By Nancy Hutchison, MD. The role of cancer rehabilitation in adding value to oncology care and its contribution to achieving the Triple Aim of health care.

1. Innovations in Cancer
Rehabilitation
Nancy Hutchison, MD
Medical Director for Cancer Rehabilitation and Survivorship
September 26, 2014

2. Success Brings Challenges
• 2014: 14.5 million cancer survivors in the US
- 2024: almost 19 million cancer survivors, 2/3 >65
• The annual excess economic burden of survivorship
- recently diagnosed cancer survivors >$16,000
- formerly diagnosed (>1 year from dx) >$4,000
- Includes direct health expenditures and disability (inability
to work).
• For geriatric survivors, cancer related medical frailty
and loss of independence leads to
- increased hospital costs
- increased cost to society for caregivers and long term care
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Guy G, et al: Economic burden of cancer survivorship among adults in the United States. J Clin Oncol 31:3749-3757, 2013
ACS Facts and Figures 2014-2015
Rowland, J. Cancer Survivorship Issues: Life After Treatment and Implications for an Ageing Population. JClinOncol. 32:2662-
2668,2014

3. • 25% of cancer survivors reported poor physical
health and 10% reported poor mental health
• Compared with 10% and 6% of adults without a
history of cancer
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The challenge: declining
HRQOL for cancer survivors
Weaver, K. Mental and Physical Health-Related Quality of Life among US Cancer
Survivors: Population Estimates from the 2010 National Health Interview Survey.
Cancer Epidemiol Biomarkers Prev;21(11);2108-17

4. • Distress in cancer survivors is highly correlated with
physical limitations imposed by cancer treatment
• Comorbidities increase the patient’s rehabilitation
needs and distress
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Cancer rehabilitation: an unmet need
Bornbaum, K. A descriptive analysis of the relationship between quality of life and distress in individuals with head
and neck cancer. Support Care Cancer. 2011. DOI 10.1007/s00520-011-1326-2
Pentinnen, H. QoL and Physical performance and activity of breast cancer patients after adjuvant treatment.
Psycho-Oncology 2011. 20: 1211–1220
Banks, E. Is psychological distress in people living with cancer related to the fact of diagnosis, current treatment or
level of disability? Findings from a large Australian study. MJA 2010; 193: S62–S67
Holm, L. Influence of comorbidity on cancer patients’ rehab needs, participation in rehab activities and unmet
needs: a population-based cohort study. Support Care Cancer 2014. 22:2095-2105

5. • “Although general exercise and behavioral interventions are
important, they should not be confused with impairment-
driven cancer rehabilitation
– focuses on diagnosis and treatment of specific cognitive and
physical problems
– addressed by qualified rehabilitation health care professionals
such as physiatrists along with PT, OT, SLP
• It is very common for survivors to have multiple impairments,
and these should be treated with an interdisciplinary
rehabilitation approach.”
• ACS Cancer Treatment and Survivorship Facts and Figures
2014-2015 page 25
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Activity is good for cancer survivors but is
not enough and is not rehabilitation

6. Cancer Rehabilitation adds value to
oncology care
• Reduces morbidity
• Reduces medical frailty
• Improves return to work
• Improves health related quality of life
• Reduces distress
• Is well tolerated and effective
- Before, during and after cancer treatment
- In advanced cancer
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Chasen,M Rehabilitation for patients with advanced cancer. CMAJ 2014.doi: 10.1503/cmaj.131402
Thorsen, L. Cancer Patients’ needs for rehabilitation services. ActaOncologica 2011. 50:212-222
Cheville, A. An Examination of the under utilization of rehabservices among people with advanced cancer. J RehabMed. 2011. 90(S): S27-37
Cheville, A. Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer. JCO.2008. 26:2621-2629
Silver, J. A journey to make cancer rehabilitation the standard of care. Work (2013) 46: 473-475
Alfano, C. Cancer Survivorship and Cancer Rehab: Revitalizing the Link. JCO 2012. 30:904-906

7. The value proposition
• A value proposition is a marketing concept for a
product being offered
- a company’s promise of value to be delivered
- the customer’s belief that value will be achieved
• What is the product? Cancer Rehabilitation
- Achieves the Triple Aim
• Who are the customers?
- Patients
- Families
- Doctors, nurses and other providers
- Payers
- Society/population health
- Administrators
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8. • AllinaHealth has excellent oncology services
• AllinaHealth has excellent rehabilitation services
“What happens to your value if you have
excellent healthcare services but the
customer doesn’t get them?“
Sean Sipko, CPA, VP Oncology Rehab Partners
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9. • Shortage of oncologists
• Huge increase in cancer survivors
• Survivors have diverse physical impairments affecting many organ
systems
• Future advances in oncology will increase treatment and survivorship
costs
• Oncologists are not trained to assess and treat disabilities and physical
impairment, rehabilitation professionals are
• Reducing morbidity can reduce total cost of care and improve HRQOL
• General agreement that cancer rehab is good for patients
• Rehabilitation services are available to cancer patients
• Health care system barriers must be identified and overcome
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Reality Check

10. AllinaHealth STAR Program
Cancer Rehabilitation
• 2012 AllinaHealth became a STAR Program through
Oncology Rehab Partners
- Standard of care for cancer rehabilitation nationally
- STAR Program is leading the way for innovation in cancer
rehabilitation
• AllinaHealth developed a Physician-led STAR Program®
- Insure evolution of evidence-based, up-to-date, care
- Create standards, excellence and proficiency in cancer rehab
- Work with Allina Research centers on cancer rehab research
- Specialty Physiatrist care for complex cancer patients
- The STAR Program has identified key areas that should be
targeted to become the standard of care for cancer survivors
• Impairment Driven Rehabilitation
• Prehabilitation
• Dual Screening for distress and physical impairment
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11. To make these standards reality,
innovation in oncology-rehab interface is
needed
• The value proposition requires oncology
and rehabilitation to innovate better systems
of rehab care navigation and sharing cost
among provider disciplines and across
clinical service line financial silos
- So that patients get the needed services at the
optimal time
- Society and health care organizations achieve the
value proposition
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12. 12

13. • Impairment Driven Rehabilitation Care
• Prehabilitation
• Early detection and early intervention for cancer
related morbidity
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Innovations in Cancer
Rehabilitation

14. Impairment Driven Cancer
Rehabilitation
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Coined by Julie Silver, MD & colleagues and adopted as standard by ACS

15. AllinaHealth STAR Program
Impairment Driven Cancer Rehab
• Over 100 Allina STAR (CourageKenny) clinicians
organized into multidisciplinary impairment teams.
- Debility/Fitness
- Balance
- Musculoskeletal problems (pain, tightness, ROM)
- Dysphagia
- Lymphedema
- Cognition
• 6 MD and NP PMR STAR specialists and 3 Cancer
Rehab Nurse Coordinators
• Orders and coordination through STAR Schedulers
according to patient impairment
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16. Allina Impairment Driven Rehab
Teams
• Lead therapist for each impairment
• Best practice protocols for impairment
• Uniform outcome tools and analysis
• Linkage with Courage Kenny Research Center
- Currently involved in a study of chemo-brain in breast
cancer survivors
• Monthly full Allina/STAR Program Journal Club
• 2x per year impairment team proficiency
training, chart review and education updates
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17. Prehabilitation: innovation in cancer care
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2013: A call to action
by Julie Silver, MD

18. Prehab reduces morbidity and
LOS in Lung Cancer Resection
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19. Prehabilitation to reverse pre-
operative physical frailty
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20. 20

21. Debility and deconditioning are
amenable to cancer rehab
• Numerous scientific articles confirm physical debility as
a risk for poor outcomes and high cost from cancer
treatment
• Numerous articles document benefits of preoperative
evaluation and treatment of debility/deconditioning for
reducing mortality, morbidity and disability
• AllinaHealth’s STAR Fitness/Debility Impairment team
has protocols to address preoperative (and post
operative) debility
- Some areas have less access, PT shortage
- Patients and PTs need lead time to have optimal results
- Care Navigation pathways need to be developed
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22. Prehab for Head and Neck Cancer
• Pre-treatment (radiation and/or surgery) Speech Therapy
swallow exercises improve outcomes in patients with tongue,
base of tongue, laryngeal, pharyngeal cancer
• reduced aspiration, improved quality of oral diet, less time
with feeding tube, improved QOL
• Waiting weeks or months after completion of treatment to
onset of clinically evident dysphagia is associated with poorer
outcomes
• Relying on a PEG is associated with poorer swallow outcomes
• Patient acceptance and adherence is excellent when the whole
provider team accepts and encourages
• Allina STAR® HNC Swallow Impairment Team prehab protocol
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Kraaijenga, S. Current Assessment and treatment strategies of dysphagia in head and neck cancer patients; a systematic
review of the 2012/2013 literature. Curr Opin Support Palliative Care 2014, 8:152-163
Starmer, H. Dysphagia in head and neck cancer: prevention and treatment. Curr Opinion Otolaryngol Head Neck Surg. 2014.
22: 195-200
Crary, M. Adoption into clinical practice of two therapies to manage swallowing disorders: exercise-based swallowing
rehabilitation and electrical stimulation.Curr Opinion Otolaryngol Head Neck Surg. 2014. 22:172-180.
Duarte, V. Swallow Preservation Exercises During Chemoradiation Therapy Maintains Swallow Functions. Otolaryngol Head
Neck Surg. 2013. 149:848-884

23. Early detection and treatment of
cancer morbidity: lymphedema
• Lymphedema is one of the most dreaded
complications of cancer treatment
• Lymphedema affects approximately 60% of
breast cancer survivors at some point in
survivorship
• Lymphedema affects 15% of all cancer survivor
• Lymphedema will not be eradicated
- Improved surgery and radiation techniques can
reduce the impact
- Early detection and early treatment reduces and, in
some cases, reverses lymphedema
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24. Distress in Breast Cancer Survivors Related to
Fear of Lymphedema
• In a study from the Mayo Clinic, 75% of
patients after ALND and 50% of patients
after SLN are worried about developing
lymphedema at one year post surgery
• Patients often perceive that they have
lymphedema when they do not and may
take extreme measures to prevent
McLaughlin, S. Trends in Arm Swelling and Patient Worry for the Development of
Lymphedema after Axillary Surgery for Breast Cancer. Presented at 2012 Annual Meeting of the Society of Surgical
Oncology
Temple, L. Sensory morbidity after sentinel lymph node biopsy and axillary dissection : a prospective study of 233
women. Annals Surg Oncol. 2002.9(7) 654-62
McLaughlin S. Prevalence of Lymphedema in Women With Breast Cancer 5 Years After Sentinel Lymph Node Biopsy
or Axillary Dissection: Objective Measurements. 2008. J Clin Oncol 26:5213-5219.

25. Paradigm shift: lymphedema as a
biologic phenomenon
• Lymphedema is an immune system, genetic,
vascular, and histologic phenomenon
• Inflammation and fibrosis of lymphatics are
major factors in onset and progression of
lymphedema
• Latent lymphedema can be detected by BIS
• Early detection reduces the severity and may
prevent BCRL
• Screening and monitoring for BCRL gives
patients the greatest chance of avoiding or
minimizing lymphedema
• Waiting until lymphedema is visible or
symptomatic leads to poorer outcomes

26. Early lymphatic dysfunction
predicts BCRL
• Clinically undetectable abnormal lymphatic flow
in muscle and sub-cutis, with elevated
peripheral lymphatic flow, has been noted in
the arms of women destined to develop BCRL
over a year later
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Stanton, A. Lymphatic drainage in the muscle and subcutis of the arm after
breast cancer treatment. Breast Ca Res Treat. 2009 Oct;117(3):549-57
Stout, N. Segmental Limb Volume Change as a Predictor of the Onset of
Lymphedema in Women With Early Breast Cancer. PM R 2011;3:1098-1105

27. Lymphedema: Not just swelling
An abnormal
accumulation of
protein-rich fluid in
the interstitium
which leads to
chronic
inflammation and
reactive fibrosis
Left post lumpectomy and radiation breast lymphedema and fibrosis Left post mastectomy, ALND, radiation, reconstruction
lymphedema. Acute cellulitis
Lymphedema causes pain,
infections and disability. It
is also costly to manage.

28. BIS Monitoring for BCRL: accurate
and clinically relevant
• 40% of patients have bouts of lymphedema, detected by
BIS, lasting at least 3 months with or without intermittent
periods of relief and 60% of those patients go on to
develop long term lymphedema
• BIS accurately detects lymphedema 10 months prior than
limb volume or self report-with a preoperative baseline
• BIS accurately differentiates lymphedema from non-
lymphedema
Hayes, S. Lymphedema after breast cancer: Incidence, risk factors and effect on upper body function. (2008) J Clin Oncol
26:3536-3542.
Smoot, B. Comparison of diagnostic accuracy of clinical measures of breast cancer-related lymphedema: area under the
curve. Arch Phys Med Rehabil 2011 Apr;92(4):603-10
Hayes, S. Lymphedema Secondary to Breast Cancer: How choice of measure influences diagnosis, prevalence and
identifiable risk factors. Lymphology: 41(2008) 18-28
Vicini F. Multi-Institutional Analysis of BIS in the Early Detection of BCRL. Presented at 2012 Annual Meeting of the Society
of Surgical Oncology
Kanbour, M. The Importance of the Identification and Early Intervention of Subclinical Lymphedema
Dept of Surgery, Magee Womens Hospital, Pittsburgh, PA. Presented MASCC/ISOO - 2012 International Symposium on
Supportive Care in Cancer

29. BIOIMPEDANCE SPECTROSCOPY
(BIS)
Impedimed L-Dex ® U400

30. Bioimpedance
Spectroscopy (BIS)
• BIS is based on the
resistance to an
imperceptible current
passed through the
arm.
• Impedance is inversely
proportion to fluid
volume.
• As fluid accumulates,
impedance or
resistance to the flow of
the current decreases.
• The definition of
Lymphedema is based
on the accumulation of
fluid.
• BIS represents a
DIRECT measure of
that fluid

31. Clinically detectable lymphedema is too
late for early detection purposes
• Clinical lymphedema does not become
visible, palpable, perceptible until a
significant increase in volume (10%)
• Negative impact on QOL begins at 5% LVC
• Monitoring needs to detect lymphedema at
3% for reversibility, well below the clinical
detection and tape measurement threshold
Cormier, S et al.(2009) Minimal limb volume change has a significant
impact on breast cancer survivors. Lymphology 42, 161-175
Armer JM. The problem of post-breast cancer lymphedema: Impact and
measurement issues. Cancer Investigation. 2005;23:76–83.

32. Treating BCRL is costly
• Patients diagnosed with post-BC lymphedema
incur significantly higher total healthcare costs
(nearly $15,000 more, after removing cancer-
specific costs.)
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Shih YC, Xu Y, Cormier JN, et al. Incidence, treatment costs, and
complications of lymphedema after breast cancer among women of
working age: a 2-year follow-up study. J Clin Oncol 2009;27(12):2007-2014.

33. BIS Monitoring for BCRL Cost
Effectiveness
• In a model developed to determine cost to 3rd
party payers, the use of BIS would save money
over current standard (patient reports symptoms
or swelling detected)
• Total cost to patient/society from less work days
lost, improved function and QOL were not
factored in.
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Bilir, S Economic Benefits of BIS-Aided Assessment of Post-BC
Lymphedema in the United States. American Journal of Managed
Care.(2012)18(5):234-41

34. Allina BIS Projects for early detection
and treatment of lymphedema
• Collaboration of VPCI United Breast Center and the
CKRI STAR Program Lymphedema Impairment Team
• Pre and Postoperative screening for lymphedema in the
Breast Center
• Assessment, education and early intervention for latent
lymphedema
• Concurrent grant funded BIS project in the CKRI STAR
Program Lymphedema Impairment Team
- With generous funding from the Tankenoff Families Foundation
• We hope to find a model of collaborative screening,
treatment and payment for lymphedema-BIS to be the
standard of care
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35. Cancer Rehab: innovation bringing value
to the future of oncology survivorship
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“Rehabilitation programs are probably the single
most underappreciated service among cancer
survivors right now.”
-Kevin Oeffinger, MD, MSKCC & Chair of ASCO’s
survivorship committee
Washington Post July 29, 2013—How to Get Healthy After the Cancer
Treatments are Done

36. Nancy Hutchison, MD
Medical Director for Cancer Rehabilitation and
Survivorship
Courage Kenny Rehabilitation Institute/Virginia
Piper Cancer Institute, Divisions of AllinaHealth
800 East 28th Street, MR12109
Minneapolis, MN 55407
nancy.hutchison@allina.com
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