Evaluation and Pharmacologic Management of Symptoms in Cancer Patients Undergoing Acute Rehabilitation in a Comprehensive Cancer Center

Patients and Medical Record Review 

After our institutional review board approved the study, we reviewed the medical records of 96 patients who underwent acute inpatient rehabilitation between September 1, 2002, and October 31, 2003, at a large tertiary care cancer center in Houston. Four physicians were staff members of the rehabilitation unit. Because 33 patients who were transferred back to acute care services did not have ESAS scores available on discharge from rehabilitation, there were only 63 patients with ESAS scores available at both admission and discharge. Patient symptoms were recorded as ESAS VASs for pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, poor appetite, insomnia, sense of well-being, and constipation (range, 0 [symptom is absent] to 10 [symptom is of worst possible severity]).14 Clinicians filled out ESAS forms after asking patients about their symptoms; patients with mild cognitive deficits were given extra time and assistance if they did not understand the terminology and/or to rate their symptom severity. Demographic data collected included age, sex, tumor diagnosis, and hospital and rehabilitation unit LOS.

We conducted a careful review of discharge medications, including the reason for each medication. The discharge medications of patients who were transferred back to acute care were also reviewed. The information was not available for 3 patients. The medications included the following agents or drug classes: analgesics (which included nonsteroidal anti-inflammatory drugs, opioids, acetaminophen, tramadol, and combinations of these drugs); metoclopramide; mirtazapine; appetite stimulants (including progestins and corticosteroids); methylphenidate; laxatives; hypnotics; and other antidepressants (excluding mirtazapine). Metoclopramide, mirtazapine, and methylphenidate were prescribed frequently. On some occasions, symptom indications were not clearly documented in the charts; therefore, the medications were listed as separate categories to avoid guessing at the rationale for a specific prescription. For example, metoclopramide was sometimes prescribed for anorexia, and sometimes for prevention of opioid-induced constipation. Mirtazapine was sometimes prescribed for depression, sometimes for poor appetite, and sometimes for both. Methylphenidate was sometimes used as a stimulant and sometimes for treatment of fatigue.

All patients had been transferred to the rehabilitation unit from acute inpatient services after their medical or surgical treatment for cancer or other complications. All had functional deficits and met the following admission criteria: an inability to function independently in activities of daily living and/or mobility; the presence of such conditions as neurogenic bowel or bladder, cognitive deficit, incoordination, dysarthria, or spasticity; and a need for at least 2 of the following services—physical therapy, occupational therapy, speech pathology, and rehabilitation nursing.

Statistical Analyses 

We used descriptive analyses to summarize information about the variables. Analyses involving differences in admission and discharge symptoms were based on information of the 63 patients with ESAS scores available at both time points. We used the nonparametric sign test to assess the change in symptoms between admission and discharge. Associations between admission symptoms and LOS were determined using Spearman correlation coefficients. We used Wilcoxon rank-sum tests to assess the associations between specific discharge medications and each symptom.

Patient Characteristics 

Table 1 lists the characteristics of our study population. The median age was 64 years (range, 26–87y), and 47 were women. Eighty percent of the patients had solid tumors; the remainder had hematologic tumors. The most common primary cancers were brain (18%), of genitourologic origin (16%), sarcoma (12%), and leukemia (11%). The discharge destinations for the study population included home (75/96 [78%]), other facility (3/96 [3%]), and transferred back to acute service (16/96 [17%]). Two patients died. The median LOS in the hospital was 21 days (range, 4–149d) and the median LOS in the rehabilitation unit was 9 days (range, 1–24d). Results were similar among the 63 patients with ESAS available at both time points (table 1). Their median age was 63 years (range, 26–87y); 34 were women. The median LOS in the hospital was 20 days (range, 8–58d) and the median LOS in the rehabilitation unit was 9 days (range, 3–23d).

Table 1. Patient Characteristics of the Whole Study Population and Those Patients With ESAS Available at Both Time Points

	Characteristics	Whole Study Population (N=96)	Patients With ESAS Available at Both Time Points (n=63)
	Median age (range), y	64(26–87)	63(26–87)
	Females	47(49)	34(54)
	Tumor diagnosis
	Leukemia	11(11)	4(6)
	Lymphoma	3(3)	0(0)
	Melanoma	5(5)	4(6)
	Primary brain tumor	17(18)	11(17)
	Primary spinal cord tumor	2(2)	1(2)
	Head and neck tumor	3(3)	2(3)
	Thoracic tumor	9(9)	6(10)
	Breast cancer	3(3)	3(5)
	Gastrointestinal tumor	9(9)	7(11)
	Gynecologic tumor	7(7)	5(8)
	Genitourologic tumor	15(16)	12(20)
	Sarcoma	12(12)	8(12)
	Total	96(100)	63(100)

NOTE. Values are n (%) unless otherwise noted.

Symptoms on Admission and on Discharge and Their Relation to LOS 

Figure 1 shows the symptoms of the 63 patients with ESAS scores available both on admission and discharge. The most intense symptom on admission (mean ESAS VAS ± standard deviation) was poor appetite (3.7±3.3), followed by fatigue (3.4±2.6), insomnia (3.0±3.0), pain (2.4±2.5), anxiety (2.2±2.8), and constipation (2.1±3.1). The patients’ overall sense of well-being was also very poor (3.9±2.4). The poor appetite and depression admission scores correlated positively with hospital LOS (P<.001, P=.05, respectively); poor appetite also correlated positively with rehabilitation LOS (P=.001).

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Fig 1. Symptom scores (based on the ESAS VAS; range, 0 [symptom is absent] to 10 [symptom is of worst possible severity]) on admission (white bars) and on discharge (black bars) in 63 patients who underwent cancer rehabilitation (n=63). P values represent the significance of the difference between admission to and discharge from an acute inpatient rehabilitation unit, as compared by a paired t test (*P<.05, †P<.01). Each patient’s scores were compared with his/her original scores.

The symptom intensity on admission for the 63 patients was similar to that of the entire study population, with poor appetite (3.6±3.4) being the most intense symptom, followed by fatigue (3.2±2.5). Poor appetite was still the most intense symptom reported on discharge from rehabilitation (2.2±2.4), with fatigue (2.2±2.1) still second. Symptoms showing significant improvements were anxiety (P=.001), constipation (P=.001), fatigue (P=.002), pain (P=.003), appetite (P=.004), sense of well-being (P=.01), and insomnia (P=.04).

Discharge Prescriptions for Symptom Control 

Figure 2 shows medications used for symptom management at discharge. Sixty-five (70%) of 93 patients were given analgesics, 4 (4%) were given an appetite stimulant, 17 (19%) were given mirtazapine, 15 (16%) were given metoclopramide, 12 (13%) were given other antidepressants (excluding mirtazapine), 7 (8%) were given methylphenidate, 45 (48%) were given laxatives, and 22 (24%) were given hypnotics.

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Fig 2. Discharge medications used for symptom management in patients (n=93).

The ESAS pain scores of patients who were given analgesics on discharge were higher on admission (P=.002) than the pain scores of patients who were not given analgesics on discharge. Patients who were given metoclopramide on discharge had higher poor appetite scores on admission than did those who were not given that medication (P=.03); also, patients who were given mirtazapine on discharge had higher poor appetite scores on admission than did those who were not given that medication (P=.001). Patients who were given methylphenidate on discharge had higher drowsiness scores on admission than did those who were not given that medication (P=.005) and patients who were given laxative prescriptions on discharge had higher constipation scores on admission than did those who were not given a laxative (P=.03). Patients who were given hypnotics prescriptions on discharge did not have significantly higher insomnia scores on admission than did those who were not given a hypnotic (P=0.1).

We assessed the associations between specific discharge medications and change of symptoms in the 63 patients with ESAS available at both admission and discharge. In patients with discharge prescriptions of analgesics, laxatives, metoclopramide, or mirtazapine, there was significant symptom improvement between admission and discharge for pain (P=.002), constipation (P=.04), and appetite (with metoclopramide, P=.004; with mirtazapine, P=.02).

Study Limitations 

The main limitation of our study is that we did not know whether the medications for symptom treatment were started before patients were transferred to rehabilitation, or on their admission to the rehabilitation unit, or during their stay in the unit. We also lacked a daily assessment of symptoms that would show how the symptoms changed chronologically. A prospective study is needed to assess the relation between the pharmacologic intervention of symptoms and the change in symptom intensity, and to assess the continuous effectiveness of symptom control. Determining the optimal frequency and rigor of symptom assessment should be an objective of future research.

An estimated 565,000 Americans died of cancer in 2006.27 Patients who will suffer functional decline and require rehabilitation as a result of cancer or its treatment will undergo rehabilitation directed by their family physician and general physiatrist. Many of these professionals have limited exposure to the complex problems of cancer patients and limited access to comprehensive multidisciplinary teams. This article provides important information about the multiple-symptom characteristics of cancer patients undergoing rehabilitation.

We believe that successful management of symptoms is a crucial part of cancer rehabilitation and QOL. A cancer patient’s functional status and symptoms are closely interconnected, in that improving a patient’s functional status can positively affect his/her mood, appetite, sleep, constipation problems, and QOL.28 In addition, easing symptoms can increase a patient’s participation in therapy and lead to improved functional status so that he/she can be safely discharged. We have found that successful symptom control can lead to speedy improvement of functional status through participation in therapy. There is a need for a study that examines the interaction between symptom intensity and participation in therapy.

We believe that a detailed assessment of symptoms coupled with good symptom control is important in inpatient cancer rehabilitation. To reach this goal, the general physiatrist should be aware of a cancer patient’s special needs and physical medicine and rehabilitation residency training programs should include cancer rehabilitation rotations.