Innovations in Cancer

Rehabilitation

Nancy Hutchison, MD

Medical Director for Cancer Rehabilitation and Survivorship

September 26, 2014

Success Brings Challenges

• 2014: 14.5 million cancer survivors in the US- 2024: almost 19 million cancer survivors, 2/3 >65

• The annual excess economic burden of survivorship- recently diagnosed cancer survivors >$16,000

- formerly diagnosed (>1 year from dx) >$4,000

- Includes direct health expenditures and disability (inability to work).

• For geriatric survivors, cancer related medical frailty and loss of independence leads to - increased hospital costs

- increased cost to society for caregivers and long term care

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Guy G, et al: Economic burden of cancer survivorship among adults in the United States. J Clin Oncol 31:3749-3757, 2013ACS Facts and Figures 2014-2015Rowland, J. Cancer Survivorship Issues: Life After Treatment and Implications for an Ageing Population. JClinOncol. 32:2662-2668,2014

• 25% of cancer survivors reported poor physical health and 10% reported poor mental health

• Compared with 10% and 6% of adults without a history of cancer

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The challenge: declining

HRQOL for cancer survivors

Weaver, K. Mental and Physical Health-Related Quality of Life among US Cancer Survivors: Population Estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev;21(11);2108-17

• Distress in cancer survivors is highly correlated with physical limitations imposed by cancer treatment

• Comorbidities increase the patient’s rehabilitation needs and distress

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Cancer rehabilitation: an unmet need

Bornbaum, K. A descriptive analysis of the relationship between quality of life and distress in individuals with head and neck cancer. Support Care Cancer. 2011. DOI 10.1007/s00520-011-1326-2Pentinnen, H. QoL and Physical performance and activity of breast cancer patients after adjuvant treatment. Psycho-Oncology 2011. 20: 1211–1220Banks, E. Is psychological distress in people living with cancer related to the fact of diagnosis, current treatment or level of disability? Findings from a large Australian study. MJA 2010; 193: S62–S67Holm, L. Influence of comorbidity on cancer patients’ rehab needs, participation in rehab activities and unmet needs: a population-based cohort study. Support Care Cancer 2014. 22:2095-2105

• “Although general exercise and behavioral interventions are important, they should not be confused with impairment-driven cancer rehabilitation – focuses on diagnosis and treatment of specific cognitive and

physical problems

– addressed by qualified rehabilitation health care professionals such as physiatrists along with PT, OT, SLP

• It is very common for survivors to have multiple impairments, and these should be treated with an interdisciplinary rehabilitation approach.”

• ACS Cancer Treatment and Survivorship Facts and Figures 2014-2015 page 25

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Activity is good for cancer survivors but is

not enough and is not rehabilitation

Cancer Rehabilitation adds value to

oncology care • Reduces morbidity

• Reduces medical frailty

• Improves return to work

• Improves health related quality of life

• Reduces distress

• Is well tolerated and effective

- Before, during and after cancer treatment

- In advanced cancer

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Chasen,M Rehabilitation for patients with advanced cancer. CMAJ 2014.doi: 10.1503/cmaj.131402Thorsen, L. Cancer Patients’ needs for rehabilitation services. ActaOncologica 2011. 50:212-222Cheville, A. An Examination of the under utilization of rehabservices among people with advanced cancer. J RehabMed. 2011. 90(S): S27-37 Cheville, A. Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer. JCO.2008. 26:2621-2629Silver, J. A journey to make cancer rehabilitation the standard of care. Work (2013) 46: 473-475Alfano, C. Cancer Survivorship and Cancer Rehab: Revitalizing the Link. JCO 2012. 30:904-906

The value proposition

• A value proposition is a marketing concept for a product being offered- a company’s promise of value to be delivered

- the customer’s belief that value will be achieved

• What is the product? Cancer Rehabilitation- Achieves the Triple Aim

• Who are the customers?- Patients

- Families

- Doctors, nurses and other providers

- Payers

- Society/population health

- Administrators

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• AllinaHealth has excellent oncology services

• AllinaHealth has excellent rehabilitation services

“What happens to your value if you have excellent healthcare services but the

customer doesn’t get them?“

Sean Sipko, CPA, VP Oncology Rehab Partners

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• Shortage of oncologists• Huge increase in cancer survivors• Survivors have diverse physical impairments affecting many organ

systems• Future advances in oncology will increase treatment and survivorship

costs• Oncologists are not trained to assess and treat disabilities and physical

impairment, rehabilitation professionals are • Reducing morbidity can reduce total cost of care and improve HRQOL• General agreement that cancer rehab is good for patients • Rehabilitation services are available to cancer patients• Health care system barriers must be identified and overcome

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Reality Check

AllinaHealth STAR Program

Cancer Rehabilitation• 2012 AllinaHealth became a STAR Program through

Oncology Rehab Partners- Standard of care for cancer rehabilitation nationally

- STAR Program is leading the way for innovation in cancer rehabilitation

• AllinaHealth developed a Physician-led STAR Program®

- Insure evolution of evidence-based, up-to-date, care

- Create standards, excellence and proficiency in cancer rehab

- Work with Allina Research centers on cancer rehab research

- Specialty Physiatrist care for complex cancer patients

- The STAR Program has identified key areas that should be targeted to become the standard of care for cancer survivors

• Impairment Driven Rehabilitation

• Prehabilitation

• Dual Screening for distress and physical impairment

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To make these standards reality,

innovation in oncology-rehab interface is

needed

• The value proposition requires oncology

and rehabilitation to innovate better systems

of rehab care navigation and sharing cost

among provider disciplines and across

clinical service line financial silos

- So that patients get the needed services at the

optimal time

- Society and health care organizations achieve the

value proposition

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• Impairment Driven Rehabilitation Care

• Prehabilitation

• Early detection and early intervention for cancer related morbidity

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Innovations in Cancer

Rehabilitation

Impairment Driven Cancer

Rehabilitation

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Coined by Julie Silver, MD & colleagues and adopted as standard by ACS

AllinaHealth STAR Program

Impairment Driven Cancer Rehab• Over 100 Allina STAR (CourageKenny) clinicians

organized into multidisciplinary impairment teams.- Debility/Fitness

- Balance

- Musculoskeletal problems (pain, tightness, ROM)

- Dysphagia

- Lymphedema

- Cognition

• 6 MD and NP PMR STAR specialists and 3 Cancer Rehab Nurse Coordinators

• Orders and coordination through STAR Schedulers according to patient impairment

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Allina Impairment Driven Rehab

Teams

• Lead therapist for each impairment

• Best practice protocols for impairment

• Uniform outcome tools and analysis

• Linkage with Courage Kenny Research Center

- Currently involved in a study of chemo-brain in breast

cancer survivors

• Monthly full Allina/STAR Program Journal Club

• 2x per year impairment team proficiency

training, chart review and education updates

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Prehabilitation: innovation in cancer care

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2013: A call to action by Julie Silver, MD

Prehab reduces morbidity and

LOS in Lung Cancer Resection

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Prehabilitation to reverse pre-

operative physical frailty

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Debility and deconditioning are

amenable to cancer rehab• Numerous scientific articles confirm physical debility as

a risk for poor outcomes and high cost from cancer treatment

• Numerous articles document benefits of preoperative evaluation and treatment of debility/deconditioning for reducing mortality, morbidity and disability

• AllinaHealth’s STAR Fitness/Debility Impairment team has protocols to address preoperative (and post operative) debility- Some areas have less access, PT shortage

- Patients and PTs need lead time to have optimal results

- Care Navigation pathways need to be developed

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Prehab for Head and Neck Cancer• Pre-treatment (radiation and/or surgery) Speech Therapy

swallow exercises improve outcomes in patients with tongue, base of tongue, laryngeal, pharyngeal cancer

• reduced aspiration, improved quality of oral diet, less time with feeding tube, improved QOL

• Waiting weeks or months after completion of treatment to onset of clinically evident dysphagia is associated with poorer outcomes

• Relying on a PEG is associated with poorer swallow outcomes

• Patient acceptance and adherence is excellent when the whole provider team accepts and encourages

• Allina STAR® HNC Swallow Impairment Team prehab protocol

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Kraaijenga, S. Current Assessment and treatment strategies of dysphagia in head and neck cancer patients; a systematic review of the 2012/2013 literature. Curr Opin Support Palliative Care 2014, 8:152-163Starmer, H. Dysphagia in head and neck cancer: prevention and treatment. Curr Opinion Otolaryngol Head Neck Surg. 2014. 22: 195-200Crary, M. Adoption into clinical practice of two therapies to manage swallowing disorders: exercise-based swallowing rehabilitation and electrical stimulation.Curr Opinion Otolaryngol Head Neck Surg. 2014. 22:172-180.Duarte, V. Swallow Preservation Exercises During Chemoradiation Therapy Maintains Swallow Functions. Otolaryngol Head Neck Surg. 2013. 149:848-884

Early detection and treatment of

cancer morbidity: lymphedema

• Lymphedema is one of the most dreaded complications of cancer treatment

• Lymphedema affects approximately 60% of breast cancer survivors at some point in survivorship

• Lymphedema affects 15% of all cancer survivor

• Lymphedema will not be eradicated - Improved surgery and radiation techniques can

reduce the impact

- Early detection and early treatment reduces and, in some cases, reverses lymphedema

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Distress in Breast Cancer Survivors Related to

Fear of Lymphedema

• In a study from the Mayo Clinic, 75% of patients after ALND and 50% of patients after SLN are worried about developing lymphedema at one year post surgery

• Patients often perceive that they have lymphedema when they do not and may take extreme measures to prevent

McLaughlin, S. Trends in Arm Swelling and Patient Worry for the Development ofLymphedema after Axillary Surgery for Breast Cancer. Presented at 2012 Annual Meeting of the Society of Surgical OncologyTemple, L. Sensory morbidity after sentinel lymph node biopsy and axillary dissection : a prospective study of 233 women. Annals Surg Oncol. 2002.9(7) 654-62McLaughlin S. Prevalence of Lymphedema in Women With Breast Cancer 5 Years After Sentinel Lymph Node Biopsy or Axillary Dissection: Objective Measurements. 2008. J Clin Oncol 26:5213-5219.

Paradigm shift: lymphedema as a

biologic phenomenon

• Lymphedema is an immune system, genetic, vascular, and histologic phenomenon

• Inflammation and fibrosis of lymphatics are major factors in onset and progression of lymphedema

• Latent lymphedema can be detected by BIS• Early detection reduces the severity and may

prevent BCRL• Screening and monitoring for BCRL gives

patients the greatest chance of avoiding or minimizing lymphedema

• Waiting until lymphedema is visible or symptomatic leads to poorer outcomes

Early lymphatic dysfunction

predicts BCRL

• Clinically undetectable abnormal lymphatic flow

in muscle and sub-cutis, with elevated

peripheral lymphatic flow, has been noted in

the arms of women destined to develop BCRL

over a year later

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Stanton, A. Lymphatic drainage in the muscle and subcutis of the arm after breast cancer treatment. Breast Ca Res Treat. 2009 Oct;117(3):549-57Stout, N. Segmental Limb Volume Change as a Predictor of the Onset of Lymphedema in Women With Early Breast Cancer. PM R 2011;3:1098-1105

Lymphedema: Not just swelling

An abnormal

accumulation of

protein-rich fluid in

the interstitium

which leads to

chronic

inflammation and

reactive fibrosis

Left post lumpectomy and radiation breast lymphedema and fibrosis Left post mastectomy, ALND, radiation, reconstruction

lymphedema. Acute cellulitis

Lymphedema causes pain, infections and disability. It is also costly to manage.

BIS Monitoring for BCRL: accurate

and clinically relevant• 40% of patients have bouts of lymphedema, detected by

BIS, lasting at least 3 months with or without intermittent periods of relief and 60% of those patients go on to develop long term lymphedema

• BIS accurately detects lymphedema 10 months prior than limb volume or self report-with a preoperative baseline

• BIS accurately differentiates lymphedema from non-lymphedema

Hayes, S. Lymphedema after breast cancer: Incidence, risk factors and effect on upper body function. (2008) J Clin Oncol 26:3536-3542. Smoot, B. Comparison of diagnostic accuracy of clinical measures of breast cancer-related lymphedema: area under the curve. Arch Phys Med Rehabil 2011 Apr;92(4):603-10Hayes, S. Lymphedema Secondary to Breast Cancer: How choice of measure influences diagnosis, prevalence and identifiable risk factors. Lymphology: 41(2008) 18-28Vicini F. Multi-Institutional Analysis of BIS in the Early Detection of BCRL. Presented at 2012 Annual Meeting of the Society of Surgical OncologyKanbour, M. The Importance of the Identification and Early Intervention of Subclinical LymphedemaDept of Surgery, Magee Womens Hospital, Pittsburgh, PA. Presented MASCC/ISOO - 2012 International Symposium on Supportive Care in Cancer

BIOIMPEDANCE SPECTROSCOPY

(BIS)

Impedimed L-Dex ® U400

Bioimpedance

Spectroscopy (BIS)• BIS is based on the

resistance to an imperceptible current passed through the arm.

• Impedance is inversely proportion to fluid volume.

• As fluid accumulates, impedance or resistance to the flow of the current decreases.

• The definition of Lymphedema is based on the accumulation of fluid.

• BIS represents a DIRECT measure of that fluid

Clinically detectable lymphedema is too

late for early detection purposes

• Clinical lymphedema does not become

visible, palpable, perceptible until a

significant increase in volume (10%)

• Negative impact on QOL begins at 5% LVC

• Monitoring needs to detect lymphedema at

3% for reversibility, well below the clinical

detection and tape measurement threshold

Cormier, S et al.(2009) Minimal limb volume change has a significant impact on breast cancer survivors. Lymphology 42, 161-175

Armer JM. The problem of post-breast cancer lymphedema: Impact and measurement issues. Cancer Investigation. 2005;23:76–83.

Treating BCRL is costly

• Patients diagnosed with post-BC lymphedema

incur significantly higher total healthcare costs

(nearly $15,000 more, after removing cancer-

specific costs.)

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Shih YC, Xu Y, Cormier JN, et al. Incidence, treatment costs, andcomplications of lymphedema after breast cancer among women ofworking age: a 2-year follow-up study. J Clin Oncol 2009;27(12):2007-2014.

BIS Monitoring for BCRL Cost

Effectiveness• In a model developed to determine cost to 3rd

party payers, the use of BIS would save money

over current standard (patient reports symptoms

or swelling detected)

• Total cost to patient/society from less work days

lost, improved function and QOL were not

factored in.

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Bilir, S Economic Benefits of BIS-Aided Assessment of Post-BC Lymphedema in the United States. American Journal of Managed Care.(2012)18(5):234-41

Allina BIS Projects for early detection

and treatment of lymphedema

• Collaboration of VPCI United Breast Center and the CKRI STAR Program Lymphedema Impairment Team

• Pre and Postoperative screening for lymphedema in the Breast Center

• Assessment, education and early intervention for latent lymphedema

• Concurrent grant funded BIS project in the CKRI STARProgram Lymphedema Impairment Team- With generous funding from the Tankenoff Families Foundation

• We hope to find a model of collaborative screening, treatment and payment for lymphedema-BIS to be the standard of care

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Cancer Rehab: innovation bringing value

to the future of oncology survivorship

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“Rehabilitation programs are probably the single

most underappreciated service among cancer

survivors right now.”

-Kevin Oeffinger, MD, MSKCC & Chair of ASCO’s

survivorship committee

Washington Post July 29, 2013—How to Get Healthy After the Cancer

Treatments are Done

Nancy Hutchison, MD

Medical Director for Cancer Rehabilitation and

Survivorship

Courage Kenny Rehabilitation Institute/Virginia

Piper Cancer Institute, Divisions of AllinaHealth

800 East 28th Street, MR12109

Minneapolis, MN 55407

nancy.hutchison@allina.com

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