Article by Bahar Golbon

Graphic design by Mimi Guo

Improvements in cancer treatment have dramatically reduced mortality rates since the 1990s.¹ This has created a large population of cancer survivors who must cope with their impairments for a much longer period of time. Unfortunately, cancer rehabilitation literature is underwhelming, and physiatrists are lacking high quality evidence-based approaches to sufficiently support these patients. 

Dr. David Langelier’s role as a clinician-investigator lies at the center of this growing issue. Dr. Langelier is an assistant professor at the University of Toronto’s Institute of Medical Science (IMS), and a physiatrist at the Cancer Rehabilitation and Survivorship Clinic at the Princess Margaret Cancer Centre (PMCC). He also works at the Toronto Rehabilitation Institute.

Dr. Langelier notes, “These survivors now have the unfortunate opportunity to potentially live with these impairments, but we’re not yet equipped to sufficiently address these impairments as we lack the necessary infrastructure.” Hence, physiatrists are relying on treatment regimens from other injured populations (i.e., spinal cord injury or brain injury) to fit the needs of oncology patients.

As a physiatrist, Dr. Langelier relies on exercise to treat his patients. Exercise is an effective method to improve symptoms, minimize disease progression and recurrence, and potentially even reduce mortality.³ Another benefit of prescribing exercise as a treatment option is that the patient regains a sense of control over their life and body. Instead of being dictated by their cancer diagnosis, treatment, and post-treatment ailments, patients can re-assert dominance over their disease through the choice to exercise. “If we can say, ‘you can exercise and you have control over potentially changing your course of treatment.’ That’s huge.”

Much of the rehabilitation provided in the oncology realm is targeted towards cancer survivors. Dr. Langelier is also passionate about providing rehabilitation to patients with incurable or metastatic disease. Although they may never be cured of their malignancy, Dr. Langelier highlights the importance of providing a chance for these patients to improve their symptoms such as fatigue, anxiety, pain, and potentially to even delay disease progression. Unfortunately, conventional exercise and rehab programs do not cater to the needs of patients with incurable cancer. Dr. Langelier elaborates, “The terminology found in educational materials presented to advanced cancer patients did not relate to them as [the materials] focus on survivors and long-term changes. Patients did not feel these terms and ideas appropriately applied to them. So, we needed to change the content.” These challenges were the ultimate inspiration for the initiation of the Cancer Rehabilitation Exercise for Advanced Cancer (CaRE-AC) program at PMCC, which is based on the original CaRE@Home program.⁴  It is an eight-week, multidimensional rehabilitation program for patients with advanced cancer. This program underwent feasibility testing as a pilot study prior to the COVID-19 pandemic. With the pandemic creating a roadblock to in-person interactions, the study was partially adapted to a virtual setting. Patients attended physical assessments at the hospital and independently performed exercises at home. In this population, it is unlikely to see large improvements, instead the goal is to minimize natural decline in their health status. The new virtual aspects proved to be immensely effective, with trends supporting stabilization and even improvement in functional ability. Ultimately, the program was deemed to be feasible and highly acceptable among patients. Dr. Langelier and his team are now working towards launching a multicenter study to further test the feasibility of CaRE-AC. Dr. Langelier explains that a constant challenge he faces with this group is the heterogeneity, as each patient is unique in their journey and the treatments they endure. Thus, the continuation of this project is vital to understand the true scope of CaRE-AC among this vastly unique demographic. Dr. Langelier expresses “I’m extremely happy with the results that we’re seeing! The interviews with patients have been so informative and uplifting, as many patients were feeling they were forgotten about when it came to rehab. We are recognizing that some of these patients have months or years of life left and we could potentially really improve their function and quality of life during this time.” 

Dr. Langelier explains that the patients lead their rehabilitation journey and initiate the research process. “The questions we need to ask are: what is the patient’s priority and what are they suffering with the most that we need to overcome?” Additionally, once a study is complete, it is necessary to share the results with the patients to inform them of their contributions and any progress made. If we saw improvements, it could even encourage patients to continue with their exercises.

Cancer rehabilitation is definitely moving in the right direction but there is always more work to be done. Dr. Langelier highlighted a gap in the current data, “I think that we haven’t appropriately established the incidence and prevalence of impairments effecting cancer patients.” To capture this data accurately, Dr. Langelier suggests developing a provincial or federal cancer rehabilitation database as a long-term goal. Physical therapists, occupational therapists, speech therapists and other rehabilitation experts must be employed to develop appropriate impairment algorithms and codes. With the minimal number of physiatrists in Canada and the growing number of Canadians who will require post-cancer rehabilitation, the need for one such database is dire. Furthermore, the next generation of medical professionals must be trained to expand their reach to the growing population of suffering patients.

With dedicated researchers like Dr. Langelier tackling the ever-growing epidemic of cancer-related impairments, we can be optimistic about the future of cancer care. As a new addition to the rehab team at PMCC, we eagerly anticipate a multitude of innovative projects in the future from Dr. Langelier and his mentors and collaborators, Drs. Eugene Chang and Jennifer Jones.

References:

1. Canadian Cancer Statistics Advisory Committee in collaboration with the Canadian Cancer Society. Canadian Cancer Statistics 2021. Canadian Cancer Society, Statistics Canada and the Public Health Agency of Canada 2021; 1–95.
2. Alfano CM, Rowland JH. Recovery issues in cancer survivorship: a new challenge for supportive care. Cancer Journal 2006; 12: 432–43.
3. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. A Cancer Journal for Clinicians 2013; 63: 295–317.4.
4. Macdonald AM, Chafranskaia A, Lopez CJ, et al. CaRE @ home: Pilot study of an online multidimensional cancer rehabilitation and exercise program for cancer survivors. Journal of Clinical Medicine 2020; 9: 1–25.