For every cancer patient there are clinical milestones: completing chemotherapy regimens, rounds of radiation, surgeries or combinations of these treatments. But for many patients, these procedures are not so much milestones as stepping stones to a different kind of life – as survivors.
Helping cancer patients not only survive cancer but thrive is an ongoing task for UCHealth, which is taking another step in that direction with the roll-out of the STAR (Survivorship Training and Rehab) Program at University of Colorado Hospital in Aurora and Memorial Hospital in Colorado Springs. The goal of STAR, which originated at Harvard Medical School and spread nationwide, is to build a rehabilitation service line that addresses the specific needs of oncology patients.
With the fall launch, STAR will be in place across UCHealth. The program launched at Poudre Valley Hospital in Fort Collins and Medical Center of the Rockies in Loveland in 2013; learning-module training wrapped up in January 2014 and the number of referrals has increased steadily since that time, said Kathleen Michie, PT, MT, CLT, program manager for Oncology Rehabilitation and Integrative Therapies at UCHealth Northern Colorado.
A total of roughly 120 rehabilitation and oncology providers will go through the current STAR training, said Erin Erickson, OT, an inpatient occupational therapist at UCH. The requirements include 10 online modules that address different types of cancer and their effects on patients and evidence-based rehabilitation treatments, Erickson said. Four in-services leading up to the launch and quarterly sessions thereafter will reinforce the information, she added.
Those who complete the modules and a test successfully become STAR-certified, Erickson said. The idea is that oncologists become familiar with the physical demands cancer places on patients and refer them to OTs, PTs and SLPs trained to deal with cancer-related issues such as fatigue, pain, sleeplessness, range-of-motion limitations, lymphedema, and other factors that can decrease the quality of life and interfere with recovery.
“Research shows the primary cause of distress for cancer patients is physical impairment,” said Michie. She noted that the American College of Surgeons’ Commission on Cancer already requires accredited institutions to conduct “distress screenings” of cancer patients. If physical ailments are a “root cause” of distress, the STAR Program gives hospitals a concrete way to address them proactively, just as they do in other areas, Michie said.
“We prescribe cardiac rehab for patients with the first heart attack,” she said. “We should also start oncology rehabilitation treatment way upstream.”
Put your hands together
Like the budding oncology supportive care program at UCH, STAR also stresses collaboration between providers in the interest of improving patient care, Michie said. Occupational therapists, for example, could address with an oncologist the challenge a breast cancer patient might have with ordinarily simple activities, like combing her hair or hooking her bra after surgery. An oncologist might explain and even demonstrate to both OTs and PTs the odd positions demanded of a patient during radiation treatments.
“It’s a multidisciplinary approach with a focus on the whole person,” Michie said. She noted that the move to STAR in northern Colorado began in order to meet a Commission on Cancer requirement that patients have access to rehabilitation services. Providers soon found the program’s value “was much more than checking a box for certification,” she noted. During the pilot of a multidisciplinary survivorship clinic, providers made 80 referrals for rehabilitation services to address physical impairments, Michie said.
“The comments we received from patients about the impact oncology rehab had on improving their quality of life were confirmation that rehab was a necessary component of the cancer journey,” she said. Patients generally expressed strong agreement that the program improved their energy, mental outlook and function while decreasing their pain levels, Michie said.
Rehab can have an impact on people at any phase of life, including the last, she added. “If a person can just be able to hold the grandkids — that can have a huge impact on his life.”
On your mark, set, prehab
The STAR approach focuses not only on treatment-related physical issues, but also on “prehabilitation” activities to prepare patients for the rigors of therapy. Physical and psychological assessments establish baseline functions, identify barriers and decide on interventions. The idea is that strengthening a patient’s physical and emotional reserves improves the chances for positive outcomes when they begin treatment, noted Jamie Bachman, executive director of Oncology Services for University of Colorado Hospital.
“We want to educate our cancer providers about the importance of proactively and preemptively sending patients for help with issues instead of waiting for problems to occur,” Bachman said. In the long run, early attention to problems can translate to patients completing their treatment, shortening their recovery times, and returning to work or everyday activities sooner, he added.
Erin Wicken, PT, a physical therapist at UCH’s Stapleton Rehabilitation Therapy Clinic, said she regularly works with cancer patients who need help with pain, fatigue, deconditioning, endurance, range of motion, and more.
“The longer issues are unaddressed, the longer it takes to restore function,” Wicken said. “The STAR Program gives us a chance to better manage their care.”
Specialist to specialist
A good example of that is treatment of lymphedema, or chronic swelling in the extremities, trunk, head and neck that occurs when the lymphatic system is disrupted. It’s a potential risk from surgery or radiation for several varieties of cancer, said Hillary Duffy, practice manager for outpatient rehabilitation at UCH, and a certified specialist in lymphedema therapy with 15 years of experience in that area.
Lymphedema is not life-threatening, Duffy said, but it can impair a patient’s quality of life. It requires complex treatment, including manual draining, multi-layer bandaging, exercises to minimize swelling, and skin care to reduce the risk of infection. The STAR Program promises to make more physicians aware that their patients with lymphedema can get specialized treatment, Duffy said.
“Physicians will have confidence that they are referring their patients to providers with the best training for all cancer-related conditions,” she said.
Walking in their shoes
Regina Brown, MD, can speak from multiple perspectives to the importance of integrating care for cancer patients. She is now medical director of Oncology at UCHealth’s Lone Tree Health Center, but was physician champion for the STAR Program launch in northern Colorado. The program dovetailed with exercise and massage services the hospitals were already offering cancer patients to help improve their function, Brown said. Patients now get these and other varieties of supportive care under one roof through The Wellness Place at the UCHealth Cancer Center in Fort Collins.
But she had a more personal connection to the program, having watched her parents physically decline as they battled and ultimately succumbed to cancer. Brown went through radiation for an early-stage cancer herself in 2010. While downplaying the physical burden of her treatment, she says the fatigue caused by the radiation was well beyond anything she’d experienced before her illness.
“It was totally different” from ordinary end-of-day tiredness, Brown said. “Radiation fatigue is like, ‘Nope, you’re done.’ You feel like you can’t take another step.”
Patients may believe such challenges are simply the price of treatment, but the STAR Program offers an alternative view, Brown said.
“The biggest thing we’ve learned through adopting STAR is that a lot of times if we weren’t asking patients these specific things, they didn’t know to ask them,” she said. “By us being aware of what it is that they could be experiencing, that’s enlightened them instead of just sitting back and saying, ‘I guess this is what it is because I’m going through chemo or radiation.’ The STAR Program has also enlightened us to check these things with our patients.”
Brown said the STAR Program received very positive reviews from patients in northern Colorado, with many citing seemingly simple benefits like better sleep, improved appetite and increased energy.
“There were patients who never thought they’d be able to do things again, like going back to work or taking up a hobby,” Brown said. “It in some ways gave them a new lease on life.”
The STAR Program is one piece of a comprehensive commitment at UCHealth to extending the boundaries of cancer care and helping patients think about their disease in a new and more hopeful way, said Erickson, the OT specialist.
“We used to say, ‘You’re cured, but you’re going to have a new normal. You can’t get back to where you were before,’” she said. “Now we are trying to help patients get back to their old normal.”