Early diagnosis and improved cancer treatments have increased the number of cancer survivors. Accordingly, cancer rehabilitation has been increasingly recognized as a key factor in the management of cancer survivors. Cancer rehabilitation involves helping cancer patients achieve maximum possible physical, social, psychological, and vocational functionality within the limits imposed by the disease and its treatment. Furthermore, rehabilitation plays a role in increasing interaction with the community [1]. Such care is based on the assumption that rehabilitation is a complex and long-lasting process involving interactions between patients, their relatives, and health professionals [2].

An integrated and cross-disciplinary approach is ideally suited for providing cancer patients meaningful benefits [3]. Multi-disciplinary rehabilitation services are naturally influenced by referral patterns, the range of available therapeutic options and services, as well as health care setting [4]. Physiatrists can influence treatment decisions [5] by informing and advising cancer patients, oncologists, and other primary caregivers. Thus, improved understanding of the barriers and opportunities related to cancer rehabilitation from the perspective of physiatrists is needed [6].

The organization and systems involved in rehabilitative care services differ markedly among countries [7]. Differences relating to funding, accessibility, and the definition of cancer rehabilitation services were recently noted in a review on current perspectives and emerging issues related to cancer rehabilitation in Europe and the United States [7]. Physiatrists have shown increasing interest in cancer rehabilitation and are playing an increasingly significant role in the care of cancer patients in Korea. However, to our knowledge, no studies have focused on rehabilitation services for cancer survivors from the perspective of physiatrists. Here, we conducted a survey to assess clinical practice and barriers associated with provision of cancer rehabilitation services from the perspective of Korean physiatrists. Our results may increase awareness of the role of physiatrists in supportive cancer care and highlight the need for collaboration among physiatrists in various countries.

Based on previous studies, expectations of oncologists regarding cancer survivorship care differ considerably from those of supportive care providers, underscoring the potential complexity of delivering consistent survivorship care [8]. Few studies have formally examined possible solutions to these discrepancies or evaluated intervention strategies for optimizing care [9]. The rehabilitation process is dependent on appropriate communication among health care sectors and should address unfulfilled needs of patients [10]. Thus, we investigated the perception of physiatrists regarding the effects of cooperation on the quality of cancer survivorship care as well as understanding of the rehabilitation requirements of cancer survivors.

This study assessed the perspective of Korean physiatrists with respect to rehabilitation of cancer survivors in terms of core content, clinical practice, attitudes, and barriers as well as examined factors that contribute to the optimal delivery of rehabilitation services.

We surveyed Korean physiatrists to assess their understanding of the benefits of cancer rehabilitation as well as the availability and delivery of rehabilitation services to cancer survivors in Korea. We defined “cancer survivor” as any individual with cancer. Until know, information on issues surrounding the delivery of cancer rehabilitation in Korea has been scarce. The majority of physiatrists recognized that cancer patients in the trajectory from initial diagnosis to ‘ end-of-life’ required rehabilitation services, and they identified multiple areas of care delivery needing improvement. Although most agreed with basic precepts such as the importance of rehabilitation services, the majority reported deficiencies in the delivery of these services. Barriers identified by physiatrists were related to lack of knowledge about cancer rehabilitation by patients, oncologists, and physiatrists. More than 80% of physiatrists in our study cited governmental support, financial support, healthcare equipment, and medical facilities as necessary to support rehabilitation services in Korea.

We also found differences in the availability and delivery of rehabilitation services according to type of cancer. Rehabilitation services for patients with breast cancer and central nervous system tumors were provided by more than 50% of physiatrists. However, other services such as pelvic floor rehabilitation programs for patients with gynecological cancer, colorectal cancer, and prostate cancer, exercise and mobilization programs during cancer treatment, weight control programs, and sexual rehabilitation were provided by less than one third of physiatrists, although most considered these services necessary for cancer patients. Previous studies from Western countries have reported that cancer patients often experience a number of problems that require rehabilitation services, including general weakness and pain [11,12], and patients’ functional status can be improved following rehabilitation [13].

Our definition of ‘cancer survivor’ involved an individual’s journey from the moment of diagnosis to the end of his/her life, as cancer survivors experience different problems according to the stage of their disease [14]. A recent study estimated that up to 10% of cancer survivors are in the rehabilitation phase at any given time [15]. In our study, most physiatrists considered patients who had completed treatment with no obvious recurrence as ‘cancer survivors,’ although they perceived patients in the ‘during treatment’ or ‘end-of-life’ stage as needing cancer rehabilitation services. Social stigma is attached to the Korean word for ‘survivor,’ which means a person who has managed to stay alive after suffering a difficult situation as a result of being unlucky or as a form of punishment. Cancer patients in Korea are reluctant to be called ‘survivors’ since it suggests that they are unlucky or are being punished. Thus, a ‘person who experienced cancer’ is a more acceptable phrase in Korea than ‘cancer survivor.’

There are various definitions of cancer rehabilitation, alternate indicators of cancer rehabilitation, and varying levels of access to those services both within and among countries, reflecting different funding systems and widening health inequalities. In Korea, interest in cancer survivorship has increased since the late 2000s, and the field of cancer rehabilitation is undergoing rapid development. The perceived discrepancy between the range of treatment phases that require cancer rehabilitation and the availability and delivery of those services may be explained by the lack of promotion of cancer survivorship and education in Korea. The term ‘cancer survivor’ is not publicly used in medical practice. However, changing social attitudes in Korea may diminish this discrepancy.

Our study showed that rehabilitation services were provided more frequently for breast, brain, and spinal cancers than for other types of cancer. In contrast, recognition levels of pelvic floor rehabilitation programs, exercise education, and sexual rehabilitation were low. There were also discrepancies between the perceived importance and delivery of rehabilitation services, particularly for general cancer-related dysfunctions such as fatigue [16]. Jo et al. [16] conducted a survey on Korean cancer patients and found that patients experienced various cancer- and treatmentspecific physical, psychological, and socioeconomic problems, thus displaying a strong need for rehabilitation services. Our data highlight the importance of developing effective and efficient rehabilitation programs that are specific to each phase of cancer survivorship.

In this study, respondents provided moderate to high quality rehabilitation services for breast cancer patients with upper-limb dysfunction (lymphedema). This finding indicates that specific dysfunction and rehabilitation services must be understood for successful cancer rehabilitation. As supportive care for cancer survivors becomes more advanced and its scope of practice expands, physiatrists should have a good understanding of cancer-related disabilities and treatment protocols. In addition to factors related to physiatrists, communication between oncologists and physiatrists, including transfer of patients from primary cancer treatment to supportive care, remains problematic. The clinical load is actually increasing on a relatively small group of oncology professionals who have little to no information regarding rehabilitation services for physical impairments, such as contracture, weakness, and deconditioning [17]. Physiatrists understand the pathophysiologies of fibrosis, deficits in muscle strength and flexibility, lymphatic insufficiency, muscle hypertonicity, and neural hypersensitivity, all of which require supportive care [18]. However, these dysfunctions appear to be under considered in the Korean health system. Early diagnosis and empirically based prevention of functional problems will limit long-term functional and psychological morbidity [19]. Thus, measurement of functional problems by physiatric evaluation during the early and most treatable stages of cancer is critical.

Levels of rehabilitation services provided to patients are influenced by the referral system and the hospital. Our findings revealed a statistically significant increase in services provided by physiatrists who worked in hospitals where oncologists referred patients for rehabilitation. The relationship between oncological and rehabilitation specialties may be important to initiate and coordinate the cancer rehabilitation process [19]. Furthermore, a referral system is necessary to refer patients for relevant rehabilitation activities [20]. The quality of rehabilitation services is likely dependent on referral patterns, team communication, and effective rehabilitation treatment processes [21]. The reluctance of oncologists in referring patients to physiatrists could be related to a lack of evidence of the benefits of cancer rehabilitation programs or inefficient patient referral processes. A systemic review examining barriers preventing access to supportive and palliative care has identified a lack of knowledge among health professionals, a lack of standardized referral criteria, and difficulty in equitable access to services [22]. Thus, the development of guidelines that specifically address supportive care should be considered [23]. Most previous studies on rehabilitation services have focused on patients, and a few have surveyed primary physicians; however, to our knowledge, none has surveyed physiatrists. A previous study revealed that 35% of European medical oncologists have collaborated with supportive care specialists, and of those, 88% felt that oncologists should coordinate supportive care for their patients [2]. Another survey of Australian cancer specialists showed that that 48% of respondents referred more than 60% of their patients to supportive care services [10]. In the present study, only one-third of physiatrists received referrals from oncologists, two-thirds of which were for patients in the “after treatment” phase or those with advanced cancer. The referral system should allow referrals of patients before and during treatment for early detection of problems as well as to provide effective rehabilitation services. The results of our survey suggest that oncologists in each field must be informed about rehabilitation services. Moreover, a lack of preparation for rehabilitation services was perceived as a barrier in Korea. Lack of governmental support, such as absence of a delivery system, limited standard guidelines for service delivery and monitoring, poor financial support for insurance coverage, and lack of medical equipment may severely restrict the delivery of rehabilitation services for cancer survivors.

The professional qualifications of personnel involved in cancer rehabilitation and palliation vary worldwide [24]. Compared with physiatrists in other countries, Korean physiatrists have played a leading role in founding and managing the Korean Research Council of Cancer Rehabilitation. Although our study revealed Korean physiatrists have a relatively low level of cancer rehabilitation knowledge and operate within an inactive referral system, they are aware of the need for cancer rehabilitation services and have specific and relevant knowledge of both general and cancer-type-specific dysfunctions.

Although most of the physiatrists surveyed believed that they should contribute to the management of cancer patients, they considered themselves ill equipped to provide appropriate rehabilitation services. Poor understanding of the effectiveness of rehabilitation services in cancer patients and lack of a cooperative referral system are the major barriers to providing rehabilitation services to cancer survivors in Korea.