Contemporary Issues in Cancer Rehabilitation An Evolving Role for Cancer Rehabilitation in the Era of Low-Dose Lung Computed Tomography Screening Sean Robinson Smith, MD, Ashish Khanna, MD, Eric M. Wisotzky, MD Abstract Lung cancer is the number one cause of cancer-related death worldwide, and is often detected in the later stages. Use of low- dose chest computed tomography in at-risk patients provides earlier detection and is being adopted as the standard screening tool, replacing less precise methods of radiography and sputum cytology. In the past, late detection of disease meant that rehabilitation interventions attempted to salvage function and to improve aerobic capacity to the point where patients could tolerate the sometimes-extensive oncologic treatment, including lobectomy or pneumonectomy. Earlier detection may shift this toward more often addressing specific neuromusculoskeletal impairments, such as postthoracotomy pain or peripheral neurop- athy, as patients with early-stage disease may not be as debilitated by chronic disease or metastases as those with late-stage lung cancer. Patients with advanced disease, however, will still require rehabilitation interventions, and this fragile population creates unique challenges. Rehabilitation professionals should look for ways to expand care to lung cancer patients, as both the number of those treated and the 5-year survival rate are expected to increase. Introduction Lung cancer is one of the most common cancer diagnoses worldwide, and remains the number one cause of cancer-related death in both men and women [1,2]. During 2016, the incidence of new cases in the United States was estimated to be 224,400, represent- ing about 14% of all cancer diagnoses [3]. Approximately 415,000 Americans have a diagnosis of lung cancer, 82% of whom are age 60 years or older, with the average age at diagnosis at 70 (less than 2% are younger than 45 years) [4]. Smoking remains the primary risk factor for developing disease, and nonsmokers who are exposed to second-hand smoke by living with a smoker have a 20%- 30% increased risk of developing lung cancer over that of the general population. About 10% of cases arise from toxic exposure, such as to radon or asbestos [3]. The risk of developing lung cancer without any of these factors is unclear. Of note, the majority of people with a history of lung cancer have had their diagnoses made within the past 5 years. Primary lung carcinoma is a heterogeneous group of tumor subtypes, with the most important distinc- tion being between small-cell and nonesmall-cell lung cancer (NSCLC). Treatment of NSCLC often involves a combination of surgery, chemotherapy, and/or radia- tion, whereas small-cell lung cancer often does not involve surgery unless there are focal, large areas of tumor burden in a location amenable to resection [5]. In those with early-stage lung cancer, surgical resection of the tumor is typically the first aspect of oncologic management [6]. The diagnosis of lung cancer is, unfortunately, often late, as patients may be asymptomatic with early-stage lung cancer, and up to two-thirds of patients have metastases at the time of diagnosis [7]. Furthermore, the stage at diagnosis is closely associated with survival, with a 5-year survival of only 6% for patients with me- tastases present on initial diagnosis, compared with 85% for patients with stage IA disease [8]. Only about 15% of patients are diagnosed with stage I disease [9,10]. Recommendations for lung screening vary by organi- zation, but most generally agree that testing should be administered in individuals 55-74 years of age with a smoking history of 30 pack-years (defined as “heavy smoking”) and who either continue to smoke or have quit within the past 15 years. Additional recommenda- tions include screening patients with a smoking history PM R 9 (2017) S407-S414 www.pmrjournal.org 1934-1482/$ - see front matter ª 2017 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2017.06.005