c------ Delbri.ick / Rehabilitacija - letn. VII, supl. 2 (2008) __________ _ REHABILITATION OF PATIENTS WITH GASTRIC CANCER Prof. dr. Hermann DelbrUck Arbeitsgemeinschaft fUr Rehabilitation, Nachsorge und Sozialmedizin (ARNS), Germany The value of rehabilitative follow-up care in patients with gastric cancer is unambiguous. In contrast to curative fol­ low up care, it is not the controlling of the diseasc which represents the focus of ali efforts. It is the minimization of tumour mass and therapy-related disability which constitutes the aim of rehabilitative procedures. The negative effects of disease and therapy in physical (somatic), psychological, social and vocational areas are to be eliminated or at least mi tigated by rehabi I i tati ve measures. A REHABILITATIVE MEASURES AIMING AT REDUCING SOMATIC PROBLEMS ("rehabilitation in order to combat disability") Before carrying out rehabilitative measures a rehabilitative assessment must take place. with rehabilitation planning and documentation of the goals to be achicved. Herc. the conse­ quences of stomach surgery constitute the main focus. Table 1: Frequent rehab ilitari,•e somatic proble111s in gastric cancer pa1ie11ts • Effects of partial ar total gastrectomy (post-gastrectomy symptoms) • Effects of chemotherapy (far example, polyneuropathy, cardiac disturbances) • Alterations in pharmacokinetics • Anemia • 0steopathy • Lack of information / need far information • Psychological strain / anxiety disorders • Social difficulties • Dependence on nursing care • lnability to perform work / pursue profession Table 2: Freq11e111 physical (so111a1ic) relwbiliwti,•e needs • Nutrition deficiencies • Weight loss • Gastric emptying syndrome • Dumping syndrome • Late dumping • Afferent loop syndrome • Reflux esophagitis • Reflux gastritis • Maldigestion, malabsorption • Alterations in pharmacokinetics • Diarrhea • Anemia • 0steopathy • Polyneuropathy • lmmobility • Necessit y of information Table 3: Possible rnuses o.f ireighl /oss in /HJte111ially rnra­ lil'el_,, reseued gaslric carci11011w patie111s • Decreased food intake due to lack of appetite • Decreased food intake due to fear of pain • Malassimilation • One-sided and incorrect nutrition • Relative (secondary] pancreatic insufficiency (with pancreocibal asynchron] • Colonization of the small intestine by harmful bacteria [with afferent loop syndrome] • D y sphagia following truncal vagotom y Table 4: General reco111111e11da1io11sjrJl/mri11g tora/ s10111ach resec1io11 • Eat slowly • Chew well • Eat 6-10 meals a day [in the first ½ year following surgery) • Eat foods with low volume and high energy • Drink liquids between mealtimes and not during mealtimes (in the first ½ year following surgery) • Avoid foods which are very hot or cold, are heavily smoked ar cured or grilled • Avoid very sweet ar very salty foods • Avoid carbonated drinks • Use hygienic utensils and dishes • Take in at least 50 kcal/ kg body weight • Eat complex carbohydrates rather than simple sugars • Eat foods rich in vitamin C and calcium • Eat easy-to-digest proteins • Eat foods and prepared foods low in fat (approx. 30% fat and in some cases medium-length triglycerides] • Raise the head of the bed 10 to 15 cm [use a wedge pillow), do not eat lying down. (Exception: dumping problems]. Ei ------------ DelbrUck / Rehabilitacija - letn. VII, supl. 2 (2008) ___________ _ Table S: Functional consequences of anemia • Physical functioning • Cognitive functioning • Social functioning • Emotional functioning • Role functioning • fatigue B REHABILITATIVE MEASURES AIMING AT REDUCING PSYCHOLOGICAL PROBLEMS ("rehabilitation to combat resignation and depression") Besides the tumour illness, which threatens the patient's life and very existence, the fear of social and occupational handi­ caps and post-gastrectomy symptoms with their nutritional problems in particular are often the cause of depression. They may be alleviated by proper dietary counselling. Fears of progress and the uncertain future are frequent. It is the task of the physician and the psycho oncologist to deal with these fears. Medicina! support may be considered. but it cannot replace cognitive therapy. Certain "disturbances in the state of health" such as resigna­ tion, depression, self-isolation, lack of motivation and loss of personal contacts are observed particularly frequently. Encouragement of compliance, coping and activation are chief tasks of psycho-oncological guidance. The basic atti­ tude of resignation of affected persons must be overcome. Table: Topics in health educationfor gastric ca11cerpatie11ts Prophylactic measures • Adjuvant therapy: when and why is it needed, which therapy • Prevention or reduction of chemotherapy / hormone/ radiation therapy side effects • Significance of follow-up examinations • Recurrence: prophylaxis, signs and therapy in cases of recurrence • Prognosis • Significance of immune resistance Nutrition • Weight loss: causes and prevention • Most common nutritional disorders • Post-gastrectomy complaints • Different farms of nutrition far the individual post­ gastrectomy symptoms • ls there a "cancer diet"? • Healthy diet Psychological aids • Opportunities far relaxation - overcoming fears - depression - fatigue • References to psychological assistance • Dealing with family members lil Social aids • lnfarmation pertaining to legal protection measures far cancer patients • lnfarmation pertaining to financial reductions • lnsurance - life insurance - granting of loans - loan payment • lnformation on self-help groups - hospice - palliative wards Vocational counselling end aids • Occupational consequences • Avoidance of certain types of work-related strain • Measures and aids far successful vocational reintegration C REHABILITATIVE MEASURES AIMING AT REDUCING SOCIAL PROBLEMS ("rehabilitation to combat the need for care") The aim of these measures is to strengthen the patient's own resources and prevent the risk of a need for care, orat least reduce such a need. By these means, the patient's risk of requiring nursing care is to be eliminated orat least reduced. If independent care is no longer possible, appropriate nursing care must be provided. It is often the case that some people (usually older) already have difficulty maintaining their household due to their advanced age; self-care at home is further endangered in many cases because of additional illness and therapy-related strain. Different forms of care assistance such as "meals on wheels", household assistance, nursing assistance, home nursing care and in some cases living in a nursing home or hospice program have to be organized with the participa­ tion of family members. It is necessary to provide contact addresses (self-help groups, counselling locations etc). A subsequent stay in a rehabilitation hospital (AHB - hospi­ tal), directly following the standard hospital stay, is recom­ mended for ali patients in Germany. In Germany, there is a special mandatory disability insurance which is set up to meet the financial demands in the case of a patient's need­ ing nursing care. D REHABILITATIVE MEASURES AIMING AT REDUCING VOCATIONAL PROBLEMS ("rehabilitation to combat early retirement") Far "cured" gastric cancer patients there are numerous occupational limitations which result from post-gastrectomy symptoms. Yocational reintegration can be expected to take place more easily for patients following B 1 partial resection than for gastrectomy patients. Limitations in ability to work, carry out a profession or occupation apply especially to those jobs which are associated with physical exertion. ____________ DelbrUck / Rehabilitacija - letn. VII. supl. 2 ( 2008 ) ___________ _ Table: Occupationaf strai11s ll'hich cured gastric carci11011w patients shoutd al'oidfoffoll'i11g totaf gastrectomy (ROJ. Limitations Work requiring frequent bending over Physi cally challenging work, no lifting or carrying heavy burdens Jobs performed at great heights with the possibility of vertigo (for example, roofers) Work requiring long-term concentration Activities in the first six postoperative months Activities associated with strong odors or caustic fumes Reason far limitation risk of reflux esophagitis Low body weight, risk of reflux esophagitis Dumping symptoms with symptoms due to low blood sugar Dumping symptoms with symptoms due to low blood su ar Relatively slow adaptation to altered food transit in the gastrointestinal tract Provocation of vomiting, nausea and diarrhea Night work and work in shift s Lower stress tolerance not allowed Work in which frequent breaks, not normally scheduled in the job, are possible Work as truck driver unsuitable More frequent mealtimes necessary Frequent breaks not normally scheduled in the job are necessary, psychological and physical stress, risk of dumping syndrome with difficult y concentratin g For many patients following total gastrectorny, but also for partially resected patients, rnany activities requiring physical exertion are no longer possible. oftcn due to weight loss and weakness alone. White coli ar workers on the other hand can more easily return to their respective occupations, although gastrectorny patients must be expected to have more difficul­ ties with concentration. Tota! gastrectomy patients are not allowed to carry out activities involving f r equently alternat­ ing, standing or bending positions due to the risk of reflux. The necessity of frequent mealtimes furthcr limits the spec­ trum of potential occupations for gastrectorny patients. In gastrectomy patie11ts 1111der 50 years cfage with prognos­ tically favourable forms of the illness. an attempt to change the workplace should be made if the forrner occupation involved physically strenuous activities. Ir a change of workplace is not possible, vocational reorientation should also be considered in young patients ( < 43 years of age) with a favourable prognosis. Occupations involving only a small amount of physical exertion in service branches are to be favoured. In partial resection patients. later adaptation can take placc accompanied by an increase in physical performance. In this case. it is recommended that one waits approximately one year to make a socio-medical assessment in order to make a more accurate and realistic assessment of the patient's performance ability possible. A step-by step approach to resumption of work is advised. HOW TO RETURN TO WORK There are many questions to be answered: (which workplace­ conserving measures are to be taken- including reintegration assistance. occupational and vocational support and voca­ tional reorientation. as well as change of vocation - who is financially rcsponsible. in which cases does a vocational reorientation make sense and can it be accomplishcd '> ). These questions are ideally answered for the cancer patient during his/her subsequent stay in an oncological rehabilita­ tion clinic which - at lcast in Germany - works closely with retirement insurance and vocational advisors. Thcsc rehabilitation clinics are obligated to counsel every canccr patient within working age and to providc voca­ tional assistance if neccssary. It is further requircd to issue a dctailed statement in paticnt's fina! medica! report which makes recommendations concerned with the ability of thc gastric canccr patient to pursuc his/her former occupation or if he/she is able to work at ali, at which point he/she will be able to be fully or only partially employed. and which further means of vocational assistancc should bc considered/ implemented. References: l. Bundcsarbeitsgcmcinschaft fUr Rehabilitation. Rah­ menempfehlungen zur ambulanten onkologischen Rc­ habilitation. Frankfurt: Bundesarbeitsgemcinschaft fUr Rchabilitation (BAR). 2003. 2. DclbrUck H, Deutsche Krcbsgesellschaft. eds. Standards und Qualitatskritcrien in deronkologischen Rehabilitation. MUnchen: W. Zuckschwcrdt Yerlag. 1997. 3. DelbrUck H. Magenkrebs: Rat und Hille fUr Betroffenc und Angehorige. 3. Aufl. Stuttgart: Kohlhammer Yerlag. 2005. -+. DelbrUck H. Locossou R. INecessitics. possibilitics and difficulties of vocational rehabilitation in patients with early stomach carcinoma -experiences in 89 patients.l f Article in German]. Rehabilitation (Stuttg) 1990: 29(2): 121- 124. 5. DelbrUck H. Rehabilitation and palliation of cancer patients: patient care. Paris: New York: Springcr. 2007. 6. Heiskanen JT. Kroger H. Paakkoncn M. Parviaincn MT, Lamberg-Allardt C. Alhava E. Bone mineral metabolism after total gastrecto my. Bone 2001: 28( 1 ): 123-127. II ____________ Delbri.ick / Rehabilitacija - letn. VII. supl. 2 (2008) ___________ _ 7. Koike H, Iijima M, Mori K, Hattori N, Ito H, Hirayarna M, et al. Postgastrectomy polyneuropathy with thiamine deficiency is identical to beriberi neuropathy. Nutrition 2004; 20(11-12): 961-966. 8. Mestrom. Essen und Trinken nach Magenoperation. Sprockhovel: Ars bonae curae Yerlag, 1998. 9. Roviello F, Fotia G, Marelli D, De Stefana A, Macchiarelli R, Pinto E. Iron deficiency anemia after subtotal gastrectomy for gastric cancer. Hepatogastroenterology 2004; 51(59): 1510-1514. lil 10. Scholmerich J. Postgastrectomy syndromes -diagnosis and treatment. Besi Pract Res Ciin Gastroenterol 2004; 18(5): 917-933. 11. Yickery CW, Blazeby JM, Conroy T, Johnson CD. Alderson D. Development of an EORTC module to improve quality of life assessment in patients with gastric cancer. Br J Surg 2000; 87(3): 362-27 3. 12. Zakharian AG, Stoliarov VI, Kolosov AE. [Yocational rehabilitation of patients after radical surgery for stomach cancer.] [Article in Russian]. Khirurgiia (Mosk) 1994 Feb; (2): 11-12.