Journal of Physiotherapy 66 (2020) 70–72
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s
Editorial
Cancer rehabilitation
Amy M Dennett a,b, Mark R Elkins c,d
a
Allied Health Clinical Research Office, Eastern Health, Melbourne, Australia; b La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Australia;
c
Editor, Journal of Physiotherapy; d Faculty of Medicine and Health, University of Sydney, Sydney, Australia
This editorial introduces another of Journal of Physiotherapy’s
article collections.1,2 These are collections of papers in a specific field
of research, published in the Journal of Physiotherapy within the past
decade and curated to: facilitate access to recent important findings
in the field; highlight trends in the study designs, methodology,
populations and interventions addressed by the research; and pro-
vide a scoping overview of avenues for further research.
The focus of this article collection is cancer rehabilitation. The
World Health Organization estimates that globally in 2018 there were
18.1 million new cases of cancer and 9.6 million deaths from cancer.3
Globally, one in five men and one in six women develop cancer
during their lifetime, and one in eight men and one in eleven women
die from cancer.3 This all contributes to its very high disease burden.
What these figures also reveal, though, is that a large proportion of
people diagnosed with cancer survive their cancer. This is reflected in
the improved survival data for several types of cancer, particularly in
high-income countries.3–6
Cancer survivors may retain many residual impacts of the disease
and its treatment. Although these impacts are diverse, many of these
impacts are physical, such as cachexia, lymphoedema, dyspnoea and
limited joint range of motion.7 This situation of improving survival
with residual physical impairments creates an enormous need for
acute care and longer-term rehabilitation.8 In response to the need
for evidence to guide such intervention, there has been an expo-
nential accumulation of evidence in the oncology subdiscipline of the
Physiotherapy Evidence Database (www.PEDro.org.au), as shown in
Figure 1. Oncology content is constituting an exponentially increasing
percentage of the PEDro database, as shown in Figure 2. Accordingly,
various national guidelines now recommend referral to physiother-
apists or other professionals with appropriate expertise for exercise
prescription and other physical interventions to prevent and reduce
long-term, adverse effects and disability.9,10
Several of the studies in this article collection relate to breast
cancer.11–13 The systematic review by Neil-Sztramko et al11 summa-
rises the results of 85 studies of the physical function of women who
had been diagnosed with breast cancer. The results of formal tests of
aerobic fitness were generally very poor compared to predicted
values, although on functional exercise tests like the 6-minute walk
test, the women performed close to their healthy age-matched peers.
Upper limb strength was also very poor. Lower limb strength was not
as affected, with reduced results during active treatment of the
cancer but improving to above average thereafter. Simple tests of
mobility also showed some impairment. Given the proximity of sur-
gery and radiotherapy, it is not surprising that the upper limb would
be more affected than the lower limb, but disuse may also be a
contributor. Many of the studies in the review by Neil-Sztramko
et al11 were conducted at a time when clinical practice guidelines
advised against lifting heavy weights or children and to avoid doing
https://doi.org/10.1016/j.jphys.2020.03.004
1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
repeated activities.14,15 The next paper in this collection, however,
shows that such guidelines were not based on evidence.
Paramanandam et al12 conducted a systematic review of rando-
mised trials of weight training in women with or at risk of developing
breast cancer-related lymphoedema. Meta-analysing the data from
over 1000 women, Paramanandam et al demonstrated that weight
training did not worsen lymphoedema if it was already present, and
weight training did not increase the risk of lymphoedema among
women who did not have it. Guidelines subsequently changed
to remove the restriction on weight training and to encourage exer-
cise.16-18
The third breast cancer study in this collection was a randomised
trial of manual lymph drainage to prevent the development of breast
cancer-related lymphoedema.13 This is particularly welcome evi-
dence, given that the most recent Cochrane review on the topic found
insufficient evidence to make a recommendation about whether
manual lymph drainage prevents lymphoedema. The long-term trial
by Devoogdt et al13 enrolled 160 participants with breast cancer and
randomised half of them to undertake manual lymph drainage. Even
with five years of follow-up, and measurement of lymphoedema in
multiple ways, the trial was unable to identify any clear preventive
effect of manual lymph drainage on the risk of developing
lymphoedema.
Another type of cancer where physiotherapists have a large role to
play is lung cancer. Fortunately for readers of Journal of Physiotherapy,
Dr Catherine Granger’s invited topical review19 expertly summarises
the available evidence about the burden associated with lung cancer,
the management of lung cancer with a particular focus on physio-
therapy interventions, and future directions for research and clinical
practice.
The remaining articles in this collection relate to exercise for
cancer, and studied mixed populations rather than a specific type of
cancer.20–22 A common sequela of many types of cancer is cancer-
related fatigue. The systematic review by Meneses-Echávez et al20
summarised data on over 1500 participants and showed that super-
vised physical activity reduces fatigue among people who have been
diagnosed with cancer. Specifically, combined aerobic and resistance
training with or without stretching are effective exercise regimens for
reducing cancer-related fatigue. This is a welcome addition to the
other benefits of exercise in cancer, which include reduced anxiety
and depression, improved muscle strength and mass, physical func-
tion and quality of life.23,24 Dennett et al21 extended this evidence by
demonstrating that moderate-intensity exercise safely reduces fa-
tigue and improves walking endurance in cancer survivors. This led to
further investigation into ways to improve the amount of moderate-
intensity exercise done by cancer survivors. Dennett et al22 subse-
quently conducted a trial of adding motivational interviewing to
oncology rehabilitation to see if it would increase the amount of
 Editorial 71

Figure 1. Cumulative oncology content on the Physiotherapy Evidence Database (PEDro) by article type, based on November 2019 update of the database.

Figure 2. Cumulative oncology content on the Physiotherapy Evidence Database (PEDro) as a percentage of the overall database content, based on November 2019 update of the
database.

moderate-intensity physical activity undertaken. This study gener-
ated clear estimates that motivational interviewing wasn’t effective in
this regard; however, possible effects on reducing sedentary behav-
iour were identified that are worthy of further investigation. Despite
the known benefits of exercise, low levels of physical activity remain
an issue for people after oncology rehabilitation; therefore, support to
increase physical activity beyond rehabilitation is needed.
In summary, this article collection includes a range of important de-
velopments in cancer rehabilitation research. The study designs address
the prevelance of cancer sequelae,11 treatment of sequelae,12,20–22 pre-
vention of sequelae,12,13,19 and adherence to recommended long-term
self-management with physical activity.22 Importantly, each paper has
clear implications for clinical physiotherapists, which are identifiable in
the paper’s ‘What this study adds’ summary box.
72 Editorial

Ethics approval: Not applicable. 11. Neil-Sztramko SE, et al. J Physiother. 2014;60:189–200.
12. Paramanandam VS, et al. J Physiother. 2014;60:136–143.
Competing interest: Nil. 13. Devoogdt N, et al. J Physiother. 2018;64:245–254.
Source of support: Nil. 14. Cancer Research UK. Breast cancer - UK incidence statistics: Cancer Research UK.
Acknowledgement: Nil. 2011. Available at: http://info.cancerresearchuk.org/cancerstats/types/breast/
incidence/. Accessed December 15, 2011.
Provenance: Invited. Not peer reviewed.
15. Breast Cancer Care. Risk of lymphoedema: Breast Cancer Care. 2011. Available at:
Correspondence: Mark R Elkins, Centre for Education & Workforce http://www.breastcancercare.org.uk/breast-cancer-information/treating-breastca
Development, Sydney Local Health District, Sydney, Australia. Email: ncer/lymphoedema/risk-lymphoedema. Accessed December 16, 2011.
mark.elkins@sydney.edu.au 16. Centre for Clinical Practice at the National Institute for Health and Care Excellence.
Advanced breast cancer: diagnosis and treatment (CG81). 2017. Available at:
https://www.nice.org.uk/guidance/cg81. Accessed November 12, 2019.
17. Centre for Clinical Practice at the National Institute for Health and Care Excellence.
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