Physios in oncology
Associate Professor at Amsterdam University of Applied Sciences, Martijn Stuiver, elaborates on his recent editorial published in the Journal of Physiotherapy about the international perspective on integrating physiotherapists in oncology care.
You initiated and attended the first conference on physiotherapy in oncology. Please tell us about the conference.
Although there are several oncology and supportive cancer care conferences that are of interest for physiotherapists, until 2018 there had never been a conference specifically aiming at physiotherapy in oncology. We thought it would be interesting to bring together physiotherapists working in oncology from around the world to truly focus on this topic. First and foremost, we wanted to connect colleagues to enable idea exchange. In addition, we wanted to inspire participants through talks by opinion leaders and researchers. Finally, we wanted to discuss the challenges we face as a profession and the way forward. We were thrilled that 280 physiotherapists attended (the maximum number we could host), from 30 countries from all regions of the world.
So what is the current state of affairs for oncology physiotherapy?
There is increasing evidence to support the role of physiotherapy in oncology. In particular, with regard to exercise interventions, the evidence is quite strong. In October 2019, the American College of Sports Medicine released three papers based on an international multidisciplinary roundtable on physical activity and cancer prevention and control, summarising this evidence.
The role that physiotherapists envision for themselves in cancer care differs somewhat across countries, dependent, in part, on the healthcare system in which they operate. For example, in some countries, the focus of physiotherapists is mostly on therapeutic exercises to address musculoskeletal issues and on prevention and treatment of lymphoedema. In other countries, physiotherapists are the key profession for delivering exercise programs during or after cancer treatment, in addition to their role in the treatment of musculoskeletal issues and lymphoedema. Yet, there is also a lot of common ground. It was discussed at the International Conference on Physical Therapy in Oncology that the basic curricula of physiotherapy already prepares physiotherapists to deal with several problems individuals living with or beyond cancer face. At the same time, physiotherapy students, and teachers, do not always recognise that this is the case. Oncology deserves more attention in the basic curricula.
What about the challenges?
Referral to physiotherapy is insufficient. There still is a lot of work to be done in terms of increasing awareness among patients and healthcare professionals. The Clinical Oncology Society of Australia has recently proclaimed that attention to exercise should be a standard ingredient of cancer care, and that patients should be referred to qualified professionals, including physiotherapists, to support exercise during and after cancer treatment. But globally, this is an exception rather than the rule.
Also, while physiotherapists with basic entry to practice qualifications can manage many issues cancer patients and survivors may face, they are not fully equipped to address the more complex issues. For example, fatigue is one of the most reported and dreaded cancer side-effects. For some patients, this can become a very complex, multifaceted health problem, relating to physical as well as emotional, cognitive, existential, or behavioural issues. Also, cancer treatment can lead to long-term physical problems such as lymphoedema, soft tissue fibrosis, peripheral nerve damage or heart disease. In patients with metastatic disease, there are many safety and ethical issues to consider. Recognising and dealing with these problems requires sufficient background knowledge about oncology, and requires additional skills as well. We need more physiotherapists with such specialised knowledge and skills to serve all patients who require our services.
Costs would be very different issues in national healthcare systems, so how was this discussion helpful?
Obviously there is no single strategy to solve the cost problems in the various countries. It became clear, however, that regardless of the healthcare system, we need to be able to show that our services do not only improve people’s quality of life, but can also be cost-reducing, or at least cost-effective within societies’ limits of willingness to pay. This means that we need cost-effectiveness studies, which are largely lacking from the literature. We also need to invest in developing and implementing care pathways from a perspective of value- based healthcare.
What strategies for improving referrals were discussed?
The strategy that was deemed most likely to be successful was to embed physiotherapists in cancer care pathways, using so-called prospective surveillance models. In addition, participants agreed that physiotherapy societies need to keep raising awareness by informing policy makers, referring health professionals, and of course patients and survivors, of the possible benefits of physiotherapy.
Finally, it is important that the physiotherapy communities develop professional standards and guidelines for cancer-related health problems, and even more so that they strive to include physiotherapy in multidisciplinary oncology guidelines.
Is much happening in Australia and internationally with regard to specialisation?
In Australia, a Level 2 cancer/palliative care lymphoedema course is currently being developed. Also, as I understand it, a titling process has already been opened for credentialing as a cancer, palliative care or lymphoedema therapist through a ‘grandfathering’ construct, which is open until next year. APA physiotherapists currently working in these areas can apply for these titles if they can demonstrate sufficient evidence of practice.
Internationally, physiotherapy associations in several countries have special interest groups or oncology sections. In several countries oncology specialisations are being developed, encouraged, or actively endorsed. In some countries, for example in the Netherlands, this includes master-level postgraduate courses and certification. Also the World Confederation for Physical Therapy now has a special interest group.
Where to from here for the group?
We need to keep striving for better access and better quality of physiotherapy services for people living with and beyond cancer. We can do this through basic and advanced education, through developing and adhering to evidence-based practice guidelines, and through engaging referring health professionals and policy makers.
We should also look across the boundaries of our own profession, to see how we can maximise the value of the supportive care services we provide, for example, by establishing close collaborations with nutritionists or clinical psychologists, and with professionals working in community services such as fitness centres. From the scientific perspective, we need to research cost-effectiveness of physiotherapy interventions and of models of care in oncology. There is a lot going on right now, and it makes me very happy that there will be a second International Conference on Physical Therapy in Oncology, in Copenhagen, Denmark, in May 2020.
Martijn Stuiver is a researcher at the Center for Quality of Life of the Netherlands Cancer Institute, as associate professor at the Amsterdam University of Applied Sciences. His main research focus is on functional recovery from cancer and its treatment, including cancer rehabilitation, and on head and neck oncology
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