Physical Therapists in Oncology Settings: Experiences in Delivering Cancer Rehabilitation Services, Barriers to Care, and Service Development Needs.

OBJECTIVE: Physical therapist-delivered rehabilitation aims to manage the side effects of cancer and its treatments. Although access to cancer rehabilitation is not yet a standard of care in many countries, physical therapists practice in many types of cancer services with different cancer populations. The purpose of this study was to explore the experiences of physical therapists in cancer care practice with regard to their role, the factors influencing service delivery and development, and physical therapists' professional development needs.
METHODS: In this qualitative study with semistructured interviews, physical therapists in cancer care settings in the Republic of Ireland were interviewed via telephone. Participants (n = 17) represented a variety of clinical settings and roles. Two researchers performed thematic analysis of transcriptions using a semantic, inductive approach. Key themes and codes were identified and illustrative quotes were selected.
RESULTS: Six main themes were found: the need for more services, barriers to service development and delivery, a lack of awareness of the role of physical therapy, facilitators to service development, goals for the future of oncology physical therapy, and training needs of staff.
CONCLUSIONS: Physical therapists provide valuable interventions across the spectrum of cancer care but experience barriers to the delivery and development of services. Investment in oncology physical therapy and developing international standards of care will allow physical therapists to meet the rehabilitation needs of survivors of cancer. IMPACT: As international guidelines increasingly recommend development of cancer rehabilitation programs, it is important to understand physical therapists' experiences of working in cancer care to assist in the development of effective oncology physical therapy services. This study demonstrates that physical therapist-led cancer rehabilitation services need investment and public promotion to enable the provision of optimal services to all patients with cancer and to meet standards of care.

Introduction

Advances in cancer diagnosis and treatment, along with growing and aging populations, have resulted in an increased number of cancer survivors worldwide., This pattern means that more people are also living with the wide-ranging side effects of cancer and its treatments. Side effects may be acute, long-term, or late-occurring, and include a reduction in quality of life due to physical and psychosocial health problems such as pain, fatigue, anxiety, depression, and work-related issues., Many of the physical consequences of cancer and its treatment can be effectively treated with rehabilitation and physical therapy interventions. Clinical practice guidelines recommend multimodal interdisciplinary rehabilitation during and after acute cancer treatment, and there is a growing body of research to support rehabilitation before cancer treatment commences (prehabilitation).,, Despite these recommendations, there remains a high prevalence of unmet rehabilitation needs in cancer populations., Physical therapists working in oncology have strong foundational knowledge and skills in cancer rehabilitation and play an increasingly important role in the multidisciplinary care of cancer survivors. Additionally, many oncology physical therapists with specialist training and skills work in specialist roles to manage cancer-related impairments such as lymphoedema, peripheral neuropathy, and cancer-related fatigue. The development of a skilled rehabilitation workforce is essential for providing high-quality cancer rehabilitation and is enabled by working environments that facilitate continuing professional development (CPD).

International guidelines recommend the provision of rehabilitation services to address the wide-ranging physical and cognitive consequences of many different types of cancer. However, formal oncology rehabilitation programs are not standard practice in many countries., An Irish patient survivorship needs assessment has highlighted that formalized cancer rehabilitation programs remain uncommon.

The Republic of Ireland (ROI) has a population of 4.9 million and a Human Development Index of 0.95, classified as “very high.”, When comparing age-standardized rates of cancer, the ROI ranks as the third highest in the world. Cancer care in Ireland is provided through public specialist cancer centers, supported by local public and private health care services. Although physical therapy–delivered rehabilitation is not an element of standard care for patients with cancer in Ireland, a range of oncology physical therapy services are provided in various settings across the country. There is a lack of information regarding physical therapists’ experiences of providing these services. Studies with a qualitative design can inform the development and improvement of cancer rehabilitation by exploring physical therapists’ perspectives, thoughts, and motivations on the topic. A qualitative exploration of the challenges and opportunities facing physical therapists who provide rehabilitation to cancer survivors will provide a greater understanding of the current landscape of cancer rehabilitative services provided by physical therapists in Ireland and assist the development of future services.

The aim of this qualitative study was to explore the experiences of physical therapists providing cancer rehabilitation in the ROI, with regards to their role, factors influencing service delivery and development, and their professional development needs.

Methods

Design

A qualitative research study design using semistructured interviews was employed, because it enables the collection of rich, detailed data, allowing researchers to effectively explore the topic of interest. The study was performed and reported according to the Standards for Reporting Qualitative Research checklist to ensure methodological rigor and comprehensive reporting. Ethical approval for this study was obtained from Trinity College Dublin School of Medicine Research Ethics Committee.

Participants

Physical therapists (locally referred to as “physiotherapists”) working in cancer care in the ROI were invited to participate in this study. Invitations were provided through emails disseminated by the Irish Society of Chartered Physiotherapists to relevant professional special interest groups. Additionally, physical therapists who completed an online survey from this research group as part of a related study (awaiting publication) were asked to indicate if they wished to participate in this qualitative investigation; those who indicated interest were then contacted via email by the researchers. To ensure that the data collected applied solely to cancer rehabilitation services in the ROI, physical therapists working in other countries were excluded from participating in this study. Suitable interested individuals were provided with participant information leaflets and informed that participation was voluntary. The sample size was determined by data saturation.

Interviews

A semistructured interview guide (Fig. 1), informed by a literature review and the study aims, was developed by 2 researchers with experience in qualitative data collection (L.O.N. and G.S.; both chartered physical therapists). All participants gave written informed consent before data collection began. One-to-one interviews were held with either L.O.N. or G.S. via telephone, and audio recorded with the participant’s consent. Interviews lasted between 20 and 30 minutes and took place from August to October 2020.

Figure 1

Semistructured interview guide.

Data Analysis

The audio recordings were transcribed verbatim and deidentified by research assistants not involved in data collection or analysis. Deidentified transcripts were imported into NVivo qualitative data analysis management software (QSR International, Melbourne, Australia). Transcripts were analyzed in full by 2 researchers with experience in thematic analysis (L.B. and G.S.), using a semantic, inductive approach as outlined by Braun and Clarke. The researchers began by reading and becoming familiar with the data, then coding each transcript to identify a wide range of conceptually similar topics (codes). They compared codes and, in an iterative, collaborative manner, grouped similar codes together to form themes. Any differences in coding were resolved through discussion. Themes were agreed, defined, and named, and the researchers chose illustrative quotes for each code. The lead author revised the themes and codes a final time to confirm that they accurately reflected the data and to ensure internal homogeneity and external heterogeneity were achieved. Analysis was performed on 15 interviews at first. Two further interviews were then conducted, and these data were analyzed and added to the existing data. No new themes were identified from the final 2 interviews, therefore researchers decided that data saturation was achieved.

Results

Participants and Service Characteristics

Seventeen physical therapists (F = 14, M = 3) were interviewed; participants had been qualified as physical therapists for an average of 13.8 years (median = 12; range = 5–30). Details of the services in which participants worked are presented in Table 1.

Table 1

Participant and Service Characteristics

Participant ID	Job Title	Experience in Cancer Care (y)	Oncology Caseload Proportion (%)	Setting	Inpatient/ Outpatient Service
PT1	Senior PT	2.5	100	Acute public hospital and cancer center	Both
PT2	Clinical Specialist	3	100	Acute public hospital and cancer center	Both
PT3	PT	1.5	35	Private practice	Outpatient
PT4	Senior PT	5	100	Acute public hospital	Both
PT5	Senior PT	5	60	Acute private hospital	Both
PT6	Senior PT	5	100	Cancer charity	Outpatient
PT7	Clinical Specialist	18	50	ICU in acute public hospital	Inpatient
PT8	Senior PT	8	80	Hospice	Both
PT9	Senior PT	7	90	Palliative care unit	Both
PT10	Staff grade	4	100	Acute public hospital	Both
PT11	Senior PT	20	80	Palliative care unit	Both
PT12	Staff grade	4	80	Palliative care community unit	Inpatient
PT13	Clinical Specialist	12	70	Hospice	Both
PT14	Staff grade	5	30	Acute private hospital	Inpatient
PT15	Clinical Specialist	18	70	Hospice	Both
PT16	Clinical Specialist	20	25	Outpatient department	Outpatient
PT17	Senior PT	3	100	Acute private hospital	Inpatient

ICU = intensive care unit; PT = physical therapist.

Themes

Six themes were identified from the data: (1) need for more services; (2) barriers to service development and delivery; (3) a lack of awareness of the role of physical therapy; (4) facilitators to service development; (5) priorities for the future of oncology physical therapy; and (6) training needs of staff. Themes and their associated codes are displayed in Table 2. Figure 2 represents the main content of the discussions, demonstrating how several key factors present across the themes act as barriers and facilitators toward achieving service success and the goals of physical therapists in oncology.

Table 2

Themes and Related Codes

Theme	Codes
1. Need for more services	Variety of services providedIncreased services needed in specific areasInconsistency of services across countryDisjointed care modelLack of other HSCP posts
2. Barriers to service development and delivery	Lack of funding for new positionsMore resources neededDifficulty protecting existing services
3. Lack of awareness of the role of physical therapy	Lack of awareness within MDTLack of awareness in patients and publicEfforts to raise awareness needed
4. Facilitators to service development	Medical teams are key source of supportSupport from management is essentialAlign with local/national goalsBe involved in developing goals
5. Priorities for the future of oncology physical therapy	Develop national standards of careGreater emphasis on cancer rehabilitation as part of routine care
6. Training needs	Wide variety of CPD activitiesGood supports availableLack of advanced CPD opportunities

CPD = continuing professional development; HSCP = health and social care professional; MDT = multidisciplinary team.

Figure 2

The main factors acting as barriers and facilitators to oncology physical therapy services and goals for oncology physical therapy. MDT = multidisciplinary team; PT = physical therapy.

Theme 1: Need for More Services

Participants provided a wide variety of oncology physical therapy services, which are presented in Figure 3. Many participants expressed an urgent need for services to expand, in terms of both size and the nature of the service.

Figure 3

List of oncology physical therapy services provided by participants.

I just feel very frustrated at the huge gap in access and in rehabilitation for these patients, and in survivorship. (PT8).

Lymphoedema management, pediatrics, community-based outpatients, exercise rehabilitation, and specialist community palliative care were identified as areas in which service development is most needed. A lack of consistency in services across Ireland was reported, as PT1 explained:

As soon as we go outside Dublin [capital city], we seem to just drop off on where our breast cancer patients might get followed up.

Participants described a disjointed care model, with unstructured referral pathways and poor connections between acute and community services; PT6 explained how, when working in the community, “getting information on people’s background can be tricky.” Additionally, it was even more difficult for patients to access other health and social care professionals (HSCPs):

Patients wouldn’t get anywhere near the same amount of…speech and language therapy or OT. (PT7).

Theme 2: Barriers to Service Delivery and Development

Lack of funding for services and for new staff positions is the primary barrier to service development, as reported by participants:

We’ve a lot of issues with staffing like we just don’t have enough staff really to provide all the services that we need. (PT4).

For example, PT5 reported being individually responsible for covering a 24-bed medical ward as well as inpatient and outpatient breast surgery rehabilitation; PT11 covered palliative care services across a hospice, acute hospital, and day hospital with just 1 other physical therapist. New services were sometimes run on a pilot basis with existing staffing levels before funding can be secured:

It was a really, really busy time trying to get it set up, but we had to do that to show to the hospital that we need full-time funding for this. (PT2).

A need for resources, including gym space and computers, was a barrier for some participants in effectively running their services:

I was doing the classes at really different times, like it could have been 12 o’clock one day, 4 o’clock the next day, because our gym space was also used by the cardiac rehab nurses, so it wasn’t available to run a set class each day. (PT2).

Several physical therapists described difficulties in protecting their existing services, especially when other teams need assistance:

The whole of physio oncology inpatients would be bumped down the list in terms of priority. We can often get pulled with respiratory surgical or orthopedics. (PT17).

Overall, these barriers limit the potential beneficial role of oncology physical therapy:

We all feel really strongly that with better funding and improved resources, that (physio) would be a really valuable role for this population. (PT8).

Theme 3: Lack of Awareness of the Role of Physical Therapy

Participants felt that the benefits of physical therapy interventions and exercise in oncology were not fully understood by some members of the multidisciplinary team, which could lead to fewer referrals to physical therapy:

The notion still persists unfortunately that patients are too unwell for physio follow-up at that point in time, when in fact what they really need is a physio referral. (PT15).

The role of physical therapy in oncology was seen as “not getting as much attention as musculoskeletal or things like that” (PT4), and it was important to physical therapists to improve this awareness as, “If people aren’t aware of the service or don’t know of the benefits, they’re reluctant” (PT3). Participants explained how patients may not be aware of all their rehabilitation needs and therefore do not recognize the potential for physical therapy interventions to assist in their recovery:

Patients with chemotherapy don’t know they are allowed to exercise, and they may never see a physiotherapist to tell them that. (PT2).

Participants felt that efforts should be made to raise the profile of physical therapy in oncology among physical therapists, multidisciplinary colleagues, and the general public. Examples of how this could be achieved ranged from educating physical therapists themselves on the full potential of their role “so that we’re kind of aware of what’s out there and what we need to bring to our own service” (PT5), to engaging the public via social media:

Patient stories tend to make a difference, I suppose people will have maybe seen a post on social media of someone using the gym or that kind of thing, and they’re like, “Oh, maybe I could do that as well.” (PT6).

Theme 4: Facilitators to Service Development

Support from oncology and surgical teams is a key facilitator to service development, as described by PT2:

If they believe in the service and they want their patients to do it, they’ll send the referrals to you.

In contrast, participants working in the community lacked strong working relationships with acute teams, and felt that communication and support suffered as a result. Support from physical therapy management and the cancer centers is also essential, and new services thrived in sites that had a culture of progression and innovation:

Myself and (my colleague) worked really, really hard in conjunction with our CEO at the time and he’s been very strong in championing it as well. (PT13).

Participants explained how management are supportive when services are in line with local or national goals.

Then they’re going to be more inclined to promote and invest in the role, our role. (PT13).

Several participants encouraged for physical therapists to be involved with setting such goals:

It’s important that we get a place at the table where decisions are made and if [cancer rehabilitation] was a tick-box in all the cancer centers [including] mobility, quality of life, access to lymphoedema services, access to HSCPs [health and social care professionals]… then it will be responded to because they hold the purse strings. (PT11).

Theme 5: Priorities for the Future of Oncology Physical Therapy

Participants called for the development of national statistics and standards of care for oncology physical therapy services. Participants felt this will allow informed, equitable service development:

To know what services are provided in other hospitals and have a bit more consensus…to see what’s standardized and have a bit more uniformity. (PT4).

Many participants described how they hoped to see a greater emphasis on rehabilitation and quality of life within cancer care. They felt that physical therapy should be part of standard care, and introduced to the patient as early as possible:

In a dream world, I would love for everybody when they receive an oncology diagnosis to also get a referral to physical therapy initially... Ideally, I would like them presenting to me before they’ve started developing any issues so I can get them into the best possible effect. (PT3).

Theme 6: Training Needs

A wide variety of CPD activities were reported, from in-house training and webinars to international conferences and Master’s degrees. Generally, participants perceived they had good support from their employers to undertake CPD, and were provided with funding and an annual allowance for study days. Many described a lack of advanced CPD opportunities in Ireland for oncology physical therapy:

You have to go internationally and that obviously has an impact on finances, but that’s definitely where, as you progress through CPD, you need to look. (PT7).

Discussion

This study explores the experiences of physical therapists working in cancer care in the ROI, the challenges and facilitators to delivering oncology physical therapy services, and the ongoing service development and professional development needs. The sample consists of physical therapists working in a diverse array of settings, with a wide range of experience. Although explorations of various aspects of oncology physical therapy have been published, this is the first qualitative analysis that the authors are aware of which addresses the overall experience of delivering oncology physical therapy services. At a time when, in line with advice from global experts, local health care systems are aiming to develop effective cancer rehabilitation services, this study provides timely, valuable insights and offers a broad understanding of the current landscape of oncology physical therapy services and the main barriers to their development. Although differences may exist in health care systems, cultures, and populations, these findings from the ROI are relevant for physical therapy practice worldwide. The unmet need of cancer survivors is a global problem, and physical therapists work toward the same global goals for cancer rehabilitation services, as described by the World Health Organization., More services are needed in this area, and physical therapists require further information on how to initiate and integrate services into clinical practice.,

A key finding of this study is that oncology physical therapy services experience barriers due to low staffing, inadequate funding for new posts, insufficient resources, and a lack of awareness of the role and benefits of oncology physical therapy. Other important findings are that support from physical therapy and hospital management, and oncology and surgical teams, is important in development of service, and that oncology physical therapists desire national standards of care for oncology physical therapy and advocate that a greater emphasis is placed on rehabilitation in cancer care. These findings echo results of other international publications. A report on integrating physical therapists into oncology care states that lack of awareness of the benefits of physical therapy and lack of structured referral pathways are 2 of the main barriers to successful integration. It recommends developing practice guidelines and standards for physical therapy in oncology; enhancing undergraduate education in oncology rehabilitation; and advocating for improved equality of rehabilitation care. The priorities for oncology physical therapy identified by participants are shared by clinical and academic experts worldwide and are viewed as essential to addressing the needs of the increasing population of cancer survivors.,

Evidence-based guidelines for cancer care frequently recommend the inclusion of physical rehabilitation services., A European Cancer Patient’s Bill of Rights, developed by a partnership of patients, patient advocates, and cancer professionals, declares the right of patients to receive rehabilitation and care that ensure the best possible quality of life. These documents provide evidence and support for oncology physical therapy, yet many health systems do not have the staffing levels required to meet the recommended standards of care. The findings of this study depict a skilled workforce who strive to provide high-quality care but can be limited by inadequate staffing and limited resources. Regarding CPD, Lawler et al state that expert and experienced health care professionals are essential for the provision of high-quality cancer services. A wide range of training and support from management was a key factor in enabling this preparedness of oncology physical therapists in Ireland. Participants, although largely satisfied with their CPD opportunities, desired more advanced training; this can be supported in future by the increased availability of online CPD content, which has occurred as a response to the coronavirus pandemic.

The inadequate connections between acute and community services, as well as the inconsistent services across the country, highlight the need for an integrated model of cancer survivorship care. This would facilitate patient transition between services and improve patient experience and health outcomes. A model of a successful integrated system for cancer services can be seen in London; this achievement was attributed to strong clinical leadership, shared informatics systems, and a focus on service quality and patient experiences.

Lack of awareness of physical therapy and rehabilitation among patients and the general public disempowers patients, as they cannot advocate for or seek rehabilitation services that they are unaware of. Within the oncology multidisciplinary team, lack of awareness of the role of physical therapy impedes collaboration and communication. Without these relationships, opportunities for rehabilitation promotion and referral are lost and patient care can be directly impacted., Enhancing multidisciplinary team knowledge and further integrating physical therapists within the multidisciplinary team are 2 recommended strategies to effectively embed exercise and rehabilitation in cancer care.

Limitations

The generalizability of these findings may be limited by the fact that participants all worked within the ROI. The authors aimed to gather a clear picture of oncology physical therapy within 1 specific context. Including physical therapists from multiple countries would make the interpretation of data challenging, with potentially less meaningful findings, because the confounding factors of different health care systems, cultural factors, and population factors could not be easily identified in a multinational data set. With a basic awareness of the health care system and other characteristics contributing to these findings from the ROI, physical therapists can effectively interpret and apply them to their own national or local contexts as appropriate.

A limitation of this study is that participants were self-selecting. Additionally, some experiences may not be represented, for example, those of clinicians who treat cancer survivors but do not identify as an “oncology physical therapist.” The use of a theoretical framework may have strengthened this research and reporting. Future research should analyze the experiences of oncology physical therapists in different countries to identify local practices and areas for shared international learning and growth. Ongoing advocacy is needed to ensure physical therapy and other allied health professionals are central components of cancer pathways and services. National and international collaborations are required to create standards of care for physical therapy in cancer rehabilitation, which will promote equal, high-quality care and facilitate commissioning of services.

Conclusion

This study presents the experience of physical therapists working in cancer care in the ROI, including the barriers and facilitators to service development. Oncology physical therapists deliver valuable interventions across cancer care services but can be limited by funding and resource issues. A greater awareness of and investment in oncology physical therapy services is required to meet the rehabilitation needs of the growing population of cancer survivors. Future work will focus on developing standards of care and promoting the role of the physical therapist in cancer care.