Diagnosing and Treating Adult Cancers and Associated Impairments (2021) / Chapter Skim
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9 Cancer-Related Impairments Leading to Functional Limitations
9 Cancer-Related Impairments Leading to Functional Limitations
Pages 253-316
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, in this chapter the committee specifically considers an impairment to be any loss or abnormality of physiological, psychological, or anatomical structure or function that can last 12 months or longer and that is of sufficient severity to alter the performance of activities and tasks required to carry out employment or self-care activities. The committee recognizes that some of the impairments discussed in this chapter may occur for periods of less than 12 months, but these episodes would not meet SSA's eligibility requirements for disability benefits.
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(organizational, environmental) FIGURE 9-1 A conceptual framework for cancer and cancer-related impairments leading to functional limitations.
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. Both scales are intended to help clinicians know whether it is safe to treat the patient, but they also have relevance to understanding cancer-related impairments and functional limitations.
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However, for many cancer survivors, cancer treatments themselves are often associated with significant physical and psychosocial effects, many of which persist for years or even decades after treatment is complete. Furthermore, poor functional capacity at diagnosis (due to cancer or underlying chronic medical conditions)
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For example, in 2018 the National Coalition for Cancer Survivorship determined that cancer care quality measures reflecting "return" to functional status after cancer diagnosis did not resonate with cancer survivors because after a cancer diagnosis, life is permanently changed. Survivors felt that "redefining" functional status more accurately captured the dynamic nature of functional status during and after cancer diagnosis and treatment (NCCS, 2019)
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b Although some cancers such as myeloma may cause peripheral neuropathy, the committee focuses on chemotherapy-induced peripheral neuropathy in this report. Pain Prevalence, Etiology, and Risk Factors The treatment of cancer pain can span the cancer continuum from before diagnosis through end of life.
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Diagnosis and Assessment In 2016 the American Society of Clinical Oncology (ASCO) released its evidence-based guideline Management of Chronic Pain in Survivors of Adult Cancers, which covered the screening and treatment of cancer-related pain.
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The ASCO and NCCN guidelines for the treatment of cancer pain include palliative and end-of-life pain management strategies. A multidisciplinary, multimodal approach to treating chronic cancer pain can be effective (NCCN, 2020b)
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. Fatigue interferes with cancer survivors' ability to participate in meaningful life activities, including work (Islam et al., 2014)
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compared with all other cancers; among post-treatment lung cancer survivors, the fatigue prevalence was 35% (Wang et al., 2014)
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. Chemotherapy-Induced Peripheral Neuropathy Prevalence, Etiology, and Risk Factors CIPN is caused by exposure to the neurotoxic agents used to treat a variety of cancers, such as vincristine, taxanes (e.g., docetaxel)
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CIPN is one of the most common side effects of cancer treatment (an estimated prevalence of 68% at 1 month after chemotherapy) , and although its prevalence decreases with time after treatment ends, it has been estimated that as many as 30% of patients have CIPN at 6 months to 1 year after finishing chemotherapy (Colvin, 2019; Seretny et al., 2014)
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. One study found that at an average of 6 years after treatment, 47% of breast cancer survivors still reported CIPN (Winters-Stone et al., 2017)
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Recent data suggest that the overall 5-year cumulative incidence of lymphedema is about 13.7% after breast cancer treatment (McDuff et al., 2019)
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Cachexia Prevalence, Etiology, and Risk Factors Cachexia, a complex metabolic syndrome seen in serious illnesses such as cancer, is characterized by a loss of muscle mass, weight loss, anorexia, asthenia, and anemia. Cancer cachexia occurs mainly during active or palliative treatment, and its signs and symptoms are considered to be indicative of advanced disease (Dhanapal et al., 2011)
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Cardiotoxicity Prevalence, Etiology, and Risk Factors The cardiotoxic effects of cancer treatment are often permanent and progressive (Virizuela et al., 2019) , leading to significant morbidity and
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. Longterm cancer survivors may experience autonomic dysfunction, particularly if they received chest wall irradiation (Coumbe and Groarke, 2018)
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. Oncology clinicians, including medical oncologists, surgical oncologists, and radiation oncologists, as well as non-oncologic clinicians such as internists, primary care physicians, nurse practitioners, and rehabilitation physicians are instrumental in the identification of cardiac risk factors and dysfunction in cancer survivors (Alfano et al., 2016)
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. Breast cancer survivors with treatment-related heart failure who participated in a cardiac rehabilitation program experienced aerobic benefits comparable to those seen in women with coronary heart disease who participated in such a program (Bonsignore et al., 2017)
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. Up to 25% of cancer survivors demonstrate cognitive impairment on a neuropsychological exam, and greater than 50% report cognitive decline across the cancer care trajectory, including impairment that appears many years after treatment (Ahles et al., 2012)
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, cognitive training (Von Ah and Crouch, 2020; Von Ah et al., 2012) , physical activity/exercise (Myers et al., 2018; Zimmer et al., 2016)
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. Cancer survivors are also twice as likely as the general population to commit suicide, and those with advanced cancer are three times as likely to do so (Misono et al., 2008)
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. Cancer survivors may also experience anxiety (Andersen et al., 2014)
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. The American College of Sports Medicine extolled the benefits of exercise on physical functioning and QOL in cancer survivors, recommending that all survivors, even those undergoing treatment, "avoid inactivity" to promote positive health outcomes (Schmitz et al., 2010)
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. Serious GI sequelae of cancer treatment (e.g., GI perforation, hemorrhagic colitis, and cirrhosis)
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Diagnosis and Assessment The identification of GI toxicity typically begins with patient reports of troublesome symptoms or a perceived abnormal bowel pattern. Normal bowel pattern is typically based on having at least three stools per week and no more than three per day; however, these criteria may be inappropriate for cancer patients.
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. Graft-Versus-Host Disease Prevalence, Etiology, and Risk Factors Graft-versus-host disease (GVHD)
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. Chronic GVHD in long-term transplant survivors may lead to functional impairments such as chronic fatigue, changes in cognition, chronic pain, anxiety, and GI effects (Baker and Fraser, 2008; Pallua et al., 2010)
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. Among breast cancer survivors there are multiple other potential adverse treatment effects on muscle health, including muscle changes resulting from mastectomies, such as a decreased range of motion, rotator cuff disease, adhesive capsulitis, axillary web syndrome, and postmastectomy pain syndrome (Stubblefield and Keole, 2014)
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. Finally, among head and neck cancer patients, surgery and the effects of radiation adversely affect function of the sternocleidomastoid, scalene, and trapezius muscles in 1–13% of patients (Gane et al., 2017)
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. Bisphosphonates for the prevention of bone loss have been successful in postmenopausal breast cancer survivors who take aromatase inhibitors, but these are not without risk, as described above.
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or intrinsic lung disease. Acute radiation-induced lung injury manifests as radiation pneumonitis in approximately 5–15% of patients who receive high-dose radiation for lung cancer and in 10–20% of patients receiving chest radiation for other tumors, including breast cancer (Garipagaoglu et al., 1999; Roach et al., 1995)
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. Diagnosis and Assessment The diagnosis of pulmonary toxicity following cancer treatment is primarily exclusionary (Shannon, 2020)
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Most clinical guidelines recommend a two-step process to identify sleep problems, with initial screening questions followed by a more comprehensive examination in cancer patients who screen positive. Common assessment tools to identify sleep disturbance in cancer survivors include sleep diaries, the insomnia severity index, and the PROMIS sleep disturbance and sleep-related impairment questionnaires (Berger et al., 2017; Howell et al., 2014)
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. These medications all have potential adverse effects, and, while they are recommended for sleep disturbances in the general population, their efficacy and safety in adult cancer survivors are not established.
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This condition may be due to cancer treatment, but may also occur with cancer involvement of the nerves such as in primary or metastatic brain and other nerve-related malignancies. Diagnosis and Assessment An assessment for ototoxicity should be initiated early, as delayed diagnosis may lead to significant impairments and functional limitations, and the ototoxicity may be misdiagnosed as other conditions, such as cognitive dysfunction or depression (Ganesan et al., 2018)
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, are common among cancer survivors, and those with such comorbidities experience poorer survival, poorer QOL, and higher health
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. Although older cancer survivors (i.e., aged 65 and older)
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The general categories of nonpharmacologic interventions that may help restore a cancer survivor's daily functioning and that may be included in a multi-component cancer treatment and survivorship care plan include the following: • Exercise/Physical Activity. Recently, a consortium that included NCCN, the American College of Sports Medicine, the American Cancer Society, the American Society of Clinical Oncology, the American Physical Therapy Association, and the National Cancer Institute published updated exercise guidance for people living with and beyond cancer (Campbell et al., 2019; Patel et al., 2019)
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. These rehabilitation profes sionals are able to diagnose and treat the physical, psychological, and cognitive impairments to help cancer survivors maintain and restore function, reduce symptom burden, maximize their indepen dence, and improve their QOL (ARN, 2017; Silver et al., 2015)
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The support and guidance of an audiologist or speech and language pathologist or therapist helps promote recovery and also helps a patient cope with the difficult speech and swallowing symptoms that may oc cur during and after cancer treatment. Ideally, the speech and language pathologist becomes involved when the patient has been identified as having a cancer that may alter speech or eat ing, such as happens with many head and neck cancers, before surgery or before any chemotherapy or radiation treatments.
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4. The common causes of functional limitations related to cancer itself, cancer treatment, or multiple factors (e.g., comorbidities)
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2. Regular assessment and re-assessment of functional status through out the cancer care trajectory are warranted, given the dynamic impacts of cancer-related acute, long-term, and late-onset impair ments that may result in functional limitations.
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2017. Prevention and monitoring of cardiac dysfunction in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline.
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2015. The level of association between functional performance status measures and patient-reported outcomes in cancer patients: A systematic review.
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adult cancer survivors. Psycho-Oncology 16(8)
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2012. An evaluation on the neuropsychological tests used in the assessment of postchemotherapy cognitive changes in breast cancer survivors.
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2012. Exercise effects on depressive symptoms in cancer survivors: A systematic review and meta-analysis.
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2013. Impact of secondary lymphedema after head and neck cancer treatment on symptoms, functional status, and quality of life.
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2013. Pain in long-term breast cancer survivors: The role of body mass index, physical activity, and sedentary behavior.
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2019. Measuring aging and identifying aging pheno types in cancer survivors.
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2014. Sleep disturbance in adults with cancer: A systematic review of evidence for best practices in assessment and management for clinical practice.
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2016. Randomized con trolled pilot trial of mindfulness-based stress reduction compared to psychoeducational support for persistently fatigued breast and colorectal cancer survivors.
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2019. It's never too late -- Balance and endurance training improves functional performance, quality of life, and alleviates neuropathic symptoms in cancer survivors suffering from chemotherapy-induced peripheral neuropathy: Results of a randomized controlled trial.
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2020. Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: ASCO guideline update.
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2019. Physical activity in cancer prevention and survival: A systematic review.
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. NCCS (National Coalition for Cancer Survivorship)
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2006. Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: Meta-analyses.
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2010. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors.
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International Journal of Clinical Oncology 24(1)
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2017. The underutilization of rehabilitation to treat physical impairments in breast cancer survivors.
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2011. Prospective neurocognitive function over 5 years after allogeneic he matopoietic cell transplantation for cancer survivors compared with matched controls at 5 years.
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2018. Relationship between self-reported cognitive function and work-related outcomes in breast cancer survivors.
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2012. Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: A randomized controlled trial.
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