Effect of Telerehabilitation on Quality of life of Cancer survivors:A Systematic Review

Introduction

Cancer is a condition in which some cells grow uncontrollably and in some cases, spread and invade organs in other parts of the body - a process called metastasis. This abnormal growth is harmful because it does not just replace healthy cells in organs, but also causes changes in our body’s biochemistry that can lead to weight loss and compromised immune system, thereby leading to death. There are over 200 different types of cancers, some of which are far more common worldwide than others such as lung cancer and breast cancer (12.3% of total cases each), colorectal i.e. the large intestine (10.6%), followed by prostate cancer (7.5%), and stomach cancer (6.1%), according to World Cancer Research Fund International statistics.¹

India has around 2.5 million cases with over one lakh new cases being registered every year, according to CancerIndia.org. In 2018, the disease led to nearly seven lakh deaths. The Indian Council of Medical Research (ICMR) estimates that the country is likely to register over 17 lakh new cases and report over 8 lakh deaths by 2020. Risk of developing cancer before the age of 75 years is 9.81% in males and 9.42% in females.²

According to WHO, in 2018, 18.1 million people around the world suffered with cancer, and 9.6 million died from the disease. By 2040, those figures will nearly double, with the greatest increase in low and middle-income countries (LMIC), where more than two-thirds of the world’s cancers will occur.³

Developments in screening and improved cancer treatments have led to improved survival. Cancer survivors suffer physical impairment after oncology treatment. This impairment reduces the quality of life (QoL) and increases the prevalence of associated with an unhealthy lifestyle, for example, decreased aerobic capacity and strength, weight gain, and fatigue, consequently cardiorespiratory deconditioning, which affects their symptoms and functional level.^4,5 In conjugation with physical symptoms, psychological symptoms such as anxiety and depression can occur leading to reduced quality of life (QOL). By providing patients with education and healthy lifestyle programs, clinicians can help cancer survivors decrease the uncertainty and physical and psychological distress associated with their disease. Physical activity appears to provide health benefits in cancer survivors, suggesting that exercise-based rehabilitation programs should be performed within cancer care. However, these programs are at risk for low adherence (remote location of the centre, familial support, and previous physical activity habits). Technological advancements may help to resolve barriers such as distance, time, and cost. Taking into account the negative impact of disease on the quality of life of cancer survivors, increasing access to programs by delivering them via telerehabilitation systems that are capable of assessing and treating their side effects might be a useful tool. A recent review showed that telerehabilitation can be an effective part of cancer care.^5,6

Telerehabilitation technologies such as telephone, video conferencing, and Internet-based interventions, have the capability of bringing services into the survivors’ home and bolster the management of symptoms without needing to have direct physical contact with the hospital or clinic services. Telerehabilitation facilitates transitioning of post-cancer treatment care from hospitals to the home and community and empowers survivors and their families or caregivers to play a more active role in managing their care.⁶

Patients have the great advantage of quick and efficient contact with a health professional. On the other hand, the health professional can provide therapeutic intervention more efficiently in response to a patient’s needs. The monitoring of some variables (for example, weight, heart rate, and arm mobility) allows the control of these patients, which may provide improved adhesion of programs that seek to increase the QoL. The motivation of patients can be increased significantly using the telehealth system by immediate feedback that may be responsible for an active approach to fitness.^4,6

A review study supported the view that telerehabilitation can lead to similar clinical outcomes as personal usual care. The purpose of this study was to examine the effectiveness of telerehabilitation on cancer survivor’s QOL on providing therapeutic support.

Objectives

The objective of this study was to perform a systematic review study to evaluate the effect of telerehabilitation programs on the quality of life of cancer survivors that includes therapeutic exercises provided through technology to reduce musculoskeletal disorders, reduce fatigue, and improve fitness, and an overall improvement in quality of life.

Methods and Methodology

Search method

A search of articles for this study was done in ICMR and WHO guideline article, PubMed, European journal, Cochrane journal, Google scholar, science direct, research gate, JAMA oncology, Bio-Med central with the strategy being “Effect of Telerehabilitation on Quality of life of cancer survivors” and keywords for the search included telerehabilitation, telehealth, cancer, quality of life, functional activity.

Inclusion criteria

• Articles involving adults who can access technology.

• Articles which were published from the year 2010 to 2020 including randomized control trials, feasible randomized control trials, and quasi-randomized control trials.

Exclusion criteria

• Articles before 2010 were excluded from this study

• Studies having patients with vulnerable subjects such as pregnant women or any pathology other than cancer were excluded

• Studies having patients with any contraindication, who were not approved by the oncologist to participate were excluded.

Methodology

• A total of 23 articles were selected for this study,which were screened for inclusion and exclusion criteria.

• Thirteen articles were included.

• After screening 13 articles for full-text eligibility, only five articles were found to fulfil the criteria of this review study.

Results

Figure 1 is a flow diagram of the article selection process and provides the details of articles included and excluded at each stage. Our initial search for articles using our search terms designated a total of 23 articles. Five articles (Table 1) ultimately fit all review study criteria.

Our analyses of included articles demonstrated significant improvement in the effect of telehealth interventions on increasing survivors’ QOL compared to usual care. The intervention program included planned physical activity and therapeutic exercise on QOL. The physical activity purpose included aerobic exercises which showed to be effective in reducing fatigue, mobility, and strengthening exercises focused on the specific areas affected, to help with pain and disability associated with area morbidity and recovery strategies focused on respiratory exercise, relaxation techniques, and flexibility exercises. Weekly aimed sessions and schedules were made according to patient’s flexible time, which was more convenient for them to attend all the planned interventions.

Three of the articles used European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 items (EORTC-QLQ-C30) for assessment of QOL and two articles used Functional Assessment of Cancer Therapy (FACT) for QOL. Quality of life was assessed with the 5-item EQ-5D-3L, in one of the articles. International PA Questionnaire (IPAQ) assessed physical activity in one of the articles and with Activity Measure for Post-acute Care Computer-Adaptive Test (AM-PAC-CAT) in one study. Assessments were done at baseline and after the intervention program usually to find out the differences and significant improvements in the telerehabilitation group compared to the usual care group. Many of the studies included in this review did not show statistical significance in the overall QOL assessment; however, some of the study outcomes were significant in the social wellbeing of QOL compared to the usual group. These interventions were found to be more effective in the younger age group or <60 years age as it was easy for them to follow instructions through the technology used in telerehabilitation compared to the older age group.

Studies also showed that interventions only through internet-based were less effective compared to the interventions through internet-based followed by telephone calls for better understanding. Although studies have shown large outcomes on physical activity as well as functional activity and small to moderate effect on QOL assessment, some studies showed significant improvement in Quality of life from this type of intervention.

Discussion

This review study was performed that utilized telehealth interventions to improve the quality of life of cancer survivors. Our analysis of included articles demonstrated significant improvement in the quality of life of survivors. Some of the studies showed small to moderate effects in the improvement of QOL. This may be due to the differences in survivors compared with their counterparts still receiving cancer therapies, which affects each patient differently and can cause multiple issues, including physical, functional, and psychosocial symptoms and complications.⁶ Studies also showed significant improvement in physical activity interventions. The recovery strategies related to physical training could produce an additional improvement in the patients increasing the adherence to exercise programs in cancer survivors.^4,6

Studies in this review also focused on physical activity, behavioural and cognitive changes, Body Mass Index, and other musculoskeletal changes after or during the treatment of cancer patients, which resulted in significant small to moderate favourable effects in telehealth interventions. Assessments used EORTCQLQ-C30 and FACT measurement scales to find out the improvements of QOL, which were done at baseline and after the intervention program. The intervention program included a CUIDATE system, web-based, home-based, internet-based video conferencing, emailbased followed by telephone call support for counselling and therapeutic exercises planned for cancer survivors.

The results of the trial were promising given that the intervention was relatively brief, pragmatic, and highly feasible. They were home-based and consisted of a single in-person counselling session followed by telephone calls.⁷ Collaborative telerehabilitation that combined remote and center-based care improved function, pain, and QOL and reduced hospital length of stay and the need for post-acute care among patients with advancedstage cancer and functional disability.⁸ Therefore, although some studies may not show a statistically significant effect on overall QOL, there are areas of a survivors’ life that improved with telehealth support programs. Likewise, studies have been conducted on the significance of a positive increase of overall QOL scores compared with negative and the meaning that has for cancer survivors.^6,8

We utilized articles as noted in Table 1 for our review study, which after analyses could give support for the use of this type of strategy in cancer survivors. The tuning process of this type of intervention could benefit the health of the prevalent cancer patients and reduce the costs of this relatively new health problem.^4,8 For this reason, telehealth systems need to explore for the increasing cancer survivor population.

Conclusion

The studies showed that these non-face-to-face approaches could be effective as an alternative to usual care rehabilitation. These broad approach technologies may minimize distance cost, time, and length of hospital stay and may provide accessibility to non-urban cancer survivors and benefit both cancer survivors and therapists by reducing the burden.

According to this review, telerehabilitation can improve functional activity of daily living and cause an overall improvement in quality of life. Furthermore, studies need to be conducted on telerehabilitation among different cancer diagnoses to gain better insight on effectiveness.

Conflict of Interest

None.