15. Rehabilitation – Cervical Carcinoma
Major changes in the chapter on rehabilitation
The statements are unchanged. The background text on rehabilitation has been rewritten; application procedures, objectives and implementation are described, as well as the legal framework and theoretical background. A new feature is the listing of evidence regarding treatments that are carried out in rehabilitation clinics. The section on lymphedema has been completely revised and aligned with the Level 2 consensus-based guideline on the subject. The background text for the section on fatigue has been expanded.
T. Dauelsberg, M.C. Koch, U. Henscher, R. Tholen, L. Kiesel, R. Wiedemann
The purpose of medical oncological rehabilitation is to provide specific treatment for the sequelae of the disease and of its treatment. All patients shall receive information and advice about the statutory options available for applying for and using rehabilitation measures.
- Consensus
- Strong consensus
Treatment-related disturbances shall be inquired after and treated during rehabilitation.
- Consensus
- Strong consensus
15.1 Before rehabilitation
All patients must be informed and advised in detail about the statutory availability of options for follow-up rehabilitation, nonmedical treatment, and outpatient rehabilitation services. The attending physician and social worker involved must collaborate for the purpose. The patient’s capacity for rehabilitation results from positive motivation and the physical and psychological ability to make use of the rehabilitation programs offered in a goal-oriented way.
The extent of the patient’s need for rehabilitation in the somatic and psychosocial areas emerges from the establishment of disease-related and treatment-related sequelae based on the principles set out in the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) (2001). These can be differentiated in greater detail into functional disturbances, disabling conditions, impairments, and context and risk factors, and can also be recorded in coded form.
Accordingly, the assessment of the need for rehabilitation (e.g., in the context of application procedures) requires consideration of bio-psycho-social impairments in addition to biomedical health problems.
Rehabilitation is carried out on an in-patient or outpatient basis, or if necessary as a mixed form, but always in an interdisciplinary and multimodal fashion.
15.2 Goals of rehabilitation
Oncological rehabilitation is the next therapeutic step for patients with cervical carcinoma after completion of primary therapy, to enable them to return to normal everyday family, social, and professional life.
The overall goal of oncological rehabilitation is the recovery of physical, mental, and social well-being. In the case of chronic disease sequelae, support and care should be provided to help patients accept or compensate for unavoidable disabilities and symptoms and lead their own lives again to their own satisfaction and on their own initiative.
Oncological rehabilitation aims to significantly improve or restore any substantially endangered or already reduced ability to work, or at least to prevent deterioration.
The aim of oncological rehabilitation is to avoid the need for long-term care or postpone the time point at which long-term care becomes needed.
15.3 Overcoming physical, mental and social effects
Oncological rehabilitation takes place in a multidisciplinary setting based on the ICF and the bio-psycho-social model:
- Diagnosis of the sequelae of the cancer and its treatment
- Preparation of an individual rehabilitation plan
- Multidisciplinary treatment of specific sequelae — e.g., local sequelae due to surgery or radiotherapy, or due to estrogen deficiency, dyspareunia, lower urinary tract or bowel disorders, lymphedema, or chronic tumor-associated fatigue syndrome
- Exercise and a physiotherapeutic training program to increase the patient’s strength and condition and overcome or compensate for specific secondary disorders
- Physical therapy, provision of aids
- Ergotherapy
- Psycho-oncological services, including individual and group services, relaxation procedures, creative therapies
- Social counseling on the professional, domestic, family or social situation
- Provision of information on the disease and healthy lifestyles
- Motivation and training to ensure a healthy lifestyle and enable the patient to cope with the disease and health on her own responsibility
15.4 Occupational support
The sequelae of cervical carcinoma and cancer treatments that have been carried out may involve impairment of the ability to work. After a cancer illness, there is a greater risk of unemployment, change of job, reduced working hours, and lower remuneration.
An important task for oncological rehabilitation is to compensate for these disadvantages and risks:
- Is the rehabilitant’s ability to work sufficient for the demands of the workplace in the medium term?
- Can the rehabilitant continue to do her job to the same extent as before?
- Does the rehabilitant need equipment for the workplace that is suitable for her condition?
- Is it necessary for her to change jobs within the company she is working for?
- Does the rehabilitant need services to promote participation (e.g., further vocational training)?
- Has the rehabilitant lost the ability to work?
Oncological rehabilitation is suitable for provide patients with competent support on their way back to working life. In the process, it satisfies the requirement in Germany’s Basic Law that “No one may be disadvantaged because of his or her disability” (article 3, paragraph 3, clause 2 of the Basic Law ) and the “right to participation” set out in Chapter IX of the Social Security Code V (Sozialgesetzbuch, SGB)
In the medical discharge report provided by the rehabilitation clinic, a sociomedical performance assessment is drawn up for patients who are of working age, which, in addition to assessing the patient’s previous activity profile, also refers to her capacity to take part in the general employment market.
15.5 State of research on rehabilitation in oncology patients
Many therapeutic measures in oncological rehabilitation are provided on the basis of scientifically proven effectiveness. For methodological reasons, the relevant research is mostly conducted in relation to the frequent diagnoses of breast cancer, prostate cancer, and colorectal cancer. Evidence has been reported for the effects described below, and we consider that analogous measures are appropriate in patients with cervical carcinoma:
- Exercise therapy: reducing fatigue symptoms, increasing exercise capacity and physical functionality, improving body image, reducing depression, improving quality of life [536], [537], [538], [539], [540], [541], [542]
- Health education: reducing uncertainty, improving quality of life, improving sense of well-being [543], [544], [545], [546]
- Patient training: reducing physical symptoms, improving quality of life, improving mood [543], [547], [548], [549], [550]
- Practical nutritional training: achieving intentional weight loss through practical interventions [551]
- Relaxation training: pain reduction, improving quality of life, reducing anxiety and depression [552], [553], [554]
- Psychological counseling and therapy: improving quality of life, reducing fatigue and stress, reducing anxiety and depression [555], [556], [557], [558], [559], [560], [561], [562], [563], [564], [565], [566], [567], [499], [568]
15.6 Funding agencies and statutory basis
Rehabilitation services are services for participation that may be charged to a rehabilitation provider (e.g., the German pension insurance system, statutory health insurance companies, statutory accident insurance companies). In the field of oncological rehabilitation, the pension insurance funds are the funding agencies most frequently responsible. In accordance with German social legislation, disabled people or people at risk of disability receive rehabilitation benefits in order to promote their self-determination and equal participation in life in society, and to avoid or counteract disadvantages. The benefits are provided by the relevant rehabilitation provider in accordance with Book 9 of the Social Security Code (SGB) and the benefits legislation applicable to the rehabilitation provider concerned — e.g., SGB V in the case of statutory health insurance (GKV) or SGB VI in the case of pension insurance (DRV).
15.7 Bio-psycho-social model
The bio-psycho-social conception of illness is a prerequisite in medical and vocational rehabilitation in order to initiate rehabilitation (including the application process for it and the report on findings) and to establish the (therapeutic) content of rehabilitation procedures and planning of the individual rehabilitation goals. The rehabilitation providers implement the WHO recommendation to apply the International Classification of Functioning, Disability and Health (ICF) in the field of health care.
15.8 International Classification of Functioning, Disability and Health (ICF)
The ICF supplements the International Statistical Classification of Diseases and Related Health Problems (ICD) in areas in which the focus is not on the diseases (diagnosis and findings) themselves, but rather on the associated impairments, including impaired earning capacity, mobility, communication, self-care, home life and participation in social life.
15.9 Physiotherapy during rehabilitation
In case of stress urinary incontinence and/or fecal incontinence, patients with cervical carcinoma should be offered pelvic floor training.
The physiotherapeutic part of follow-up treatment focuses on therapy for various side effects of cancer treatment (surgery, radiotherapy, or chemotherapy). This includes treatment for incontinence, lymphedema, and interventions to relieve fatigue syndrome.
Functional disturbances in the pelvis may occur during treatment of gynecological tumors using surgery or radiotherapy. These disturbances include symptoms of urinary incontinence (urge incontinence, stress incontinence, and mixed incontinence) and fecal incontinence, pain, dyspareunia (e.g., due to a shortened or scarred vagina), circulatory changes, or inadequate elasticity in scar tissue.
These disturbances can be reduced using various passive physiotherapy techniques (scar mobilization, stretching of vaginal tissue, positioning, complex physical decongestive therapy, etc.), as well as active techniques (instructions on low-pain everyday behavior, exercises to promote the circulation, decongestive exercises, therapeutic exercise measures and training forms).
Pelvic floor training is still the treatment of choice in relation to urinary incontinence [570], [572], [576]. Specific data on patients with cervical carcinoma are not available, and this is the reason for the grade B recommendation. Pelvic floor training is particularly effective with stress incontinence and mixed incontinence, and also particularly in women under the age of 60 [569]. In addition, there is evidence that supervised training is more successful than training that is carried out independently by the patient [576]. If supportive forms of treatment — such as machine-aided biofeedback or electrostimulation — are used in addition to pelvic floor treatment in accordance with the relevant diagnosis, they can enhance the pelvic floor training [577], [578].
In the treatment of urge incontinence, combined therapy with bladder training, pelvic floor training, and educational measures has shown the best results and is quite comparable with drug treatment [579]. Another possible option in the treatment of urge incontinence may be treatment with functional electrostimulation [580], [581].
In the treatment of fecal incontinence, there is strong evidence for anal sphincter muscle training and pelvic floor training [571], [573]. It is not clear whether additional use of biofeedback and electrostimulation shows better results than pelvic floor training alone [571], [573].
15.10 Treatment for lymphedema during rehabilitation
In case of manifest lymphedema, combined therapy with skin care, manual lymph drainage, therapeutic exercises, and compression should be offered.
- Consensus
- Strong consensus
The standard therapy for lymphedema is complex physical decongestive (CPD) therapy. This consists of the following coordinated components:
- Skin care and, if necessary, skin cleansing
- Manual lymphatic drainage, supplemented with additive manual techniques if needed
- Compression therapy with special multilayer, compressive temporary bandages and/or lymphological compression stockings
- Exercise/movement therapy to promote decongestion
- Information and training for individual self-therapy
The goals of treatment are to return the disease to an edema-free state or to a lower lymphedema stage and thus allow continuing stability of the findings, improvement of the patient’s quality of life and participation in social and occupational areas of life, and to prevent complications. The combination of CPD with self-management and the provision of information ensures long-term therapeutic success (analogous to the Level 2 consensus-based guideline “Diagnosis and Treatment of Lymphedema,” AWMF register no. 058-001, May 2017) [582].
15.11 Treatment of fatigue syndrome during rehabilitation
Cancer-related fatigue has been reported in 53% of women treated for gynecological cancers, with a higher proportion in the cervical cancer group, followed by ovarian cancer. Younger participants were more likely to report fatigue than older participants. With adjustment for age, the type of cancer a woman experienced was found to have little effect on her risk of experiencing fatigue. Participants with fatigue reported higher levels of anxiety and depression than participants without fatigue. There was an association between fatigue and quality of life as measured by the SF-36 domains in health questionnaires.
Fatigue in cancer patients refers to unusually persistent tiredness that occurs during or after the treatment. In addition to physical limitations such as pain, nausea, and fatigue, psychological aspects such as depression or anxiety are very important here. Other causes of weakness or exhaustion symptoms, such as anemia, metabolic disturbances, and other differential diagnoses should always be checked as a matter of principle beforehand.
A systematic literature search identified four systematic reviews and in addition 16 randomized studies on exercise interventions in cancer patients and patients receiving treatment for fatigue. No studies on exercise interventions in cervical carcinoma patients were identified. The available studies mainly included breast cancer patients, as well as prostate carcinoma patients and mixed groups. The guideline group regards these data as being in principle transferable to the situation for cervical carcinoma patients. Due to the indirect evidence of the efficacy of exercise interventions in cervical carcinoma patients, the recommendation grade was reduced to B (recommendation).
The studies included (for a detailed presentation, see the evidence report accompanying this guideline) show that exercise therapy measures can lead to improvement in cancer-related fatigue [583], [584], [585]. This applies both to patients during primary therapy and also to “cancer survivors.” Forms of exercise such as stamina training, strength training, or a combination of the two appear particularly suitable. The question of the frequency of training cannot be clearly answered; on average, treatment frequencies of two to three times per week for 8–12 weeks were examined [586], [587], [588], [589], [590], [591], [592], [593], [594], [595], [596], [597], [598], [599]. An important factor behind a lack of improvement in fatigue syndrome is a lack of compliance on the part of the patients in relation to exercise interventions. Additional cognitive interventions did not show any clear improvement in the results [591], [596], [597], [600].
The general approach to the management of cancer-related fatigue (CRF) includes providing information, counseling, and other strategies. Nonpharmacologic interventions include psychosocial interventions, exercise, yoga, physically based therapy, nutritional management, and sleep therapy [601]. The first approach to any fatigue treatment is to provide information and counseling for the patient and family. Information, establishment of an individualized treatment plan, self-confidence, and stress management can be important and crucial factors that influence the treatment of patients’ CRF. In addition, an individualized treatment plan should essentially include diet, exercise, sleep, and stress management tactics to help the patient gain confidence in the treatment plan. Nonpharmacological treatments have shown promising results in the areas of exercise, sleep therapy, and cognitive-behavioral interventions [602].
Although a gold standard treatment for fatigue is not currently available, a variety of intervention approaches have shown positive effects in randomized controlled trials, including physical activity, psychosocial, physical-mental, and pharmacological treatments [603].
15.12 Sexuality
Malignant tumors of the genital tract, and cervical carcinoma and its treatment in particular, have enormous effects on the patients’ sexuality. In addition to reduced libido, the patients report vaginal dryness and dyspareunia as being particularly troublesome subjectively [604], [605]. In addition, the disease and its treatment have serious effects on emotional integrity, associated with the change in sexual anatomy [606]. Identity crises are not rare [606], [424], [418].
There is good epidemiological evidence for the effects of the disease on sexual health, but the literature on ways of treating this is limited [607]. However, a positive effect of psychoeducational measures on quality of life has been demonstrated for patients who received treatment with curative intent [608]. These patients benefit from receiving information about alternative hormone therapies, vaginal suppositories, and vaginal dilators [609], [610]. From the point of view of functional, emotional, and partnership considerations, sexual activity should be resumed soon after the completion of therapy, depending on the patient’s wishes and anxieties. The patient’s anxieties should be relieved through discussion and the provision of information about support. After the completion of each treatment, an interval of approximately 3–6 weeks after surgery and radio(chemo)therapy has become established as an interval that can usually be recommended.
Due to the integral nature of the complex of symptoms, multi-professional and interdisciplinary care for these patients, including psychological and psycho-oncological expertise, is recommended.
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