U.O. di Riabilitazione Specialistica
Sez.: Riabilitazione Neuromotoria - Riabilitazione Oncologica
dir.: Springhetti Isabella MD
Istituto Scientifico di Pavia
CLINICAL and SOCIAL ADVANTAGES
of
ONCOLOGICAL REHABILITATION:
a PROSPECTIVE SURVEILLANCE PROGRAM
for WOMEN with BC (FSM-PSP)
Jedrychowska Iwona MD, Sparpaglione Diego MD,
Zancan Arturo MD, Morisani Elena MD,
Villani Chiara MD, Rodigari Alessandra MD, Lodola Elena FT
Shifting the focus of
attention and resources
from disease………..
…..to disabilities
Interaction between
psychological burden and
physical illness:
Mood Disturbances
Anxiety-Depression
Emotional Distress
Fors, Egil A., et al. "Psychosocial
interventions as part of breast cancer
rehabilitation programs? Results from a
systematic review." Psycho-Oncology 20.9
(2011): 909-918.
New models are required
.
Wide variability among european
countries (Governs, providers,
stakeholders) about how to conceive
programs and deliver services.
Literature data: clinical issues
Hellbom, Maria, et al. "Cancer rehabilitation: A Nordic and European perspective." Acta oncologica
50.2 (2011): 179-186.
Alfano, Catherine M., et al. "Cancer survivorship and cancer rehabilitation: revitalizing the link."
Journal of clinical oncology 30.9 (2012): 904-906.
Shockney, Lillie D., et al. "Healthcare Providers' Knowledge of the Benefits of Cancer
Rehabilitation." Journal of Oncology Navigation & Survivorship 4.2 (2013).
Stubblefield, Michael D., et al. "Current perspectives and emerging issues on cancer
rehabilitation." Cancer 119.S11 (2013): 2170-2178.
Prehabilitation..
..is not a new concept
models
Interventi psicosociali e fitness per ridurre i tempi di ripresa e
migliorare il benessere psicofisico
Selezionare le persone a rischio, o già affette trattando
problemi specifici
What to save from models:
informazione e supporto prima dell’avvio dei trattamenti:
conoscenza degli eventi,
controllo dell’ansia,
sensazione di accompagnamento,
collaborazione proattiva
What to save from models:
L’idea di una sorveglianza prospettica nel tempo
Goals of surveillance:
•
per gli impairment più comuni e le limitazioni
funzionali associate ai trattamenti neoplastici:
•
RISK LOWERING :riduzione del rischio /prevenzione degli effetti
avversi, facilitare l’identificazione precoce di impairment fisici e
limitazioni funzionali
• APPROPRIATE REHAB INTERVENTIONS: interventi riabilitativi
appropriati in caso di rilevazione di impaiments
• HEALTHY LIFESTYLE: promuovere e supportare adeguati attività
fisica ed esercizio, controllo del peso, durante l’intero percorso di
cura e di sopravvivenza
Nicole L. Stout - Breast Care Center
W. Reed Military Medical Center
8901 Wisconsin Ave, Buld 19, Bethesda MD
Silver, J. K., Baima, J. and Mayer, R. S. (2013), Impairment-driven cancer rehabilitation:
An essential component of quality care and survivorship.
A Cancer Journal for Clinicians, 63: 295–317. doi: 10.3322/caac.21186
Prehabilitation..
start immediately after diagnosis e prior to treatments
it is a physical psychosocial assessment
it constitutes the baseline for future clinical and functional comparisons in order to
plan targeted interventions
reduces incidence and/or minimize severity of present or future impairments
enhances tolerability and response to pharmacological/radiation treatments
Stout NL, et al. A prospective surveillance model for rehabilitation for
women with breast cancer. Cancer. 2012 Apr 15;118(8 Suppl):2191-200.
doi: 10.1002/cncr.27476.
Current activities
at Fondazione Maugeri
Current Breast Unit Activity
AUDIT 2013
UO BREAST UNIT
Treatment Registry
AUDIT 2013
UO BREAST UNIT
Operative Registry
FSM Breast Unit is certified according to EUSOMA criteria (www.eusoma.org)
Current FSM rehabilitation path for BC
STEP
GOAL
REFERRAL
*Psychologist Referral available
at any stage on pt request
CONTENTS
1) IMMEDIATELY
AFTER SURGERY
(IN HOSPITAL)
educational,
preventative,
from Surgeon directly to Physical
Therapist (PT)
general informations
/depending on the kind
of surgery
2) FIRST
POSTOPERATIVE
CLINIC
Rehabilitative, From Surgeons to Physiatrist/
therapeutic
from Physiatrist to PT
ROM, single muscular or
girdle impairment, AWS,
pain, UB impaired
function, scars, lymphatic
drainage, etc
3) FOLLOW UP
rehabilitative,
supportive
From Surgeons /Oncologist
to Physiatrist; /OT/ST et al.
pain, lymphedema,
fibrosis, neuropathies,
recurrence of functional
impairments, etc..
4) RECURRENCE
supportive
From Oncologist
/Radiotherapist to Physiatrist;
from Physiatrist to/OT/ST et al.
All above + complications
(fractures, etc..)
Current rehabilitation activity for BC
STEP
WOMEN
aa 2013
Current Standard
in use Indicators
1) IMMEDIATELY AFTER
SURGERY (IN HOSPITAL)
268
2) FIRST POSTOPERATIVE
CLINIC
59
3) FOLLOW UP &
4) RECURRENCE
42
ROM
DASH
Comp. Upper Limb Circumf. Cm
(FIM, If needed)
VAS
5) LIMPHEDEMA NEW CASES
7
Specific condition (i.e.:balance)
AUDIT EUSOMA FSM
2013
UO RRF/RO
REHABILITATION PROGRAM
Needs for more standardized indicators:
A) Burden of disease
Cancer registries data
B) Rehab success
Return to work, quality of life, and satisfaction of specific
rehabilitation needs
Paolo Bailia, et al. “Cancer rehabilitation indicators for Europe;The EUROCHIP-3
Working group on Cancer Rehabilitation” European Journal of Cancer, Volume 49,
Issue 6, April 2013, 1356–1364
New launched Program at Fondazione Maugeri
1.- PREOPERATIVE SCREENING AND ASSESSMENT
Concomitant anesthesia visit
Surgery provided within 6-8 wks
PATIENT HISTORY ( previous fractures, neuro-muscular ,
autoimmune, ortopedic disorders)
MEDICATION: (nsaids, steroids, neoadiuvant)
LIFESTYLE: (smoke, alchol, herbal)
DEMOGRAPHIC DATA ( race, age,)
GENERAL RISK factors (menopausal status, cholesterol,
diabetes, cardiovascular, etc)
# PT ASSESSMENT FOR IMPAIRMENT
TREATMENT if needed
# PHYSIATRIST REFERRAL: if needed
# PSYCHOLOGIST on pt request
SPECIFIC RISK >>>>
1.- PREOPERATIVE SCREENING AND ASSESSMENT
Concomitant anesthesia visit
Surgery provided within 6-8 wks
SPECIFIC RISK factors:
*Surgery: quart, mastectomy,
sentinel Ln, axillar dissection;
*Reconstruction: type of reconstruction,
implant, flap, )
# PT COUNSELLING : information, education,
# SPORT /exercise REFERRAL if no impairments
2.- POSTOPERATIVE / STARTING TREATMENT RE ASSESSMENT
Concomitant first postsurgical follow up
Adiuvant therapy
provided within 4-6 wks
# PT RE ASSESSMENT FOR post surgical impairment (ROM,
single muscular or girdle impairment, AWS, pain, UB
impaired function, scars, lymphatic drainage, edema, etc, )
TREATMENT if needed
# PHYSIATRIST REFERRAL if needed; specific impairments/
instrumental assessment for: bone density, supplement. etc..
# PSYCHOLOGIST REFERRAL proposal , or on pt request
SPECIFIC RISK >>>>
2.- POSTOPERATIVE / STARTING TREATMENT RE ASSESSMENT
Concomitant first postsurgical follow up
Adiuvant therapy
provided within 4-6 wks
# PT ADVICE SESSION :
information about possible
effect of adiuvants; training,
side
# EXERCISE PROGRAM REFERRAL :
preventative, with respect to
osteoporosis, arthralgia, fatigue, cv
condition, balance
# SPORT REFERRAL:
impairments
if no major
3.- ALONG THE COURSE OF ADIUVANT TREATMENTS AND FORTH
Concomitant oncological follow up
A) ADIUVANT therapy SIDE EFFECTS:
# REASSESSMENT: prior any start of treatmeent
( every 3 or 4 wks) Check for new signs and symptoms
# PHYSIATRIST REFERRAL if needed; specific
impairments/ instrumental assessment for: bone
density, supplementation etc..
# TREATMENT if needed (drop in clinic )
B) NO ADIUVANT therapy IS NEEDED:
# REASSESSMENT yearly during 3 yrs
SPECIFIC RISK >>>>
3.- ALONG THE COURSE OF
ADIUVANT TREATMENTS AND
FORTH
SPECIFIC RISKS FACTORS :
Chemio: cardio -neurotoxicity
Ormono: ovarian failure
Biologic therapy: cardiotoxicity
Radiotherapy: inflammation/ fibrosis
Concomitant oncological
follow up
# PT ADVICE SESSION :
information about possible
effect of adiuvants; training,
side
# EXERCISE PROGRAM REFERRAL :
remedial
on
specific current
conditions: osteoporosis, arthralgia,
fatigue, cv condition, balance, upper
limb volume ad function, pulmonary
function
# SPORT REFERRAL:
impairments
if no major
promising
advantages:
• A chance to detect more needs
• Enhancing tolerability to treatments
• Fast recovery after treatments
• Reinforce correct lifestyles
• Reduced expenses for impairments
current
limitations:
promising
advantages:
Scarce flexibility to adapt to different
current approaches: time consuming
Excessive medicalisation
Overdiagnosis fo minor impairments
Cost increase for frequent visits / controls
Cover only the range of physical symptoms
Scarce consideration of psychological
burden
current
limitations:
realtà nazionale
barriere:
Conoscenza
Consapevolezza
Aderenza
il modello puo funzionare ed essere sostenibile, se l’ambiente
sanitario condivide:
la necessita’ di adeguare lo stile di vita ai cambiamenti indotti
dalla malattia
la necessita’ di promouovere ed accompagnare le pazienti
nell’auto presa in carico
U.O. di Riabilitazione Specialistica
Sez.: Riabilitazione Neuromotoria - Riabilitazione Oncologica
Dir.: Springhetti Isabella MD
Istituto Scientifico di Pavia
CLINICAL and SOCIAL ADVANTAGES
of
ONCOLOGICAL REHABILITATION
A PROSPECTIVE SURVEILLANCE PROGRAM
for WOMEN affected by BC
Jedrychowska Iwona MD, Sparpaglione Diego MD,
Zancan Arturo MD, Morisani Elena MD,
Villani Chiara MD, Rodigari Alessandra MD, Lodola Elena FT