Multicomponent Rehabilitative Intervention

• FINAL NUMBER STUDIES INCLUDED = 6
• TOTAL PATIENTS INCLUDED IN REVIEW = 550 (prevention intervention); 169 (amelioration intervention)
• KEY SAMPLE CHARACTERISTICS: In both intervention groups, adults aged ≥ 18 years, received radiotherapy for the treatment of brain metastasis, primary or secondary brain tumors, or prophylaxis for other cancer. For amelioration, intervention group documented cognitive impairment in at least one cognitive domain at baseline. At least 80% of the sample had to receive radiotherapy, and radiotherapy may have been provided during childhood, but the cognitive intervention performed in adulthood.

PHASE OF CARE: Multiple phases of care

Three cognitive interventions aimed at preventing cognitive decline during radiation therapy were reported. Two were pharmacologic. One tested memantine versus a placebo and found significant improvement in overall cognitive function, and one tested methylphenidate versus a placebo but failed to detect any significant differences between groups. The third study was nonpharmacologic and investigated the use of a rehabilitation program to prevent cognitive decline but did not statistically compare differences between groups. Three cognitive interventions aimed at ameliorating cognitive decline were reported. All three were pharmacologic studies. Two studies compared methylphenidate versus modafinil and one study examined donepezil versus a placebo. Both methylphenidate and modafinil interventions resulted in improved cognitive function. Combination therapy resulted in greater adverse events. Donepezil was found to improve the domain of memory after radiotherapy.

The authors reported that there was evidence for the use of memantine for preventing cognitive decline in patients receiving radiotherapy for brain metastasis. Likewise, there was supporting evidence for the use of donepezil in improving memory after radiotherapy for primary or metastatic brain tumors. There was limited evidence for cognitive behavioral or training interventions in preventing cognitive decline.

• Small sample sizes of less than 30 subjects
• High risk of bias, particularly for nonpharmacologic interventions
• Large number of patient withdrawals

Patients who receive cranial radiation therapy for primary brain tumors or metastatic lesions are at risk for declining cognitive function. The use of memantine during radiation therapy may aid in preventing cognitive decline. Those who develop cognitive decline after the completion of radiation therapy, even years afterwards, may benefit from donepezil administration. Additional exploration of interventions that may prevent or ameliorate cognitive decline related to cranial radiation therapy is warranted.

To evaluate the effectiveness of a multidisciplinary rehabilitation program for individuals after treatment for primary brain tumors

Patients were assigned to treatment or wait-list control comparison groups according to an assessment of their needs by the clinical provider. The rehabilitation treatment team was blinded to study group assignment. The intervention included individualized 30-minute therapy sessions with social, psychological, occupational, and physical therapy in half-hour sessions two to three times a week for as many as eight weeks. The individualized intervention incorporated elements of education, health promotion, intensive mobilization, and task reacquisition programs as determined appropriate by the rehabilitation team. Study assessments were done at baseline and at three and six months. Functional independence measures were the primary outcomes of the study.

• N = 106 (85 completed the six-month assessment)
• MEAN AGE = 51.4 years (range = 21–77 years)
• MALES: 43%, FEMALES: 57%
• KEY DISEASE CHARACTERISTICS: Primary brain tumors with a median time since diagnosis of 2.1 years; all received initial treatment involving surgery, chemotherapy, and/or radiation therapy; 53% of subjects in both groups had World Health Organization grade III or IV tumors and similar rates of steroid use; intervention group reported more symptoms at baseline (i.e., ataxia, cognitive impairment, seizures, paresis, visual impairment, dysphasia, dysarthria, sensory-perceptual deficits, bowel or bladder dysfunction) than the wait-list control group; proportion of patients with ataxia, dysarthria, and visual impairment was significantly larger in the intervention group
• OTHER KEY SAMPLE CHARACTERISTICS: More than 80% of participants in both groups were living with a partner, and the majority had at least a secondary level education.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Australia

• PHASE OF CARE: Transition phase after active treatment

Prospective trial

• Visual Analog Scale (VAS) for pain
• Cancer Rehabilitation Evaluation System Short Form (CARES-SF)
• Depression Anxiety Stress Scale (DASS)
• Functional Independence Measures (FIM) for motor skills and cognition
• Perceived Impact of Problem Profile (PIPP)

At three months, FIM Motor (self-care, sphincter, location, and mobility subscales) and FIM Cognition (communication and psychosocial subscales) scores were significantly improved in the treatment group compared to the control group. At six months, the FIM Motor (sphincter subscale) and FIM Cognition (communication, psychosocial, and cognition subscales) scores were significantly improved in the treatment group compared to the control group. There were no significant differences between groups in DASS measures of anxiety or depression from baseline to three or six months. There also were no differences observed between groups in PIPP results from baseline to three or six months, which measured the impact of functional areas also on the FIM. The greatest improvements seen were at the three-month follow-up date.

The findings of this study demonstrated that multicomponent rehabilitation can improve measures of self-care and some specific areas of motor and cognitive function.

• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)
• Selective outcomes reporting
• Key sample group differences that could influence results
• Measurement validity/reliability questionable 
• Findings not generalizable
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: Functional independence was higher at baseline in the wait-list control group by study design, because those with more obvious needs were given the intervention immediately. Therefore, the scoring of function by the control group may have been subject to a ceiling effect in the study measure. Results regarding motor and cognitive function were based on single subscales of the FIM assessment measure with no confirmatory data from a more objective measurement. It is not clear how many patients may have been receiving chemotherapy or radiation therapy during the timeframe of this study, which also could have affected outcome measurements. The fact that findings on perception of impact did not align with FIM results calls into question the overall reliability of findings. The findings are specific to patients with brain tumors and are not necessarily generalizable to other groups.

The findings of this study showed some functional benefits of multicomponent rehabilitation for patients with primary brain tumors. This study was limited by its design and the clinical nature of rehabilitation aimed to provide individualized interventions on the basis of needs assessed by care providers. This suggests that patients may benefit in the areas of self-care. The degree to which these benefits are maintained over time is not clear from this study.

To examine the effects of inpatient and outpatient rehabilitation (i.e., physical therapy, psycho-oncological treatment, patient education, medical treatment, group sessions) on quality of life and psychosocial outcomes

Patients who had radical prostatectomy participated in inpatient and/or outpatient rehabilitation within 14 days after completion of acute oncology treatment

• N = 714   
• AGE = 57 years (SD = 4.4)
• MALES: 100%  
• KEY DISEASE CHARACTERISTICS: Prostate cancer stages T1–4, pN0, M0; average KPS 79 (SD = 8.7)
• OTHER KEY SAMPLE CHARACTERISTICS: Patient who had radical prostatectomy aged 18–64 years and were employed. Excluded those with excessive psychological or physical distress or cognitive limitations as assessed by rehabilitation physicians, those who were unable to speak and read German, and those who were diagnosed with a second cancer requiring treatment.

• SITE: Multi-site   
• SETTING TYPE: Multiple settings    
• LOCATION: Four clinics in Germany

PHASE OF CARE: Transition phase after active treatment

• Quasiexperimental repeated measures design with convenience sampling from inpatient and outpatient treatment areas
• No blinding

• European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QLQ)-C30: Two items for subjective cognitive function
• EORTC QLQ-Prostate-specific 25 (PR25)
• Hospital Anxiety and Depression Scale (HADS)

Subjects reported similar cognitive function scores at baseline and one year after rehabilitation. Cohen’s d  was 0.51 and 0.54 respectively (both p < 0.001). They reported higher cognitive function at the end of rehabilitation (F [df 1.8, 1238.2] = 138.1, p < 0.001). Quality of life was higher at a one-year follow-up (p < 0.001). Anxiety was lower at the end of rehabilitation for inpatient and outpatient rehabilitation groups (p < 0.001). Depression was lower at end of rehabilitation and sustained at a one-year follow-up (p = 0.008).

The effect of structured rehabilitation on outcomes in this study was unclear, and no clear differences in outcomes based on whether patients received inpatient or outpatient rehab services were observed.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results
• Intervention expensive, impractical, or training needs
• Subjective cognitive function measure was limited; objective measures of cognitive function were not used.  
• Because rehabilitation was given as part of standard medical care, many other factors could have influenced the results.

Rehabilitation, whether provided in an inpatient or outpatient setting, improved patients’ perception of quality of life, depression, anxiety, and cognitive function by the end of rehabilitation. Perceived improvements in quality of life and depression persisted at one year after treatment.

To evaluate the effectiveness of a residential rehabilitation course for patients with cancer in decreasing psychological distress

Patients who had completed cancer treatment were randomly assigned to receive either usual care or a six-day residential psychosocial course. Those in the residential group had weekly rehabilitation courses in groups of 20. Course activities included education, supportive talks, physical activity, relaxation, massage, social activities, peer discussions, and dietary instruction. At the end of the course, individuals created a personal action plan to reinforce what was learned. Data were collected at baseline and at 1, 6, and 12 months after completion of the intervention.

• The study reported on a sample of 394 patients.
• Mean patient age was 61 years (range = 39–82 years).
• The sample was 64.4% female and 32.2% male.
• Patients had diagnoses of breast, prostate, or colon cancer.
• Average time since diagnosis was 15 months (range = 2.5–28.1 months).
• Of the sample, 48% were employed, 47.5% had higher than youth education, and 72% were married or cohabiting.

• Single site
• Other setting
• Denmark

Transition phase of care after initial treatment

Randomized controlled trial

• Profile of Mood States Short Form
• EORT QLC-C30

At one-month time point, findings revealed significantly more improvement in anxiety (p = 0.03), total mood disturbance (p = 0.04), emotional role function (p = 0.02), and cognitive functioning (p = 0.0009) in the control group. At the six-month time point, a significantly improved outcome for the control group was also found for depression (p = 0.005) as well as sustained improvement in anxiety (p = 0.003), total mood disturbance (p = 0.02), emotional role function (p = 0.04), and cognitive functioning (p = 0.03).

The residential rehabilitation course studied did not have a positive effect on anxiety, depression, or cognitive functioning. In this study, the control group improved more over time than those who received the intervention.

• The study had a risk of bias due to no blinding and no appropriate attentional control condition.
• This type of residential program or intervention would require training and be expensive and impractical for many individuals. It is not clear if participants incurred any costs to participate.
• Usual care was not described.
• Measurement for cognition was one item on a subjective measure.
• There was 13% attrition at time of six-month follow-up testing.

 This study suggests that an intensive residential program for cancer survivors, as examined, was of no benefit.