Working with people affected by cancer from diagnosis to cure or end of life identifies the common need – help from the right person, at the right time in the right way. So how do we identify who that is, where that should be and how that should be delivered?
Treating people with cancer is a growing specialty and every single diagnosis manifests itself differently. There is no single cure and even the word ‘cure’ is subjective. Current statistics predict that by 2030, one in every three people will be diagnosed with cancer in their lifetime. We know cancer care is improving; people are living longer but many have unmet needs. There are more than 200 cancers identified presenting challenges in developing individualised care, so is it possible to develop a streamlined and evidence based referral pathway for everyone?
Nationally and internationally the evidence base outlining the role of exercise for people affected by cancer is well established and accepted. In response to this the role of the physiotherapist in cancer care is expanding and developing, for example following mastectomy shoulder morbidity is often bilateral and present for up to 6 years with a high prevalence of rotator cuff tear (Shamley et al., 2012). Addressing pain modulation, improving range of movement and muscle strength the physiotherapists can help shift the focus from illness to wellness, helping people to live as fully and actively as possible. The World Congress of Physiotherapy has identified this need and will be presenting a one day course in Geneva in 2019, raising awareness amongst physiotherapists from around the globe.
The Kaiser Permanente Triangle (Fig 1) illustrates in level 1 that the vast majority of the cancer population could be referred directly to the Macmillan Move More exercise programmes. Those requiring care in level 3 would likely be supported by specialist staff, but who supports patients with musculoskeletal conditions related to their cancer diagnosis providing treatment in level 2? Who prevents a crisis from developing prompting escalating into level 3? And who supports a return to level 1 when possible? We know people want to be treated local to home and have a positive experience (Scottish Government 2011) so is this the role of physiotherapists working in local GP practices and community hospitals or is this only the role of secondary care staff and how is this service developed?
Training for physiotherapists allowing them to complement the role of the local fitness instructors is provided by the New Zealand PINC and Steel online training programme, and this is accessed by physiotherapists worldwide.
Having completed the PINC training in 2016, I am now part of a global team of physiotherapists, and through a social media platform we share knowledge and ask questions in a safe and supportive environment. During training I could speak to and discuss approaches with physiotherapists working in small private practices in the outback of Australia, in large city practices in New Zealand, in rural Ireland and the vast plains of Kenya. Quite an amazing experience in itself!
When problems present, referring staff often report they are unsure when to refer to physiotherapy or to community based exercise referral programmes such as ‘Move More’. To help establish clear pathways, in 2013, physiotherapists from Guys and St Thomas’ NHS Foundation Trust developed a cancer activity tool which helped identify to whom and when referrals should be made.
Cancer Activity Tool
In Scotland, now that health and social care services have integrated, following the ‘Cancer Activity Tool’ could provide an opportunity for a new approach with physiotherapists and fitness instructors working closely together to provide a joined up, person-centered approach, helping to keep as many people as possible at level 1 of the Kaiser triangle.
Risk and exercise for people with metastatic bone disease is often seen as another barrier to advocating exercise. However, in March this year Macmillan Cancer Support published guidelines for healthcare professionals so that patients can become or remain as physically active as possible.
Looking ahead it is important that we plan for the future; population demographics are changing. There have been significant developments and progress in cancer rehabilitation in Scotland in the last 5 years, but without a streamlined referral pathway in place, many people still report unmet need or miss out on referral to support that is otherwise available.
Is it posssible for clinicians, service managers and policy makers to work together to establish clear evidenced-based pathways which utilise current resourses and enable people living with cancer to access physiotherapy services that are in line with those available to other patient groups? And when morbities which prevent physical activity exist, can referral to physiotherapy become the rule rather than the exception for people living with cancer?
(2012) Shoulder morbidity after treatment for breast cancer is bilateral and greater after mastectomy, Acta Oncologica, 51:8, 1045-1053,
Scottish Government (2011) 2020 Vision https://www.gov.scot/Topics/Health/Policy/2020-Vision
Mandy Trickett MSc, Specialist Physiotherapist (@MandyTrickettPT)