A cancer survivor is anyone living that has been diagnosed with cancer. The treatment for cancer varies based on cancer type and stage. What happens when the treatment is complete?

As the rate of cancer survivorship increases, there are more individuals who are considered cancer survivors that are living longer. Cancer survivorship is now considered a chronic condition.

Individuals who are cancer survivors often experience disruption in their roles, habits, and routines of daily living. This section provides informational tools to help the cancer survivor reestablish their previous activities and occupations.

The level of engagement and timing to return to paid employment varies for individuals who are cancer survivors. During the initial stages, adaptations may be needed. This section addresses aspects of survivorship that are important to consider prior to returning to work.

Individuals who are cancer survivors may experience residual effects of cancer treatment which impact daily living. This section discusses the role of the occupational therapy practitioner in promoting well-being and quality of life for the individual who is a cancer survivor.

Cancer and its treatment can have a significant impact on the individual who is diagnosed. It is important for the occupational therapy practitioner to recognize the various aspects of cancer survivorship and provide interventions that aid in improving the quality of life for an individual who is a cancer survivor.

A cancer diagnosis does not only impact the individual diagnosed, but also the primary caregiver. This chapter offers tools to best assist the cancer survivor in maintaining his/her life throughout diagnosis, treatment, recovery, and end of life.

Providing physical assistance is one component of caregiver training. The trend in the United States health care system is to decrease the length of stay for patients in the hospital. With this comes the responsibility of the caregiver to provide assistance in the home and community.

Being diagnosed with cancer may be emotionally trying for the cancer survivor. A caregiver may find him or herself providing emotional support to the cancer survivor through being present, listening, and providing comfort. Addressing emotional issues that may arise is yet another important aspect of being a caregiver.

It is not uncommon for the caregiver to “want to do it all” for their loved one. The reality is that not everyone is able to do everything for someone else. It is important to know the financial, emotional, and physical limitations of being the sole caregiver, as well as recognize the caregiver's threshold.

The caregiver cannot provide proper care if they are not taking care of themselves. The caregiver often has a great deal of responsibility when caring for the cancer survivor. It is instrumental in the continued care of the cancer survivor that the caregiver establishes a routine of self-care.

The role of occupational therapy in caregiver training can be multifaceted. As more individuals become caregivers, it is paramount that the caregiver be provided with the best tools possible to care for someone else. This section will address the distinct role of the occupational therapy practitioner in caregiver training.

This course has provided several examples of how the caregiver can best provide care for the cancer survivor and for oneself. Additional resources will be discussed in this section to provide suggestions and opportunities for support provided to the caregiver.

A published article and a grassroots organization set the stage for cancer survivorship, both as a phenomenon and a movement. This chapter describes how a small group of survivors impacted the national scene with a perspective that individuals diagnosed with cancer are survivors and not victims.

The National Academy of Medicine, formerly called the Institute of Medicine, published reports that addressed cancer care in the US. In particular, this chapter addresses a seminal report with ten recommendations provided by the foundation for addressing survivorship as part of the cancer care continuum.

Following the publication of landmark reports, cancer-related organizations developed standards of survivorship care and guidelines that addressed the physical and psychosocial effects associated with cancer treatment. These organizations are comprised of accrediting bodies and those that develop evidence-based guidelines regarding major treatment-related effects. This chapter provides an overview of these important organizations.

The number of cancer survivors is increasing due to advances in early detection and treatment. With this increase in the number of survivors and their longevity, a multidisciplinary approach is essential to addressing the late and long-term effects of treatment in this population. This chapter presents ways to address the impact the increased number of cancer survivors will have on the health care system.

Various models of delivering survivorship care have been developed and implemented in the US. However, no one model has been found to be the exact fit for all health care facilities that care for cancer survivors. This chapter discusses the various models and the advantages and disadvantages of each.

The Commission on Cancer is an accreditation program of the American College of Surgeons which sets standards to improve the survival and quality of life of cancer patients. The standards reflect a multidisciplinary, patient-centered approach and a commitment to quality cancer care. This chapter provides an overview of these standards, particularly, those addressing survivorship.

A major recommendation of the 2005 Institute of Medicine report was to provide patients with a treatment summary and survivorship care plan following completion of cancer treatment. Standards now require that both documents contain specific components, that the content of each must be discussed with the survivor, and that copies are given to the patient. This chapter provides a full discussion of the purpose and importance of these documents as well as the components of each.

Health care providers need to understand the definition of a treatment-related effect. These effects can be broken down according to temporal relationship to the treatment including acute, subacute/delayed, and late effects. Specific cancer treatment such as surgery, radiation, and chemotherapy present individualized side effect risk profiles. Understanding these concepts will assist in creating the most effective method of addressing the health issues of cancer survivors.

Cancer-related fatigue is the most frequent treatment-related effect reported by cancer survivors. This symptom frequently persists after the completion of treatment and impacts overall quality of life. Fatigue in cancer patients is multifactorial, and comprehensive assessment is essential in development of a successful treatment plan. Symptoms most often respond to exercise, which is considered first-line treatment for this condition.

Long-term assessment of psychosocial distress is a fundamental aspect of survivorship care. Depression and anxiety may decrease long-term survival and overall quality of life. Care centers now focus on the impact of mind-body interaction on treatment success. Practitioners are expected to conduct ongoing assessments for distress and psychosocial symptoms that may impede the treatment plan. Developing treatment resources and collaborative relationships is an important component in the care of these treatment-related effects.

Cancer rehabilitation plays a pivotal role in the treatment of cancer-related pain. Common causes of pain in cancer patients include musculoskeletal and neuropathic etiologies. Addressing and eliminating pain is the first step in correcting functional limitations found in this patient population. Neuropathy is a significant treatment effect that can worsen pain issues and create functional limitations. Chemotherapy-induced peripheral neuropathy and radiation-induced plexopathy are well-known syndromes that health care providers need to understand how to appropriately diagnose and treat when providing care to cancer survivors. Ongoing research shows that limited research supports pharmacologic agents; therefore, other modalities of treatment and addressing secondary consequences, such as gait issues are core concepts in improving an individual’s health. Pharmacologic treatment of pain and neuropathy has significant risks and limitations, so it is essential to determine non-pharmacologic interventions to restore the patient to a higher level of health.

Lymphedema is most often associated with breast cancer survivors who are at an increased risk after mastectomy and axillary lymph node dissection. This treatment effect is not isolated to this population and may cause significant issues in other survivors. Any individual who has extensive lymph node biopsy is at elevated risk. Head and neck cancer survivors can have a 40-50% chance of developing lymphedema that can compromise the airway or vision and also cause cosmetic defects. Preventative interventions and early identification are important components of treating this issue. Many cancer rehabilitation programs have created comprehensive lymphedema programs.

Cancer survivors manifest cognitive impairments in areas of memory, attention, and processing speed. These issues influence daily life within realms of education, work, and social interactions. Health care professionals require understanding of the components of the neurocognitive assessment and patterns of cognitive symptoms, along with effective interventions.

The specialty of cardio-oncology is continuing to evolve in the treatment of cancer patients and survivors. An extensive amount of research has focused on screening for changes in left ventricular function in patients taking high-risk chemotherapy agents, and well-established guidelines are in place. The true toxic effect to cardiac and vascular structures may only become evident months to years after treatment. Cardiac concerns extend beyond myocardial dysfunction to areas of ischemia, hypertension, and dysrhythmia. Radiation places cardiac structures and vessels at risk for pathologic changes, such as valvular disease, chronic pericarditis, and vessel dissections.

The number of cancer survivors continues to increase; however, many of these individuals undergo aggressive treatment that involves multiple modalities of treatment. Side effects of these treatments can be cumulative and can create significant disability. The restorative component of rehabilitation is suited to allow these patients to obtain the highest level of wellness possible. Evaluations that focus on functional limitations are an integral part of a global patient assessment. Physical issues such as decreased range of motion, spasticity, and deconditioning, can be impacted by a well-structured cancer rehabilitation program.

Before understanding the implications of breast cancer survivorship for rehabilitation, it is important to understand the treatment options available to individuals experiencing breast cancer. The first chapter of this course provides this vital context by describing the choices available to patients and the implications of those options.

This chapter explores the musculo-skeletal effects of different breast cancer treatments, and introduces the participants to the implications for rehabilitation scenarios including shoulder dysfunction, cancer related fatigue, and the effects of chemotherapy.

This chapter provides additional background on the management of the effects of breast cancer in a rehabilitation setting, including the effects of breast cancer on the lymphatic system, and musculoskeletal systems.

In the final chapter of this course, Michelle Lyons demonstrates some of the most relevant exercise interventions for breast cancer survivors, including examples of breathing exercise, spinal extension, and self massage for lymphedema.

The first chapter of this course describes the implications of prostate cancer survivorship for rehabilitation patients, and the important role that pelvic physiotherapy can play for these patients.

What treatment options are available to patients experiencing prostate cancer, and what are the rehabilitation implications of these choices? This chapter answers these questions, and compares the outcomes of treatments that are currently available.

This chapter explores the complex pelvic heath implications for patients who peruse various prostate cancer treatments, including erectile dysfunction, urinary incontinence, and pelvic pain.

In the final chapter of this course, Michelle Lyons demonstrates key home program exercises for prostate cancer survivors.

Terminology in advance care planning and advance directives can be complex and often confusing. Terms that sound alike may have different meanings and there may be several terms that mean the same thing. This course reviews common terms to help the health care provider explain these to patients and their families.

It has taken a long time to get to where we are today. This chapter will review the history and evolution of advance directives and advance care planning. Additionally, significant court cases that have impacted advance care planning will be reviewed.

From “beginning the conversation” to “what to do with completed documents,” this chapter reviews the important process of assisting patients with their advance care planning. Qualifications for a health care proxy will be reviewed and the options available for inclusion in living wills will be discussed.

Some conversations are just going to be difficult, but each difficult conversation increases the clinician's experience and preparedness for the next one. This chapter reviews barriers and facilitators to effective communication as well as ways to minimize our own personal bias and assumptions when engaging in these conversations. Finally, this chapter will look at how to balance empathy with professional boundaries to avoid compassion fatigue.

Patients and families want to be heard, but clinicians want to have answers. This chapter will help the clinician bridge this gap in goals of communication. Patient-centered communication will be examined so power and responsibility can effectively be shared. This chapter also discusses facilitating difficult conversations between the terminally ill and their family members.

This chapter will present four actual cases for review. Topics in this course will include pain management, refusal of care, pediatric issues, family disagreements, and suicidal ideations. Each case will examine the conversations that occurred and the outcomes of those conversations.

In any difficult conversation, there are things that went well and things that could have been handled better. This chapter looks at professional growth through meaningful reflection and after-action reviews. There is an opportunity to learn from each experience and be even better prepared for the next time.

Using a case study of a patient newly diagnosed with ALS, this chapter will explore the concept of palliative care as an extra layer of support to assist with the coordination of care, the promotion of quality of life and the management of symptoms which limit this. This chapter will also explore past and current models of palliative care as well as services provided, payment models and practice settings. Finally, barriers to palliative care access will be explored.

The origins of compassionate end of life care began with the vision of Dr. Cicely Saunders, who is known as the founder of the contemporary hospice movement. This chapter will explore the hospice care from several perspectives including the services provided, eligibility requirements and the primary diagnoses served. Finally, eligibility requirements for admission to hospice will be discussed.

If you were in a serious accident today, with no hope for recovery, would your family or loved ones know what to do? Surprisinlg, only 30% of Americans can answer positively to this question. Advanced directives may well be the single most important step towards individualized and compassionate end of life care. This chapter will discuss the two components of an advanced directive; the durable medical power of attorney and the living will. Videos of actual end of life discussions will be shown to highlight approaches to end of life planning. Finally, the emerging use of physician orders for life sustaining treatment (POLST) will be discussed, including indications for completion of this document.

"My father is dying, why would he need a physical therapist?" This question, commonly asked by patients, and even by other physical therapists, belies the reality of the benefits of physical therapist intervention. This chapter will explore the role of the physical therapist in the provision of non- pharmacologic pain management, patient education and exercise. Briggs’ 2007 model of physical therapist practice patterns will be briefly discussed to provide a contextual framework for the delivery of interventions. A brief overview of end of life outcome measures will be presented and the chapter will end with a patient case study and video.

The first chapter of this course defines the concept of a contemplative care practice, and will help the participant to recognize clinically relevant live situations that elicit personal reflection. This chapter also introduces the concept of recognizing mind, body and spirit when contemplating loss and suffering.

This chapter takes a closer look at the concepts of suffering and non-attachment. Participants will learn to differentiate between pain and suffering, and recognize mental and emotional responses in order to better identify clinical opportunities to better utilize presence and non-attachment approaches.

Engaging in the practice of mindfulness can help therapists to experience personal awareness of mindfulness for use in client interactions. This chapter will help the participant to recognize the varying cultural manifestations of ‘presence’ and 'beingness,’ and provide strategies to promote mindful awareness in patients.

This chapter delves into the emotional responses of patients and clinicians, and provides tools for identifying opportunities to support patient emotional expression, and to recognize personal responses to challenging clinical situation and the consequences of those responses.

The final chapter of this course addresses an often-overlooked aspect of hospice and end of life care: self care for therapists. This chapter emphasizes the importance of recognizing one’s own issues of unfinished business, and identifying opportunities for growth with reflective self-examination.

The first chapter of this course introduces participants to the concept of cognitive reframing, as well as the limits of patient and family understanding and acceptance. Participants who complete this chapter will be able to identify overall observation and listening skills, and utilize primary observation and listening skills.

This chapter addresses the difficult topic of addressing changes in physical status and functional mobility during hospice care, including family education about disease processes, affirmation of maximal patient aerobic and anaerobic effort, and discerning variable life course trajectories.

This chapter pays particular attention to orthopedic considerations during the trajectory of the disease process, including decision-making around functional activities and activities of daily living.

The final chapter of this course addresses the non-physical aspects of palliative care, unpacking the complex relationship between body, mind, and spirit as patients and their families approach end of life situations.