On the front lines of the war on cancer, nurses are often the field commanders—in charge of safely navigating patients through treacherous terrain as well as delivering medical treatment that should provide maximal health benefits and minimize adverse effects. Oncology nurses interface with the “new recruits” and help them through many difficult challenges. Nurses are well positioned to see the short- and long-term effects of cancer and its treatment on patients. They see the physical and emotional impairments develop and accumulate over time. And yes, they see the “financial toxicity” that is caused by the disease and health professionals’ attempts to treat it. Oncology nurses are also uniquely positioned to contribute to and/or lead prehabilitation efforts that may reduce the burden of cancer on individuals and society.1
One cancer survivor wrote a blog that included this question in the title: Are we doing too much in oncology backwards?2 In his blog post he said, “I was reviewing my blood work after my recent stem cell transplant and noticed that my hemoglobin and red blood cells had dropped 47% from my normal health to their lowest values two weeks after my transplant. I then checked what altitude a 50% drop in oxygen would correspond to. A 50% drop in oxygen represents an altitude of over 19,000 feet. Mt. Everest south base camp is 16,700 feet.” The survivor continued, “It would be irresponsible to send someone to Mt. Everest base camp without training them first, but it is common practice in oncology to physically challenge patients in a similar manner without training them for the difficulty to come. Instead, we nurse patients through the treatment challenge, cheer them when they are finished, then send them off to physical therapy to address injuries.” Then, in bold and italics for emphasis, he admonished, “This is not a success story, this is poor survivorship planning.”
Lillie D. Shockney, RN, BS, MAS, a University Distinguished Service associate professor of breast cancer at Johns Hopkins University School of Medicine and director of the Johns Hopkins Cancer Survivorship Program, is a big proponent of evidence-based prehabilitation care. Lillie, who is also the program director and cofounder of the Academy of Oncology Nurse & Patient Navigators (AONN+), says, “We need to focus on survivorship care beginning at the time of diagnosis. Our institution embraced this concept some time ago. It works. Patients value it. The oncology specialists have seen its benefit to their patients. Survivorship care needs to begin at the moment of diagnosis. Prehab is part of that process of implementing survivorship care early on.”
Important Lessons From a Best Practices Prehabilitation Model
In 2013, my colleague and I published the first-ever review on cancer prehabilitation.3 In this journal article, we highlighted the growing body of research in the field that supports making changes in clinical care delivery, now. At the editor’s request, we included a list of the search terms we used because, unfortunately, “prehab” and “prehabilitation” are the least likely terms to be found in the scientific literature. Terms such as “prophylactic cancer rehabilitation” or “preoperative cancer rehabilitation” are much more common. Consequently, it’s easy to underestimate the evidence base.
About a year or so before the cancer prehabilitation review article was published, I led the launch of STAR Program Prehab in the United States—a best practices model that translates the current evidence base into protocols that hospitals and cancer centers can implement. As the evidence base grows, the ability to provide more guidance increases. STAR Program Prehab is a multimodal model that involves 5 key components of prehabilitation care, including general and targeted exercise, nutrition, stress reduction, and smoking cessation (Figure 1).
In the past year, we’ve seen exponential growth in implementation that is probably due to multiple factors, including recently released research studies and reviews, clinicians becoming more familiar with the concept of prehabilitation, and patients wanting these services. Over the past 3 years, we’ve learned a lot about what works and what doesn’t, to anticipate the barriers and effectively overcome them. Listed next are some of the most important lessons gleaned from implementing cancer prehabilitation services.
Lesson #1: Take the time to define cancer prehabilitation for your entire team.
One of the key lessons we’ve learned is that a lot of healthcare professionals believe they are already delivering cancer prehabilitation services, when what they are offering is “usual care” preoperative preparations or “usual care with education” (Figure 2). Prehabilitation is defined as “[A] process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and 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.”4
By definition, prehabilitation is time based, and requires documented assessments and interventions that demonstrate specific outcomes. Therefore, it is data driven. It is imperative that the entire healthcare team understands the definition or there will be people who believe that prehab is “whatever is done prior to surgery or the start of other cancer treatments.” This inaccurate and overly simplistic view of cancer prehabilitation—which is medical treatment—results in poor implementation and suboptimal patient outcomes.
Lesson #2: Engage an oncology physician champion.
Ron Ponchak, PT, MBA, is the director of rehabilitation at Lahey Hospital and Medical Center in Massachusetts. Ron knows firsthand that an engaged oncology physician can make all the difference. He advises, “You need a champion and a few key people who are really engaged, and those people are the drivers of your program.” At Lahey, Ron works closely with Andrea McKee, MD, a radiation oncologist specializing in lung cancer. Dr McKee says, “Prehab is part of patient-centered care. One of the first things patients ask me during our initial visit together is, ‘What can I do to help myself?’ Patients already intuitively understand that prehab will benefit them. It has taken the medical community a little bit longer to catch on. [At Lahey] our team is very excited to offer pulmonary prehab. Everyone is completely engaged and eager to work together for the benefit of our thoracic oncology patients.”
Lesson #3: Arm your champions with the information they need to convey to colleagues how to overcome the 2 biggest barriers: time and money.
With regard to time, there are 2 approaches—one is to avoid delays in starting cancer treatment and the other is to accept delays if they can be justified by the benefit-versus-risk assessment. This is something that individual oncologists must decide on a case-by-case basis. For example, in some patients with lung cancer who have comorbidities, surgery to resect the cancer may carry considerable risk. Dr Timothy Sherwood, a thoracic surgeon at Mary Washington Healthcare in Virginia, says he is not overly concerned about delays and sends all of his “mid-risk” and “high-risk” patients with lung cancer to prehab for 4 to 8 weeks. He explains that there are already built-in delays with staging and that, regardless, he wants his patients to safely get through the surgery. He says, “I would rather have them get through surgery safely than have a horrific postoperative outcome.”
Delays may be due to the need for further diagnostic testing or to patients getting second or even third opinions. Sharon Gentry, RN, MSN, a breast nurse navigator at Novant Health Derrick L. Davis Cancer Center in North Carolina, says, “There is usually a ‘hurry up and wait’ time as oncology patients undergo biopsies and scans to establish the stage of their disease prior to treatment planning. This is a perfect time to engage the patient, physically and emotionally, to become active against their disease.” Dr McKee at Lahey concurs: “I am not concerned that treatment will be delayed by prehab. The program is designed to gently encourage and build the reserve of our patients prior to surgery or treatment, not run them into the ground.”
Dr Sherwood and his team have shown not only that they are able to get their patients safely through surgery, but that some of the survivors are actually healthier after cancer treatment than they were at diagnosis.5 Beth Ann Palmento is one of Dr Sherwood’s former patients who had this experience. When her lung cancer was diagnosed at age 74 years in February 2013, she was offered the choice of either palliative radiation therapy or lung cancer prehabilitation followed by surgical resection to potentially cure her disease. Beth Ann wanted to have surgery. “I knew the radiation option meant I wouldn’t have a very long life. When Dr Sherwood delayed the surgery, I understood he had a reason for doing it. He told me in the beginning that I wasn’t ready for surgery.” After several weeks of prehabilitation, Beth Ann went into surgery with more confidence than she would have had without it. “I think it helped a lot. After my surgery, my husband had to slow me down, because I felt so good.”
Of course, delays aren’t always appropriate or even necessary. Matt LeBlanc, RN, BSN, is an oncology rehabilitation nurse navigator at Anne Arundel Medical Center in Maryland. He heard from colleagues, “We don’t have time for patients to do prehabilitation, because we are doing such a great job and getting them into acute cancer treatment right away.” Matt calculated the time from diagnosis for head and neck cancer patients to see a speech-language pathologist: 57 days. He knew that starting targeted swallowing exercises and offering other prehabilitation interventions would likely improve patients’ outcomes.6 Matt says, “We set a goal that all head and neck patients would see the speech therapist either the week before or the week they started radiation.” To do this, Matt recognized that the speech therapist needed to be embedded in the radiation department. He reports that the start of speech therapy changed from 57 days to −6 days—meaning that, on average, patients now see the speech therapist 6 days prior to the start of radiation treatment rather than 57 days after treatment has started (Figure 3).
Matt knew that to get the oncologists on board, he needed to show them data. He says, “Once we set the goal, it’s been much better.”
The second commonly stated barrier that your champions will need to address with colleagues is money. Usually this takes one of two forms—either that prehabilitation won’t be covered by third-party payers or that patients will incur additional co-pays that become a financial burden to them. Co-pays and other expenses for prehabilitation can usually be justified when one considers the often overwhelming financial difficulties of patients who, after treatment, develop significant physical impairments requiring many rehabilitation visits, lost time from work, and sometimes permanent disability. It is less expensive for the patient and society to prevent or reduce physical impairments from the start.
With regard to third-party payer coverage, a lot of confusion exists among healthcare professionals, because there is no “prehabilitation” reimbursement code. As with all medical care, the delivery of these services, as well as the coding and billing with appropriate documentation, is essential for reimbursement. Lori McKitrick, MA, CCC/SLP, MBA, the senior director of program management for the STAR Program, says, “We are working with our programs to implement a multimodal and interdisciplinary reimbursable model for cancer prehabilitation. To date, the majority of services have been covered, as long as there is proper documentation and coding.”
Lesson #4: Include Nurses and Rehabilitation Professionals on the Prehabilitation Team
Nurses are a critical part of offering successful cancer prehabilitation services.7 The STAR Program actively engages oncology nurses.8 Lori McKitrick explains, “The STAR Program sees all patient care as interdisciplinary. The nurse and/or navigator is a key driver in the patient’s course of treatment.” Lillie Shockney agrees: “As more and more people become diagnosed with cancer and fewer oncology specialists exist to take care of them, the role of nurses, nurse navigators, and other healthcare professionals will increase. We need to make sure rehab medicine specialists are part of that healthcare team.”
Although the STAR Program has begun to implement best practices prehabilitation protocols, there is still much work to be done. Messina Corder, RN, BSN, MBA, is the manager of the Mary Washington Healthcare Regional Cancer Center administration department. Despite their early success with physical outcomes and a downward trend for hospital length of stay in their prehabilitation patients with lung cancer, she says, “Prehab is underutilized in general and in our institution. It has taken our STAR Program’s continued physician education, networking, and evidence of positive patient outcomes to build a network of trust and understanding about prehab.” Sharon Gentry believes that prehabilitation services will become the standard of care and says, “Think of prehab as a phase in population management—a way to make the patient remain an active member of society and possibly a stronger, healthier member.”
Julie Silver, MD, is an associate professor at Harvard Medical School and a founder of Oncology Rehab Partners (www.OncologyRehabPartners.com), which developed the STAR Program, a service-line model for high-quality cancer prehabilitation and rehabilitation care that has been adopted by more than 200 hospitals and cancer centers and is now available at hundreds of sites throughout the United States.
1. Silver JK. Cancer prehabilitation and its role in improving health outcomes and reducing healthcare costs. Semin Oncol Nurs. 2015;31(1):13-30.
2. Workoutcancer.org website. https://workoutcancer.wordpress.com/2014/01/22/regarding-exercise-are-
we-doingtoo-much-in-oncology-backwards-2/. Accessed January 27, 2015.
3. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options and improve physical and psychological health outcomes. Am J Phys Med Rehab. 2013;92(8):715-727.
4. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. 2013;63(5):295-317.
5. Hunt E, VanderWijst K, Stokes B, et al. Prehabilitation improves the physical functioning of a newly diagnosed lung cancer patient before and after surgery to allow for a safe surgical resection and decreased hospital length of stay: a case report. J Oncol Navigation Survivorship. 2014;5(4):34-35.
6. Kotz T, Federman AD, Kao J, et al. Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: a randomized trial. Arch Otolaryngol Head Neck Surg. 2012;138(4):376-382.
7. Knowlton SE, Silver AJ, Silver JK, et al. Can nurses provide assessments and interventions for prehabilitation? A survey study of cancer rehabilitation service line coordinators. J Oncol Navigation Survivorship. 2014;5(4):44.
8. Silver AJ, Knowlton SE, Silver JK, et al. Cancer rehabilitation service line directors perceive navigators as having high value on multidisciplinary rehabilitation teams and identify 3 key barriers to improving their value. J Oncol Navigation Survivorship. 2014;5(4):43.