# Rehabilitation is recommended everywhere and commissioned almost nowhere

Source: https://onco.cc/bottlenecks/rejuv-agenda-rehabilitation-not-commissioned/  
OnCo record `rejuv-agenda-rehabilitation-not-commissioned` (Bottleneck). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

The interventions with the best evidence after cancer are supervised exercise, psychological therapy and specialist rehabilitation. The commonest finding across this whole front is that the evidence exists and the service does not.

## Summary

This is the gap that appears most often across the two hundred records on this front, and it is not a gap in knowledge. Structured exercise has randomised evidence of improved survival in colon cancer; cognitive behavioural therapy has randomised evidence for insomnia and for fatigue; decongestive therapy and supervised resistance training have evidence in lymphoedema; vocational rehabilitation has trial evidence for return to work. What they have in common is that each needs a salaried person to deliver it, and most services do not employ one.

The facets of this round recorded the same finding independently. On muscle: few services employ anyone to deliver supervised resistance training. On fatigue: behavioural treatments need weeks of effort and are poorly funded. On exercise: supervision helps for mood and is hard to fund. On bowel function after pelvic radiotherapy: referral pathways from oncology to gastroenterology rarely exist. On teeth after head and neck radiotherapy: lifelong specialist dental care is not reliably paid for in most health systems and the cost falls on the survivor. On psychological care: what is missing is not evidence but a commissioned route, and the mind facet calls that the single clearest finding of its facet. On fear of recurrence, the most reported unmet need in survivorship, OnCo could not find a health service anywhere that commissions a named service for it with a referral route.

England measured the scale of this once. Its 2013 national report found that 24 per cent of people were offered a written assessment and care plan, averaged across trusts, which is the least demanding component of the package it was recommending.

The structural reason is that none of these interventions is a product. There is no marketing authorisation to obtain, no company to lobby for a payment code, and no tariff that follows a person out of the oncology clinic. A drug with CHALLENGE's hazard ratio would be in every guideline and on every formulary within a year; an exercise programme with the same hazard ratio is in the guidelines and in almost no budgets.

## Fields

- Kind: Bottleneck
- Last checked: 2026-10-02
- Tags: rejuvenation; survivorship; open-problem; rehabilitation; commissioning
- Stage: access-delivery
- Severity: critical
- Metrics: People in England offered a written assessment and care plan, averaged across trusts: 24% (Department of Health, Living With and Beyond Cancer (2013), England cancer survivorship in numbers); Health services found by OnCo that commission a named service for fear of recurrence with a referral route: None in any country (OnCo mind facet, rejuv-mind-fear-of-recurrence-treatment); CHALLENGE: eight-year overall survival with and without a coached exercise programme after colon cancer chemotherapy: 90.3% against 83.2% (Courneya et al., NEJM 2025)
- Causes: Rehabilitation is a staffed service rather than a product, so it has no sponsor, no payment code and no tariff that follows the patient.; The benefit accrues years later and often to a different budget than the one that would pay, which is the classic prevention financing problem.; Oncology services are commissioned and measured around active treatment, and discharge is the point at which measurement stops.; Workforce is the binding constraint for several of these: physiotherapists, clinical psychologists, lymphoedema specialists and dietitians are already short.; Trials of these interventions report function and quality of life, which are not the endpoints health systems were built to pay for.

## Sources

- Courneya et al., Structured exercise after adjuvant chemotherapy for colon cancer, the CHALLENGE trial (NEJM 2025;393:13-25): https://doi.org/10.1056/NEJMoa2502760
- Campbell et al., Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable (Medicine and Science in Sports and Exercise 2019;51:2375-2390): https://doi.org/10.1249/MSS.0000000000002116
- Mustian et al., Comparison of pharmaceutical, psychological and exercise treatments for cancer-related fatigue: a meta-analysis (JAMA Oncology 2017;3:961): https://doi.org/10.1001/jamaoncol.2016.6914
- Department of Health, Living With and Beyond Cancer: Taking Action to Improve Outcomes (England, 29 March 2013): https://www.gov.uk/government/publications/living-with-and-beyond-cancer-taking-action-to-improve-outcomes

## Connected records

- technologies: [Bowel function after pelvic radiotherapy](https://onco.cc/technologies/bowel-after-pelvic-radiotherapy/), [Dry mouth, teeth and taste after head and neck radiotherapy](https://onco.cc/technologies/dry-mouth-teeth-after-head-neck-radiotherapy/), [Exercise & lifestyle oncology](https://onco.cc/technologies/exercise-oncology/), [Fatigue after cancer treatment: what actually works](https://onco.cc/technologies/cancer-related-fatigue-management/), [Getting psychological help after cancer: the stepped-care model, and what is actually commissioned](https://onco.cc/technologies/rejuv-mind-access-to-psychological-care/), [Going back to work after cancer: the rates, and the programmes that change them](https://onco.cc/technologies/rejuv-life-return-to-work/), [Muscle and strength after treatment: sarcopenia, cachexia and what rebuilds](https://onco.cc/technologies/muscle-recovery-after-cancer-treatment/), [Prehabilitation before cancer surgery](https://onco.cc/technologies/prehabilitation/), [Structured exercise programmes after curative treatment](https://onco.cc/technologies/structured-exercise-survivorship/), [The exercise prescription after cancer: the dose the guidelines state](https://onco.cc/technologies/exercise-prescription-after-cancer/), [Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available](https://onco.cc/technologies/rejuv-mind-fear-of-recurrence-treatment/), [What actually works after treatment](https://onco.cc/technologies/rejuv-frontier-what-works/)
- ideas: [Give survivorship interventions a shared control arm](https://onco.cc/ideas/idea-rejuv-survivorship-platform-trial/), [Pay for supervised exercise the way we pay for drugs](https://onco.cc/ideas/idea-bio2-exercise-reimbursement/), [Vocational rehabilitation integrated into cancer care so survivors can return to work](https://onco.cc/ideas/idea-acc-return-to-work-rehabilitation/), [Write a rehabilitation prescription at the end of treatment, and fund it like a drug](https://onco.cc/ideas/idea-rejuv-rehabilitation-prescription-at-discharge/)
- trials: [CanWork: an occupational therapy programme to help women return to work after breast cancer](https://onco.cc/trials/rejuv-trial-canwork/), [EX-CIPN: virtual exercise-based rehabilitation for persistent chemotherapy nerve damage](https://onco.cc/trials/rejuv-trial-ex-cipn/)
- terms: [Counting the people who live after cancer, and why the number is not a detail](https://onco.cc/terms/rejuv-history-counting-survivors/), [The National Cancer Survivorship Initiative in England, and the Recovery Package](https://onco.cc/terms/rejuv-history-ncsi-england/)
- roadmaps: [Recovery and rejuvenation roadmap: cure is not enough → survivorship gets a name → the cohorts that measured the cost → exercise proven as treatment → biological ageing measured and sold → repair, if anyone funds it](https://onco.cc/roadmaps/rejuvenation-roadmap/)
- fronts: [Recovery & Rejuvenation](https://onco.cc/fronts/rejuvenation/), [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)

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