Background
Breast cancer is the most commonly diagnosed cancer among women in the United States, with approximately 50% of all cases diagnosed in younger women aged <65 years.1 The 10-year survival rates for breast cancer survivors (BCSs) is 85%2; however, many BCSs report significant challenges in returning to work and experience difficulty maintaining employment.3–5 Upper extremity disability, pain, lymphedema, weakness, fatigue, cognitive problems, and functional limitations are reported by BCSs in acute, long-term, and late-onset phases.6,7 Without intervention, these impairments are likely to worsen over time,6,8,9 negatively impacting ability to work5,10 and health-related quality of life (HRQoL),3–5,11 and putting BCSs at increased risk of early mortality.12 In a recent cohort study including 5,989 BCSs and matched controls, cancer diagnosis was an inflection point, after which BCSs experienced accelerated declines in physical function for up to 10 years.9 Due to the high prevalence and negative sequelae associated with diminished work ability and HRQoL among BCSs, the ability to assess and provide appropriate interventions to optimize these outcomes is an urgent need in oncology care.9,13–15
Outpatient rehabilitation services provided by people trained in cancer-specialized physical therapy and occupational therapy (PT/OT) are targeted interventions that address physical, functional, and cognitive impairments to support successful transition to post-treatment life.16,17 Expanding high-level evidence18 demonstrates that when provided to BCSs, cancer-specialized rehabilitation interventions can mitigate,18–21 and may even prevent,22 treatment-related impairments. Furthermore, evidence from systematic reviews5,23–25 and observational studies of cancer rehabilitation services delivered in the community16,21,26,27 demonstrate that participation in these interventions is associated with improved HRQoL, including physical, mental, functional, and social domains. Taken together, this evidence suggests that rehabilitation interventions may enhance work ability by addressing HRQoL needs. However, there is minimal evidence to support this, because previous studies in this population have not yet captured work outcomes beyond employment status.21,28 Although maintaining employment status is an important goal for many younger BCSs, it can be heavily dependent on their physical and mental ability to work. Referral to PT/OT could initiate multifaceted interventions aimed to improve work ability and HRQoL domains for BCSs. However, researchers estimate that as little as 10% of all survivors experiencing impairments are referred to these services.29 Improved understanding of the impact of participating in outpatient PT/OT services is needed to inform oncology clinicians’ referral decision-making and to improve access to rehabilitation services for BCSs. Furthermore, although both disciplines provide cancer rehabilitation services, the approach differs; evaluations of the impact of these services separately, and in depth, are lacking. Considering the impact of PT and OT together, and separately, will allow for a more nuanced view, potentially encompassing a wider perspective of HRQoL including global health, activity, and participation,30,31 and may decrease the strain on the workforce needed.
To that end, our research questions were: (1) what are the needs of younger BCSs who attend community-based PT and OT, and (2) what is the impact of participation in this service (PT/OT combined and separately) on patient-reported work ability and HRQoL.
Methods
This is a retrospective, observational, uncontrolled, pre-post study using data extracted from the rehabilitation electronic medical records (EMRs) of a national outpatient rehabilitation provider. We report the study methods following the Professional Society for Health Economics and Outcomes Research (ISPOR) checklist for retrospective database studies.32 This study was approved by the Institutional Review Board at the University of Southern Maine (21-07-1714).
Cancer Rehabilitation Service Delivery
BCSs attended PT and/or OT services delivered in community-based outpatient rehabilitation clinics (565 clinics located in 20 states) by licensed cancer-specialized therapists. The content and frequency of rehabilitation interventions was directed by the treating therapist based on each patient’s needs and goals.33–36 Therapists completed an internal cancer-specific training program that included >50 hours of cancer and cancer rehabilitation–specific education with ongoing built-in support, and they maintained specialization annually by participating in ongoing cancer-specialized continuing education seminars and other learning opportunities.
Patient Identification and Data Extraction
Rehabilitation patients that met the following criteria were included: breast cancer diagnosis (identified by ICD-10 codes), female sex, age 18 to 64 years, attended at least 3 PT/OT visits, self-reported impaired work ability on the Work Ability Index (WAI) at baseline (defined as a baseline overall work ability score of ≤9 out of 10), and patient-reported outcome measures available at initial evaluation (pre-rehabilitation) and discharge (post-rehabilitation). This study was approved in September 2022 to evaluate data from 2020 to 2022, reflecting current practice patterns needed to answer the research questions. An honest broker used these criteria to identify eligible patients in the rehabilitation EMR to create a de-identified dataset for analysis. Available patient characteristics included age, sex, race, US region, payer type, therapy discipline (PT/OT), ICD-10 codes, number of visits, and length of care (weeks).
Outcome Measures
Outcome measures available for this study included an abbreviated version of the WAI37 and the Patient-Reported Outcome Measurement Information System (PROMIS) short forms covering HRQoL domains of physical and mental health, physical function, and ability to participate in social roles and activities.
Work Ability
The WAI is a valid and reliable patient-reported outcome measure used in occupational and rehabilitation research and practice to evaluate the extent to which someone is able to work.38,39 Although originally created and validated as a 7-item measure, individual items of the WAI are also validated for stand-alone use,40,41 including with cancer-specific populations.42 The abbreviated WAI used by treating therapists included 3 items: overall work ability score (WASoverall), physical WAS (WASphysical), and mental WAS (WASmental). The WASoverall item asks: “Assume that your ability to work at its best has a value of 10 points and 0 means that you cannot currently work at all. How many points would you give your current ability to work?” WASphysical and WASmental items then ask patients to rate their ability to perform the physical and mental demands of their work, respectively, on a 5-point Likert scale from 0 (very good) to 4 (very poor). WASoverall has been validated as an appropriate screening tool to identify rehabilitation needs,43 measure responsiveness to change attributed to rehabilitation interventions,41 and predict poor outcomes, including future work ability, sick leave, and HRQoL for cancer and noncancer populations.40,42
Health-Related Quality of Life
PROMIS measures were developed and validated by the National Institutes of Health and are recommended for evaluating health status in general and clinical populations with high precision and low response burden.44–48 The 3 PROMIS measures used in this study have shown high feasibility, sensitivity, and specificity for evaluating HRQoL, specifically in the cancer survivor population.49–54 These measures include Global Health, which contains 10 items that were scored with 2 domains (Global Physical Health [GPH] and Global Mental Health [GMH])55; Physical Function (PF; 4 items); and Ability to Participate in Social Roles and Activities (SRA; 4 items). We followed established guidelines45 and scored each PROMIS measure using a T-score scale. Higher T-scores indicated that more of the domain was being measured; this has been shown to be sensitive and specific in capturing improvement or decline in HRQoL during or after cancer treatment.56 A T-score of 50 represents the mean for the general US population [SD=10].45,46 The established within-group minimal important change (MIC) is 2 points on the T-score scale.57
Statistical Analyses
We evaluated patients’ characteristics descriptively by using frequencies or measures of central tendency (mean [SD] or median [IQR]). To describe the prevalence of common physical impairments among BCSs, we grouped ICD-10 codes applied to each patient into major categories (Figure 1) and then used a chi-square test to compare the prevalence of impairment in each category between disciplines. To examine within-group change in each WAI and HRQoL outcome over time (ie, from initial evaluation [pre] to discharge [post]), we used linear mixed effect models; covariates are described in Table 1 and included age, race, US region, payer type, rehabilitation discipline, number of visits, and length of care. From each model, we report the estimated marginal (EM) means and standard error (SE) at each timepoint, EM mean change between timepoints, and the P value for the timepoint. To examine outcome scores by discipline, we added the timepoint-by-discipline interaction effect into each model. From these models, we report the P value of the timepoint-by-discipline interaction. We checked all model assumptions. The level of significance was set to α=.05 for all hypothesis tests. All analyses were performed using SPSS Statistics, version 28 (IBM Corp).
Physical impairments experienced by breast cancer survivors participating in outpatient cancer rehabilitation services.
Abbreviations: OT, occupational therapy; PT, physical therapy.
a“Other” includes PT parameters such as difficulty walking (n=48; 6.4%), posture (n=57; 7.6%), and neuropathy (n=37; 5%), and OT parameters such as neuropathy (n=7; 5%), cognition (n=4; 2.9%), and posture (n=3; 2.2%).
*Between-group difference, P<.05 (N=898).
Citation: Journal of the National Comprehensive Cancer Network 22, 5; 10.6004/jnccn.2023.7329
Characteristics of BCSs Who Participated in Outpatient Cancer Rehabilitation Services
Results
All PT/OT patients (N=898) were female, most (81.5%) had private insurance, and they tended to live in the southern region of the United States (45.7%). Mean [SD] age was 51.39 [8.49] years. They attended a median of 12 visits (IQR, 8.0–19.0) over 10.71 weeks (IQR, 6.14–17.00); 84% attended PT (n=758) compared with OT (n=140). All characteristics are reported in Table 1.
Needs of Younger BCSs Seen in PT/OT
Common impairments listed by ICD-10 codes by therapy discipline are reported in Figure 1, and they included lymphedema, weakness or atrophy, upper extremity impairment, and pain. The prevalence of each impairment was similar between disciplines, except for lymphedema, which was higher among OT patients (χ2=39.26; P<.001).
Impact of PT/OT on Work Ability and HRQoL
Overall, after rehabilitation, significant improvement was observed for each WAS and PROMIS outcome while controlling for covariates (all P<.001; Table 2). The average improvement exceeded the MIC for each PROMIS measure. The timepoint-by-discipline interaction effect was nonsignificant for each outcome: WASoverall, P=.393; WASphysical, P=.800; WASmental, P=.908; GPH, P=.204; GMH, P=.802; PF, P=.299; and SRA, P=.233.
Work Ability and HRQoL Outcomes of BCSs Who Participated in Outpatient Cancer Rehabilitation Services (N=898)
Impact of PT and OT, Evaluated Separately
Among PT and OT patients, outcome scores were similar at each timepoint (all P>.05), with both groups experiencing significant improvement (all P<.01). EM mean scores for each outcome and by discipline are shown in Figure 2 (WAS) and Figure 3 (HRQoL).
Work ability outcomes of breast cancer survivors who participated in outpatient cancer rehabilitation services. Work ability was measured by the WAI. Scales are defined as (A) overall ability to work (cannot currently work at all [0] to lifetime best ability to work [10]), (B) physical ability to work (very good [0] to very poor [4]), and (C) mental ability to work (very good [0] to very poor [4]). No between-group differences were observed. EM means were adjusted for the following covariates: age, race, US region, payer type, number of visits, and length of care.
Abbreviations: EM, estimated marginal; OT, occupational therapy; PT, physical therapy; WAI, Work Ability Index.
*P<.01 for within-group improvement from pre- to post-rehabilitation.
Citation: Journal of the National Comprehensive Cancer Network 22, 5; 10.6004/jnccn.2023.7329
HRQoL outcomes of breast cancer survivors who participated in outpatient cancer rehabilitation services. HRQoL was measured using PROMIS instruments: (A) Global Physical Health, (B) Global Mental Health, (C) Physical Function, and (D) Ability to Participate in Social Roles and Activities. No between-group differences were observed (all P>.05). EM means were adjusted for the following covariates: age, race, US region, payer type, number of visits, and length of care.
Abbreviations: EM, estimated marginal; HRQoL, health-related quality of life; OT, occupational therapy; PROMIS, Patient-Reported Outcome Measurement System; PT, physical therapy.
*P<.001 for within-group improvement from pre- to post-rehabilitation.
Citation: Journal of the National Comprehensive Cancer Network 22, 5; 10.6004/jnccn.2023.7329
Discussion
This study provides pragmatic evidence suggesting that participation in outpatient cancer-specialized PT and OT could improve ability to work and HRQoL among younger BCSs. At initial evaluation, patients included in this study experienced common physical impairments associated with poor work ability and HRQoL. After rehabilitation, they improved significantly in overall, physical, and mental ability to work and HRQoL outcomes that measure physical and mental health, physical functioning, and ability to participate in social roles and activities. Furthermore, improvements were similar for patients who attended PT and those who attended OT. This study provides difficult-to-obtain evidence needed to understand the impact of real-world cancer rehabilitation services in the United States, and our findings support previous calls to improve access to specialized therapy services as a strategy to enhance work ability and HRQoL outcomes for BCSs.15 These findings can be used to inform oncology referral decision-making and guidelines, as well as to support policy and improve reimbursement for rehabilitation services, considering the high cost of cancer care and the increased risk of mortality if rehabilitation needs are left untreated.
Needs of Younger BCSs Seen in PT/OT
BCSs can face acute, late, and long-term treatment effects from cancer and cancer treatment that impact functional and physical health. In our study, we were able to examine the physical impairments identified through ICD-10 codes. Although this list is helpful in delineating the needs of younger adults with breast cancer who attended PT and OT, it is not expected to be an exhaustive list, and represents physical impairment codes selected by the therapists (as opposed to patient-reported needs for rehabilitation). That being said, the impairments we report here, including lymphedema, weakness or atrophy, upper extremity impairment, and pain, are consistent with other research and reviews of the literature.58
Impact of PT/OT on Work Ability and HRQoL
In this study, younger BCSs who attended outpatient PT/OT improved significantly in work ability and HRQoL while controlling for covariates previously associated with these outcomes and/or response to rehabilitation interventions. To our knowledge, this is the first study to examine the impact of PT and OT services, respectively, on a combination of patient-reported work ability and HRQoL outcomes, and the only study of its kind conducted in the United States. However, the magnitude of improvement observed in this study was comparable to, and often greater than, that of previous studies that examined these outcomes separately and in studies in other countries.20,21,28 Our findings are especially notable because we controlled for covariates previously associated with work ability or HRQoL, which was a limitation of previous nonrandomized studies.19–21,28
In previous studies of outpatient rehabilitation programs across the Netherlands and Belgium, Leensen et al,28 Gjerset et al,21 and Leclerc et al20 each reported significant improvements in HRQoL outcomes among working-age BCSs after rehabilitation. However, the study by Leensen et al28 was the only one to collect patient-rated work ability outcomes. Pre- and postintervention WAS observed in our study were similar to those reported by Leensen et al28; however, Leensen et al measured and reported continued improvement over time and postintervention in work ability and HRQoL. Although more research is needed, the long-term benefits observed in the study by Leensen et al suggest that the positive impact of rehabilitation on these outcomes may be sustained and may potentially continue to improve during survivorship.
In the study by Gjerset et al,21 22% to 46% of patients achieved clinically significant improvement in HRQoL measured by the EORTC Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Comparatively, in our study, 57% (GMH) to 71% (GPH) of participants achieved clinically significant improvement measured by PROMIS instruments. Also using the EORTC QLQ-C30, Leclerc et al20 showed that compared with BCSs who participated in rehabilitation services, those who did not experienced significant declines in HRQoL over time. Taken together, the effects observed in this study and others contribute to the mounting evidence showing that participation in outpatient rehabilitation services could attenuate, and possibly prevent, declines in HRQoL and work outcomes for BCSs.
Impact of PT and OT Evaluated Separately
At initial evaluation, patients in this study experienced common effects related to breast cancer treatment,59 including weakness and atrophy, pain, lymphedema, and upper extremity impairment (eg, range of motion, mastodynia, joint stiffness), and reported PROMIS T-scores below the US population average score on all measures. In this study, patients attending PT or OT experienced similar, and statistically significant, improvements in work ability and HRQoL outcomes, suggesting that both of these rehabilitation services could be better utilized to meet the increasing survivorship needs. The differences in PT and OT scores at discharge were negligible and do not represent a clinically relevant difference (MIC <2 points). Furthermore, considering the range of needs and baseline scores on patient-reported outcomes described in this study, BCSs need support across the domains of health condition, function/body structures, activity, and participation in life roles. Although more research is needed, this study adds to the evidence suggesting that access to PT and OT in the community should be improved to meet the needs of BCSs. Considering that declines in HRQoL are a common unmet need among BCSs and are associated with increased mortality,9,12 we suggest that a renewed focus on access to cancer rehabilitation services is needed to optimize the health and well-being of the BCS population.
Limitations and Future Directions
The retrospective design limited this study to outcomes collected within a patient’s course of rehabilitation care. Due to reliance on rehabilitation data from EMRs, limited clinical characteristics and participant demographics were available to help us understand the potential influence of cancer treatment–related covariates on the impact of rehabilitation on work ability and HRQoL. However, we attempted to address this limitation by controlling for as many covariates as possible in our analyses. Additional covariates previously associated with work ability and HRQoL in this population that warrant future analysis include cancer stage, treatments received (especially axillary node dissection), patient occupation, and socioeconomic status. Although our sample size is large, our sample may not be fully representative because it describes individuals who attended PT/OT and therefore had access to these services. Furthermore, our results may be limited by threats to internal validity; without a controlled design, we cannot rule out other factors (eg, socioeconomic status, education, employment status) to determine whether this sample is truly representative of community-dwelling survivors, which could potentially influence our findings. That being said, in the absence of a usual care comparison group, we used analytic models to adjust for covariates previously shown to influence BCS utilization of60 or response to ancillary services, including cancer rehabilitation.61,62 In future studies, consideration of these other factors will be key to singling out the specific impact of PT and OT. For now, we can only compare historically to other studies in which younger patients with breast cancer report similar declines. The PT and OT services evaluated in this study were provided by licensed therapists who were employed by a single institution and had completed an internal cancer-specific training program. Although not protocolized, interventions provided by these therapists are based on a comprehensive evaluation and are tailored to meet the individual needs of BCSs. Our study also had missing demographics data, which could potentially limit our results. Although assumed to be high, it is possible that the generalizability of these findings to services delivered by rehabilitation clinicians without cancer rehabilitation training is low.
This study helps fill important gaps in the literature and provides greater understanding of the role of cancer rehabilitation services in survivorship care for younger BCSs. Ability to work is an important public health goal, considering the high levels of financial burden, toxicity, and distress in cancer treatment and survivorship.63 It is important for health care providers to assess work ability and HRQoL during breast cancer care and to provide appropriate interventions to improve these outcomes.9,13–15 Results of this study demonstrate that when referred, BCSs who experience difficulty with work ability may benefit significantly from PT and OT interventions. Our findings should be used to aid oncologists’ understanding of the needs of young BCSs and how cancer PT and OT can meet those needs. These findings support previous calls for referral to cancer rehabilitation to be recommended in oncology practice guidelines and to be considered as standard of care for women with breast cancer.15,64–66 In addition, our results should be used to inform health policy to expand access to quality cancer rehabilitation services and improve reimbursement for services that deliver high-value care, considering the extraordinary cost of cancer care and potential loss of productivity if rehabilitation needs are not addressed.
Conclusions
Young women with breast cancer have significant needs during survivorship regarding their work ability and HRQoL. In this large retrospective study of real-world cancer rehabilitation services, we observed significant improvements in work ability and HRQoL outcomes for young BCSs who attended outpatient PT/OT. Considering the personal, clinical, and financial implications in combination with our findings, increased access to specialized outpatient PT and OT to improve work ability and HRQoL are recommended to become the standard of care for all young BCSs. Future research could build upon this study to support this recommendation and to address this important public health issue for young BCSs.
Acknowledgments
We thank all the individuals who participated in cancer rehabilitation services and their therapists. We also thank Dave Hopwood, MSHI, for data extraction; Jessica Bertram, PT, DPT, for assistance with data coding; and Nikita Godbole, PT, DPT, for assistance with literature review.
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