Cancer Rehabilitation: An Overview of Current Need, Delivery Models, and Levels of Care.

The relevance of cancer rehabilitation as a public health issue grows steadily as cancer incidence, survival, and mean patient age increase. Reported rates of physical impairment and disability are already high, prior to the anticipated influx of aged cancer survivors. Despite the high prevalence of cancer-related disablement, treatment rates, even for readily remediable physical impairments, are as low as 1-2%. In addition to low referral rates, a challenge to patient-centric cancer rehabilitation is a fractured system that requires multiple visits to a range of specialists to address even a single issue, and cancer survivors generally have several. Effective solutions must acknowledge the limited cancer rehabilitation clinical work force and its clustering in tertiary centers, as well as the lack of consensus regarding the essential and effective components of a cancer rehabilitation program. A number of models of cancer rehabilitation service delivery have been developed, but, as yet, none have been empirically validated. This paper describes these models and proposes a taxonomy for stratifying the needs of cancer survivors. Modalities used to preserve or restore function among survivors range from simple, relatively intuitive activities to complex, integrated programs that include diagnostic and multi-modal pharmacological, manual, and even procedural interventions. Criteria for determining a survivor's needs across this spectrum are proposed, and the role of the physiatrist as a vital advocate and champion discussed.

The role and efficacy of exercise in persons with cancer.

Improvements in cancer screening, diagnosis, and treatment have resulted in an increasing population of cancer survivors with impairments in physical function, cancer-related symptoms, and reduced quality of life. Exercise and physical activity have therapeutic value at multiple points along the cancer disease continuum, spanning disease prevention, treatment, survivorship, prognostic outcomes, and end-of-life issues. Molecular mechanisms for the influence of exercise in persons with cancer include altering tumor initiation pathways and affecting hormonal, inflammatory, immune, and insulin pathways. Physical activity has been found to play a role in the prevention of certain malignancies, including breast, colon, and other cancers. An increasing amount of evidence indicates that physical activity may affect prognostic outcomes in certain cancer diagnoses, especially breast cancer. Structured exercise and physical activity interventions can be helpful in addressing specific survivorship issues, including overall quality of life, cardiorespiratory impairment, cancer-related fatigue, and lymphedema. Exercise also may be helpful during the palliative care phase to alleviate symptoms and increase physical well-being. This article will familiarize physiatrists with the current state of evidence regarding the role and efficacy of exercise in persons with cancer.

From furuncle to axillary web syndrome: shedding light on histopathology and pathogenesis.

Axillary web syndrome (AWS) is defined as a cord-like structure extending from the axilla to the medial arm following axillary surgery in women with breast cancer. There is only limited literature on the pathogenesis of this syndrome and the etiology of the cord. A 57-year-old man presented with a band-like skin depression and tightness over the medial aspect of his arm extending from the axilla to the antecubital fossa following development of a furuncle in the ipsilateral axilla. Histopathologic examination of the 'band' revealed fibroblastic proliferation surrounding the lymphatic vessel which was identified by presence of an obvious valve as well as positive staining for D2-40, a specific marker for lymphatic endothelium. This is the first report of AWS following axillary furunculosis. This case adds to the limited data on the histopathology of AWS, further confirming the etiology of the 'cord' to be of lymphatic origin.

Cutaneous lymphatics and chronic lymphedema of the head and neck.

Extensive attention has been directed to lymphedema involving the extremities. However, there has been relatively limited study of the cutaneous lymphatics of the head and neck. In this review of head and neck lymphatics, we capsulize the history of the lymphatics, the anatomy of the cutaneous lymphatics, lymphatic function and physiology, and imaging modalities used to define this intricate vascular system. To appreciate the clinical challenges associated with head and neck lymphatic dysfunction, we also provide an overview of disease processes of the cutaneous lymphatics and their treatment, theories on the etiology of lymphedema, and future directions to better understand lymphatic function and disease. Knowledge of the cutaneous lymphatics of the head and neck are critical to the clinical evaluation of patients, who present with this debilitating condition and to our understanding of its pathogenesis and appropriate management.

The future of cancer rehabilitation: emerging subspecialty.

In this article, the subject of the future for the field of cancer rehabilitation is embarked upon. Future practice innovation models must involve the appropriate and comprehensive evaluation of cancer patients' rehabilitation needs using better functional measurement tools, as well as the forging of new partnerships through the presence and initiation of physiatric coordinated rehabilitation teams, particularly during the acute phases of treatment. Partnering rehabilitation teams closely with oncology colleagues during surveillance years, through the development of outpatient survivorship clinics for diagnosis and treatment of many of cancer patients' ongoing symptoms and functional limitations, will allow for more comprehensive and coordinated follow-up cancer care. Integration of rehabilitation into palliative care and continued efforts to increase oncology's awareness and acceptance of rehabilitation benefits and expertise are needed. Future education models for medical school, residency, and postresidency training are discussed, as are future research goals to help in placing cancer rehabilitation at the forefront of acute cancer care and survivorship care.

Thyroid dermopathy: an underrecognized cause of leg edema.

Leg edema is a common clinical problem and the differential diagnosis is extensive. We present 4 patients in whom thyroid dermopathy was the cause of leg edema. Examination of the eyes and the nature of the edema were clues to the diagnosis of thyroid dermopathy. Clinical signs should be documented and analysis of skin biopsy specimens should be performed in patients suspected to have thyroid dermopathy.

Principles and process in the development of the Mayo Clinic's individual and institutional conflict of interest policy.

In 1995, federal regulations required all academic medical centers to implement policies to manage individual financial conflict of interest. At the Mayo Clinic, all staff are salaried, and all medically related intellectual property from the staff belongs to the clinic. Hence, it was necessary to develop a policy for institutional conflict of interest to complement the policy for individual conflicts of interest. This article addresses the principles and process that led to the development of the Mayo Clinic's policies that guide the management of conflict of interest of individuals and of the institution. Empowered by the Bayh-Dole Act, the Mayo Clinic participates in technology transfer through its entity Mayo Medical Ventures. Individual conflicts of interest arising from such technology transfer are associated with Institutional conflicts because all individual intellectual property belongs to the institution, per clinic policy. This policy addresses conflicts of interest that arise in research, leadership, clinical practice, investments, and purchasing. Associated with the statutory annual disclosure on personal consulting and other relationships with Industry, which are guided by federal regulations, all research protocols or grant applications require financial disclosure on initial submission and in annual progress reports. The clinic's Conflict of Interest Review Board was established to review each disclosure and recommend management of individual and institutional conflicts of interest according to policy.

Conflict of interest.

The clinical research enterprise is increasingly scrutinized, in part because of the issue of conflict of interest. The issue is broad and its implications touch on a wide range of concerns, from the safety of patient care to the viability of a large industry. Numerous constituencies are affected by conflict of interest, and representatives of all of them convened in November 2002 for a one-and-a-half day discussion of the issues as well as possible solutions to both the perception and the actuality of such conflict. Participants included medical journal editors, news reporters, physician investigators, representatives of institutional conflict-of-interest oversight committees, representatives of the medical products industry, and Federal regulators. The resulting manuscript provides a review of the issues as well as desirable ways for each of the players to monitor themselves; each section thus contains provocative recommendations for eliminating conflict of interest to ensure that our vibrant health care system continues to foster exciting new advances to improve patient care.