GUIDELINES FOR REHABILITATION IN PATIENTS WITH LUNG CANCER

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1 GUIDELINES FOR REHABILITATION IN PATIENTS WITH LUNG CANCER 1. GENERAL PRINCIPLES Cancer rehabilitation aims to improve the patient s quality of life by maximising their ability to function, to promote their independence & to help them to adapt to their condition. 1 Cancer rehabilitation may help improve psychological well-being and physical functioning. 1 There are recognised symptom clusters which occur in patients with lung cancer i.e. 2, 3 - Pain - Psychological distress - Dyspnoea - Fatigue The rehabilitation needs of lung cancer patients may include a number of different symptoms / issues. (see Table 1 and Figure 1) 4 Patients with lung cancer may have rehabilitation needs at different phases of their disease trajectory. Four cancer rehabilitation stages have been identified: 5 Preventative: reducing the impact of expected disabilities and learning to cope with any disabilities that do occur Restorative: returning the patient to their pre-illness level of functioning Supportive: in the context of continual disease. Aim to limit functional loss and provide support Palliative: in the context of further loss of function, provide support and put in place measures that eliminate or reduce further complications Table 1 Rehabilitation Needs of Patients with Lung Cancer 4 Anorexia and cachexia Anxiety / stress Communication difficulties Difficulties with work and leisure activities Dysphagia Dyspnoea Fatigue Impaired mobility Need for specific equipment Pain Reduction in independence for activities of daily living

2 Merseyside & Cheshire Cancer Network Clinical Indicators for Referral to Lung Cancer Rehabilitation Pathway Patients are at risk of developing or experiencing the following clinical indicators and should be assessed for referral to rehabilitation pathway interventions at all stages in the cancer care pathway as described below: Diagnosis & Care Planning Treatment Post Treatment Monitoring/ Survivorship Palliative Care End of Life Care Consider level of intervention required: Information support General rehabilitation services Specialist oncology/palliative rehabilitation Ensure patient has contact details for timely access to rehabilitation services (see local cancer services directory-rehabilitation services) Physiotherapy Difficulties with functional activities of daily living, leisure and work resulting from: Difficulty walking and getting around Breathing difficulties Fatigue/Tiredness Impaired balance/weakness Anxiety/role and function change/body image Cognitive impairment Equipment/environmental/information needs Difficulties with function, movement and symptom control: Difficulty walking and getting around Breathing difficulties/cough Fatigue/tiredness Weakness and loss of muscle strength (focal or generalized) Pain/sensory changes/body image Impaired Balance Equipment/information needs Occupational Therapy Dietician Impaired or risk of impaired communication, eating and drinking: Coughing on eating or drinking Weak voice or cough Difficulty with speech and/or understanding Nutrition and diet: Reduced appetite (anorexia) Malnutrition Weight loss/weight management (cachexia) Fatigue/tiredness Nausea and vomiting Difficulties swallowing Information needs Speech & Language Therapist Rehabilitation is not solely the responsibility of allied health professionals (AHP). All health and social care professionals may need to play a part. 6 Allied health professionals not only help cancer patients recover from the physical changes of their illness but also help them function in everyday activities and adapt to their new needs. 6 Key professionals providing cancer rehabilitation include: 6

3 Physiotherapists Occupational therapists Dieticians Speech and language therapists Lymphoedema therapists Other professionals who may contribute to the rehabilitation process include: 7 Podiatrists Psychosexual counsellors Stoma therapist Therapy radiographers Appliance officers Oral health specialists 2. GUIDELINES The rehabilitation needs of lung cancer patients should be reviewed at the different stages of their illness. 5 [Level 4] This will include: Diagnosis Treatment Post treatment Monitoring and survivorship Palliative care In last hours to days of life Holistic assessment tools can help in the assessment of rehabilitation needs e.g. distress thermometer, SPARC. 6, 8 [Level 4] A key worker for each patient should be identified to provide continuity of care throughout the patient pathway. 9 [Level 4] There is evidence which supports the role of rehabilitation for lung cancer patients in several areas.(see sections below) 2.1 Cancer-related fatigue Exercise interventions have been shown to have some benefit in the management of cancer-related fatigue during and post cancer therapy. No studies have specifically been conducted with lung cancer patients. Initial studies looking into the role of a pre- and post-surgical exercise program for lung cancer patients show promising results and further randomised controlled trials are required. 10,11,12,13

4 Exercise is a simple low-risk intervention and should be considered to help patients suffering from cancer-related fatigue both during and after treatment. 10 [Level 1+] Non-pharmacological therapies combining exercise and psychosocial interventions also show potential for improvement in functioning. e.g. cognitive-behavioural techniques Breathlessness Non-pharmacological interventions and pulmonary rehabilitation have been shown to improve patients management of their breathlessness and functional ability although some of the trials have been conducted with COPD patients. 15,16,17,18,19 A referral for more intensive non-pharmacological and psychological intervention should be considered for lung cancer patients to help improve both their dyspnoea and functioning level. 15 [Level 1+] Simple measures like the use of walking aids and breathing re-training should be considered to help lung cancer patients manage their breathlessness. 19 [Level 2+] 2.3 Anorexia /cachexia The role of multimodal strategies to address food intake and metabolic change remains controversial. There have been some studies demonstrating an improvement in function and quality of life but more research is required Pain Successful pain management can be achieved through the co-ordinated efforts of team members e.g. input from an occupational therapist can help modify pain perceptions & lifestyles for individual patients. 21 There is evidence to support the use of acupuncture in the management of nausea / vomiting and breathlessness but not currently for pain. 7, 19 There is some evidence of the effectiveness of massage interventions on pain and psychological well-being. Although the evidence for acupuncture and massage is limited, these can still be beneficial interventions for some lung cancer patients. 22 [Level 4] Relaxation therapy should be considered as an intervention to help with psychological symptoms and somatic symptoms such as pain. 23 [Level 1-]

5 3. STANDARDS 1. All lung cancer patients approaching the end of life should have their rehabilitation needs assessed, ideally using a holistic assessment tool e.g. distress thermometer, SPARC 6, 8 [Grade D] 2. Lung cancer patients approaching the end of life should have access to rehabilitation services according to need and in a timely manner. Routine referrals should be seen within two weeks. Urgent referrals should be seen within 48 hours e.g. high risk of falls; to prevent an acute admission; patient in last hours or days of life. 6 [Grade D] 3. A cancer rehabilitation team should consist of, but not be limited to, the following five key Allied Health Professionals (AHPs) highlighted within the National Cancer Action Team Rehabilitation Care Pathway physiotherapist, occupational therapist, speech and language therapist, dietician, and lymphoedema specialist. 6 [Grade D] 4. There should be clear referral pathways for general rehabilitation services and specialist AHP services (who can deliver rehabilitation interventions). 6 [Grade D] 4. REFERENCES 1. Rankin J, Robb K, Murtagh N. (eds) Rehabilitation in Cancer Care.2008 Oxford. Wiley-Blackwell. 2. Gift A, Jablonski A, Stommel M, Given C. Symptom clusters in elderly patients with lung cancer. Oncol Nurs Forum 2004; 31: Fox S, Lyon D. Symptom clusters and quality of life in survivors of lung cancer. Oncol Nurs Forum 2006; 33: NHS National Cancer Action Team. National Cancer and Palliative Care Rehabilitation Workforce Project. Project Overview Report January Available from: hs.uk/our-work/living-beyond-cancer/cancer-rehabilitation#. [Last accessed October ] 5. Dietz (1981) cited in Rankin J, Robb K, Murtagh N. (eds) Rehabilitation in Cancer Care Oxford: Wiley-Blackwell 6. National Institute for Clinical Excellence. Guidance on cancer services - Improving supportive and palliative care for adults with cancer - The manual London, NICE. Available from: [Last accessed October ] 7. Rehabilitation Care Pathway Lung. NHS National Cancer Action Team. Crown Copyright Cramp F; Daniel J. Exercise for the management of cancer-related fatigue in adults (Review). Cochrane Database Systematic Review 2008 April 16 ;(2): CD doi: / CD pub2.

6 9. Dimeo F, Schwartz S, Wesel N, Voight A, Thiel E. Effects of an endurance and resistance exercise program on persistent cancer-related fatigue after treatment. Ann Oncol 2008; 19(8): Hanna LR, Avila PF, Meteer JD, Nicholas DR, Kaminsky LA. The effects of a comprehensive exercise program on physical function, fatigue and mood in patients with various types of cancer. Oncol Nurs Forum 2008; 35 (3): Kangas M, Bovbjerg D, Montgomery G. Cancer-related fatigue: A systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychol Bull 2008; 134(5): Jones LW, Peddle CJ, Eves ND, Haykowsky MJ, Courneya KS; Mackey JR et al. Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer 2007; 110 (3): Bredin M, Corner J, Krishnasamy M, Plant H, Bailey C, A Hern R. Multicentre randomised controlled trail of nursing intervention for breathlessness in patients with lung cancer. Br Med J 1999; 318(7188): Corner J, Plant H, A hern R, Bailey C. Non-pharmacological intervention for breathlessness in lung cancer. Palliat Med 1996; 10: Nici L. The role of pulmonary rehabilitation in the lung cancer patient. Semin Respir Crit Care Med 2009; 30: Hateley J, Laurence V, Scott A, Baker R, Thomas P. Breathlessness clinics within specialist palliative care settings can improve the quality of life and functional capacity of patients with lung cancer. Palliat Med 2003; 17: Bausewein C, Booth S, Gysels M, Higginson IJ. Non-pharmacological interventions for breathlessness in advanced stages of malignant and nonmalignant diseases. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD DOI: / CD pub Fearon K. Cancer cachexia: developing multimodal therapy for a multidimensional problem. Eur J Cancer 2008; 44: Luebbert K, Dahme B. Hasenbring M. The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: a meta-analytical review. Psychooncol 2001; 10: Wilkinson S, Barnes K, Storey l. Massage for symptom relief in patients with cancer: systematic review. J Adv Nurs 2008; 63 (5): Lloyd C, Coggles L. Contribution of occupational therapy to pain management in cancer patients with metastatic breast disease. Am J Hosp Care 1988; 5(6): Merseyside and Cheshire Cancer Network. Key Worker Guideline Available from: UIDELINE%20V2%20- %20Reviewed%20November%202011%20(Final)(1).pdf [Last accessed October ]

7 23. National End of Life Care Programme. Holistic Common Assessment of Supportive and Palliative Care Needs for Adults requiring End-of-Life Care. March Available from: [Last accessed October ] 5. CONTRIBUTORS Lead Contributors Dr K Gaunt, StR in Palliative Medicine, Aintree Palliative Care Service. Aintree University Hospital NHS Trust, Liverpool Dr A Nwosu, Academic Clinical Fellow in Palliative Medicine, Aintree Palliative Care Service, Aintree University Hospital NHS Trust, Liverpool Contributors Ms J Bayley, Senior Physiotherapist, Aintree Palliative Care Services, Aintree University Hospital NHS Trust, Liverpool Dr C Mayland Consultant in Palliative Medicine, Aintree Palliative Care Services Aintree University Hospital NHS Trust, Liverpool Invited Experts Ms G Eva, Research Fellow, Institute of Neurology, University College London Mrs L Morgan, Lung Cancer Clinical Nurse Specialist, The Clatterbridge Cancer Centre NHS Foundation Trust Date of Guideline Production September 2010 Date of Guideline Review August 2014 Date Posted on Network Website April 2015

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