity of fatigue and its impact on daily functioning. In addition, the physiotherapy program improved the patients' overall sense of well-being and reduced the intensity of coexisting symptoms, such as pain, drowsiness, anorexia and depression. 63 Maddock et al concluded that even in individuals with cancer-cachexia with advanced disease, skeletal muscles have the capacity to respond to exercise training. 64 A flexible, multidisciplinary, integrative model of palliative rehabilitation for newly diagnosed advanced cancer was recently utilized in a single center randomized controlled trial, (the Pal-Rehab Study Protocol 65 ), to investigate the effect of concurrent palliative rehabilitation with standard oncology treatment, versus standard treatment alone. The study concluded that a more flexible model gave the patients higher levels of satisfaction along with a higher level of adherence to the 12 week group exercise program. 66 In addition to enabling independence with activities of daily living (ADLs) and reducing the burden to one's caregivers, therapeutic interventions such as physical therapy may also be perceived as giving patients hope and a feeling of general well-being.

Cancer Rehabilitation and Palliative Care are two distinct, although interrelated, disciplines. Cancer rehabilitation has been defined earlier in this paper. Palliative Care is defined by the WHO as: an approach which improves the quality of life of patients and their families facing lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. 67 Clearly, there are similarities between the disciplines. Both disciplines are multi-disciplinary, focus on the effect of the illness and its treatment, employ a broad set of interventions and concentrate on the needs of the individual patient and their carers. The differences lie in their objectives and emphases. Palliative Care primarily concentrates on symptom management, psychosocial and spiritual support of a patient and their family up to and including the death. Cancer rehabilitation concentrates on the preservation and, where possible, restoration of function throughout the cancer trajectory, to maximise independence and improve quality of life. As Silver and colleagues observed, the two disciplines are "aligned in goal setting but distinct in approach." 5 Over time, the sharpness of these distinctions has blurred. At the interface of the disciplines, lies the work of Palliative Care in integrating the expertise of physiotherapy, dieticians, occupational and speech therapy in overall care. [68] [69] [70] Where that integration exists, it mainly, although not wholly, concentrates on attempting to restore or maintain function, preparing patients to return home, supporting outpatients in the community or in their deteriorating phase. There are two problems here. Firstly, the level of such integration in palliative care services varies considerably around the world. The second is the pathway and timing of referral to Palliative Care. The work of palliative care is predicated on cancer patients being referred in a timely fashion. Unfortunately, many clinicians equate palliative care with terminal care or fear that raising the name of the discipline will evaporate patient hope. As a result, referrals may come as late as the terminal phase itself. Ideally, referrals are made sufficiently early in the trajectory of the cancer process to allow the skills of the allied health professionals to help.

The services provided by Palliative Care are broad. Historically founded in the care of cancer patients, the discipline increasingly focuses on non-malignant diseases. Multi-disciplinary Palliative Care teams work in three main locations -consultative services in hospitals, in-patient palliative care units and community palliative care. In terms of cancer, there is a strong focus on the management of symptoms secondary to the underlying malignancy and its treatment, an exploration of the psychosocial dimensions of cancer, support for families and care of the dying patient.

The range and scope of Palliative Care has expanded over the years. The recognition of its importance by the discipline of medical oncology has undergone a significant shift in the modern era. In a seminal paper, Temel and colleagues showed that the addition of early palliative care to standard oncology practice provided an advantage in health related quality of life, symptoms and survivorship in patients with advanced non-small cell lung cancer. 70 A series of studies in the context of other advanced malignancies showed similar results. [71] [72] This culminated in authoritative guidelines by the American Society of Clinical Oncology (ASCO), expressly recommending the early involvement of palliative care in all cancer patients with a high symptom burden or metastatic malignancy. 73 This recommendation has been internationally recognized. 74 Nevertheless, and despite this shift in perspective, there remain significant deficits in the provision of palliative care globally. 75 As significant as the ASCO guidelines were, they did not recommend the involvement of palliative care in the care of all cancer patients. In contrast, the definition of cancer rehabilitation includes care at all times in the cancer trajectory, from diagnosis and prior to treatment (prehabilitation), through treatment and its sequelae to the final stages of life. That span is one of its inherent strengths.

Assuming an alliance between palliative care and cancer rehabilitation existed, what would be the role of the former discipline? That role would require a perspective both internal and external to itself. Internally, it would necessitate the best practice of Palliative Care in the skilled identification and assessment of symptoms and psychosocial and spiritual distress of the patient and their family and a plan to meticulously address these issues. As part of that plan, palliative care should simultaneously look externally to cancer rehabilitation in all aspects of care. These approaches have their respective strengths and, as such, highlight the potential dividends that may flow where both disciplines, and in an alliance with oncology, work together. A crucial aspect of any alliance is the preparedness of palliative care clinicians to reach out to and learn from their rehabilitation colleagues and to set aside pre-conceptions. 76 Another role of palliative care is advocacy -explaining and reinforcing the importance of cancer rehabilitation to the disciplines of oncology / haematology. Further, palliative care has a role in collaborative research with cancer rehabilitation, identifying the potential benefits of the individual components and whole approach of the disciplines. Finally, palliative care has, and will continue to have, a crucial role in the education of students in medicine, nursing and allied health in the principles and practice of the discipline and, as part of this, the importance of cancer rehabilitation in the overall architecture of care.

It is equally important to examine the role of cancer rehabilitation at the interface with palliative care. In essence, this requires in the former discipline, an openness to understanding the philosophy and practice of the latter. In particular, it is important that cancer rehabilitation understands the holistic response to suffering as well as appreciating the work in preserving and restoring function that occurs in palliative care services. Secondly, it requires a creative approach by cancer rehabilitationists in developing a truly multi-disciplinary approach where both disciplines are involved in patient care. The synergies that may flow from this alliance are discussed in the next section. The points made in the previous section regarding the role of palliative care in education and advocacy, apply equally to cancer rehabilitation.

What dividends may result from the two disciplines of cancer rehabilitation and palliative care working together? The synergies lie at several levels. Like the disciplines themselves, this discussion starts with the identification of the needs of the patient and their family. There are three near-universal phenomena with cancer: the experience of symptoms, emotional distress and functional impairment. The discipline of palliative care has a forensic interest in the pathophysiology and management of symptoms. Palliative care has been shown to improve symptoms and quality of life. 77 Cancer rehabilitation focuses on the assessment and management of functional limitations. Cancer rehabilitation improves functional outcomes 14 and quality of life, even in patients with advanced malignancy. 57 It is the combination of these approaches that will present the greatest dividend to the patient and their carers. Indeed, the American College of Surgeons' Commission on Cancer requires that patients have access to both disciplines. 78 Synergies lie deeper, however, than simply the benefits of each discipline acting in parallel. Evidence shows that the work of each benefits and fulfils the objective of the other. In a systematic review of 13 studies of the effects of cancer rehabilitation in patients with advanced cancer who were receiving palliative care, Salakari and colleagues found significant improvements in QoL and general well-being as well as positive effects on fatigue, mood and coping with cancer. 62 In a systematic review of rehabilitation in advanced cancer, Albrecht et al showed that including rehabilitation in a palliative care program can have a positive effect on multiple cancer-related symptoms. 56 Conscious of the benefits of early palliative care, cited above, Nottelman et al conducted a randomized controlled trial involving patients with newly diagnosed advanced cancer. The control group received standard oncology care; the intervention group received standard oncology care plus palliative rehabilitation tailored to the individual patient. The latter consisted of an initial consultation with palliative care health professionals with follow up and, in addition, for eligible patients, a 12-week group program, including exercise and supplementary individual consultations. The intervention group reported high levels of satisfaction. 66 

It may be that an expanded cancer rehabilitation service is itself a source of referral to palliative care, and vice versa, where appropriate, outside the conventional referral pathway from medical and radiation oncology and haematology. A good example is cancer pain, which may be the source of significant impairment in function and quality of life. Quickly conscious of that impairment, a cancer rehabilitation service would refer to palliative care. Similarly, a patient with cancer-related fatigue and deconditioning may be referred by palliative care to cancer rehabilitation. This reciprocity of referral would allow the patient to receive a wide and comprehensive set of interventions.

For the discipline of Cancer Rehabilitation there is a disconnection. Although multiple bodies have recommended cancer rehabilitation and many cancer patients would benefit from it's integration into standard oncology care, the discipline is underutilized. Cheville and colleagues reported that less than 30 % of women with advanced breast cancer who had functional impairment received rehabilitation services. 76 Similarly, and strikingly, Pergolotti and colleagues found that only 9 % of older adults with cancer used physiotherapy or occupational therapy, despite having a modifiable functional limitation detected by a comprehensive geriatric assessment. 13 Why is Cancer Rehabilitation underutilized? What are the challenges and barriers for the discipline?

A significant barrier to the referral of cancer patients to both Cancer Rehabilitation and Palliative Care are professional misconceptions about their roles. Palliative Care may be seen to be purely terminal care and only to be introduced when all active treatment options are exhausted; rehabilitation is often confused with community exercise and fitness programs or viewed as ineffective. Both disciplines are far broader than these narrow perceptions. Perceptions are important. In a study of medical oncologists of their opinion of the appropriateness of rehabilitation for patients with advanced cancer, there were significant variations in view. 12 This raises the issue of the training in, and exposure to, rehabilitation medicine for medical students and trainees in oncology (medical, radiation and surgical), haematology and palliative care. The creation and nurturing of alliances between the disciplines is also a matter of medical leadership.

One of the major barriers to cancer rehabilitation is the interest and knowledge of cancer patients in the nature of the discipline and what benefits may flow from interventions. In one study, 1179 cancer patients were given a Cancer Rehabilitation Interest questionnaire that comprised 16 different rehabilitation activities. The interest in cancer rehabilitation for patients in this study was 21%. Most interested were women, young patients, university educated and those who received their diagnosis 12 months earlier. About 30% of the participating cancer patients reported an interest in information and support groups, physical training and support from a hospital social worker. Patients with a low level of education reported a low interest in Cancer Rehabilitation. 80

One of the reasons for low utilization is a workforce shortage of Rehabilitation physicians and Allied Health professionals generally and, specifically, of those with experience or training in oncology. 81

There is a clear need for further research in this area. Lyons and colleagues describes the "research gap" in cancer rehabilitation in two general areas -testing the effects of specific interventions "beyond functioning, on survival, health care utilization, and costs" and, secondly, testing the overall efficacy of multidisciplinary rehabilitation delivered concurrently with oncology treatment. 82

For an emerging discipline, the relative dearth of research and the lack of clinical guidelines have been impediments to growth. Gradually, however, expert standards and recommendations are emerging. Arguably, the most authoritative are the recommendations of the expert panel convened by the US National Institutes of Health (NIH), that covered all aspects of establishing and growing a cancer rehabilitation service. 11 As Lyons and colleagues state, more needs to be done. 82

Other factors that challenge the provision of cancer rehabilitation include economic issues, such as a lack of private health insurance in nations without universal health insurance coverage and the challenge, in many nations, of service coordination across sectors, e.g. hospital and the community.

Australia has been progressively adopting telehealth services, out of necessity, because of the concentration of many medical sub-specialties in the major cities situated on the coastline, coupled with the relatively underserviced population, widely dispersed in regional, rural and remote locations over our vast landmass. The COVID-19 pandemic has rapidly accelerated the adoption of telehealth and our local experience has yielded a mix of positive and negative outcomes.

-Improved accessibility to health consultations, particularly for those with significant frailty or mobility impairment. -Convenience, for both the caring team as well as the patient and their care

givers. -Maintenance of isolation requirements to reduce potential spread of COVID-19, which serendipitously has markedly reduced the incidence of other viral illnesses locally, such as influenza, when comparison is made to equivalent months in years past. This is particularly important for those who are immunocompromised as a consequence of their disease and / or treatment.

Negative factors include: -Inability to examine patients and determine the extent of impairments; -Difficulty fulling engaging with patients and care givers, particularly for new patients where rapport has not been established at an earlier face to face consultation. -As a 'physical' specialty, it is challenging for allied health teams to implement and evaluate exercise programs, self-care and home assessments; swallowing evaluations and provide wound care. -Older patients often lack the requisite IT hardware and / or software, or the experience to participate in telehealth consultations, often resulting in videoconference consultations being downgraded to voice-only telephone calls.

Notwithstanding these factors, telerehabilitation is becoming increasingly useful for people with cancer. The COPE study, a 3-arm randomized trial by Cheville et al., revealed that collaborative, (primary and specialist care), telerehabilitation modestly improved function, pain and QoL with a reduction in hospital utilization and inpatient length of stay. 83 

Cancer rehabilitation is not yet a well-established concept in Australian medicine, despite 30-40 years of evidence worldwide revealing benefits in all the stages of the cancer care continuum. The main foci of cancer care have been treatment and surveillance. An examination of cancer rehabilitation in Australia reveals the same disconnection set out above between a recognition by cancer bodies and professional organizations of it's importance and undeveloped services. The available programs mostly include exercise and education components, with education covering issues related to exercise, nutrition, fatigue, relationships and sleep. 84 Jefford et al found from a population-level cross sectional study in 2017 that substantial proportions of Australian cancer survivors demonstrated problems with mobility, pain, anxiety, depression and daily activity limitations, one, three and five-years following diagnosis. 85 Additionally, up to a third of survivors in this study reported wanting more information on the physical aspects of living with and after cancer, including advice regarding diet, lifestyle, physical activity and exercise.

Cancer Australia released a national framework, titled 'Principles of Cancer Survivorship' in 2017. 86 It recognizes the importance of supportive physical, psychological and social care, as well as holistic care that is coordinated between various providers throughout the cancer care continuum. The breadth of this care is a reminder to all disciplines, including cancer rehabilitation, of the importance of attention to the psychosocial and existential dimensions of the suffering associated with cancer. This attention is a strength of palliative care and bolsters the argument for an alliance of disciplines, each benefitting from an involvement of the other.

The Clinical Oncology Society of Australia (COSA), has also developed a consensus-based 'Model of Survivorship Care' that describes the crucial elements of survivorship care, though this has not yet been implemented. 87 COSA published a position statement on cancer survivorship care in 2019 concluding that: "At present, the evidence basis remains incomplete, and successful implementation will require research, education, coordination and advocacy. The COSA Survivorship Model of Care provides a template for change, guiding the key steps for implementation into the future." 87

In the modern era, three phenomena have emerged. The first is a growing number of cancer survivors and a recognition of their complex needs. The second is the international recognition of the importance of early palliative care in patients with advanced cancer or who are highly symptomatic, coupled with continuing deficits in service provision. The third is an enlarging body of evidence that rehabilitation can benefit the function and quality of life of cancer patients and, further, that this benefit can occur at any point along the cancer continuum. From this, emerged the concept and practice of a discipline, cancer rehabilitation, devoted to all cancer patients where the skills of a multi-disciplinary rehabilitation team could be employed. With time, this care has become an imperative. As Silver states: "Gaps in providing cancer rehabilitation services to those who would benefit equates to unnecessary physical and psychological suffering." 3 While endorsed, the discipline continues to be challenged by issues of public and professional perception, manpower, funding and the need for research. The disciplines of cancer Rehabilitation and Palliative Care are natural allies and, over time, the level of mutual respect, understanding and combined work will hopefully strengthen that alliance.

The authors received no funding for this article and have no conflict of interest. Exercise promotes significant improvements in clinical, functional, and in some populations, survival outcomes and can be recommended regardless of the type of cancer. Exercise is beneficial before, during, and after cancer treatment, across all cancer types, and for a variety of cancer-related impairments. 50 6, 14, 15 Preventative Rehabilitation

Also referred to as prehabilitation or prospective surveillance. Early intervention and exercise to identify potential impairments and prevent or delay complications related to cancer or therapies.

For cancer patients with potential to attain a full functional recovery, restorative rehabilitation offers comprehensive therapy to regain function, to return to work or school.

For patients with some temporary and permanent deficits from cancer and / or treatments, and patients with slowly progressive or chronic cancer, supportive rehabilitation can give the opportunity to re-establish and maintain functional independence.

For patients with treatment refractory cancer or advanced disease, less intense palliative rehabilitation may play a role in assisting the patient and their family by maximizing patient comfort and reducing caregiver burden.

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From Cancer Patient to Cancer survivor

Cancer Care for the Whole Patient: Meeting Psychological Health Needs

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis

Exercise interventions on health-related quality of life for people with cancer during active treatment

Clinical exercise interventions in prostate cancer patients-a systematic review of randomized controlled trials

Randomized controlled trial of a structured training program in breast cancer patients with tumor-related chronic fatigue

A randomised controlled trial testing the feasibility and efficacy of a physical activity behavioural change intervention in managing fatigue with gynaecological cancer survivors

Effects of supervised exercise on motivational outcomes and longer-term behavior

Maximizing Functional Outcomes in Head and Neck Cancer Survivors Assessment and Rehabilitation

Exercise interventions on health-related quality of life for people with cancer during active treatment

A Systematic Review of Exercise Systematic Reviews in the Cancer Literature

Interventions for promoting habitual exercise in people living with and beyond cancer

Cancer cachexia: rationale for the MENAC (Multimodal-Exercise, Nutrition and Anti-inflammatory medication for Cachexia) trial

A randomized controlled trial of outpatient Cancer Rehabilitation for older adults: The CARE Program

Older Adults with Cancer: A Randomized Control Trial of Occupational and Physical Therapy

Rehabilitative Palliative Care: Enabling people to live fully until they die -a challenge for the 21 st century

Physical activity in patients with advanced-stage cancer: a systematic review of the literature

Safety and feasibility of a combined exercise intervention for inoperable lung cancer patients undergoing chemotherapy: a pilot study

Rehabilitation in advanced, progressive, recurrent cancer: a randomized controlled trial

A home-based exercise program to improve function, fatigue, and sleep quality in patients with stage IV lung and colorectal cancer: a randomized controlled trial

An interprofessional palliative care oncology rehabilitation program: effects on function and predictors of program completion

Changes in and Associations Among Functional Status and Perceived Quality of Life of Patients With Metastatic/Locally Advanced Cancer Receiving Rehabilitation for General Disability

Effects of rehabilitation among patients with advanced cancer: a systematic review

Physiotherapy programme reduces fatigue in patients with advanced cancer receiving palliative care: randomized controlled trial

Therapeutic exercise in cancer cachexia

A parallel-group randomized clinical trial of individually tailored, multidisciplinary, palliative rehabilitation for patients with newly diagnosed advanced cancer: the Pal-Rehab study protocol

A new model of early, integrated palliative care: palliative rehabilitation for newly diagnosed patients with nonresectable cancer

World Health Organization. WHO Definition of Palliative Care

Occupational therapy in palliative care

Oxford Textbook of Palliative Medicine

Early palliative care for patients with metastatic nonsmall-cell lung cancer

Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomised controlled trial

Effects of early integrated palliative care in patients with lung and GI cancer: a randomised clinical trial

Integration of palliative care into standard oncology care:American Society of Clinical Oncology Clinical Practice Guideline update

European Society for Medical Oncology (ESMO) Program for the Integration of Oncology and Palliative Care: a 5-year review of the designated centers' incentive program

Mapping Levels of Palliative Care Development in 198 Countries: The Situation in 2017

Integrating Function-Directed Treatments into Palliative Care

Do hospital based palliative care teams improve the care of patients or families at the end of life ?

American College of Surgeons. Commission on Cancer. Cancer program standards 2012: ensuring patient-centered care

Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer

Cancer patients' interest in participating in cancer rehabilitation

The underutilization of rehabilitation to treat physical impairments in breast cancer survivors

Follow the Trail: Using Insights from the growth of Palliative Care to Propose a Roadmap for Cancer Rehabilitation CA

Effect of Collaborative Telerehabilitation on Functional Impairment and Pain Among Patients With Advanced-Stage Cancer

Exercise therapy in oncology rehabilitation in Australia: A mixed-methods study

Patient-reported outcomes in cancer survivors: a population-wide crosssectional study

Principles of Cancer Survivorship

Clinical Oncology Society of Australia position statement on cancer survivorship care