When you hear about cancer treatment, you traditionally hear about patients undergoing surgery, radiation and chemotherapy. You may even hear about biological therapy, hormonal therapy and anti-angiogenesis treatment. But what is often missing from traditional treatment is diet, exercise, stress management, side effect maanagement and caregiver support and training to assist with the physical and emotional needs of the patient and their loved ones, according to cancer survivor Dr. Kathryn DeSouza, who also happens to be the only practicing physiatrist in The Bahamas.
"We didn't hear anything about diet," said Dr. DeSouza, who recently went through treatment herself. "It's really important when you have cancer to review your diet, because there are many things that can actually make your diet worse; or even if you have a history of cancer in your family, may increase your predisposition to cancer."
An example in breast cancer, she said, has shown that there is a link between alcohol consumption and breast cancer and that breast cancer survivors or people with a family history of breast cancer should probably either not drink, or limit their alcohol intake to one or two drinks a week. She also noted that there is also possibly a link with dairy and soy, ingredients that people should consider going without when they have breast cancer. The other nutritional aspect to cancer, she said, is that sometimes during treatment people don't feel like they can eat, and don't have a taste for anything and they lose weight and get weak. She said looking at their nutrition to offer some advice as to what foods may be more palatable to them is also important.
Speaking at the recent Doctors Hospital Distinguished Lecture Series on cancer rehabilitation and wellness, the physiatrist who serves as a liaison between the oncology team and the rehabilitation team likens herself to the contractor who coordinates the home restoration after the fire is put out by the fireman (oncologist).
Importance of exercise
Dr. DeSouza also cited the importance of exercise for cancer patients as she said oftentimes they lose muscle because they might have long periods in bed, may not be eating well or just might not be up to doing their regular activity. She said exercise could improve a patient's heart and lung function in cancer, as some of the drugs used in cancer treatment can affect heart function and some diseases can affect lung function. Ensuring that they get in exercise, she said, could also increase patients' endurance, which is important as it provides more energy to complete activities of daily living. Exercise can also improve a patient's mood, which is an important part of cancer rehab.
"Stress management... relaxation exercises, yoga are important in breast cancer rehabilitation, and are often not thought of when you think of traditional cancer treatment techniques," she said. "Lifestyle management is also incredibly important [because] when you have cancer and are tired from your chemotherapy, you need to know how to prioritize, what really needs to get done, and what you need to ask help for from someone, and what you cannot do. If you do not get the chance to mop the floor, it's probably not the end of the world, so you have to prioritize and make sure that you have the energy to do what really needs to get done and what's important to you to get done."
Cancer patients often have to incorporate rest periods into their day. And those people who may still be working should assess whether their work places can accommodate them needing to take breaks during the day, or not having to climb stairs.
The number of side effects from the surgery, radiation and chemotherapy, she said, have to be managed and can often be easily done with interventions like exercise and physiotherapy.
She said one aspect to cancer rehabilitation and wellness that is often neglected is caregiver support; the focus is centered on the person with cancer, but the person who is taking care of the person with cancer also requires support.
Cancer rehabilitation is a process that assists cancer patients with obtaining maximum physical, social, psychological and vocational functioning within the limits created by the disease and its resulting treatment. It is necessary in treatment the world over, but even more so in The Bahamas where the statistics are frightening. In The Bahamas one in 10 women will develop breast cancer, and the average age of a Bahamian woman who is diagnosed with breast cancer is 42. In other countries, it's in the 60s. Twenty-three percent of Bahamian women also carry the BRCA1 gene mutation. And the person who has this gene mutation has a much higher level of having aggressive, early cancer said Dr. DeSouza.
The Bahamas has the highest proportion of breast cancer mutations in the world, and the most people with the gene mutation.
Rehabilitation strategy
"Sometimes you're not going to be able to have your very best function that you had before cancer while you're undergoing cancer treatment, but you need to get to the best of it you can with your treatment. After treatment, you might be left with some side effects of the treatment. Our goal in cancer rehab is to get you to the best that you can be within the limitations of your disease or your treatment," she said.
The other thing that specialists in cancer rehabilitation like Dr. DeSouza to look at is the whole person. The physician said an individual may be a cancer survivor, but may also might be obese, have high blood pressure or suffer from cardiac disease.
"You might have been perfectly healthy, but now with your cancer, you've developed some of these diseases -- heart disease, lung disease, pain, obesity, osteoporosis (thinning bones), cognitive defects (memory deficits) inactivity, diabetes, weakness/fatigue -- all of these conditions must be accounted for by the healthcare team when we develop your program for cancer rehab," she said.
She said it's definitely a team approach to dealing with cancer. The team consists not only of the oncologist and the oncology nurse and the patient's family, but the physiotherapist, the exercise physiologist, the nutritionist and physiatrist working together to help the patient to be the best they can be. And she said it's important that patients' family members and significant others be active participants in the program and help them to develop goal setting.
"It does not make sense for me to work on having you climb stairs when you have no stairs in your house, and no part of your day ever deals with stairs," she said.
Dr. DeSouza said many patients with cancer have easily remediable but unrecognized rehabilitation needs. And that it can be something very simple that the team can figure out to help the patient make their life better.
As a physiatrist, a doctor of physical medicine and rehabilitation, Dr. DeSouza's goal is to improve her patient's function -- whether they're an athlete with a sports injury, a construction worker who has back pain, or a cancer survivor who isn't able to go to work because they are fatigued.
When rehabilitation is needed
The physiatrist said a person may need rehabilitation when he or she is unable to do now what he or she could do before a cancer diagnosis. Other situations in which a person may require rehabilitation include: a change in diet and appetite; seeing a change in activity level or exercise regimen; having cancer and treatment affect the ability to work; experiencing the inability to perform daily tasks or recreational activities that were previously enjoyed; experience disruptions in the ability to function, including getting sleep, due to pain; developing an interest in building up strength or stamina; being tired and having a lack of energy affect the ability to function day to day; or being sad, worried, anxious or depressed and having those moods affect the ability to function.
The length of time a person needs rehabilitation, Dr. DeSouza said, is an individual answer; some people will need ongoing rehabilitation from the day they are diagnosed until they recover. Others only need a brief period of rehabilitation. It really depends on the type of cancer a person has how severe it is, and what the treatment or the disease has caused to become a problem in their life.
She said for cancer patients some of the physical side effects they may experience are only temporary and occur during or right after cancer treatment, but some are longer term, such as cardiomyopathy (cardiac damage from chemotherapy) and also peripheral neuropathy which is damage to the nerves from chemotherapy and that in breast cancer they often see a problem called lymphedema. If health care providers are not certain how to address a cancer patient's rehabilitation needs, Dr. DeSouza said they can refer the patient to a physiatrist who can prescribe an appropriate treatment plan.
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