# Where rehabilitation is commissioned, and who misses out

Source: https://onco.cc/technologies/rejuv-rehab-commissioning-inequity/  
OnCo record `rejuv-rehab-commissioning-inequity` (Technology). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Whether a person gets rehabilitation after cancer depends on where the problem was noticed, how far they live from the service, how much money they have and what they were treated for. In the benchmark study a problem found in hospital was 88 times more likely to be treated than the same problem found in clinic.

## Summary

This is the closing record because it is the honest one. The therapies in this file have varying evidence behind them. The strongest and most reproducible finding across the whole literature is about who receives them.

Where the problem is noticed. Cheville's study of 163 women with metastatic breast cancer found that an impairment detected during a hospital admission had an odds ratio of 87.9 (28.5 to 271.4) for receiving any rehabilitation intervention, and 558.8 (187.0 to 1,669.6) for receiving physiotherapy or occupational therapy, compared with an impairment detected as an outpatient. Those are among the largest effect sizes in survivorship research and they are about administration rather than biology.

Money and ethnicity. The same study recorded that "Low socioeconomic and minority status were significantly associated with nontreatment". The DAMA cohort in Barcelona found that age, occupation, education level and holding private or mutual insurance all influenced whether a woman with breast cancer saw a physiotherapist, and that only 20 to 35 per cent of symptomatic women did.

Distance. The vestibular rehabilitation study is the cleanest measurement of this. Greater distance from a therapy site lowered the odds of completing therapy (odds ratio 0.91, 0.85 to 0.97), and women, older patients and those further away had significantly higher attrition. The voice prosthesis study found greater distance from the hospital associated with abandoning the device (p equals 0.017), alongside homelessness or incarceration (p equals 0.043).

Age. Older patients were more likely to drop out of vestibular rehabilitation and are the group with the most to gain from prehabilitation, which is the reason the high-risk abdominal trial restricted itself to patients over 70 or with high anaesthetic risk and found the largest effect in this file. A German study of 238 women after breast cancer surgery is the counterexample that should be recorded: 63.3 per cent attended inpatient rehabilitation, women with more years of schooling were less likely to go, and the authors concluded they found no evidence of social barriers in that system, with the reasons for not attending being personal rather than socially patterned. A system where rehabilitation is a funded entitlement produces different inequity from one where it is a referral.

Diagnosis. Rehabilitation provision follows the cancers with organised services. Breast cancer has lymphoedema and shoulder services; head and neck cancer has speech and language therapy embedded in the multidisciplinary team; lung cancer can be referred into existing respiratory rehabilitation. Haematological cancers, upper gastrointestinal cancers and brain tumours generally have no equivalent, and the Irish study found haematological cancers were the largest single group reporting unmet need.

Telemedicine changes some of this and not all of it. A multicentre retrospective study of 7,004 cancer rehabilitation encounters across four American academic centres found in-person patients were slightly older than telemedicine patients (62.9 against 60.7 years), a small race effect, and no gender difference. Prescribing and imaging were ordered at similar rates in both modes, while other orders were less likely by telemedicine. The honest reading is that telemedicine removes the travel barrier and does not by itself remove the referral barrier.

What would change it. The prospective surveillance record here describes the mechanism that has been proposed for fourteen years: measure function at fixed points so that referral does not depend on a patient complaining or a clinician noticing. It has not been widely implemented, and the reason given in every implementation study is the same, which is that the referral has nowhere to go without a funded service at the other end.

## Fields

- Kind: Technology
- Status: established
- Last checked: 2026-10-02
- Tags: rejuvenation; survivorship; rehabilitation; evidence:moderate
- Principle: Access to rehabilitation is determined at three gates, and the literature can tell them apart. The first is detection, which depends on the setting and explains the inpatient odds ratios. The second is referral, which depends on the clinician knowing the service exists. The third is completion, which depends on distance, money and the number of visits required. An intervention aimed at one gate does nothing about the other two.
- Strengths: The inequity is measured rather than asserted, with large and consistent effect sizes; The three gates can be addressed separately; Telemedicine demonstrably removes the travel gate
- Limitations: Mostly single-centre retrospective data; No national audit in the United Kingdom to measure against; Screening without a funded service to refer into changes nothing

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Health_equity
- Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer (JCO 2008): https://doi.org/10.1200/JCO.2007.12.3075
- Unmet cancer rehabilitation needs and access to survivorship services across the cancer continuum (Support Care Cancer 2026): https://doi.org/10.1007/s00520-026-10752-5
- Social inequalities in the use of physiotherapy in women diagnosed with breast cancer in Barcelona: DAMA cohort (Breast Cancer Res Treat 2024): https://doi.org/10.1007/s10549-023-07191-9
- Barriers to vestibular rehabilitation in acoustic neuroma surgical patients (Otol Neurotol 2025): https://doi.org/10.1097/MAO.0000000000004613
- Are there social inequalities in the utilisation of oncological rehabilitation by breast cancer patients? (Gesundheitswesen 2012): https://doi.org/10.1055/s-0030-1269840
- Telemedicine impact on patient disparities and physician practice patterns in cancer rehabilitation (PM R 2024): https://doi.org/10.1002/pmrj.13199

## Connected records

- ideas: [Multimodal prehabilitation for older patients before major cancer surgery](https://onco.cc/ideas/idea-acc-prehabilitation-older-surgery/), [Vocational rehabilitation integrated into cancer care so survivors can return to work](https://onco.cc/ideas/idea-acc-return-to-work-rehabilitation/)
- cancers: [Colorectal cancer](https://onco.cc/cancers/colorectal/), [Diffuse large B-cell lymphoma](https://onco.cc/cancers/dlbcl/), [Head and neck squamous cell carcinoma](https://onco.cc/cancers/head-and-neck/), [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Multiple myeloma](https://onco.cc/cancers/multiple-myeloma/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/)
- fronts: [Recovery & Rejuvenation](https://onco.cc/fronts/rejuvenation/), [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Balance, dizziness and falls after cancer treatment](https://onco.cc/technologies/rejuv-rehab-balance-vestibular/), [Cancer rehabilitation: the discipline that puts function back](https://onco.cc/technologies/rejuv-rehab-cancer-rehabilitation/), [Financial toxicity and financial navigation](https://onco.cc/technologies/financial-navigation/), [Global oncology and access in low- and middle-income countries](https://onco.cc/technologies/global-oncology-access/), [Prospective surveillance: looking for the problem before it becomes a disability](https://onco.cc/technologies/rejuv-rehab-prospective-surveillance/), [Telehealth and hospital-at-home in oncology](https://onco.cc/technologies/telehealth-oncology/), [Telemedicine, teleoncology, and telepathology](https://onco.cc/technologies/telemedicine-teleoncology/), [The devices that do the restoring, and who pays for them](https://onco.cc/technologies/rejuv-rehab-assistive-devices/), [The gap between the rehabilitation people need and the rehabilitation they are offered](https://onco.cc/technologies/rejuv-rehab-provision-gap/), [Voice after the larynx is removed](https://onco.cc/technologies/rejuv-recon-voice-after-laryngectomy/)
- terms: [Late effects and survivorship toxicity](https://onco.cc/terms/late-effects/), [Quality of life](https://onco.cc/terms/quality-of-life/)
- bottlenecks: [Patients lack understanding, navigation and agency](https://onco.cc/bottlenecks/b-patient-voice/), [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)

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