American cancer catalog society

INTRODUCTION

According to the American Cancer Society, approximately 9.6 million Americans were surviving after cancer as of January 2000 (representing approximately 3% of the US population at the time), and approximately 1.4 million new cases will be diagnosed in 2004.1 Physical therapists have much to offer cancer patients and survivors. While actively fighting cancer or in hospice (depending on the cancer, its stage, and treatment) patients may experience symptoms or side effects of treatment such as pain, nausea, fatigue, weakness, loss of range of motion, increased fracture risk, anxiety, and loss of function. Depending on cancer site, treatment experience and general health, some survivors may experience functionally limiting long-term physiologic effects such as weakness, contracture, lymphedema, gait disturbance, neuropathy, paralysis, cardiopulmonary problems, fracture, stress incontinence, or renal failure.2 The American Cancer Society has declared pain management to be a major priority, since fewer than half of the cancer patients who experience pain receive adequate pain management.1 Physical therapy measures including appropriately dosed exercise, relaxation, physical agents, and manual interventions can be important adjuncts to medical pain management in cancer care. Well-informed physical therapists, working cooperatively with other members of the cancer team, can provide a valuable resource to promote optimum function among patients with movement disorder resulting from either the effects of an invasive tumor, or from side effects of chemotherapy, radiation, or surgery. No articles were found concerning the number of patients that physical therapists treat for cancer-related issues, or about the number of patients whose needs go unmet.

PURPOSE

The purpose of this study was to examine cancer-related practice patterns of licensed physical therapists in the state of Washington.

MATERIALS/METHODS

We composed a questionnaire and mailed it to 1374 licensed physical therapists that were members of the American Physical Therapy Association (APTA) and the Physical Therapy Association of Washington, Inc. (PTWA), as of March 2002. We asked the therapists about their practice settings, whether their practice included patients with either a primary or secondary diagnosis of cancer, and what proportion of their practice was made up of such patients. When therapists indicated they treated patients with cancer, we asked about forms of treatment they used, and typical dosing/monitoring procedures. Nonrespondents received a duplicate follow-up mailing 6 weeks later. The University of Puget Sound Institutional Review Board approved the study. We used the Statistical Package for the Social Sciences (SPSS 10.0 for Windows) for tabulation and analysis of data.

RESULTS

We received 824 questionnaires, for a response rate of 60%. Of those responding, 386 therapists (46.8% of respondents) indicated that their practices included patients with either a primary or secondary diagnosis of cancer. Of the therapists who indicated they were treating patients with cancer, 85% indicated that patients with cancer made up less than 25% of their case load, and only 0.3% indicated that their case load consisted primarily of patients with cancer (Figure 1). Therapists who indicated their caseloads included patients with cancer worked in a wide variety of settings, but the largest group (56.6%) worked in outpatient orthopedic settings (Figure 2).

When treating patients with cancer, responding therapists indicated using a variety of intervention types including exercise, patient education, manual lymphatic drainage, compression garments, and various forms of stretching (Figure 3). During treatment, a majority of these therapists indicated they monitored heart rate, blood pressure, ratings of perceived exertion, and medications taken, but less than 30% indicated they monitored blood values such as hematocrit and blood sugar, and 9.3% indicated they do not monitor anything during treatment. While 53% of these therapists indicated they use aerobic exercise when treating patients with cancer, only 37% establish a baseline by which to monitor progression of aerobic exercise (Figure 4). Among responding therapists who indicated they treat patients with cancer, 49.7% treat lymphedema, using manual lymph drainage, compression bandages and/or garments, and exercise. Among therapists who indicated they see patients with cancer, 68% noted that they use functional outcome measures, most frequently Functional Impact Measure (30.7%), while 42% indicated they do not measure function (Figure 5).

CONCLUSION/DISCUSSION

Patients with either a primary or secondary diagnosis of cancer appear to make up at least part of the caseload of a relatively large number of therapists in Washington state, a finding that is not surprising considering the prevalence of the disease in the general population. However, the majority of therapists indicate they see relatively few patients with cancer. The caseload proportion may have been under-reported by some therapists, since not all patients reveal the existence of their cancer during intake history for a problem they may feel is unrelated to the cancer. There are indications in these data that many therapists do not follow best practices with this population in terms of appropriate monitoring of exercise and measuring functional outcome. Of those who measure function, the majority chose the Functional Impact Measure, which may not be ideal for this population because of its relative insensitivity to slow gradual improvements in function.

Our study has certain limitations. In asking therapists about the proportion of their practice that included patients with a primary or secondary diagnosis of cancer, the smallest increment we provided for the answer was "less than 25%." In retrospect, we believe that question was not sufficiently sensitive, since the response would not clarify whether a respondent saw oncology patients only occasionally or 25% of the time. We surveyed only members of the American Physical Therapy Association, and their practice patterns may not be representative of all therapists. Our data cannot be generalized to represent the experience of physical therapists throughout the United States, since our sample involved only Washington state physical therapists, and there is considerable geographic variation with regard to the existence of major facilities for cancer treatment. It is not surprising that our sample did not include many therapists whose primary case loads were made up of oncology patients. There is one regional cancer research center in Washington state, and that facility has one physical therapist on staff, who is actively working to increase awareness of physical therapy in that setting. However, even within facilities with larger physical therapy staffs, therapists report struggles with educating colleagues about the benefits of physical therapy.8

CLINICAL RELEVANCE

While the emphasis in cancer treatment in research has clearly been on cure over the years, rehabilitation for cancer survivors was designated as a specific emphasis of the National Cancer Institute in the 1970s, and emphasis on cancer rehabilitation has grown through the 1990s.7 Many physical therapists in the workforce completed entry-level degrees more than a decade ago, thus their education would predate increasing awareness of cancer rehabilitation. The Interactive Guide to Physical Therapist Practice is of limited help in disseminating the appropriate knowledge for this population since there is not a practice pattern for oncology per se.9 Thus, physical therapist knowledge in this area depends on an active choice to seek continuing education in the area. Findings of this study suggest that renewed attention to best practices for oncology patients may be merited in physical therapy education and continuing education.

ACKNOWLEDGEMENT

This study was funded by the University Enrichment Committee of the University of Puget Sound.

REFERENCES

1. American Cancer Society. Cancer Facts and Figures 2004. Available at: http://www.cancer.org/docroot/STT/stt_0.asp. Accessed January 18, 2004.

2. Loescher LJ, Welch-McCaffrey D, Leigh SA, et al. Surviving adult cancers. Part I: Physiologic effects. Annals Int Med. 1989;111(5):411-432.

3. Dimeo F, Rumberger BG, Keul J. Aerobic exercise as therapy for cancer fatigue. Med Sci Sports Ex. 1998;30:475-478.

4. Drouin J, Pfalzer LA. Aerobic exercise guidelines for the person with cancer. Acute Care Persp. 1998;6:3-5.

5. Spranger K. Resistive and aerobic exercise: Tools in lymphedema management. Acute Care Persp. 1998;6:3-5.

6. Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. Cancer J Clin. 2000;50:292-307.

7. Mellette SJ. Cancer Rehabilitation. J National Cancer Institute. 1993;85(10):1-4.

8. Framroze A. Therapy and oncology: A partnership evolves. Rehab Management. 1991; April/May: 91-94