Questions & Answers on Rehabilitation Oncology

Miami Cancer Institute’s Adrian Cristian, M.D., discusses his specialty as he prepares to host an informative symposium.

Adrian Cristian, M.D.

Adrian Cristian, M.D., Chief of Cancer Rehabilitation

Rehabilitation should not be an afterthought in cancer treatment. The sooner strategies are implemented, the better the results, especially when patients have already experienced impairment, says Adrian Cristian, M.D., chief of Cancer Rehabilitation at Miami Cancer Institute.

“With more and more cancer survivors out there, they are living longer with the effects of cancer and cancer treatment. It’s important for clinicians to be aware of the types of physical impairments that cancer patients and cancer survivors live with, and to initiate rehabilitative interventions early,” Dr. Cristian explains. “Early identification, intervention and surveillance into survivorship can maximize the patients’ function and quality of life.”

LIVE, Virtual Symposium on October 30 - Register Now >

Dr. Cristian is co-hosting a live, virtual symposium for clinicians on October 30. The program features topics such as the current state of science and future horizons for oncology rehabilitation, exercise therapy, shoulder pain and dysfunction in breast cancer, cancer-related cognitive dysfunction and more. The faculty includes experts from Miami Cancer Institute, Memorial Sloan Kettering Cancer Center and West Virginia University Cancer Institute. Enroll at Oncology Rehab Symposium: Restoring Function and Maximizing Quality of Life.

Here, Dr. Cristian shares insights on oncology rehabilitation and what to expect at the symposium.

Do you think some impairments are accepted as a fact of life of cancer treatment? 

There are a lot of patients who very often are just grateful to be alive, so they accept a new norm of how they move and how they are functioning. However, there can be a significant impact on their ability to care for their physical needs, for their work, for their life-care roles as spouses or caregivers. Some people learn to accept it, but that is not necessarily how it should be. We need to educate the patients, their families and their providers about the role of rehabilitation and various other interventions. 

Can you share some statistics that would help give perspective? 

It has been projected that by 2030 there will be approximately 22 million cancer survivors in the United States. That is a striking number. It is very common for cancer patients and cancer survivors to experience limitations in their ability to perform one or more self-care activities. The limitations vary depending on type of cancer, cancer treatment and stage of cancer. Very often, these patients may lack access to rehabilitative services. It’s not uncommon for us to see patients months or years after their cancer diagnosis, after they have been living with various physical limitations for a while. The goal is to prevent these limitations in the first place — however, if that is not possible, to identify and treat them as early as possible.

Do you think some of these limitations are not addressed because patients go through their cancer treatment, ring the bell, and then they just want to get out of there? They do whatever follow-up is required, but they don’t want to continue focusing on the thing that brought them to a cancer center in the first place. 

I think a lot of times the last place they want to be after they finish their treatment is a cancer center. They went through a very challenging time and they want to resume their lives. But what actually happens, and we see this a lot, is that as they reenter that life, they start coming up against physical limitations associated with their cancer and cancer treatment. Maybe they are unable to function at work because they are so fatigued from radiation treatments, or they may have a job that requires them to do a lot of lifting overhead and they find they can’t move their shoulder very effectively. Maybe they have problems with short-term memory or multi-tasking. The limitations were not apparent when they were undergoing treatment, but now they are back in their life and they are facing daily challenges. Many times these physical impairments are slow to develop and can be subtle initially, until something happens that brings them to medical attention — for example, a fall in a person with weakened legs.

The clinicians who sign up for this symposium, what do you hope they get out of it?

We’re hoping for a broad audience — including physicians, physical therapists, occupational therapists, speech therapists. There are therapists out there who may have limited experience in caring for patients with cancer, so this symposium will provide them with knowledge on how to best provide rehabilitative care for this growing population of patients. And then for the medical, radiation or surgical oncologists that we hope will join us, we hope to make them aware of the type of resources available for their patients and of the interventions that could improve their patients’ quality of life.

The schedule for the symposium outlines a wide range of topics that are going to be addressed, from shoulder pain, to cognitive impairment, to exercise during treatment. It’s a very wide-ranging specialty, it seems.

It’s broad in scope because not all cancers have the same kinds of physical limitations. There may be some common threads that run through all of them — for example fatigue and neuropathy. Neuropathy is very common among cancer patients who are treated with certain types of chemotherapeutic agents. However, there are also very specific types of physical limitations for certain types of cancer — for example, head and neck cancer, or gynecological cancer. 

Any examples of things you see commonly?

In head and neck cancers, patients are very often treated with a combination of chemotherapy and radiation therapy and surgery, and they can develop problems with swallowing, swelling of the neck, difficulty opening the mouth, shoulder and neck pain, and restricted movement. In the breast cancer population, it is very common to see shoulder pain, swelling of the arms, and hand weakness and pain; they may also have neuropathy associated with chemotherapy. In prostate cancer, patients often receive a combination of androgen deprivation therapy, radiation therapy and surgery, which can cause problems with balance, bowel and bladder dysfunction, and swelling of the legs. 

How would you treat those things? 

The treatment very often requires a holistic multidisciplinary approach. We often collaborate with a medical, surgical and radiation oncologists. We collaborate with physical therapists, occupational therapists, speech pathologists, nutritionists, social workers and psychiatrists, just to name a few disciplines. Nutritionists, for example, are very important because one common thread among all cancers, especially the late stages, is sarcopenia, the loss of muscle mass, which leads to weakness. The scientific literature points to the importance of having nutritional rehabilitation and physical rehabilitation to help treat this condition. 

You helped build the program at Miami Cancer Institute. Can you tell us about any cases that stand out?

Every single patient has a unique story and it’s such a privilege to be part of their journey. I learn from them every day. I do have a recollection of one lady who was being treated for breast cancer and was referred to us for a shoulder problem. We worked on her shoulder, but we also picked up at the time that she was very frail. We track and measure the functional status of every one of our patients in very specific ways – grip strength, balance, how many times they can get up out of a chair in 30 seconds, all sorts of things. In this particular case we found the patient could barely stand up, so we put in our prescription plan to try to work on her strength and balance in addition to her shoulder. A few months later, every time she would come back, she was doing a little better. At first she couldn’t stand up, but then she was walking with a cane, and then she was walking down the hallway. I saw her in the community once and she was walking outside without assistance. She kept getting better and stronger. Why am I telling you about her? A few months after we started working with her, I ran into her oncologist and was told that the patient qualified for a clinical trial. Until that point, participation in a clinical trial was not a possibility — she was too frail. But now she qualified. That trial extended her life by several years, according to her oncologist. To me this story sticks out as an example of the power of cancer rehabilitation to extend both the quantity and quality of life.

In today’s medicine, especially in oncology, physicians are very focused on their specialty. You seem to have a wider view. Is that a requirement of what you do?

It’s an approach, and a philosophy of how to think about the patient. Oncologists are focused on the medical, surgical and radiation therapy needs of the patient to save the person with cancer. Where I hope to be of assistance is in evaluating the patient’s physical ability to tolerate those treatments. How do we prepare the patient? How do we keep that patient going during and after their treatment, so that they can get the benefit of cancer care? Very often a patient has beaten the cancer, but is so frail and has so many limitations that it is very difficult for them to enjoy the fruits of their labor. They’ve just finished this battle, but now they are so depleted that they can’t do their life’s work, whatever that might be for them. We can help our oncology colleagues identify who is at risk for developing this type of problem in the first place, and then help in reducing the impact.

Do all cancer centers have this department or division?

There are not that many cancer rehabilitation physicians across the country, and they are typically housed in larger institutions or academic centers. At Miami Cancer Institute we have two – me, and Dr. Romer Orada. We are fortunate to have a very supportive team in the Cancer Patient Support Center led by Dr. Beatriz Currier. She and the leadership at Miami Cancer Institute have created an environment where this holistic approach to cancer patient care can thrive for the benefit of our patients. Generally speaking, there are not that many physicians who specialize in this field. If you go out to the community at large, people may not even be aware of our specialty, which is a challenge. I am hoping that through the symposium we are able to get the word out. 

What is the message we need to share with the public?

The message is that cancer and its treatment can cause physical limitations that can affect quality of life, but many of these conditions can be treated – ideally even prevented. Through early interventions, and utilizing rehabilitative interventions, we can improve quality of life. Patients need to be informed about the physical impairments associated with their particular cancer and treatment, and to proactively seek out rehabilitative interventions to address them  — not to just accept that this is their new normal.