A cancer rehabilitation assessment it likely to include many of the following elements depending on the type of cancer, the stage of the pathway the person is at (diagnosis, having treatment, post-treatment, etc), the needs of the individual and the aims of the professional undertaking the assessment.

There are some generic elements that are likely to be included in a rehabilitation assessment at any stage of the cancer pathway and for any tumour type, for example:

Undertake baseline holistic needs assessment

General functional assessment to include:

• independent functional status
• quality of life and daily living
• fatigue
• anxiety and depression
• mood and coping strategies
• lifestyle, including diet & nutrition, smoking and alcohol use, physical activity

Other elements of assessment are specific to certain times in the pathway or for specific treatments or tumour types, e.g.

• Cognitive and perceptual ability: level of understanding and ability to make decisions. This will affect the person’s capacity to give informed consent and to follow a rehabilitation treatment plan.
• Communication and impact treatment or cognitive changes may have/have had on this.
• Swallowing and impact treatment may have/has had.
• Nutritional assessment including monitor and record weight, height and waist as a benchmark to enable any weight gain or loss to be monitored.
• Functional and neurological assessment to improve quality of life including mobility, exercise tolerance, functional task, balance, vestibular and upper limb function.
• Respiratory function, mobility, muscle strength, symptom/side effects.
• Assess and assist in management of incontinence.
• For cancers involving, or in the location of lymph nodes, undertake limb volume measurements and screen for lymphoedema.
• Risk assesses the possibility of pathological fracture and spinal cord compression especially in cancers of the breast, lung, skin, prostate, renal, ovarian, teenage and young adult sarcoma and myeloma.

Many people with cancer struggle to maintain a healthy weight.  People may put on weight during cancer treatment due to being less physically active than normal or due to the effects of steroids, or they may find they struggle to eat for a range of reasons including nausea and vomiting, loss of appetite, changes to smell/taste, anxiety/depression, physical swallowing impairment (e.g. head & neck cancer) or sore mouth.

It is recommended that all health and care professionals at a supportive, assistive and registered level can take a role in nutritionally screening for malnutrition and provide advice or refer to a specialist as indicated.

The dietitian can:

• carry out in depth assessment of nutritional need
• establish case history, current extent of disease and proposed form of treatment
• undertake detailed dietary assessment to include anthropometric (e.g.., height, weight) and biochemistry measurements (blood test results)
• assess for body image alteration/adjustment
• assess functional ability relating to activity stamina, food preparation and eating
• consider/manage oral nutritional supplements both non-prescribable and prescribable

Prescribing members of the multi-disciplinary team may consider pharmaceutical agents e.g., appetite stimulants, steroids, pancreatic enzymes and prokinetics.

A physiotherapist or specialist exercise professional e.g. clinical exercise physiologist at a registered and enhanced level can provide exercise advice and treatment to maintain muscle bulk, improve stamina and functional ability and advise on exercise regime and activity tolerance.  Occupational therapists may be able help with body image adjustment and psychological concerns, relaxation and visualisation techniques and assess and address issues around meals, timings and preparation, weakness and pressure care and equipment provision.

It is important to recognise signs of anxiety/depression which may be impacting on appetite and nutritional status and provide anxiety management as appropriate.

Breathlessness, or feeling short of breath, is when a person perceives that it is harder to breathe. The medical term for this is dyspnea (pronounced ‘disp-nia’).  People living with cancer may experience breathlessness for many reasons and anxiety can make this worse. Associated anxiety is particularly common towards the end of life.

Breathlessness can be caused by pain, lung disease, cardiac disease, exercise, anxiety and more.  It may be treatable, for example with analgesia (painkillers) where pain is a contributing factor, anxiety management or breathing exercises. Identifying the cause of breathlessness is important for successful management and sometimes new or sudden onset breathlessness should always be reported to an appropriate healthcare professional.

The treatment strategies for breathlessness suggested below are non-pharmacological as the research base is strong for these approaches and yet medication is often prescribed in its management.  People experiencing breathlessness may benefit from specific breathing techniques from physiotherapists or occupational therapists who can assess and assist with breathing control and potential issues around dysfunctional breathing and anxiety management. Some people benefit from relaxation techniques to manage their breathlessness including visualisation or mindfulness.  People who are at risk of developing breathlessness as a side effect of treatment (or due to the tumour site) may be taught coping strategies early (e.g. during prehabilitation) so that they can be practiced and known about when needed, rather than trying to learn coping strategies when the person is in a state of anxiety or distress.

Breathlessness can be supported by physiotherapists, clinical nurse specialists and occupational therapists at registered and enhanced levels and by support workers in supportive and assistive levels of practice supervised by registered practitioners.

People with cancer may experience a range of communication difficulties, which may be due to the cancer or their treatments.

Surgery for head and neck cancer may affect the mouth, throat or the vocal cords, impacting on speech and making it sound slurred (dysarthria) or hoarse (dysphonia).

A brain tumour can lead to aphasia or dysphasia (difficulties with understanding and talking as well as, reading and writing).  It can also result in cognitive changes, such as planning and memory issues. Communication can also be impacted by consequences of treatment on hearing and eyesight.

Identification of communication problems includes the following:

• Difficulty understanding the spoken word
• Difficulty with reading and writing
• Difficulty finding the right word (word finding difficulties)
• Inability to make clear speech sounds (dysarthria)
• Hoarse voice (dysphonia)

Multi-disciplinary management strategies include:

• Consider impact of treatment, infection and /or medication on communication impairment
• Ensure glasses and hearing aids are present
• Use of clear, simple language
• Offering the person choices if they cannot find the correct word such as ‘Would you like tea or coffee’?
• Reducing background distractions such as TV and radio when speaking with the person
• Recognising the need to refer to specialists such as speech and language therapy or to occupational therapy for cognitive issues
• Referring to Ear, Nose and Throat (ENT) doctors if concerned about hoarseness

Speech and language therapy involvement at either a registered, enhanced and advanced level depending on the complexity of the patient may include:

• A comprehensive case history establishing the person’s current functioning, with regards to understanding, speech, reading and writing
• Family involvement as needed to aid with case history
• Carry out assessment of cognition and its impact on communication including insight and awareness, liaising with Occupational Therapy.
• Educate people with cancer, communication partners, appropriate health and social care professionals on patient specific communication difficulties.
• Provide interventions for communication problems, personalised to each person and their diagnosis
• Continue education, support and advocacy throughout the pathway.
• Provide specialist support for professional colleagues.

Clinical nurses specialist maybe involved in supporting people with communication problems at a registered, enhanced and advanced level. Support workers in supportive and assistive levels of practice supervised by registered practitioners can also support communication issues patients may present with.

Cancer treatment can affect bladder and bowel control in lots of different ways, and it can be one of the most distressing consequences and one that people with cancer (and sometimes health professionals) find difficult to talk about.  Problems may start during treatment and not get better or may develop months (or years) after treatment (‘late effects’).

Cancer treatment can cause changes to the way the bladder and/or the bowel work. Surgery on the bladder and bowel area can cause direct effects on continence. Interventions like surgery or radiotherapy to the pelvic area may weaken the pelvic floor muscles which help to keep the bladder and bowel closed and prevent leaks.  This means that small amounts of urine can leak out from the bladder.  Some people also experience bowel incontinence with leaks of faecal matter from the bowel.  Leaks from the bladder or bowel are called incontinence.

Urinary incontinence

Cancer treatments, including surgery, may affect the pelvic floor muscles which can sometimes lead to urinary or faecal incontinence, which is the involuntary loss of urine or faeces. There are two different types of urinary incontinence:

Stress incontinence – leaking small amounts of urine when you laugh, sneeze or cough, or when exercising.

Urge incontinence – leaking of urine due to an overactive bladder and struggling to ‘hold on’ when you get the urge to go.  If you have an overactive bladder, you may find that you cannot always get to the toilet in time.

Urinary frequency (needing to go to the toilet more often) and/or urgency (powerful urge to go to the toilet and feeling like you cannot ‘hold on’) are also another common side effects of cancer treatment.

Bowel incontinence

Bowel problems might include:

• changes in bowel habits
• loose stools or diarrhoea
• hard stools or constipation
• needing to empty your bowel urgently
• cramping pains in the abdomen, pelvic area or rectum
• passing a lot of wind

Treatment can help improve bowel incontinence and reduce the impact it has on a persons life. Treatment will depend on what is causing the problem.

Treatments include:

• incontinence products such as pads worn in underwear
• changes to your diet such as avoiding foods that make diarrhoea worse
• medicines to reduce constipation or diarrhoea
• pelvic floor exercises to strengthen the muscles used to control bowels

Surgery may also be considered of other treatments do not help.

Multidisciplinary management of incontinence

Multidisciplinary management of incontinence includes advice from clinical nurse specialist and allied health professionals such as specialist physiotherapists and therapeutic radiographers at a registered and enhanced level in a prehabilitation or rehabilitation setting.  People experiencing significant problems should be referred to their nearest Women’s Health Physiotherapy Teams (many of whom also treat men with continence problems) or alternatively if available, specialist gynae-oncology physiotherapy services for pelvic floor re-training exercises and advice.

Fatigue is a feeling of tiredness or exhaustion that is not relieved even by a good night’s sleep. It can be caused by the cancer itself, or the side effects of treatments. As many as 9 out of 10 people with cancer (90%) get cancer-related fatigue (CRF).

We do not know exactly why cancer treatments cause fatigue, but we do know that many people with cancer experience excessive tiredness which impacts on their daily life. This could be during or following treatment, last for weeks, months or even years, or may be a symptom of the disease itself.

The first step in management is to screen for treatable causes such as anaemia, hypothyroidism, depression, anxiety, weight loss, pain, medication side effects, infection, anorexia, malabsorption, and other comorbidities.

Those scoring 3 or below a 1–10 scale (0 being no fatigue, 10 being worst possible) can be supported to self-manage e.g., provide written information and agree realistic goals

Fatigue management principles can be introduced to the person early in the pathway (e.g., during prehabilitation) to help them cope with the potential impact fatigue can have.  Macmillan and the University of Southampton have developed an online fatigue management resource for people living with cancer called RESTORE.  It provides information about things people can do to help them cope with fatigue and aims to improve confidence for people to self-manage fatigue.

Support for fatigue could be from support workers at a supportive, assistive level, clinical nurse specialists and specific AHPs such as occupational therapists and physiotherapists at a registered and enhanced level.

People with severe or recurrent fatigue may be referred for specialist review management (often an occupational therapist or physiotherapist).

Specialist fatigue management might include:

• Clinical assessment and re-assessment
• Provide written information
• Agree realistic goals
• Discuss relaxation and sleep techniques
• Energy conservation, pacing and compensatory techniques
• Anxiety and stress management
• Exercise programme aimed at improving mobility, strength and stamina. Will include cardio-vascular work and muscle strengthening programme
• Psychological therapy of cognitive behavioural therapy/hypnosis
• Nutritional support and advice
• Acupuncture and complementary therapies

The lymph system is part of the body’s immune system that helps protect us from infection and disease. Lymph fluid contains white blood cells to fight infection and is a one-way drainage system moving fluid from tissues into the blood. If the drainage systems blocks, this leads to lymphoedema.

Lymphoedema is a permanent swelling condition caused by radiotherapy or surgery to lymph nodes. There is a higher risk of developing this if patients have both treatments.  Lymphoedema usually affects an arm or leg, but can also affect other areas.

Early diagnosis of lymphoedema results in easier and more successful management.  Treatments include manual lymph drainage techniques, compression garments and multilayer, advice on recommended exercises, positioning and skincare measures and lymphoedema bandaging by specialist practitioners (generally specially trained nursing and physiotherapy staff).  People with lymphoedema who cannot carry out their own foot care or are at increased risk such as diabetes will also need a podiatry assessment.

Those with lymphoedema may develop skin breakdown and it is important to be mindful about caring for the limb or area that is affected, for example do not use blood pressure cuffs on, or put needles in, an arm affected by lymphoedema as this can make it worse.

Specialist lymphoedema practitioners can be nurses, AHPs such as physiotherapists and occupational therapists, or Manual Lymph Drainage (MLD) therapists who have completed additional training. These staff would generally be working at an enhanced or advanced level.

Sometimes cancer grows in the bones of the spine, or in the tissues around the spine and causes pressure on the spinal cord. This is called malignant or metastatic spinal cord compression (MSCC) and should be treated as an emergency.

Metastatic spinal cord compression (MSCC) is defined as spinal cord (or cauda equina) compression caused by collapse of vertebra(e) or instability due to metastatic spread or direct extension of a malignant tumour that threatens or causes neurological disability.

It is important for all health and care professionals to be aware of the signs of MSCC and carry out a risk assessment particularly for high risk tumour groups (people with cancers of breast, prostate and lung which have a higher likelihood of spreading to the bone, or people with myeloma).

Signs (‘red flags’) of MSCC include:

• A new, unexplained back or neck pain
• Numbness or pins and needles that is new or quickly getting
• Reduced mobility, falls or feeling unsteady on the feet (including leg weakness or legs giving way.
• Problems passing urine (incontinence or passing only small amounts of urine or none at all).
• Bowel problems (incontinence, being newly constipated, or constipation getting worse).

These symptoms can also be caused by a number of other conditions but should always be checked by a relevant healthcare professional.  In England, every setting providing cancer treatment should have access to a metastatic spinal cord compression (MSCC) coordinator to advise what to do if the person with cancer you are with has signs of MSCC.  MSCC coordinators are frequently part of an Acute Oncology specialist advisory service and there is usually a triage line or hotline number linked to the local cancer centre you can call for advice. This is increasingly the case across other regions of the UK, too.  Contact the MSCC coordinator immediately to discuss the care of patients with cancer and symptoms suggestive of metastatic spinal cord compression or new spinal metastases.

Management of people with suspected or confirmed MSCC is covered by NICE Clinical Guidelines Metastatic Spinal Cord Compression (2008) and includes the following:

• Assume the spine is unstable until investigations prove otherwise: keep the person flat on bed or stretcher with neutral spine alignment (which might mean transferring to hospital via a stretcher, not walking or in a wheelchair). People with confirmed or suspected neck MSCC in the neck, immobilisation with hard collar may be needed.
• Usually, an MRI scan of the whole spine will be requested within 24 hours.
• Treatment for MSCC should start as soon as possible after the diagnosis (usually within 24 hours) and may be spinal surgery or radiotherapy.
• Refer to physiotherapist within 24 hours of admission, occupational therapist within 24/48 hours of admission⁷ and to other members of MDT as appropriate, e.g., social worker, specialist nurse, specialist palliative care team, clinical psychologist who would be at a registered, enhanced or advanced level of practice.

The physiotherapist and occupational therapist at a registered, enhanced or advance level of practice will:

• Carry out holistic assessment and assessment for co-morbidities.
• Undertake respiratory assessment and treat as appropriate.
• Carry out neurological assessment.
• Teach active, active/assisted exercises; perform passive movements within pain limits as appropriate.
• Ensure good positioning and provide advice on pressure relief management.
• Commence gentle re-mobilisation as soon as possible and when pain well controlled and spinal stability has been established.  This usually involves gradual sitting from lying flat to 45 degrees initially. If tolerated, progress to 60 and 90 degrees as able, usually the same day. Monitor neurology and pain during this process.
• Carry out mobility assessment and gradually mobilise as patient’s condition allows and as per agreed local protocol (NB. Return to bedrest on increased symptoms such as increased pain and/or neurological symptoms).
• Teach transfers as appropriate (e.g., how to get out of bed into a chair or onto a commode or toilet).
• Assess for and provide mobility aids and gait re-education, stairs assessment and continue rehabilitation.
• Carry out wheelchair & cushion and/or hoist assessments as indicated and provide advice on regular pressure relief.
• Assist with psychological adjustment and goal setting related to loss of functional independence, self-esteem and quality of life.
• Assess home environment and support equipment and adaptations as indicated.

Physical function has many dimensions and can be impacted by cancer and its treatment in a multitude of ways.  For example, someone who is frail with multiple co-morbidities may struggle with simple activities of daily living such as being able to wash and dress themselves, walk around (mobility) or climb stairs.  Others may have specific impairments caused by the cancer or its treatment e.g., shoulder dysfunction and ‘cording’ after mastectomy for breast cancer, muscle weakness or ‘hemiplegia’ from a brain tumour, amputation for sarcoma, or neck and shoulder problems after surgery for head and neck cancer.

Physiotherapists and occupational therapists at a registered and enhanced level can:

• Complete an initial assessment of patient’s functional, social, emotional, spiritual and psychological needs including details of home environment for example, stairs, toileting.
• Assess respiratory status, mobility and general physical fitness.
• Carry out musculoskeletal assessment for specific impairments e.g., arm & shoulder problems after breast cancer surgery
• Assess and treat neurological impairments
• Teach exercises for maintenance and improvement of muscle tone and joint function
• Assess and treat mobility problems including transfers and gait re-education.
• Undertake risk assessment for falls and manual handling and provide safety advice.
• Assess and advise on hand dexterity, eye sight and cognitive ability
• Assess and assist with ability to carry out domestic activities of daily living
• Environmental adaption needs including provision of equipment
• Wheelchair assessment and provision
• Advise carers on safe handling and moving techniques for use in the home environment, if necessary

Those staff at a supportive and assistive level such as allied health support workers will often support with treatment plans under the supervision of a registered practitioner.

Impaired nutritional status can be a significant problem for people living with cancer and can affect response to treatment (e.g. healing after surgery). Someone with poor nutritional status is less able to withstand side effects of cancer treatments and side effects of treatment such as nausea and vomiting can impede nutritional status further.  It is recommended that all patients are screened for nutritional problems each outpatient appointment, admission to hospital and/or in the community/primary care across the pathway (including during prehabilitation) with referral to a dietitian as indicated.

Nutritional assessment of the patient (where appropriate) from a dietitian at a registered, enhanced or advanced level may include:

• Review of current nutritional intake
• Current nutritional problems as a result of disease, symptoms or cancer treatment
• Degree of nutritional depletion and the likelihood of further nutritional depletion
• Nutritional implications of specific tumour types
• Physical state
• Current food and drink intake
• Anthropometric measurements (height, weight, waist etc.)
• Biochemistry
• Nutritional requirements (energy, protein, fluid, electrolytes, micronutrients, fibre) using validated assessment tools

The dietitian will devise an individualised nutritional care plan providing practical dietary advice tailored to the individual’s needs, prognosis, symptoms, and circumstances and ensure interventions are commenced, provide counselling on eating and drinking problems and perioperative feeding and provide on-going dietetic monitoring and support.

Some people with cancer will require supplementary oral nutrition or enteral/parenteral nutritional support (‘tube feeding’) to help improve quality of life.  In these cases, the dietitian will plan and coordinate enteral feeding tube discharges and ensure referral to community services for continued support, provide education regarding feeding tube management and the administration of feed and advice on weaning from enteral tube feeding to oral diet.

Cancer pain is a complex phenomenon that is still not well understood or classified.  People with cancer may experience pain that is either related to the cancer itself, or to cancer treatment.  Pain can occur for several reasons and is different for every person. The way a person feels and describes pain can vary significantly and this can make it challenging to define and treat pain successfully. Post-treatment pain can start or get worse months or even years after treatment has finished. This may be due to the nervous system rewiring itself after damage to the nerves and pain relating to cancer can last for years, or even decades, after diagnosis and treatment.

Classification of pain is complicated and there are many different types of pain, each arising through unique mechanisms, e.g., sharp pain, prickling pain, thermal pain, aching pain.  Pain can arise from a physical cause or a psychological cause, or a combination of both. Physical causes are both due to the underlying disease and/or the various cancer treatments and pain has been known to exacerbate other symptoms, such as stress and anxiety.

Cancer treatments can cause pain for a range of reasons, for example, chemotherapy can cause painful chemotherapy-induced peripheral neuropathy (CIPN), radiotherapy can produce late effect radiation toxicity causing pain linked to the areas and surrounding tissues treated (pelvic, brachial plexus etc.) and surgery may lead to the development of persistent post-surgical pain syndromes.  Some people may experience phantom limb pain after an amputation (e.g., for sarcoma).   In addition, the emotional and psychological aspects of the person, and their wellbeing can have a profound impact on the ability to tolerate pain, and for example, feelings of anxiety or depression may make pain worse.

Multi-disciplinary management of pain by clinical nurse specialists, pharmacists, occupational therapists, physiotherapists and speech and language therapists at registered, enhanced and advanced level includes:

• Undertake holistic/biopsychosocial assessment
• Consider both pharmacological and non-pharmacological approaches to pain management
• Be guided by the nature and cause of the pain and the context in which it is present
• Refer to physiotherapy or occupational therapy if pain results in any of the following (NB this is not an exhaustive list):
  • loss of general mobility
  • difficulty performing activities of daily living/low levels of performance status
  • maladaptive pain behaviours e.g. fear, avoidance
  • muscle weakness or joint stiffness
  • loss of social/family/productivity (including paid work) role
  • distress due to any of the above
• Refer to dietitian if pain results in poor nutritional status

In addition to pharmacological/medical management of pain, rehabilitation professionals can add:

• Holistic assessment using biopsychosocial model incorporating the impact of beliefs, thoughts and emotional responses towards the pain experienced by the person.
• Identification of pain impact on functional performance: self-care, leisure, productivity and maintenance of roles.
• Teach therapeutic exercise, set graded and purposeful activity, provide postural re-education (physiotherapists).
• Massage and mobilise soft tissue (e.g., from physiotherapists).
• Provide Transcutaneous Electrical Nerve Stimulation (TENS), heat and cold therapies to help ease pain.
• Assess for and provide orthoses.
• Occupational therapists can ensure graded engagement in meaningful activity using goal setting and activity scheduling techniques, manage anxiety, help with relaxation and provide guided imagery training, help with lifestyle adjustment to include task adaptation, work simplification, compensatory techniques, time management, ergonomic principles and energy conservation, provide equipment and adaptations and advise on posture, seating, positioning and pressure care.
• Consider cognitive-behavioural approaches
• Offer complementary and alternative medicine (if appropriately trained) e.g., acupuncture, mindfulness based stress reduction.

Peripheral neuropathy is damage to the nerves that carry messages between the brain, the spinal cord and the rest of the body. Different things can cause peripheral neuropathy, such as diabetes, injury, cancer and some cancer treatments.

For most people, the symptoms of cancer-related peripheral neuropathy will slowly improve when their cancer treatment has finished.

• Clinical Nurses Specialists can often diagnose peripheral neuropathy and provide appropriate support.
• Physiotherapists at a registered and enhanced level can help with coordination, muscle weakness, balance and walking.
• An occupational therapist at a registered and enhanced level can support with daily tasks because of peripheral neuropathy, such as washing or dressing. They can assess needs and recommend appropriate aids and equipment to help and provide advice and support about falls prevention and safety advice in function due to the sensory impairment often in the hands and feet.

Cognitive changes and perceptual deficits include problems with memory, concentration and how a person can think. It is also sometimes called cognitive impairment, chemo brain or chemo fog. Cognitive changes can affect quality of life, however there are things that patients can do to try to improve your symptoms and help them cope.

Cognitive training means regularly practising skills to improve:

• a person’s attention
• the speed at which their doing things
• their memory
• executive functioning, meaning their ability to plan, focus attention, remember, and juggle multiple tasks

Physical activity can help with the physical and psychological symptoms of cancer and its treatment. There is some research that shows exercise can help with cognitive changes.

Mind-body treatments that might help with cognitive changes include:

• meditation
• guided imagery
• mindfulness

Support with the above can be from occupational therapist and clinical nurse specialists at a registered, enhanced or advanced level. The supportive and assistive workforce can also support patients with these issues under the supervision of a registered professional.

The National Comprehensive Cancer Network (NCCN) recommends trying the above treatments before any drug treatment for cognitive changes. Some of the drugs that studies have looked at include anti-depressants and anti-dementia drugs.

People with cancer can experience a range of respiratory and cardiac problems. These may be as a result of the cancer itself (e.g. lung tumours) or the cancer treatment (e.g. post-operative surgical complications like chest or wound infections) or due to toxicity of anti-cancer drugs that affect the cardiac or respiratory system.

Clinical; Nurses Specialists and physiotherapists at registered and enhanced level can help with the management of common respiratory symptoms including difficulty clearing chest secretions (‘sputum’ or ‘phlegm’), shortness of breath/ breathlessness or changes to respiratory mechanics e.g. loss of lung volume (the ability to take a deep breath) which may be affected by pain or muscle weakness.

Physiotherapists and exercise professionals at registered and enhanced level can help with advice around safe physical activity for people who are breathless or have other cardiac or respiratory symptoms. This can be supported by fitness instructors and support workers at a supportive and assistive level of practice. Occupational therapists at registered and enhanced level can help with adaptations to lifestyle and activities of daily living and fatigue management.

Skin may become sore or develop a rash as a reaction to cancer treatment.  Some people may experience altered or reduced skin sensation (e.g. ‘tingling’ or ‘numbness’) due to nerve damage or neuropathy from direct nerve compression or from systemic anti-cancer drugs (e.g. chemotherapy).

Clinical nurse specialists, physiotherapists, podiatrists and occupational therapists at a registered and enhanced level use a range of testing techniques (e.g. light touch/pin-prick tests) to assess skin sensation and will work with people to implement management strategies (e.g. to minimise risks of injury from pressure or trauma to areas of reduced sensation).  Where an area of skin has become very sensitive (‘hypersensitive’), therapists can also teach desensitisation strategies. Occupational therapists will assess for appropriate seating, cushions and mattresses to maintain minimise risk of injury due to pressure.

Referral to podiatry may be indicated for people with painful neuropathy, or where the ability to walk is impacted by skin or nail problems affecting the feet and lower limb. There are a number of skin conditions linked to cancer, such as hand-foot syndrome, which may impact on footwear or the ability to remain physically active and referral to a podiatrist is recommended.  Podiatrists will assess gait (walking pattern), detect joint deformities and pressure areas on the feet and can provide appropriate customised orthotics and deflective pressure pads to reduce the risk of falls/injury, minimise skin and soft tissue breakdown and advise on products that can help with painful neuropathy symptoms. Podiatrists will also provide footwear assessment and advice.

Scar formation is a normal response to injury, including after surgery for cancer and can be distressing because of appearance (e.g. to the face and neck after head and neck cancer surgery).  Scar tissue is also not as stretchy and compliant as normal tissue and may form adhesions (become stuck down) to surrounding anatomical structures resulting in loss of movement and pain.  Referral to appropriate professionals to support this should be considered e.g. to physiotherapy for soft-tissue mobilisation or electrotherapy techniques or podiatrists for lower limb soft-tissue mobilisation, laser and therapeutic ultrasound.

Some cancer treatments can have a significant impact on the nails including changes in rate or shape of growth, risk of nail infections, nail thickening or separation of the nail from skin (‘onycholysis’).  People having cancer treatment with a high risk of nail problems should be referred to a podiatrist for close monitoring and treatment of the nail conditions as indicated.

A person with cancer can experience major sleep disruptions in sleep, affecting the ability to fall asleep and stay asleep through the night.

It is estimated that half of all people with cancer have sleep problems. Some studies have found even higher numbers of sleep disturbances depending on the type and stage of cancer.

There are many potential causes of sleep problems in people with cancer, which can vary for any individual depending on the type of cancer they have, the treatment they are receiving, and their overall health, including coexisting conditions. Sleep problems may be caused by:

• Pain or discomfort caused by a tumour or by treatment
• Gastrointestinal or urinary problems caused by cancer or its treatment
• Struggling to sleep during hospital stays
• Stress, anxiety and depression that can result from having cancer
• Infection and fever, as a result of reduced immune function during chemotherapy
• Cough or difficulty breathing
• Side effects from medications
• Disrupted sleep schedule resulting from daytime fatigue and napping

Tips to improve sleep can include:

• Spending too much time in bed is likely to affect the quality of sleep. People should try to sleep for long enough to feel refreshed the next day, without oversleeping. Most adults need between 7 and 8 hours of sleep.
• Doing more physical activity during the day can improve the quality of a persons sleep. It will also help to build up strength. This can be difficult if people have recently had treatment and are struggling to cope with low energy levels or side effects.
• Going to bed and waking up at the same time each day can help.
• If people wake up during the night and find it difficult to go back to sleep, advice includes going to another room in the home until they feel ready to sleep again. If people need to sleep during the day, they should go to their bedroom and sleep.
• Keep the bedroom a constant temperature, not too hot or cold.
• People should take a break from trying to get to sleep.
• People should avoid watching TV or using a mobile phone, tablet or computer before going to bed. It can make your brain more active, which can delay sleep. The screens on these devices have a blue light that can make it harder to fall, and stay, asleep.

Being hungry can disturb sleep. Having a light bedtime snack, warm milk or a hot drink before going to bed can help. It is best to avoid large meals and a lot of fluids. It is best to try to avoid food and drinks that contain stimulants, such as caffeine, or lots of sugar, such as coffee, tea, cola or chocolate. It is a good idea to avoid smoking cigarettes in the late evening too.

Swallowing can be impaired for a range of reasons but is particularly a problem for people with head and neck cancers or neurological tumours. People with other cancers (e.g. lung, gastrointestinal), people who are significantly de-conditioned (from being very unwell for a long time), those who are approaching end of life or those with nerve damage to the throat (such as a vocal fold palsy) may also be affected.

Dysphagia may be caused by the cancer itself or its treatments. Surgery to the head and neck will result in altered anatomy which may affect the mouth, including tongue, jaw, lips and palate. Changes to these structures can lead to a varying degree of dysphagia.  Radiotherapy to the head and neck will result in a number of side effects such as dry mouth (xerostomia) sore mouth (mucositis) thick, sticky phlegm, nausea, vomiting, pain, reduced mouth opening (trismus), which can also impact on swallowing. Longer term side effects can also occur such as fibrosis, which can result in significant dysphagia.

If untreated, swallowing problems can lead to poor nutritional status (see Nutrition) and potentially life-threatening complications such as aspiration pneumonia (a type of lung infection that is due to food and drink from the mouth entering the lungs instead of the stomach).

The primary specialists in assessment and management of swallowing problems are speech and language therapists at a registered and enhanced level however all health and care professionals have a role in screening for swallowing problems and making appropriate referrals for specialist support as indicated. Nurses and respiratory physiotherapists at a registered and enhanced level have a key role in identifying when someone may have signs of aspiration and dietitians may be involved to assess and maintain nutritional status if someone has problems eating and drinking normally.

Identification of swallowing problems include the following:

• coughing, clearing the throat, or choking when eating
• pain on swallowing
• food sticks abnormally in the throat
• taking longer to finish a meal
• avoiding certain foods because they are too difficult to eat
• unexplained pneumonia, chest infections or fever
• wet, gurgly voice

Other signs can include:

• Excess saliva in the mouth and/or drooling
• Bringing food back from the throat
• Food or drink coming down the nose

If the patient is an inpatient they should be kept nil by mouth, referred to a speech and language therapist for assessment and alternative intravenous fluids considered.

Management of swallowing problems includes:

• Carry out simple swallowing screen followed by diagnostic swallow assessment from a speech & language therapist if indicated.
• The 100ml water swallow screen is often used in head and neck cancer but would be replicable in other cancer patients.
• This can be undertaken face to face or remotely by any trained medical professional. It involves a measured 100 ml of water and the larynx is palpated by the trained professional to count upward movement to indicate a swallow whilst the time taken to finish the amount after the instruction to the patient to drink this a quickly as you comfortably can is given. Normal swallow rates are anything up to 10 swallows in 10 seconds and watching for signs of coughing, throat clearing or wet voice quality. Obviously, this should be stopped if overt signs of significant coughing, choking which will indicate swallowing difficulty.
• Although only water an abnormal score would indicate likely difficulty with solids as well.
• Local SLTs tend to get people to observe 4 tests then they are observed to check they have palpating and timing the test correctly.
• A simple swallow screen is also carried out in stroke units which could also be appropriate to be used with cancer patients by other professionals this does involve quite a bit of training ½ day then observation of 2 screens and then competency checking with 3 patients of their own by an SLT or a nurse already trained in swallow screening. This includes diet as well as fluids.

Swallowing questionnaires are often used to help patients identify they have swallowing issues to act as a screening toll for referral onto to SLT.

Most usual are:

• Sydney Swallow Questionnaire (SSQ)
• Eating Assessment Tool (EAT10) – often used but any score above 3 is considered abnormal which is quite a low cut off for referral on
• • Carry out nutritional screening for malnutrition, followed by a dietetic assessment if indicated.
  • Ensuring correct positioning
  • Ensuring excellent mouth care
  • Ensuring correct utensils for eating and drinking

Referral to specialists is needed for the following:

Dietitian:

• carry out a detailed dietary assessment including assessment of current intake, nutritional status, functional capacity, biochemical markers and potential for further problems
• manage oral nutritional supplements both non-prescribable and prescribable
• manage enteral and parenteral nutritional support
• discuss ethical issues/ quality of life and potential feeding routes

Speech and Language Therapy:

• carry out a detailed swallowing assessment, with a full case history, examination of oro-motor system and trials of oral intake
• provide information pre-operatively (prehabilitation) for people who are high risk of swallowing problems postoperatively, e.g., certain surgical procedures for head and neck cancer
• advise on diet modification and swallow manoeuvres to facilitate oral nutrition as appropriate
• provide a prehabilitation dysphagia therapy programme for maintenance of swallow function during cancer treatment
• assess impact of interventions on quality of life