In Brief

Cancer and its treatments can lead to a range of physical issues, from fatigue and pain to severe mobility restrictions. Oncology physical therapy plays a critical role in helping patients who have cancer manage these issues, regain strength and function, and improve their quality of life. However, referral rates for physical therapy remain low for people with cancer. As a result, many patients are left with unmet needs and long-lasting adverse effects of cancer treatment. These adverse effects can be addressed by oncology physical therapy. This article discusses oncology physical therapy, the barriers to access, and future steps needed for appropriate and timely referrals to improve the function and quality of life for those with cancer.

Cancer is among the most prevalent diseases globally, with over 15 million cases reported in the United States alone.1 While the incidence and prevalence of cancer continue to rise, advancements in early detection and treatment have significantly improved 5-year survival rates over the past 40 years. Consequently, today, people with cancer tend to have a longer life expectancy.2 Cancer treatments often result in long-term impairments and functional limitations affecting various body systems. After completing acute oncology treatment, many patients face a range of unmet needs, dealing with both short- and long-term adverse effects of cancer and its treatments.3 As a result, many patients with cancer face substantial disability and persistent treatment-related adverse effects, which can negatively impact their quality of life. These issues could be effectively addressed by rehabilitation professionals if identified appropriately and in a timely manner.

Common symptoms reported include fatigue (42%–92%), pain (36%), and numbness/tingling (29%), which can restrict physical capabilities and interfere with patients’ ability to perform daily activities and fulfill life roles.2,4 Despite the high prevalence of these adverse effects and the recognition of rehabilitation as a critical component of cancer care, access and referrals to services like physical therapy remain a significant issue. In 2008, Cheville documented 530 impairments in 163 patients with metastatic breast cancer, yet only 39.2% of these patients received physical or occupational therapy services and only 30% of the impairments were treated.5 This low referral rate may stem from insufficient knowledge about the role and benefits of oncology physical therapy among both patients and health care providers, as well as poor access to such specialized services due to a limited number of specialists and a lack of personal resources.3

Traditional physical therapists often lack the experience and training needed to address the full range of functional complications experienced by patients with cancer.

The Role of Physical Therapy in Cancer Care

Physical therapists are experts in movement and function, specializing in assessing and addressing deficits caused by disease and its treatments. Using a combination of manual therapy techniques, therapeutic exercises, neuromuscular re-education, and balance and gait training, the goal of physical therapy is to optimize the patient’s physical, social, psychological, and vocational well-being through personalized care. Physical therapists use techniques such as scar tissue mobility, myofascial release, and soft-tissue massage to help reduce pain and improve mobility. Targeted exercises are also used to boost mobility, strength, and overall function.

In cancer rehabilitation, physical therapy is crucial in managing symptoms, optimizing outcomes, and reducing disability by addressing physical impairments and functional limitations early in the disease course. However, traditional physical therapists often lack the experience and training needed to address the full range of functional complications experienced by patients with cancer. Given that most patients have 1 or more comorbidities, treating this population requires extensive training and an understanding of the mechanisms of anticancer therapies and how they affect physiological systems. In addition, physical therapists treating patients with cancer should be aware of safety considerations and oncologic emergencies. Therefore, to provide safe, effective, and high-quality care, patients with cancer should be referred to oncologic physical therapists.

Addressing a Range of Issues

Cancer and its treatments can lead to a variety of impairments, including pain, reduced strength and range of motion, fatigue, deconditioning, decreased cardiovascular capacity, lymphedema, bone loss, axillary web syndrome, radiation fibrosis syndrome, and balance issues. These challenges can make it difficult for patients to return to their previous level of function, affecting daily activities, community engagement, and even employment.

The goals of physical therapy in cancer rehabilitation include offering comprehensive, client-centered interventions that consider both preexisting and treatment-related comorbidities. Physical therapists aim to address acute and long-term cancer-related impairments (Table 1), incorporate surveillance strategies to prevent or mitigate late-presenting adverse effects, facilitate timely cancer treatment, and promote self-management and lifestyle strategies for overall wellness and secondary disease prevention.6

Integrating Physical Therapy Throughout the Cancer Care Continuum

Physical therapy can be beneficial at all stages of the cancer care continuum. Engaging physical therapists early in the treatment process enables ongoing assessment of changes in physical function due to the disease and its treatment. The 4 stages of cancer treatment include prehabilitation, restorative rehabilitation, supportive rehabilitation, and palliative rehabilitation.5 Prehabilitation occurs before the initiation of treatment, aiming to reduce functional decline from cancer and its treatment. For example, intensive pulmonary rehabilitation before lung cancer surgery has been shown to decrease postoperative hospital stays and reduce pulmonary adverse events.1 Restorative rehabilitation takes place after treatment completion, to return the patient to pretreatment levels of function. Supportive rehabilitation is provided during the diagnosis of advanced cancer, aiming to maintain current function levels and prevent further decline. Palliative rehabilitation focuses on maximizing functional independence and autonomy at the end of life, along with symptom control and caregiver support. Even in advanced cancer stages, rehabilitation has been shown to improve function, independence, and quality of life.

Barriers to Access

Research highlights several barriers to accessing supportive and palliative care services, with a lack of physician awareness about the role of physical therapy constituting a significant obstacle.7 Many oncologists report having minimal education in cancer rehabilitation, suggesting that oncology fellowship programs often overlook this crucial area despite its inclusion in curriculum requirements.1 This lack of knowledge can lead to missed referrals and can negatively impact patient care. Furthermore, limited patient awareness about physical therapy services can prevent patients from seeking out these services or advocating for themselves.

Screening is vital for identifying patients with impairments and functional limitations who, consequently, need physical therapy. However, even when the need for rehabilitation is recognized, finding a physical therapist who specializes in cancer rehabilitation can be challenging. According to the American Board of Physical Therapy Specialties, there are only 216 board-certified oncology physical therapists in the United States, with some states having none.8 This lack of trained professionals presents a significant barrier to access. Moreover, personal resource limitations, including time, money, transportation, and insurance coverage, can further restrict access for many patients with cancer.

Future Directions

While oncology rehabilitation is increasingly recognized as an essential part of both rehabilitation medicine and oncology care, much remains to be done in terms of educating health care providers and raising awareness among patients with cancer. Efforts should be made to promote multidisciplinary educational opportunities for providers in primary care, oncology, and other subspecialties.9 At a national level, physical therapy associations need to increase awareness among other health care professionals about the potential of physical therapy in oncology and develop care models suited to various system constraints.

Timely Identification of Impairments

Identifying impairments early is crucial. Ideally, rehabilitation professionals would work with patients at risk for developing deficits both before and during treatment, such as breast cancer patients before mastectomy. Screening for impairments can be accomplished using valid and reliable tools like the Edmonton Symptom Assessment System revised (ESAS-r) scale and the Canadian Problem Checklist (CPC), which help identify common symptoms and concerns. The ESAS-r is a valid and reliable measure that includes commonly reported symptoms such as pain, tiredness, shortness of breath, and well-being. The CPC screens for other problems that are not captured by ESAS-r, including emotional (eg, fears, worries, coping), informational (eg, understanding illness, making treatment decisions), social and family (eg, relationship difficulties, feeling alone), practical (eg, work, school, child care), spiritual (eg, meaning and purpose in life), and physical (eg, concentration, sleep, loss of balance). Once 1 or more mild to moderate impairments are identified, referral to physical therapy should be initiated.10

Developing Standardized Rehabilitation Programs

It is important to develop professional practice guidelines and standards for physical therapy in oncology to improve awareness among health care providers and ensure consistency in delivery of care.

Adequate Training in Oncologic Physical Therapy

More rehabilitation professionals need to have specific training in the field of oncology rehabilitation. Integrating oncology-specific issues into entry-level physical therapy education and demonstrating how core principles of physical therapy apply to cancer care can establish a solid foundation for advanced practice in this area and foster greater interest in specializing in oncology. The American Physical Therapy Association currently supports this field through its oncology rehabilitation section, which offers a journal, continuing education programs, and a clinical specialist certification. Although this specialty remains relatively small within the broader physical therapy profession, it is steadily growing both in numbers and in its evidence base.

Concluding Thoughts

Cancer rehabilitation plays a critical role in helping patients who have cancer achieve and maintain the highest possible physical, social, psychological, and vocational functioning within the limits imposed by cancer and its treatments. Despite the proven efficacy of cancer rehabilitation, services remain underutilized, mainly due to a lack of knowledge among patients and clinicians and patients having limited access to specialists. As the field of oncologic physical therapy grows, international collaborations in clinical practice, education, and research could significantly enhance the integration of these services into the multidisciplinary team as well as the cancer care continuum, which can aid in timely referrals and improve patients’ quality of life.

Berfin Mahmut, PT, DPT, CLT-LANA, OnCS, is a board-certified oncologic physical therapist, certified lymphedema therapist, and cancer exercise specialist with more than 5 years of experience in the field. Dr. Mahmut currently practices at Mount Sinai Health System in New York City.

References

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8. American Board of Physical Therapy Specialties. Number of board-certified specialists by state. Updated July 25, 2024. Accessed August 12, 2024. https://specialization.apta.org/about-abpts/abpts-data-outcomes/ number-of-certified-specialists-by-state

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