Patients diagnosed with cancer who are undergoing treatment may experience symptoms such as pain, fatigue and anxiety. Moreover, the diagnosis, progression and treatment of cancer can severely hinder physical activity levels and overall well-being. Evidence on integrating rehabilitation in cancer care is still scarce in South Africa.
To explore factors influencing the integration of rehabilitation services in cancer management in a tertiary academic hospital.
Data were collected at an academic hospital in Gauteng province.
Face-to-face semi-structured interviews with healthcare professionals were conducted. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis on MAXQDA version 2020.1 software.
Fifteen health professionals involved in cancer care at a tertiary academic hospital were interviewed. The main theme was ‘we know, but we are not doing it’. The sub-themes related to the main themes were health challenges experienced by patients with cancer, rehabilitation services for cancer patients, benefits of rehabilitation for cancer patients, barriers and facilitators to integrating rehabilitation in cancer care and recommendations to improve the integration of rehabilitation services in cancer care.
Participants recognised the importance of rehabilitation in cancer care. However, integrating rehabilitation into the cancer care continuum was not done due to many barriers. The findings may help policymakers ensure the implementation of the National Cancer Strategic Framework, which promotes inclusion of rehabilitation as part of holistic cancer care.
We highlight the importance of rehabilitation in cancer care.
Cancer is a global health challenge. The World Cancer Reports estimated 14 million cancer cases in 2014, with projections indicating an increase to 19.3 million cases by 2025.
Cancer and its associated treatments are linked to a variety of continuing and debilitating impairments.
Rehabilitation is one of the essential services that can benefit patients with cancer. Rehabilitation is a process aimed at restoring mental and/or physical capabilities that may have been compromised due to injury or illness, enabling individuals to function in a manner that is normal or close to normal (National Cancer Institute Dictionary of Cancer Terms). The Dietz model shows how cancer rehabilitation includes aspects of prevention, restoration, support and palliative care.
Access to rehabilitation for patients with cancer is still a challenge in South Africa. The South African National Cancer Strategic Framework (2017–2022), the guiding framework for cancer management, added rehabilitation as part of cancer management.
An exploratory qualitative design using semi-structured interviews was used. This study design helped to obtain the health professionals’ insights and an understanding of factors influencing the integration of rehabilitation services in cancer management.
Data were collected at an academic hospital in Gauteng province, which is the most populous province in South Africa. The academic hospital is a public facility that offers specialised cancer services in Johannesburg. The hospital has 1068 beds and receives oncology referrals from 14 nearby district hospitals and neighbouring provinces.
The participants who were included were health professionals with an oncology background (
Staff working in the oncology department.
| Staff description | |
|---|---|
| Doctors |
12 |
| Nursing staff |
6–7 |
| Social workers | 2 |
| Psychologists | 2 |
| Physiotherapists | 3 |
| Occupational therapists | 2 |
| Speech therapists | 3 |
| Palliative care specialists |
6 |
, Medical oncology and haematology;
, 6–7 nursing staff per day shift or per night shift;
, 1 social worker, 3 nurses, 1 doctor and 1 chaplain.
After obtaining ethical clearance and hospital permission, the principal researcher began recruiting participants. The principal researcher conducted face-to-face semi-structured interviews using an interview guide with open-ended questions and probes to facilitate a discussion on current cancer management practices, their roles in cancer care, factors affecting the integration of rehabilitation into cancer care, and potential solutions. The demographic information (age, profession, educational background, work experience) was collected as well. All interviews were audio recorded, and the researcher kept field notes to document observations throughout the process. Given the busyness of the academic hospital, the duration of each interview ranged from 20 min to 30 min. When no new information was coming from the participants, the researcher concluded that data saturation had been reached.
The interviews were transcribed verbatim, and the transcripts were exported to MAXQDA version 2020.1 (VERBI Software, Berlin, Germany). We read the transcripts to familiarise ourselves with the data and to grasp the primary concepts articulated by the participants. This was followed by separate systematic data coding by Mathabo Modiba and Sonti Pilusa. The researchers initially coded a transcript using an inductive approach, followed by a discussion on the codes and categories. A coding framework was established and employed to deductively code the remaining transcripts. The researchers discussed the codes, the categories and the emerging theme. To ensure rigour, all the interviews were audio-recorded, and the data collection process was detailed in depth. Debriefing sessions were held throughout the research process.
All the authors have experience in oncology care and have observed gaps in the health system that affect cancer care.
An application for full ethical approval was made to the University of the Witwatersrand Human Research Ethics Committee, and ethics consent was received on 16 December 2024. The ethics clearance number is M240814. The study was explained to the health professionals, and those who were willing to participate signed the informed consent. The recordings and the transcripts are kept safe by the principal researcher. No identifiers were added to the quotes to ensure anonymity.
Nineteen healthcare professionals employed in oncology wards at the tertiary hospital were invited to take part in the study. Out of these, four individuals were excluded for not meeting the inclusion criteria. Fifteen participants were interviewed; the age range was 26–40 years.
Participants’ demographic profile.
| Variable | |
|---|---|
| Female | 11 |
| Male | 4 |
| Physiotherapist | 2 |
| Occupational therapist | 2 |
| Speech therapist | 2 |
| Palliative care specialist | 2 |
| Social worker | 2 |
| Psychologist | 2 |
| Oncology doctor | 1 |
| Nurse | 2 |
Note: Age (years), range 26–40, mean 32.5, s.d. 4.4. Work experience (years), range 3–15, mean 8.3, s.d. 2.8.
s.d., standard deviation.
From the analysis of the results, the main theme, ‘
‘We know, but we are not doing it; numerous factors contribute to our inability to fulfil the expectations placed upon us.’ (Physiotherapist 2, 29 years old, male)
The subthemes related to the main theme were:
Health challenges experienced by patients with cancer.
Rehabilitation services rendered to patients with cancer.
Benefits of rehabilitation for patients with cancer.
Barriers and facilitators to integrating rehabilitation in cancer care.
Recommendations to improve the integration of rehabilitation services in cancer care.
The participants mentioned how the cancer diagnosis and its subsequent treatment reduced physical activity, which can consequently cause muscle weakness, joint stiffness, contractures, and a decline in mobility and performance of daily activities, including eating, drinking and dressing:
‘Patients can experience loss of appetite, nausea, fatigue, difficulty in breathing and pain due to cancer and its treatment.’ (Physiotherapist 1, 28 years old, female)
A nurse added:
‘Due to pain and fatigue, some patients tend to always want to be in bed, and this makes it more likely for them to get bed sores and general muscle weakness.’ (Nurse 2, 33 years old, female)
The participants stated that patients with cancer often experience emotional challenges because they grapple with feelings of anxiety, anger, fear, and denial:
‘Patients tend to have psychological breakdowns and social anxieties.’ (Psychologist 1, 35 years old, male)
‘They struggle with anxiety, anger, fear and denial.’ (Psychologist 2, 36 years old, female)
Patients with cancer may become depressed, often feeling sorrowful and losing interest in activities that once brought them joy:
‘They get depressed, often feeling sad and no longer enjoying activities that they would normally enjoy.’ (Palliative care specialist 2, 35 years old, female)
Another source of distress is worrying about their mortality and feeling guilty for being a burden to their family members:
‘They fear death …’ (Psychologist 2, 36 years old, female)
‘They often fear death and feel guilty about the burden of taking care of them on the family or caregivers.’ (Palliative care specialist 1, 40 years old, female)
The participants mentioned that the patient’s physical and psychological challenges can lead to difficulties in relationships and restrict participation in community activities they previously enjoyed:
‘Many of these problems patients with cancer face may affect their ability to participate in activities of daily living, including personal care, mobility and social activities.’ (Occupational therapist 2, 26 years, female)
‘They struggle to cope within the community due to always feeling weak and sick; they would sometimes complain that they are unable to participate in activities they used to do in the community.’ (Nurse 2, 33 years old, female)
Additionally, some individuals face financial hardships due to their inability to maintain employment due to illness:
‘Some patients experience financial loss or employment loss due to the inability to work.’ (Social worker 2, 30 years old, female)
Breadwinners are particularly anxious about their capacity to support their families during incapacity:
‘Breadwinners worry about providing for their families when they are unable to work.’ (Social worker 1, 38 years old, female)
These physical and emotional health problems reduce the patients’ quality of life:
‘Cancer patients may present with speech, communication, voice and swallowing difficulties which hugely impact activities of daily living and quality of life.’ (Speech therapist 1, 29 years old, female)
‘The social, physical and emotional problems patients get due to cancer, and its treatment can greatly impact negatively on the health-related quality of life.’ (Social worker 1, 30 years old, female)
Rehabilitation services rendered to patients with cancer aim to protect and enhance the patient’s well-being and promote independence in activities of daily living and quality of life:
Physiotherapy can manage the health complications linked to cancer and cancer treatment such as pain, enhance mobility and functionality:
‘We maximise independence and improve quality of life.’ (Physiotherapist 1, 28 years old, female)
‘Rehabilitation care can assist in minimising or slowing down the disabling effects of cancer and its treatment.’ (Occupational therapist 1, 27 years old, female)
The psychosocial interventions include counselling, support groups, educational sessions, and peer support networks:
‘We provide counselling to help overcome or manage social or psychological effects of disability on employment or independent living.’ (Social worker 2, 30 years old, female)
Other interventions include a referral to social services for social grants to assist with financial challenges. In addition, psychologists offer counselling services for individuals facing crises or experiencing emotional distress: ‘We provide counselling before surgical procedures’ (Psychologist 2, 36 years old, female).
Palliative care specialists provided supportive and spiritual care. They assist patients with cancer and their family members to understand the implications of cancer and provide spiritual guidance. Their main goal is to enhance the ability of patients and their families to manage their circumstances more effectively:
‘We provide supportive care that can help reduce pain, lessen anxiety and depression, improve communication between patients and their healthcare team, and overall satisfaction with life.’ (Palliative care specialist 2, 35 years old, female)
‘Palliative care is designed to relieve pain, manage symptoms, and cater for the physical, emotional, and psychological needs of both patients and their families.’ (Palliative care specialist, 40 years old, female)
Other services included health education, self-management strategies and issuing assistive devices:
‘We educate on speech and swallowing to make life easier for patients.’ (Speech therapist 1, 29 years old, female)
‘Rehabilitation services can equip the patients with self-management strategies, assistive devices required and address pain and other complications.’ (Occupational therapist 1, 26 years old, female)
The participants also expressed their views on integrating rehabilitation into cancer care. The health professionals highlighted the significance of a holistic approach through collaborative care that addresses physical, emotional and psychological aspects. ‘Patients require holistic support including physical, psychological, spiritual, and social dimensions’ (Doctor 1, 38 years old, male):
‘It is advantageous for patients when various members of the rehabilitation team collaborate to address their individual needs. For instance, a speech therapist assists patients in developing communication skills and ensures their safety during eating and drinking. An occupational therapist focuses on enhancing the skills necessary for daily living activities and employment. Meanwhile, physiotherapists evaluate and manage any issues related to physical mobility and functionality. This comprehensive support ensures that patients receive high-quality care from all dimensions.’ (Palliative care specialist 1, 40 years, female)
Although the participants saw the value of rehabilitation, they mentioned various barriers to integrating rehabilitation into cancer care. Some of the barriers included staff shortages, lack of awareness of the role of rehabilitation, high patient turnover and cancer care is not holistic.
‘Integrating rehabilitation services would be great, but do we have enough capacity?’ (Physiotherapist 2, 29 years old, male)
‘More staffing, sometimes we don’t see our patients daily due to short staffing.’ (Speech therapist 1, 29 years, female)
The participants mentioned that there is a lack of awareness of the role of rehabilitation, which affects patient referrals:
‘I strongly believe that if health care professionals know and understand each other’s roles, it will lead to them knowing when to refer patients that need rehabilitation, which will make it easier to improve referrals among the multidisciplinary team.’ (Physiotherapist 1, 28 years old, female)
‘Inadequate patient screening in the ward results in individuals being discharged without receiving essential interventions, as there is a failure to recognise their need for rehabilitation.’ (Doctor 1, 38 years old, male)
Participants highlighted how cancer care is still curative-focused:
‘Oncology professionals focus on survivorship, often overlooking the extensive care requirements that arise once they reach that stage.’ (Doctor 1, 38 years old, male)
And cancer care is still in silos:
‘I usually refer to health professional members whom we work closely with, such as occupational therapists and speech therapists, and we forget about palliative care and psychologists.’ (Physiotherapist 1, 28 years old, female)
‘I also think not having enough or regular multi-disciplinary meetings makes us work in silos.’ (Occupational therapist 2, 27 years, female)
‘Alright, so I feel that we also do not necessarily involve or engage the patients and their families to participate in rehabilitation as much as we should.’ (Physiotherapist 2, 29 years old, male)
‘The hospital experiences a significant turnover of patients. Upon arriving to attend to your referred patient, you may discover that the patient has already been discharged, resulting in their departure without receiving the necessary intervention and follow-up care.’ (Occupational therapist 2, 27 years old, female)
Participants have also suggested strategies to improve the integration of rehabilitation services in cancer care (
Recommendations to improve the integration of rehabilitation services in cancer care.
| Recommendation | Participant quotation |
|---|---|
| Raise awareness on the role of rehabilitation in cancer care | ‘Increasing awareness of cancer rehabilitation is crucial, as it plays a significant role in ensuring that patients obtain the necessary care to enhance their quality of life and functionality.’ (Psychologist 1, 35 years old, male) |
| Increase essential resources | ‘I believe the key to effectively integrating rehabilitation services lies in increasing staffing levels and resources.’ (Social worker 2, 30 years old, female) |
| Promote holistic health through collaborative care | ‘Innovative interventions that engage patients, provide family support, and offer training will also be necessary. Additionally, interdisciplinary collaboration in oncology wards must be reinforced and closely monitored.’ (Psychologist 2, 36 years old, female) |
| Research | ‘It is crucial to develop programs and resources that address the needs of cancer patients evaluated in oncology wards. This involves assessing current practices and identifying areas for improvement that healthcare professionals must address to enhance the integration of these services.’ (Palliative care specialist 1, 40 years, female) |
To the authors’ knowledge, this is the first study to explore the integration of rehabilitation in cancer care in South Africa. The main theme that emerged was: ‘We know, but we are not doing it’. We found that participants were aware of the need for and importance of rehabilitation in cancer care; however, the integration of rehabilitation services was not done. The findings align with previous studies that have shown health professionals recognise the need for rehabilitation in cancer patients.
The finding shows how neglecting to integrate rehabilitation care into cancer care undermines the health challenges experienced by patients with cancer. Patients with cancer need rehabilitation because of cancer-related complications such as pain, fatigue, diminished appetite, nausea, and breathing difficulties as a result of cancer and its associated treatments.
Holistic care encompasses all domains of life, including physical, spiritual, psychological and psychosocial support. Rehabilitation services from the different rehabilitation health professionals can offer the support needed by patients with cancer.
Other barriers to integrating rehabilitation include the lack of understanding of the role of rehabilitation in cancer care, a shortage of staff, and a lack of holistic cancer care practice. The lack of awareness of the role of rehabilitation in cancer care is a common problem globally that can be addressed from undergraduate training through interprofessional education.
Integrated cancer care encompasses a multidisciplinary team. The multidisciplinary team consists of physicians, nurses, physiotherapists, occupational therapists, psychologists, social workers, palliative care workers, and other healthcare experts who work together to deliver comprehensive cancer care.
Increasing awareness of the importance of rehabilitation in cancer treatment and advocating for holistic care would significantly enhance the well-being of cancer patients. Participation in ward rounds and multidisciplinary team meetings could be another way we could facilitate the integration of rehabilitation services within cancer care.
Given the qualitative nature of our research, the results cannot be generalised to other settings.
Rehabilitation uses multiple interventions to assist patients with cancer to avert further deterioration, facilitate recovery, and provide support to live with and beyond the cancer diagnosis.This study explored factors influencing the integration of rehabilitation services in cancer management. Health professionals understand the significance of rehabilitation in cancer care. Albeit practice was not done. Numerous barriers were hindering the integration of rehabilitation into the cancer care continuum. These barriers can be target points for future research and health system strengthening interventions. The study findings confirm the significance of rehabilitation in cancer treatment, indicating that it should be incorporated into the management of cancer patients. Integrating rehabilitation into cancer care can start from diagnosis to prevent disability related to the cancer care complications, enhance well-being and support the family and caregivers. However, rehabilitation should be customised to meet the specific needs, goals and disease trajectory of each patient.
The authors thank all the health professionals who participated in the study.
This article includes content that overlaps with research originally conducted as part of Mathabo Modiba’s master’s thesis titled ‘Factors influencing the integration of rehabilitation services in cancer care in a tertiary hospital, South Africa – health care workers’ perspective’, submitted to the Physiotherapy Department, University of the Witwatersrand in 2025. The thesis was supervised by Sonti Pilusa and Mpho Ratshikana. Portions of the data, analysis, and discussion have been revised, updated, and adapted for publication as a journal article. The author affirms that this article complies with ethical standards for secondary publication, and appropriate acknowledgement has been made of the original work.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. The author, Mathabo Modiba, of this publication received research funding from the Bristol Myers Squibb Foundation.
Mathabo Modiba: Conceptualisation, Data curation, Formal analysis, Writing – original draft. Mpho Ratshikana: Conceptualisation, Supervision, Writing – review & editing. Sonti Pilusa: Conceptualisation, Formal analysis, Supervision, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.
The data that support the findings of this study are available from the corresponding author, Sonti Pilusa, upon reasonable request.
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.