Sean Robinson Smith

National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group Report

The 2006 National Institutes of Health (NIH) Consensus paper presented recommendations by the Ancillary Therapy and Supportive Care Working Group to support clinical research trials in chronic graft-versus-host disease (GVHD). Topics covered in that inaugural effort included the prevention and management of infections and common complications of chronic GVHD, as well as recommendations for patient education and appropriate follow-up. Given the new literature that has emerged during the past 8 years, we made further organ-specific refinements to these guidelines. Minimum frequencies are suggested for monitoring key parameters relevant to chronic GVHD during systemic immunosuppressive therapy and, thereafter, referral to existing late effects consensus guidelines is advised. Using the framework of the prior consensus, the 2014 NIH recommendations are organized by organ or other relevant systems and graded according to the strength and quality of supporting evidence.

Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services.

Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life. Cancer rehabilitation and palliative care involve the delivery of important but underutilized medical services to oncology patients by interdisciplinary teams. These subspecialties are similar in many respects, including their focus on improving cancer-related symptoms or cancer treatment-related side effects, improving health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision-making. They also aim to improve healthcare efficiencies and minimize costs by means such as reducing hospital lengths of stay and unanticipated readmissions. Although their goals are often aligned, different specialized skills and approaches are used in the delivery of care. For example, while each specialty prioritizes goal-concordant care through identification of patient and family preferences and values, palliative care teams typically focus extensively on using patient and family communication to determine their goals of care, while also tending to comfort issues such as symptom management and spiritual concerns. Rehabilitation clinicians may tend to focus more specifically on functional issues such as identifying and treating deficits in physical, psychological, or cognitive impairments and any resulting disability and negative impact on quality of life. Additionally, although palliative care and rehabilitation practitioners are trained to diagnose and treat medically complex patients, rehabilitation clinicians also treat many patients with a single impairment and a low symptom burden. In these cases, the goal is often cure of the underlying neurologic or musculoskeletal condition. This report defines and describes cancer rehabilitation and palliative care, delineates their respective roles in comprehensive oncology care, and highlights how these services can contribute complementary components of essential quality care. An understanding of how cancer rehabilitation and palliative care are aligned in goal setting, but distinct in approach may help facilitate earlier integration of both into the oncology care continuum—supporting efforts to improve physical, psychological, cognitive, functional, and quality of life outcomes in patients and survivors.

The multidisciplinary management of bone and soft tissue sarcoma: an essential organizational framework.

The rarity of bone and soft tissue sarcoma, the difficulty in interpretation of imaging and histology, the plethora of treatment modalities, and the complexity and intensity of the treatment contribute to the need for systematic multidisciplinary team management of patients with these diseases. An integrated multidisciplinary clinic and team with a structured sarcoma tumor board facilitate team coordination and communication. This paper reviews the rationale for multidisciplinary management of sarcoma and details the operational structure of the Multidisciplinary Sarcoma Clinic and Sarcoma Tumor Board. The structured Multidisciplinary Sarcoma Tumor Board provides opportunity for improvement in logistics, teaching, quality, and enrollment in clinical trials.

Cancer Survivorship: A Growing Role for Physiatric Care

Cancer survivors are growing in number, with an estimated 14.5 million people alive in the United States with a diagnosis of cancer and an expected 19 million by 2024 [1]. Many cancer survivors have well-documented medical needs related to the cancer diagnosis and treatment [2]. Survivorship represents a distinct period along the continuum of cancer care and necessitates a unique approach to meet the demands of this patient population. As a result, the Commission on Cancer, a program of the American College of Surgeons which accredits hospital cancer centers based on established quality standards, is requiring that by 2015 all designated cancer centers have a survivorship care plan in place for patients upon the completion of acute treatment for malignancy [3]. This treatment typically consists of a combination of chemotherapy, radiation therapy, and surgery. The Commission on Cancer mandate is informed by the 2005 Institute of Medicine report, “From Cancer Patient to Cancer Survivor: Lost in Transition” [4] and aims to create a structure to (1) screen for recurrent and new cancers; (2) try to prevent recurrence of cancer; (3) identify and manage late effects of the cancer or its treatment; and (4) improve coordination between oncology providers, primary care physicians, and specialists. Different models for survivorship exist, including those that begin at diagnosis and after primary treatment [5], but any interpretation of survivorship must reasonably conclude that significant morbidity and health risks are directly or indirectly associated with the cancer diagnosis even after treatment is presumably complete and that patients will require ongoing medical care to treat these impairments even if they have no evidence of recurrent disease. Many symptoms and conditions intrinsic to cancer and/or its treatment lead to physical and cognitive impairment, which may require expert evaluation by a multidisciplinary team led by a physiatrist [2]. In fact, physical impairments have been described as the most bothersome comorbidity in patients with a cancer

Musculoskeletal, Neurologic, and Cardiopulmonary Aspects of Physical Rehabilitation in Patients with Chronic Graft-versus-Host Disease

Chronic graft-versus-host disease (cGVHD) has the potential to cause significant morbidity and mortality in people who undergo allogeneic hematopoietic stem cell transplantation. Management of complications due to cGVHD can be challenging because of multiorgan involvement and variable presentation of the disease. This paper outlines the diagnosis and management of musculoskeletal, neurologic, and cardiopulmonary manifestations of cGVHD that have the potential to cause profound functional impairment and that may significantly impact quality of life and lifespan. Expert evaluation by a physical medicine and rehabilitation physician and multidisciplinary team may be beneficial in the treatment of the disease sequelae, and examples of specific rehabilitation interventions are described.

An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report

Spinal metastases are becoming increasingly common because patients with metastatic disease are living longer. The close proximity of the spinal cord to the vertebral column limits many conventional therapeutic options that can otherwise be used to treat cancer. In response to this problem, an innovative multidisciplinary approach has been developed for the management of spinal metastases, leveraging the capabilities of image-guided stereotactic radiosurgery, separation surgery, vertebroplasty, and minimally invasive local ablative approaches. In this Review, we discuss the variables that should be considered during the management of these patients and review the role of each discipline and their respective management options to provide optimal care. This work is synthesised into a practical algorithm to aid clinicians in the management of patients with spinal metastasis.

Connecting the dots: A comparative global multi-institutional study of prohibitive factors affecting cancer pain management

Objective. The goal of this study was to elucidate the attitudes, beliefs, and barriers interfering with cancer pain management, the degree of barrier interference with trainees’ care of patients, and the relationships among prohibitive factors to pain management for physicians in a low–middle-income countries (LMICs) vs high-income countries (HICs). Design and Setting. A multi-institutional cross-sectional survey of physicians in specialties with a focus in pain management training was performed. All surveys were completed anonymously from July 1, 2015, to November 30, 2015. Subjects. One hundred and twenty physicians participated in the survey. Methods. Surveys were based on prior questionnaires published in the literature. Descriptive statistics were calculated, and chi-square (ℵ2) analysis, Fisher’s exact test, and Spearman rank correlation analyses were performed. Results. Compared with their peers in HICs, physicians in LMICs reported less experience with cancer pain management despite seeing more cancer patients with advanced disease (41% vs 15.2%, p < 0.05). Some barriers were common to both environments, but a few were unique to each setting. Organized by percentage of severity of interference, cultural values/beliefs about pain (84% vs 76%) and lack of training and expertise (87% vs 78%) were significantly more prohibitive for physicians in LMICs than those in HICs; p < 0.05. Conclusion. There are significant differences in perceived barriers and degree of prohibitive factors to cancer pain management among trainee physicians in low- vs high-resource environments. Understanding these differences may spur further collaboration in the design of contextually relevant solutions, which could potentially help improve the adequacy of cancer pain management

The Intersection of Oncology Prognosis and Cancer Rehabilitation

Purpose of reviewThis review examines the delivery of rehabilitation care to cancer patients with relation to disease prognosis. This includes the evaluation when patients are referred for rehabilitation services and the effectiveness of rehabilitation interventions across the cancer continuum.Recent findingsAlthough prognosticating life expectancy is difficult, referrals for rehabilitation interventions appear to be affected by physician attitudes towards patients with advanced disease, in part because of misconceptions about the nature of rehabilitation for oncology patients. Rehabilitation may also be underutilized in long-term survivors with no evidence of disease. Despite this, our review found that rehabilitation in advanced disease, end-of-life, geriatric cancer patients, and in long-term survivors can be beneficial. There is a relative dearth in studies on rehabilitation interventions specifically at the end-of-life.SummaryCancer rehabilitation can be helpful to patients along the spectrum of cancer prognoses. Examining more accurate ways to prognosticate life expectancy, improving communication and education between oncologists and rehabilitation team members, and modifying survivorship plans to include patient education on functional changes over time may improve the delivery of rehabilitation care.

Improved Arousal and Motor Function Using Zolpidem in a Patient With Space-Occupying Intracranial Lesions: A Case Report

Patients with disorders of consciousness (DOC) have profound functional limitations with few treatment options for improving arousal and quality of life. Zolpidem is a nonbenzodiazepine hypnotic used to treat insomnia that has also been observed to paradoxically improve arousal in those with DOC, such as the vegetative or minimally conscious states. Little information exists on its use in patients with DOC who have intracranial space‐occupying lesions. We present a case of a 24‐year‐old man in a minimally conscious state due to central nervous system lymphoma who was observed to have increased arousal and improved motor function after the administration of zolpidem.

An Evolving Role for Cancer Rehabilitation in the Era of Low-Dose Lung Computed Tomography Screening

Lung cancer is the number one cause of cancer‐related death worldwide, and is often detected in the later stages. Use of low‐dose chest computed tomography in at‐risk patients provides earlier detection and is being adopted as the standard screening tool, replacing less precise methods of radiography and sputum cytology. In the past, late detection of disease meant that rehabilitation interventions attempted to salvage function and to improve aerobic capacity to the point where patients could tolerate the sometimes‐extensive oncologic treatment, including lobectomy or pneumonectomy. Earlier detection may shift this toward more often addressing specific neuromusculoskeletal impairments, such as postthoracotomy pain or peripheral neuropathy, as patients with early‐stage disease may not be as debilitated by chronic disease or metastases as those with late‐stage lung cancer. Patients with advanced disease, however, will still require rehabilitation interventions, and this fragile population creates unique challenges. Rehabilitation professionals should look for ways to expand care to lung cancer patients, as both the number of those treated and the 5‐year survival rate are expected to increase.